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The key to epilepsy surgery is localization of the seizure focus. Typically, seizures that can be cured with surgery will arise from one of the inner portions of the temporal lobe, either left or right. Bilateral seizures, those that sometimes start on the left and sometimes start on the right, are not amenable to surgery because removal of both temporal lobes creates very severe memory problems. The path of the spread of a seizure is not critically important to outcomes of seizure surgery. The surgical target is the seizure focus, the place at which the seizure originates. Secondarily generalized tonic-clonic seizures will stop if the focal point of origin is removed.
One type of epilepsy surgery is a partial temporal lobectomy. Surgeons sometimes can cure seizures with operations on other regions of the brain, but the targets and boundaries of surgery are less clear than they are in temporal lobe surgery. An exception to this is surgery in the area of a lesion. Such lesions may be malformed blood vessels, post-traumatic scars, low-grade brain tumors, prior brain abscesses, or developmental lesions, such as migration problems, dysplasias, and heterotopias. Surgery around well-circumscribed lesions is often quite successful.
To evaluate a patient for temporal lobe surgery, the first key is to make certain that they have epilepsy and not one of its imitators, such as psychogenic (non-epileptic) seizures. EEG may help to localize the focus. Although interictal spikes, which are abnormal electrical signals that can at times be seen between seizures, are suggestive of where seizures come from, they are not as reliable as the electrical activity at the start of a seizure. For that reason, surgical candidates usually undergo video-EEG monitoring as an inpatient in order to capture five or six of their typical seizures.
Medications may be reduced or discontinued while undergoing monitoring, in order to provoke seizures. The hope is to find that all seizures come from some recognizable spot at the anterior to mid portion of one temporal lobe. MRI can be useful to rule out causative lesions and to show a subtle form of scarring in the temporal lobe called mesial temporal sclerosis. This is not always present, but when it is present, it is a strong indication that temporal lobe is involved in the epilepsy.
Neuropsychological tests are performed to determine whether a patient has impairments in the verbal sphere, usually reflecting injury to the dominant left hemisphere, or in the sphere of picture, face and shape recognition, which usually reflects right hemisphere damage.
Neuropsychological testing can screen for depression, which is highly prevalent in this population. Psychosocial adjustment after epilepsy surgery is key to the success of the procedure, since the goal is improvement of quality of life, rather than just attenuation of seizures.
Can I drive?
Much discussion occurs about driving. People with frequent seizures should not drive, but people with infrequent seizures may be allowed to drive as a risk that is comparable to those taken with other medical conditions. Different states have different seizure-free intervals, varying from three months to two years. The shorter time intervals allow people with epilepsy to make other arrangements for work or driving, and theoretically encourage honesty in their reporting of seizures. People with seizures can obtain exemptions allowing driving if the seizures are restricted to times of sleep, or if the seizures have a prolonged and consistent warning that would allow someone to pull safely over, or if seizures are of a type that does not affect driving.
Most states make it the responsibility of the person with epilepsy to notify the motor vehicle division. California is one of the six states that require seizure reporting by patients and doctors as a matter of law. Failure to report can result in criminal prosecution. Most physicians disagree with the required reporting, because it encourages dishonesty with the physician about the occurrence of seizures, which may prevent adequate treatment.
Can I work?
Most people with epilepsy work full and productive jobs. Certain jobs that involve driving, operation of life- or limb-threatening machinery, caustic chemicals, prolonged periods of working on heights or working underwater, should not be done by people with uncontrolled seizures. Any job restrictions should be individualized.
The 1990 Americans for Disabilities Act prohibits discrimination in the marketplace against people with disabilities. This includes epilepsy. If people with epilepsy cannot do their job because of seizures, an attempt must be made to make a reasonable accommodation for them within the framework of their employment.
Can I go to school?
Children with epilepsy can do well in school, but some do not. This may be because of social and peer pressure factors and factors of self-image and expectations. Other children have epilepsy because of an underlying injury to brain, and that brain injury may impair their ability to learn. Another major factor is anti-epileptic medications, which can impact negatively on learning and behavior. This is particularly true for barbiturate medications. A balance must be struck between the need for seizure control and the side effects of medications on schooling.
Can I become pregnant?
Women with epilepsy can become pregnant, have normal children, and participate fully in parenthood. Pregnancies are higher risk for women with epilepsy, because of the seizures and the antiepileptic medications. Occasionally, seizures may increase during pregnancy, but they are just as likely to improve or remain stable.
Birth defect risks are a few percent higher in women with epilepsy. The baseline rate of birth defects, large or small, is about two percent for American women. This birth defect risk increases to 5-10 percent among women with epilepsy. Looked at positively, more than 90 percent of women will have healthy babies. Some contribution to the birth defect risk is made by seizures, and by underlying general risk factors, but the main birth defect risk is from antiepileptic medications. Monotherapy (one anti-seizure drug, rather than many) is preferred during pregnancy, provided it controls the seizures. Although there is much debate about medications that are best during pregnancy, no scientific study gives us guidance as to one medication truly being safer than another medication.
Phenytoin (Dilantin), and barbiturates can cause cleft lip/palate, or other skull, face, or heart malformations. Valproic acid (Depakote) and carbamazepine (Tegretol, Carbatrol) are linked to open spine problems. Carbamazepine can cause "minor defects," such as fingernail malformations, or mild facial feature distortions, that resolve by age five. Many other birth defects are possible, and any seizure medicine has the capacity to induce any of the defects. The best rule is to use the single medicine that is most effective in treating the woman's seizures.
Supplementation with folic acid (folate) 0.4 – 1.0 mg per day reduces risk for open-spine birth defects among populations of women without neurological disease. By analogy, most epilepsy doctors prescribe folic acid for women who might become pregnant while on antiepileptic medications. The best dose is not known, but quantities range from 1 - 5 mg per day. Most over-the-counter daily vitamins contain 0.4 mg (400 micrograms) of folic acid, and most prenatal vitamins, 1 mg. Doses of folic acid of 1 mg or less seem to have no side effects, although high doses can sometimes suppress signs of blood disorders. The folic acid should be taken every day, since most women are not even aware that they are pregnant as the spine is being formed in the first 6 weeks of pregnancy.
Breastfeeding is beneficial, and the benefits usually outweigh the risks from trace amounts of seizure medicine present in the breast milk. The mother should recognize that the child already has been exposed for 9 months to the medicine in the placental bloodstream.
A pregnancy registry for women with epilepsy is being maintained in Boston, at 888-233-2334, and internationally at several other sites. We recommend that pregnant women with epilepsy call this number, obtain information and provide some information to the registry. By such tracking of pregnancies, we will obtain accurate information on which to base future advice.
Can I be injured during a seizure?
Occasionally seizures can provoke injuries. The goal is to live your life as fully as you can, but with common sense about potential injuries. People with infrequent seizures (for example, small seizures less than every three months) may have no need for restrictions. People with frequent seizures should exhibit special care in water, including bathtubs (it may be safer to shower sitting), around hot water or flames, on prolonged heights (brief climbs up ladders or stairs are usually safe for most people), around dangerous cutting and chopping machinery without safety guards, or in other obvious potentially dangerous situations. These potential risks apply both to the home environment and to the workplace.
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