Neurology - Epilepsy Surgery

This leaflet will give you information about epilepsy surgery at Salford Royal Hospital.

If you have any questions after reading this leaflet, please feel free to contact the Epilepsy Surgery Team.

Useful contacts

Your Neurologist
Name:
Telephone:

Your Neuropsychologist
Name:
Telephone:

Your Epilepsy Specialist Nurse
Name:
Telephone:

Your Neurosurgeon
Name:
Telephone:
 

What is epilepsy surgery, and why is it relevant to me?

You have been given this leaflet because your Neurologist thinks that surgery might be the right treatment for you.

Epilepsy surgery is a type of brain surgery. It can be used to treat some types of epilepsy. It involves removing areas of the brain which are causing seizures.

The goal of this surgery varies from patient to patient. For most patients, we hope to stop the seizures.

In other cases, we only expect surgery to make seizures less frequent or less severe.

Epilepsy surgery is not for everyone with epilepsy. We will consider surgery if epilepsy medications do not control your seizures.

You can only have surgery if:

• Your seizures are starting in one area of your brain
• We can do an operation without too much risk of harm

Finding out if you can have surgery

To decide if you can have surgery, we need to do some tests. It takes several months to complete the tests.

These tests will show if your epilepsy is caused by an area of your brain which we can remove.

You will need to come to hospital for the tests. For some tests you will need to stay in hospital.

What happens next?

1. An appointment will be made with the epilepsy specialist neurologist, and you will be offered some tests.
2. You may need an MRI scan, Video Telemetry and neuropsychology tests
3. We will discuss the test results at the Multi-Disciplinary Team (MDT) meeting and decide if you might be able to have surgery.
4. The MDT may recommend surgery or may decide that surgery is unlikely to benefit your epilepsy. The MDT may also recommend further tests before a decision can be made. Your neurologist will write to you or meet with you to discuss the MDT decision.
5. If you undergo further tests, we will discuss these results at the MDT meeting and then decide if surgery is an option for you. If surgery is an option, your neurologist will meet with you to discuss the risks and benefits.
6. If you decide to proceed with surgery, an appointment will be made with your neurosurgeon. The neurosurgeon will discuss the details of surgery, and risks and benefits.
7. A health check will need to be completed before surgery can take place.

This process usually takes around 18 months but can vary between patients.

The Epilepsy Surgery Team

This includes your Neurologist, Neurosurgeon, Neuropsychologist, Epilepsy Specialist Nurse, EEG team, Radiologist, Neuropsychiatrist, and sometimes other doctors and medical staff who perform your tests.

The Neurologist is a doctor who treats problems with the brain and nerves.

The Neuropsychologist helps with the psychological aspects of your epilepsy, including your memory and emotions.

The Neurosurgeon is a surgeon who does operations on the brain and spine.

The Epilepsy Specialist Nurse can provide more information and help you prepare for surgery and advise regarding treatment after surgery. The nurse can also arrange for you to speak to other patients who have had epilepsy surgery.

The Neuropsychiatrist is a doctor who treats mental health symptoms in people with brain and nerve problems.

The Tests

The following is a list of tests that you may be asked to undergo.

You may not need to undergo all these tests.

Magnetic Resonance Imaging (MRI)

An MRI scan uses magnetic waves to create images of your brain. This can show if there is an area of your brain which may be causing your seizures. You will need to lie inside a large tube whilst the scanner takes pictures. It takes about an hour.

An MRI scan is harmless and painless. The scanner can be noisy. Some people may find the experience of being in the scanner worrying. We can discuss ways to help with this, such as relaxation exercises or taking an anti-anxiety tablet before the scan.

Electroencephalogram (EEG)

An EEG can show which part of your brain is causing your seizures. During an EEG, electrodes (leads) are attached to your scalp with special glue. These leads are then connected to an EEG machine.

The machine records the electrical activity of the brain. The test will take about an hour. The test is harmless and painless.

