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Surgical Alternatives for Epilepsy (SAFE) Offers Counseling, Choices for Patients by R UNIVERSITY of PITTSBURGH NEUROSURGERY NEWS Surgical alternatives for epilepsy (SAFE) offers counseling, choices for patients by R. Mark Richardson, MD, PhD Myths Facts pilepsy is often called the most common • There are always ‘serious complications’ from Epilepsy surgery is relatively safe: serious neurological disorder because at epilepsy surgery. Eany given time 1% of the world’s popula- • the rate of permanent neurologic deficits is tion has active epilepsy. The only potential about 3% cure for a patient’s epilepsy is the surgical • the rate of cognitive deficits is about 6%, removal of the seizure focus, if it can be although half of these resolve in two months identified. Chances for seizure freedom can be as high as 90% in some cases of seizures • complications are well below the danger of that originate in the temporal lobe. continued seizures. In 2003, the American Association of Neurology (AAN) recognized that the ben- • All approved anti-seizure medications should • Some forms of temporal lobe epilepsy are fail, or progressive and seizure outcome is better when efits of temporal lobe resection for disabling surgical intervention is early. seizures is greater than continued treatment • a vagal nerve stimulator (VNS) should be at- with antiepileptic drugs, and issued a practice tempted and fail, before surgery is considered. • Early surgery helps to avoid the adverse conse- parameter recommending that patients with quences of continued seizures (increased risk of temporal lobe epilepsy be referred to a surgi- death, physical injuries, cognitive problems and cal epilepsy center. In addition, patients with lower quality of life. extra-temporal epilepsy who are experiencing • Resection surgery should be considered before difficult seizures or troubling medication side vagal nerve stimulator placement. effects may also benefit from talking to an epilepsy surgeon, especial those with a brain • A seizure focus near the language area of the • Language and movement areas of the brain can lesion such as a tumor or vascular malforma- brain cannot be removed. be preserved by carefully mapping these func- tion. tions with electrical stimulation. Tragically, it takes an average of 20 • A seizure focus near the movement area of the years for patients with drug-resistant epilepsy brain cannot be removed to be referred to an epilepsy surgeon. For this • Surgery on the head leaves a huge scar where • Cosmetic changes are often only noticed by the reason, the University of Pittsburgh Adult hair doesn’t grow and is disfiguring. patient, and hair does grow back over the incision. Epilepsy Surgery Program has implemented a process for patients and their families to Surgical Alternatives For Epilepsy 10% and drops to less than 3% after failing meet with the epilepsy surgeon earlier in the (SAFE) counseling is a process that allows three medications. course of their disease treatment. epilepsy patients, and their families, to talk • 70-90% of patients are seizure free to a neurosurgeon about the role of brain one year after temporal lobe surgery (see surgery in the treatment of epilepsy, even figure 1 at left). if surgery has not yet been recommended. • 100,000 people with drug-resistant In this program, neurologists and general temporal lobe epilepsy are eligible for surgery practitioners are referring epilepsy patients every year in the U.S., but less than 3% get as soon as surgical candidacy is a possibility, surgical treatment. recognizing that surgery for epilepsy is not a Why are more patients who would “last resort” but a potential cure. benefit from epilepsy surgery not referred and SAFE counseling is an appropriate step treated? Myths and lack of education about even if patients are not ready to undergo brain epilepsy surgery probably play a large role (see surgery, as meeting with the neurosurgeon table above). does not represent a commitment to surgery. As part of a neurosurgical consultation The philosophy of our comprehensive epi- at UPMC, epilepsy patients also have the op- lepsy program is that early education about portunity to talk to a representative from the surgery gives patients more control over Epilepsy Foundation of Western Pennsylvania the treatment of their disease. Also, surgical (EFWP) to learn about available resources for treatment earlier in the course of epilepsy is people with epilepsy. Additionally, in conjunc- more effective. Some facts that are discussed tion with the EFWP, our department hosts 1 include: an Epilepsy Surgery Discussion Group every • Up to 40% of people with epilepsy third Friday of the month, where anyone who Post-operative MRI demonstrating a right an- terior temporal lobectomy (red dashed line) in cannot control their seizures with medication. has had, or is considering having, surgery for an epilepsy patient who has been seizure-free • The chance of becoming seizure- epilepsy is invited to come and share their after surgery, without any cognitive changes. free after failing two medications is less than experiences or ask questions. • PAGE 4.
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