Epilepsy: Types, Treatment And Myths

Epilepsy Surgery

Epilepsy is chronic disorder, which cripples many people around the globe and is a huge social stigma associated with it. These people lose many privileges of life like sports, driving, family, education, and employment only to become dependent on others for even routine activities. The problem is more severe in children as most of the kids with epilepsy become mentally challenged due to epilepsy and medications side effects. Unfortunately, proper advice and diagnosis facilities are not enough to cater this huge population and they are not aware of recent advances and treatment options available. With proper and timely treatment of epilepsy, these kids can have an almost normal life.

What is Epilepsy?
Epilepsy is a chronic condition in which patients experience recurrent seizures without any provoking cause because of chronic underlying brain etiology. A seizure is just a symptom of epilepsy disorder. Epilepsies can be associated with brain malformations, tumors, previous ischemic insults, infection, birth-related injuries etc. Very few patients can have a genetic component as well for epilepsy.

What are the different type of epilepsies?
There are major three types of epilepsies. In the first type, no cause can be found out irrespective of all the tests and investigations. These are called as idiopathic one. In another one, there is some obvious cause in the brain like tumor or malformation or previous birth injury related changes responsible for epilepsy. These are called as symptomatic epilepsy, which is treatable. The third type is actually a grey area between these where doctor strongly suspects that there should be some cause, but with present investigations, a doctor cannot find it. These are labeled as cryptogenic one, which should be investigated further.

What are treatment modalities for epilepsy?
Single episode of seizure does not constitute epilepsy and hence most of the times you don’t need any treatment for single seizure. However, once epilepsy is diagnosed with careful clinical history and EEG by experienced neurologist or physician; standard modality of treatment is antiepileptic medications. And if seizures don’t respond to antiepileptic medications i.e. they become drug resistant, they can be evaluated and successfully treated with small and simple surgeries. If surgery does not appear to be feasible after an evaluation is complete, such patients can be treated with palliative procedures.

What is drug-resistant epilepsy?
Generally, once a diagnosis of epilepsy is made by a neurologist, the patient is prescribed one drug at first and the dose is escalated gradually over weeks to control the seizures. Approximately, 50% of patients benefit from single drug only and epilepsy is controlled. In those, which continue to have seizures after the first drug, the second drug is started which generally relieves another ~15% patients. However, if the patient continues to have seizures even after two drugs, the chances of controlling seizures with the third drug is minimal. Hence, patients who continue to have a seizure after trying two drugs for an adequate time, are labeled as drug-resistant. Generally, patients who have something abnormal in their brain do not respond to medications and mostly becomes drug resistant.

What is epilepsy surgery?
In some patients diagnosed with epilepsy, drugs cannot control epilepsy. Most of the time, these patients have something visibly abnormal in their brain. So, logically if one can deal with abnormality which is visible on MRI Brain, one can practically cure epilepsy. Surgery for epilepsy are surgeries on the brain, where doctors remove or alter the abnormal currents in brain circuits so as to stop/alter/modify the seizures and improve the quality of life of the person affected with epilepsy.

Why go for epilepsy surgery?
If your seizures are controlled with one or two drugs, then there is no need for surgery. However, when you have to take more than two medications and you continue to have seizures, surgery is a rational choice for following reasons.
a. Seizures are bad to experience and you lose many privileges in life like employment, driving, swimming, and sports. Adding further drug is not going to control your seizures. You will be under constant threat of having a seizure and will be dependent on a companion for routine activities.
b. Few patients die with epilepsy every year. However, chances of dying from epilepsy surgery are minimal and its one-time risk. Hence surgical treatment is safer than medical treatment in uncontrolled epilepsy.
c. Epilepsy medications have many side effects which include bone problems, weight gain, mood problems, cognitive decline and loss of memory and depression. More medications you take, more chances of cognitive decline overtime period.
d. Also, with every seizure, some neurons die of ischemia and capacity of the brain goes down. It’s a slow process of memory and cognitive decline.
e. Even financially, if you are on two medications, your monthly healthcare cost is high. The cost of epilepsy surgery is one-time cost to avoid continuous healthcare costs.
What are steps for epilepsy surgery?

Once you are categorized as drug-resistant epilepsy and being considered for epilepsy surgery, you will have to undergo three major steps. Pre-surgical evaluation followed by a consensus decision and finally surgery. In the pre-surgical evaluation, the doctor decides the exact parts of your brain which is responsible for this epilepsy with various tests, clinical evaluations etc. And a team of medical specialists from various related fields meet together to discuss and reach a consensus about the type of surgery you will need. A final plan is decided in the multidisciplinary meeting.

What is a pre-surgical evaluation for epilepsy surgery?
The pre-surgical evaluation consists of three main domains. Most important is video EEG followed by investigations like MRI, PET scan, SPECT scan. This MRI scan done here is not the routine MRI but customized scan which will depend on your video EEG recordings. A neuropsychological evaluation is also a crucial part of presurgical evaluation which provides important insight into the localization and possible problems you will be having after surgery. Once all these investigations are ready, it is generally discussed in meetings to reach a consensus about the plan.