EEG Video-Telemetry (VT)

During video telemetry, you will stay in hospital for up to five days in an ensuite room on the neurology ward. You will have EEG leads attached to your scalp.

Video cameras in your room will record you. There are no cameras in the bathroom or toilet. We can then compare the electrical activity in your brain with your actions during a seizure.

We may decrease or stop your epilepsy tablets. We may also keep you awake during the night. This will make it more likely that you will have a seizure which we can record.

You will not be able to leave the room during your admission. If you smoke, ideally you should stop smoking before you come into the hospital. You will be offered support and nicotine replacement to help stop smoking.

This test is done by the Neurophysiology Department (EEG team), who will send you more details before the test.

Neuropsychological interview and assessments

The Neuropsychologist will interview you and someone who knows you well, such as a family member or close friend.

You will be asked questions and asked to complete tests to look at your thinking abilities. The Neuropsychologist will assess your mental health including possible stress or depression you may have and assess memory and speech function.

These tests will help us to understand how your thinking abilities are affected by your epilepsy and if you might have problems with memory or speech after surgery.
 
The results will also help the team to understand what support you might need before or after surgery.

The assessment usually takes between four to five hours to complete and is done over two to three appointments.

You will also be offered a follow up appointment with the Neuropsychologist to discuss the test results. You may be offered further therapy to help you with any memory or mental health problems.

You will have further appointments with the Neuropsychologist after surgery (see later).

Functional Magnetic Resonance Imaging (fMRI)

fMRI is the same as an MRI scan, except that we will ask you to do simple tasks during the scan.

The scan takes 45 minutes to one hour to do, and it shows us changes to activity of your brain whilst you are doing these tasks. This can show which areas of your brain you use when you think of words and when you move. The results help us to plan the details of your surgery.

Positron Emission Tomography (PET)

The PET scan involves an injection with radioactive dye, which can then be traced as it travels through the brain.

It helps us to see parts of the brain that might not be working as well as other areas, which can give us more information about where your seizures are coming from.

This dye gives off small amounts of radiation. You will be asked to lie down on a bed with a large circular scanner at one end.

The radiation given off by the dye is then used to form a picture of the activity in your brain. The scan can take up to an hour.

Deciding if surgery is for you

The Epilepsy Multidisciplinary Team (MDT) meeting takes place every two weeks. We will discuss your test results at this meeting. We then decide if we can recommend surgery to you.

If we decide that surgery is likely to help, then it is up to you to decide whether you would like to proceed. The Neurosurgeon, Neurologist, Epilepsy Specialist Nurse and Neuropsychologist will help you to decide if you would like to go ahead. They will discuss the risks and benefits of the surgery with you.

There are risks associated with epilepsy surgery. These include infection, bleeding, stroke, vision problems, pain, and a small risk to life. After surgery, some people can experience problems with memory, speech or mood.

There is also the risk that the surgery will not make your seizures any better. There is a small risk that your seizures could be made worse.
 
We will not suggest that you can have surgery unless these risks are small in your case and do not outweigh the benefits.

You may decide not to have surgery. You should discuss your choice fully with your epilepsy team. They will make sure that you have all the right information.

They may also be able to answer any worries that you might have. There is always the possibility of revisiting surgery in the future if you decide that it is not the right time for you.

What happens before the surgery?

If you decide to go ahead with surgery, then you will be sent an appointment for a ‘pre-operative assessment’. This is to check that you are well enough to have surgery.

This will usually involve an ECG (a test to assess the health of your heart), blood tests and a blood pressure check.

You will be admitted to hospital on the day of your surgery. You will not be able to eat or drink for about 6 hours before the operation.

You will still need to take your epilepsy medication as usual.

What does the surgery involve?

The Neurosurgeon will discuss the details of your surgery with you beforehand. There are three main types of epilepsy surgery which we do at Salford Royal Hospital.

