Epilepsy Surgery

Epilepsy surgery may be an option for children with epilepsy whose seizures are not well controlled on anti-epileptic medication. Surgical treatment is usually (but not exclusively) recommended for young people with a focal epilepsy.

We are able to offer children and young people the opportunity to be assessed to see whether surgery may be appropriate for them. Assessment for epilepsy surgery involves a number of tests and investigations and can take up to 18 months.

Alongside these investigations we hold regular multidisciplinary team discussions both here in Sheffield and with our colleagues in Birmingham.

Your child will be seen regularly in the Epilepsy Surgery Clinic to discuss the results of any tests and to discuss further investigations that might be necessary. Our ethos is to ensure that children and young people are involved in the decision-making throughout the epilepsy surgery work up as far as is possible.

Your child’s surgery will take place at Sheffield Children’s Hospital or if they are under six years of age at Birmingham Children’s Hospital.

Your child will usually be admitted to hospital the day before the planned surgery when your child will be seen by the neurosurgeon, the anaesthetist and their consultant neurologist. Your child will have an opportunity to visit the ward before they are admitted if they would like to do so.

Following surgery your child may spend one night in the high dependency unit before they are transferred back to the ward.

Most children can go home between four and seven days after surgery, but this does depend on the type of surgery that has been performed.

When they leave hospital your child may have less energy than usual for several weeks. Sometimes they may feel more easily upset or anxious. These feelings are usually a temporary reaction to having had major surgery and to any change in their seizure pattern.

A member of the epilepsy nurse team will support your child following discharge and will help integrate them back into school / college through a phased return programme.

Your child will be seen for regular reviews by the neurosurgical team who undertook the surgery. They will also continue to be seen in the epilepsy surgery clinics here in Sheffield.

Approximately three-six months after surgery your child will have a repeat MRI scan to see how well the brain is healing.

It is normally recommended that your child stays on the same dose of medication for a year after surgery. If they are seizure free after this time, then your neurologist will consider starting to slowly wean them off some of their medication. If this is successful then your child will continue to be weaned off all their medication.

You child will also have a repeat neuropsychometric assessment at one year and two years after their surgery. This is to look at the impact that surgery has had on their development, memory and social skills. This will be the same type of assessment that they had before surgery, so that we can compare the results.

Depending on the type of surgery that your child has had they may have follow-up care from the therapy team to ensure that they regain their strength and get back to their usual activities.

If your child were to have any ongoing behavioural and emotional issues following surgery, you will have ongoing care to assist with this.

Unfortunately, not every child who is evaluated for resective epilepsy surgery will be found to be a suitable candidate. It may be that after all the tests and investigations have been completed we are unable to find a particular area of the brain that causes your child’s seizures.

It is also possible that the part of the brain that is causing your child’s epilepsy is also responsible for important functions such as speech or movement. If this is the case, the surgeon may feel that by operating this would cause your child more harm than the epilepsy itself is causing.

If for any reason resective epilepsy surgery is not suitable for your child, there may be other options.

1. To try other medications that may assist with seizure control.
2. To consider the ketogenic diet. This is a special diet that has been proven to improve seizure control for some children.
3. To implant a Vagus Nerve Stimulator. This is a procedure in which a small pacemaker-like device is surgically implanted under the skin on your child’s upper chest. The device delivers a small electrical current to the vagus nerve in the neck and the impulse continues up the nerve to the brain. This device has also been shown to improve seizure control for some children.

These options will be discussed in detail with you in clinic.

We may reduce your child’s medication prior to their admission or during their admissions to ensure that seizures do happen but rest assured that their medication will be resumed prior to discharge.

A MRI scan is needed to see whether there is a structural cause for your child’s epilepsy. The MRI scanner can pick up the small abnormalities in the brain that may be causing the epilepsy. It is important that the child lies completely still during the scan as any movement can affect the quality of the scan and it may then have to be repeated.

For young children who would not be able to lie still we will do the scan with a general anaesthetic so that we get good pictures and to avoid delays in your child’s treatment.

This scan is very similar to an MRI scan. Your child needs to lie on the table in the scanner and while they are being scanned they will be asked to do some tasks. This may include saying words that appear on a screen, tapping fingers / thumb, or naming pictures that appear on a screen. This is because when the child is asked to do these tasks there is an increased flow of oxygen to certain specific areas of the brain. This helps us to see which areas of the child’s brain are controlling thoughts, speech, movement and sensation.

This scan might be needed if the area where the epilepsy is coming from is very close to these important areas of brain function.

This scan uses a radioactive substance (tracer) that is injected into your child to help us understand how their brain is working. Usually, the child will have an EEG at the same time enabling us to compare the images to the EEG done without the radioactive tracer.

The PET scan is another test used to show us which part of the brain is causing the epileptic activity because the part where the seizures start does not soak up as much of the tracer as the normal brain.

There are two types of SPECT scan. One is called an inter-ictal scan which is done when your child HAS NOT had a seizure; this is done as an outpatient. The other is called an ictal SPECT which is done after the child has had a seizure and is done as an inpatient. Comparison of the two scans shows the different areas of blood flow in different colours. Once again this test is used to locate seizure onset.

Your child will be given an injection of a radioactive dye within seconds of a seizure starting and this will be taken up by the brain. The dye highlights different areas of blood flow within your brain. Usually, blood flow is higher in that part of the brain where the seizures start.

Every child who is thought to be suitable for epilepsy surgery will have a neuropsychology assessment. This assessment is carried out as an outpatient over one or possibly two visits where your child will be asked to complete different tasks. Some will be related to your child’s memory, some about written skills, some about speech skills and some about numeracy.

As parents / carers you will also have to fill in a questionnaire about how epilepsy has affected your child.

The purpose of this assessment is to see whether the area within your child’s brain where we are considering operating is responsible for any of these important functions. This assessment is also helpful in telling us if the epilepsy has caused your child any memory or learning problems. This assessment can be very helpful in helping to gain extra support for your child in school if difficulties are identified.

Invasive EEG monitoring is a surgical procedure. There are various types of invasive monitoring and include: monitoring in which EEG electrodes are placed directly on the surface of the brain (subdural grids or strips); or depth electrodes which are small multi contact probes inserted into specific areas of the brain via small burr holes made in the skull.

Your child may require invasive monitoring to determine more precisely where the seizures are coming from. While the invasive monitoring is taking place the neurosurgeon can map out exactly which part of your child’s brain is responsible for speech, memory and movement.

Invasive monitoring takes place in hospital under a general anaesthetic. Following placement of the electrodes your child is then moved back to the ward and connected to the EEG machine. Once the electrodes / probes have been recording for a sufficient length of time to ensure that we have gathered enough information, your child will return to the theatre to have them removed.

Your child may then have their epilepsy surgery straight afterwards or this may be done later as a separate operation.