When to consider epilepsy surgery for your child

If medications aren’t controlling your child’s seizures, surgery could help.

If your child has epilepsy, medication is generally the first option for controlling seizures. But if medications aren’t working, then surgery for epilepsy may help your child gain better seizure control. In some cases, epilepsy surgery may even help your child be free from seizures altogether.

“Epilepsy surgery has been around for a long time,” said Dr. Robert Naftel, a pediatric neurosurgeon with Monroe Carell Jr. Children’s Hospital at Vanderbilt Neurosurgery. “There’s been a lot of research done on epilepsy surgery, and it’s been found to be highly effective in treating epilepsy, especially in children who have failed two medications.”

When to consider epilepsy surgery

About 70% of children with epilepsy will do well on medication. “They can take one antiepileptic and get good control of their seizures,” Naftel explained. “But 30% is still a big number of children who don’t have success with one medication.” When that happens, about 5% of those patients may do well with the addition of a second prescription, Naftel added.

However, if two medications together do not work, a third is unlikely to be the solution. “Once you have failed two medications,” Naftel said, “we typically like to start considering surgery because certain surgeries may have a higher likelihood of giving good seizure control.”

Types of epilepsy surgery

The type of surgery that may be a good fit for your child will depend on several factors, including the type of epilepsy your child has. “Epilepsy surgery is not one-size-fits all,” Naftel explained. “We really have to individualize treatment to each child.”

Options include:

• Ablation – using a laser to destroy the area of the brain where the seizures start.
• Brain stimulation or vagus nerve stimulation – inserting an electrode into the place causing the seizures and controlling the seizures with a pacemaker-like device.
• Craniotomy – traditional, open surgery in which part of the brain tissue is removed.
• Corpus callosotomy or functional hemispherectomy – procedures that remove connecting nerves or tissues without removing actual pieces of the brain.

Determining the best type of surgery for your child

First, your child will undergo some initial testing to help determine where in the brain the seizures start. In some instances, a minimally invasive procedure is required to pinpoint the location.

If your child has focal epilepsy, in which the seizures originate from just one place, then surgery may involve removing that area, as long as doing so would be safe. “The goal of such a surgery would hopefully be a cure of their epilepsy and to gain seizure freedom,” Naftel said. “It’s reasonable to consider that perhaps, in the long run, they’d be able to come off of their seizure medications.”

Sometimes targeting the area can involve a minimally invasive procedure that uses ablation with a laser to destroy tissue. In other cases, when working with a larger section, the procedure may require a more invasive technique or even the removal of brain tissue.

Your child may not have a type of epilepsy that can be cured completely. But surgery might still be a good epilepsy treatment option for providing significantly better seizure control than with just medications alone.

Some children have multi-focal epilepsy with “drop attacks,” where their head or body goes limp. “We might do a corpus callosotomy,” Naftel said, “where we disconnect one of the main pathways between the two sides of the brain to slow down the spread of the seizures.”

Another option might be a stimulation device. A responsive neurostimulator is a device that both detects and treats seizures. In this procedure, a stimulator is implanted into the brain to treat epilepsy. Alternatively, other children may be treated with a vagus nerve stimulator. In this procedure, a surgeon implants a small electrode in your child’s neck that will stimulate a nerve via a device. The stimulation can help reduce seizures and improve quality of life, Naftel explained.

Working as a team on your child’s care

If your child is a candidate for epilepsy surgery, a team of care providers will collectively help plan on the best course of action based on testing and examination results and then help you decide what’s best for your child.

“All that data we have collected is presented in a team meeting that includes several representatives from different aspects of your child’s care – epileptologists, radiologists, other team members and myself,” Naftel said. “And we present a child’s epilepsy story and test results and then discuss it as a group to determine the best option.”