What are EEG and video EEG and their necessity?
Video EEG is nothing but simultaneous recording of EEG along with video camera focused on you all the time. You will be admitted and EEG leads will be attached to you. You will be under the camera for 24 hours with continued EEG recordings. When you will have a seizure, it will record the exact movements you do during your seizure activity and simultaneous EEG recordings. This will give the doctor the fair idea of the area of your brain responsible for producing these seizures. Generally, doctors record 3-10 episodes of seizure and hence patients generally stay for 3-4 days in the hospital. Doctors generally stop your drugs so that more seizures can be obtained in short time. It is safe as you are having seizures in a controlled environment of the hospital, equipped with doctors and nurses all the time. During the same hospitalization, you will undergo neuropsychological evaluation and MRI and PET testing as and when required. A plan is finalized at the end of your hospitalization. Other major advantage of video EEG is proper diagnosis of epilepsy. At times, the patient is taking wrong medicines or right medicines for the wrong type of epilepsy or they don’t have epilepsy at all and they are taking medicines for no reason. Thus proper diagnosis can help patients to get rid of medications.

What are different types of epilepsy surgeries?
Epilepsy surgeries are mainly of two types. In patients where the doctor finds a small, focal brain area responsible for epilepsy, the doctor will go for resection of that area. These surgeries are called curative surgeries where once that area is removed; the patient will be mostly free of epilepsy. However, there is a group of patients in which a large area is responsible or doctor could not define a small area or removing complete area is not feasible; surgeries are meant to just reduce seizure frequency and improve quality of life. These surgeries are called palliative surgeries.

What are improvement chances for epilepsy surgery?
Chances of seizure control depend on many variables and vary between 50-90%. If there is tumor or malformation or localized area which could be removed completely, then ~90% patient achieves freedom from epilepsy. Outcome typically depends on the responsible pathology. Overall, ~80 % patients become seizure free and ~60% become drug-free for life in properly worked up cases. If MRI shows some lesion which could be removed, then ~9 out of 10 people can achieve seizure freedom and almost ~6 out of 10 patients can be off the medicine.

What are complications with epilepsy surgery?
Complications are infrequent in epilepsy surgery with major complications like motor deficits, language deficits, vegetative states, and disabilities are low in numbers. Other treatable complications like infections, prolonged hospitalizations, transient deficits, speech problems, mood problems, visual field deficits occur in ~5-7% of patients and do not alter the normal daily life. Overall, epilepsy surgery is safe surgery and it improves quality of life of many patients and their caretakers significantly.

What is the usual post-operative course for epilepsy surgery?
For most of the procedures, the patient stays for one week in the hospital after surgery. It depends upon the type of surgery patient is undergoing. If it is a major surgery, the patient may spend ~3-5 days in intensive care units and another week in the ward followed by rehabilitation services. Palliative surgeries take longer durations. It also depends on patient’s preoperative condition.

What are usual recovery and return to job period for epilepsy surgery?
When a patient who is doing job undergoes epilepsy surgery, a doctor typically advises a two weeks period for complete recovery and returning back to the original job. However, it may depend upon the nature of job and surgery done.

What are myths about epilepsy surgery?
There are few myths are seen in our society and unfortunately, doctors are also misinformed. Most importantly, routine EEG did not show anything specific means there is nothing doctor could do further is the most common belief. Secondly, normal report of MRI is mostly cited reason by relatives for not going for further work up. Actually routine EEG many times does not reveal anything and this is a well-known fact about EEG. Secondly, routine MRI may not pick up more than ~50% of anomalies responsible for epilepsy. Hence, doctors have to go for MRI under epilepsy protocol to see it for more details. Also, positive report rates are higher in centers routinely doing epilepsy work. The third misconception is that one cannot do epilepsy surgery in mentally challenged kids. On the contrary, it has been found that after epilepsy surgery; seizure control, learning capability and memory functions of kids improve along with scholastic performance.

Epilepsy Key Facts?
Almost affecting one percent of general populations, Pune district has almost 1,00,000 people suffering from epilepsy.
a. About 50 million people in the world suffer from epilepsy.
b. Approximately 80% of the people with epilepsy live in low and middle-income areas.
c. Epilepsy treatment results in positive outcome around 70% of the time.
d. Nearly 75% of people in low and middle-income areas do not get the treatment they need.
Source: World Health Organization: WHO

Epilepsy evaluation and surgery cost
Cost of epilepsy surgery including pre-surgical evaluation, hospitalization, and surgery varies from hospital to hospital and city to city in India. Private and known brand of hospitals in cities such as Mumbai, Bangalore, Pune, Hyderabad, New Delhi, Chennai and Kolkata will have higher charges compared to new/upcoming hospitals. Some of the non-profitable trust hospitals can do surgeries at reduced costs as they are supported by donations. Costs also depend on the facilities and type of rooms availed during hospitalization. Patients are typically advised to discuss the potential cost with hospital/primary healthcare advisor and make an informed decision.

Why Epilepsy Surgery In India?
International patients should consider India as a potential location for epilepsy treatment because:
a. Indian doctors are among the best in the world.
b. Latest high-end technology infrastructure available across many hospitals in cities such as Mumbai, Bangalore, Pune, Hyderabad, New Delhi, Chennai and Kolkata.
c. Healthcare professionals are well versed in English. Translators are available for other foreign languages.
d. International patient handling processes are standardized.
e. Availability of medicines and drugs.
f. Comparatively economical cost to other locations.

Why iHealthMantra?
iHealthMantra is disrupting the way patients interact with Indian healthcare ecosystem. We bring transparency and trust in our interaction with patients. Our objective is to enable patients to make informed decisions by sharing information transparently and ethically. We also ensure the patient receives focused attention from our partner hospitals. Our salient features:
a. We work on patients behalf to get best possible information and economical prices from hospitals/healthcare clinics. Our advisors negotiate the economical prices and pass on the benefits to patients.
b. We facilitate patients to connect with service providers such as accommodation, transportation etc. ensuring best quality providers at economical prices.

We negotiate, influence and leverage our network for the patient benefit.