1.    Anterior Temporal Lobectomy and Amygdalo-hippocampectomy
If the test results confirm that your seizures start from the temporal lobe, then we remove a part of your brain called the anterior temporal lobe and two specific structures called the hippocampus and amygdala.

2.    Hemispherotomy
If the test results show that there is damage to one half of your brain which is causing seizures, then we can disconnect the damaged side of your brain from the normal side.

This is usually done with people who also have a long history of weakness down one side of the body caused by the damage to the opposite side of the brain.

3.    Lesionectomy
If the test results show that seizures are coming from an abnormality in your brain, such as a ‘cavernoma’ or a tumour, we remove this area of brain.

For all these operations, you will be put to sleep with a general anaesthetic. The surgeon will then remove a small area of your skull to get to your brain. Afterwards, the bone is replaced and fixed to the rest of your skull.

The surgery usually takes a few hours, and most people stay in hospital for at least five days following the operation.
 
Before surgery, your hair will need to be shaved around the area that is going to be operated on. The Neurosurgeon will explain where this will be done, however, the hair usually grows back as normal after surgery.

You will have a scar from surgery. The Neurosurgeon will explain where the scar will be, but it is usual for the scar to be covered by your hair when it grows back (unless your hair is very short) and the scar is not normally obvious to others.

What happens after the surgery?

Recovery from surgery

Before your surgery, your Neurologist and Neurosurgeon will talk to you about what results you can expect from your surgery. In most cases, the surgery is a success, and patients find that they have fewer seizures.

People usually stay on their usual epilepsy tablets for at least 12 months after the surgery. After that, you may decide with the Neurologist to slowly reduce the dose.

It can take several months to feel back to normal after brain surgery. The team will discuss with you how you might feel in the first few months after surgery.

It is common to feel very tired in the first few weeks. You will need plenty of rest and may need some help with your day-to- day activities at first.

As you recover from the surgery, you may notice problems with balance, memory, language and concentration. It is also quite common to feel more/less emotional than before your surgery in the first few months. Some patients also have mood swings or feel irritable.
 
Not everyone has these problems but for people who do, most of these symptoms should improve over the first 12 months.

Usually, memory and language improve to a similar level as it was before surgery. So, if you had memory problems before surgery then you are likely to have memory problems after surgery.

However, some people’s memory or language abilities are worse after surgery. This may be hard to cope with at first, but you should not find that it stops you from doing your daily activities in the long term.

Support after surgery

You can get help from the Epilepsy Surgery Team.

If needed, you may be offered therapy such as medication, psychological therapy to help with changes in your mood or thinking abilities, physiotherapy to help with any physical weakness or occupational therapy to help with any practical activities that you find difficult.

Routine appointments

6-8 weeks after your surgery, you will have a check-up with the Neurosurgeon. After this, you should be able to travel and exercise.

The Epilepsy Specialist Nurse will see or speak to you at regular intervals after surgery and is available to talk to you over the telephone if you have worries or questions about the surgery or your recovery.

You will receive regular appointments with your Neurologist after surgery.
 
You will be followed up by the Neuropsychologist, who will send you an appointment at 3 months, 6 months, 12 months, and 2 years after surgery.

Your thinking abilities, including memory, will be tested in detail 12 months after surgery so that we can compare the results to how you did before surgery.

Who should I contact for advice or support?

You can speak to your Neurologist, Neurosurgeon, Epilepsy Specialist Nurse or Neuropsychologist. We can complete the contact details at the start of this leaflet at your appointments.

The Epilepsy Nurse Specialist is available to give you advice and support over the telephone.

Contact details

For more information about our department please contact:
Epilepsy Nurse Team, Department of Neurology, 3rd Floor, Humphrey Booth Building, Salford Royal Hospital, Stott Lane, Salford,
M6 8HD.

Tel: 0161 206 2951 or email epilepsynurseteam@nca.nhs.uk