Therapy

Epilepsy Surgery

The healing of the epilepsy with the removal of the brain tissue responsible for the epileptic seizures, or the improvement of the situation through separation of the nerve fibres where the seizures spread, were established in the last century as a safe and successful treatment internationally wide.

The following questions must be answered in the framework of pre-surgical epilepsy diagnosis:

• Is it really epilepsy?
• Is this epilepsy medically resistant?
• In principle, can this seizure be operatively treated?
• Can the origin of the fits be more precisely isolated?
• Can damage to the other functions be ruled out with an operation?
• Does the relationship between chance and risk compare favourably with a non-surgical treatment option?

All results will be discussed in depth with the patient and family following completion of the examinations in order to make an informed decision for or against an operation possible.

In close co-operation with the neurosurgery at The Beta Klinik, all diagnosis procedures in preparation for epilepsy surgery can take place, including the implantation of stereotactic electrodes to identify the source of the epilepsy. Through MRI guided laser ablation, these epilepsy surgical procedures are especially gentle.

In-depth information on epilepsy surgery for professionals and patients has been made available by the European Project “e-pilepsy.eu” since February 2015.

Epilepsy Surgical Procedures

Epilepsy surgical procedures in the treatment drug resistant epilepsy.

Strategies:

• Curative: removal of the area of brain responsible for the fits by means of focus resection.
• Palliative: disruption of the nerve pathways through which the seizure activity is spread by means of disconnection.
• Combination of resection and disconnection
• Focus resection
• Extended lesion resection: Removal of a brain structure abnormality in whose surrounding area the fits begin.
• Lobectomy: Removal of a brain lobe (lobus)
• Selective amygadalohippocampectomy: Removal of the hippocampus and amygdala.
• Topectomy: Removal of brain tissue in which the seizures begin but which are unobtrusive.
• Hemispherectomy: Removal of half of the brain

Even with major surgery it is possible not to remove the brain tissue but rather to leave it still in the skull supplied by blood vessels, and separate all nerve pathways: Lobotomy (the removal of brain lobe), hemispherectomy, respectively functional hemispherectomy (half of the brain).

• Disconnection
• Callostomy (split brain): the separation of the front, back or complete bridge of nerve fibres which joins both halves of the brain together
• Multiple subpial transection: vertical separation in the brain surface without tissue removal.

Vagus Nerve Stimulation

Der X. Brain nerve (nervus vagus) supplies the vegetative organs in the throat, chest and upper stomach area and sends signals from there to the brain. These signal paths can be made use of with Vagus Nerve Stimulation (VNS). An electrode can be securely fixed to the vagus nerve in the throat and neck area. A cable is implanted under the skin in the chest area which is connected to a pulse generator, similar to a pacemaker. The stimulator sends a regular pulse to the vagus nerve (e.g. every five minutes for thirty seconds). The vagus nerve has multiple connections to the whole brain.

In the meantime, nearly 45,000 epilepsy patients have had vagus nerve stimulators implanted, most of them in the USA. Nearly 700 patients in Germany have had implants of which over 200 were in Bonn. The health insurance companies pay for the treatment through clinic budgets.

One observes that nearly 40 to 50 percent of patients experience a steady and sustained lessening of seizures (at least by half). The quality of life and the emotional state of patients seem to improve with VNS. A maximum of 10 percent of cases are seizure free. In general, the treatment is well tolerated although hoarseness is often experienced during the stimulation phases.

Vagus nerve stimulation is an option for patients who are severely affected and drug resistant and for whom an operation was either unsuccessful or not possible.

Deep Brain Stimulation

Deep brain stimulation (DBS) for difficult to treat epilepsy has been available as a new treatment procedure since 2010.

DBS has been used for a long time with great success in other neurological illnesses such as Parkinson disease, essential tremor and dystonia.

DBS comes into consideration when your epilepsy is difficult to treat, when freedom of seizures has not been sufficiently achieved through various medications and also when epilepsy surgery is either unsuccessful or not possible.

Our special DBS surgery in our clinic includes:

• Advising of patients and relatives about DBS
• Checking whether DBS in special cases makes sense
• Support and accompanying of patients before, during and after the operation

Drug Therapy

The correct diagnosis of epilepsy is the most important requirement for promising medical treatment. Often, success is possible even after the first or second attempt with a drug in monotherapy or two drugs used in combination. The dose must be carefully prepared so that on one hand it effectively protects against seizures and on the other hand allows for no or the very minimum of side effects to be experienced. Side effects are often the reason for discontinuation of the therapy.

Changes to the medication plan can take place ambulatory and only in very seldom cases are patients advised to be hospitalised.

Changes to the dose should never happen without consulting the doctor. Sudden discontinuation of medicine can result in dangerous side effects.

The regular taking of medicine together with a trusting relationship between doctor and patient are the guarantors of an optimal therapy.

All questions relating to wanting to have children should be spoken about and discussed with a specialist before pregnancy.

Active pharmaceutical ingredients, brand names of compounds (selection)

• Barbexaclone – Maliasin (Phenobarbital + Levopropylhexedrine) – only until the end of 2004
• Carbamazepine – Carba, Carbagamma, Carbium, Carbamazepin, Finlepsin, Fokalepsin, Sirtal, Tegretal, Timonil
• Clobazam – Frisium
• Clonazepam – Antelepsin, Rivotril
• Diazepam – Diazep, Diazepam, Faustan, Lamra, Stesolid, Tranquase, Valiquid, Valium, Valocordin
• Ethosuximide – Petnidan, Pyknolepsinum, Suxilept, Suxinutin
• Felbamate – Taloxa
• Gabapentin – Neurontin
• Potassium bromide – dibro-Be
• Lamotrigine – Lamictal
• Levetiracetam – Keppra
• Mesuximide – Petinutin

• Oxcarbazepine – Trileptal
• Phenobarbital – Fali-Lepsin, Lepinal, Luminal, (Maliasin – until end of 2004)
• Phenytoin – Zentropil, Phenhydan, Epanutin, Phenytoin AWD
• Pregabalin – Lyrica
• Primidone – Liskantin, Mylepsinum, Resimatil
• Retigabine – Trobalt
• Sultiame – Ospolot
• Tiagabine – Gabitril
• Topiramate – Topamax
• Valproic Acide/Valproat – Convulex, Convulsifin, Ergenyl, Leptilan, Myproin, Orfiril
• Vigabatrin – Sabril
• Zonisamide – Zonegran

There are a number of other treatment strategies which some patients make use of.

Only the ketogenic diet has been proved effective in severely handicapped children. Convincing effectiveness lacks in other procedures such as acupuncture or homeopathy amongst others.

Psychotherapy has its place in the treatment of epilepsy with the often-resulting psychological illnesses such as depression or anxiety. Psychotherapy can lead to a general improvement in one’s quality of life. The therapist, however, should be experienced in treating epilepsy patients.

Self-regulation of seizures and patient training can contribute to an improvement in the situation through avoiding unwanted behaviour or a reduction in seizures. They are not a replacement for drug therapy though.

Our recommendation: Speak openly to your doctor when you are unsatisfied with the conventional medicine and are thinking about other alternatives!