Primary steps: When to refer to an epileptologist for epilepsy surgery evaluation

Primary Steps for Primary Care | July 20, 2022 | Cynthia Keator, M.D.

Drug-resistant (a.k.a. intractable) epilepsy is defined as the failure of at least two appropriately chosen anti-seizure medications used at adequate doses. When this occurs, a referral to an epileptologist is often encouraged, as the likelihood of achieving seizure freedom with additional medications is significantly reduced. Epileptologists are trained to evaluate complex epilepsies. They can offer multiple treatment options, including additional medications, dietary therapy and epilepsy surgery. For appropriately selected patients, epilepsy surgery has the highest chance of achieving seizure freedom, yet surgery remains vastly underutilized. There are a number of misconceptions leading people to regard surgery as a last resort. This underscores the importance of working with an epileptologist who has special training in surgical evaluation. Seizure freedom can be achieved in many patients, particularly those with focal lesional epilepsy. Seizure freedom following surgery offers the best opportunity to ultimately wean off anti-seizure medications.

Epilepsy surgery can be beneficial for a wide spectrum of drug-resistant epilepsies with differing etiologies, seizure types and epilepsy syndromes. Even palliative procedures, those intended to result in seizure reduction but not seizure freedom, have been shown to reduce seizures but also to improve quality of life along with cognitive and neuro-developmental outcomes. In addition, successful epilepsy surgery reduces mortality and decreases the risk of sudden unexplained death in epilepsy (also called SUDEP.) With numerous new technologies to treat epilepsy patients, including minimally invasive surgical techniques, the pool of people who could benefit from epilepsy surgery has grown considerably.

A patient who is a candidate for epilepsy surgery typically begins the process by undergoing a “phase I” evaluation, intended to gather data to assess whether surgery is an option and what type surgery to offer. These patients are carefully evaluated by our clinical team in our epilepsy monitoring unit where we record seizures on video EEG, along with other neuro-imaging studies including PET, SPECT, MEG and fMRI as warranted to further localize seizure onset. Also, Neuropsychology testing helps us to evaluate current/baseline cognitive assessments. Once the work up is complete, our team discusses each patient in comprehensive epilepsy surgery conferences attended by neurologists, epileptologists, neurosurgeons, neuroradiologists and neuropsychologists, where we can determine recommendations regarding the patients' surgical therapy.

For some, epilepsy surgery evaluation will not reveal a single focus amenable to resection or ablation. Seizure onset may be near eloquent cortex (such as primary motor or language function.) Seizures may be diffuse or generalized in onset, or multiple regions of seizure onset may exist. Fortunately, there are surgical options that may still be beneficial in these cases. Too often, these patients are significantly delayed for a surgical referral and may have further adverse impact on their cognitive or behavioral development.

With so many epilepsy surgery tools available, all patients with intractable epilepsy should be considered for treatments beyond medications alone. This starts with a comprehensive evaluation by an epileptologist to discuss the seizure syndrome and options available.

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Cynthia Keator, MD

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Contact the Jane and John Justin Neurosciences Center at Cook Children's to refer a patient: 682-885-2500.