Surgery for Epilepsy & Seizure Disorders in Children
Medication can keep seizures under control for many children with epilepsy. However, in children whose symptoms aren’t managed well with medication, surgery can be very effective. At the Pediatric Epilepsy Program, part of NYU Langone’s Comprehensive Epilepsy Center, neurosurgeons from Hassenfeld Children’s Hospital at NYU Langone offer several types of surgery to control seizures.
The Comprehensive Epilepsy Center is one of the largest treatment centers in the United States for adults and children. During the past 6 years, our surgeons have performed more than 250 brain surgeries for children with epilepsy.
Because of our doctors’ tremendous successes in treating children who were not considered surgical candidates at other centers, the Comprehensive Epilepsy Center has earned an international reputation for treating children with the most challenging conditions. It has also established an exceptional record of safety and effectiveness.
To determine if surgery is the best treatment option, your child’s doctor starts with a preoperative workup that may include intracranial monitoring to determine the source of seizure activity. If surgery is recommended, the next steps may be cranial epilepsy surgery or laser interstitial thermal therapy.
The goal of epilepsy surgery is to neutralize or remove parts of the brain that aren’t working correctly, without injuring healthy brain tissue or impairing neurologic function. To accomplish this, our epilepsy specialists first identify the areas of the brain that are problematic. This process is known as a preoperative workup.
During a preoperative workup, your child’s doctor performs tests to identify the epileptic and healthy brain areas and determine if your child is a good surgical candidate. The tests the doctor recommends depend upon your child’s symptoms but always include brain imaging scans, tests of language and memory, and video electroencephalography (EEG), which is performed in the hospital to record seizures as they occur.
When these tests do not provide enough information to pinpoint the source of the seizure activity, your child may need intracranial monitoring.
Intracranial monitoring may be recommended when EEG does not provide enough information about the source of seizure activity. During this surgical procedure, fine, flexible electrodes are placed in several areas of the brain. The electrodes provide continuous monitoring for seizures, allowing your child’s doctor to pinpoint the source of the troublesome electrical activity.
In most situations, NYU Langone’s pediatric neurosurgeons use robotic stereotactic assistance, known as ROSA, to place electrodes inside the brain. This robotic surgical approach allows the electrodes to be placed using multiple small incisions into the skull—each about 2 millimeters. This technique allows for surgery that is quicker and has a faster recovery time than craniotomy, which requires removing a portion of the skull in order to place the monitoring devices.
Using imaging scans, the ROSA system creates a 3D image of your child’s brain. The neurosurgeon uses this image to map out exactly where electrodes need to be placed.
On the day of surgery, the ROSA guidance system uses the surgical map to pinpoint the exact spots where electrodes should be placed. The neurosurgeon directs the robotic surgical arm to create tiny holes in the skull that align with the electrode placement. The electrodes are then advanced through the small holes and put into position.
Data received from these electrodes help doctors to determine the exact part of the brain that triggers seizure activity.
Cranial Epilepsy Surgery
Using the data received from intracranial monitoring, pediatric neurosurgeons can remove the brain tissue that monitoring has revealed to be problematic.
Cranial epilepsy surgeries are performed in the hospital with general anesthesia. Children typically stay in the hospital for about 4 to 10 days, depending on which type of surgery is performed.
Advancements in neurosurgical technology have made epilepsy surgery much less invasive than it was 20 years ago. Little hair is removed, and surgery is performed with greater accuracy.
About 90 percent of the best candidates for surgery have complete seizure control after surgery. At least half of people with more complex types of epilepsy show a significant reduction in seizures after surgery. In total, about 65 percent of those who have had epilepsy surgery at NYU Langone, both children and adults, become free of seizures.
Types of cranial epilepsy surgery include the following.
Temporal Lobe Resection
In a temporal lobe resection, the most common surgical procedure for epilepsy, a small portion of the temporal lobe is removed. More than 80 percent of people who have this surgery at NYU Langone become seizure-free or enjoy a significant improvement in seizure control.
Most people need less antiepileptic medication after surgery, and about 25 percent of people who are seizure-free can eventually discontinue antiepileptic medication.
In corpus callosotomy, a surgeon cuts the connection between the right and left sides, or hemispheres, of the brain. This slows the electrical activity between the two halves of the brain that can lead to a seizure. Although this procedure doesn’t prevent seizures altogether, it decreases their severity.
Surgeons perform this technique in people who have sudden “drop” seizures, including the tonic and atonic seizures experienced by children with Lennox-Gastaut syndrome. These seizures can cause falls and injuries.
Corpus callosotomy helps reduce the severity of drop seizures in children and adolescents. Seizure frequency is reduced by an average of 70 to 80 percent after a partial callosotomy and 80 to 90 percent after a complete callosotomy. During a partial callosotomy, about 20 percent of the back part of the corpus callosum—the thick band of nerve fibers that separates the two hemispheres of the brain—is left intact.
If doctors find that a child’s recurrent seizures are caused by a specific abnormality or lesion in the structure of the brain, they may perform a procedure called a lesionectomy to remove it. For many people, the procedure results in complete seizure control.
A hemispherectomy involves disconnecting one side, or hemisphere, of the brain from the rest of the brain. This procedure is considered for children who have Sturge-Weber syndrome, Ohtahara syndrome, or Rasmussen syndrome, as well as for those who have severe epilepsy or seizures that arise from only one side of the brain, leading to poor function in that hemisphere.
The best candidates for this procedure are typically young children who already have severe weakness and a loss of sensation and vision on one side of the body. The side of the brain that is to be disconnected functions very poorly and often impairs the functions of the other side of the brain.
When this procedure is performed in young children, the opposite hemisphere of the brain may compensate for the loss. More than 75 percent of children who have a hemispherectomy experience complete or nearly complete seizure control.
Multiple Subpial Transection
Multiple subpial transection is a procedure used to control focal seizures that originate in areas of the brain that can’t be removed safely. This procedure involves making a series of shallow cuts, called transections, in an area of the brain called the cerebral cortex.
Because of the complex way the brain is organized, these cuts are thought to interrupt some fibers that connect neighboring parts of the brain. These transections do not appear to cause long-lasting impairment in the critical functions of these areas.
Multiple subpial transections can help to reduce or eliminate seizures that occur in vital, functional areas of the brain. Transections have been used to successfully treat children with Landau-Kleffner syndrome, but it is uncertain whether this procedure can lead to long-term seizure control.
Recovering from Surgery
Most children are able to get out of bed the day after cranial epilepsy surgery. They can return home about two to five days after the procedure. Most children return to school four to six weeks afterward.
By the time they return home from the hospital, most children are able to dress, feed, and wash themselves. However, they may feel tired and require a nap during the day, and their sleep–wake cycles may be altered. Most children only need over-the-counter pain relievers after leaving the hospital, but sometimes the doctor prescribes a mild prescription pain medication.
Staples used to close incisions in the scalp are removed 7 to 14 days after surgery, depending on the type of procedure performed. During the follow-up visit, the staples are removed during a simple procedure. Your child can bathe and wash their hair five days after surgery, even if the staples have not yet been removed.
Laser Interstitial Thermal Therapy
Our doctors may recommend laser interstitial thermal therapy when the area of tissue involved in epilepsy is small or deep in the brain. It is less invasive and has fewer side effects than cranial surgery. Laser interstitial thermal therapy helps manage focal seizures in the temporal lobe that do not respond to medications. In addition, the therapy can manage seizures related to hypothalamic hamartomas; mesial temporal sclerosis, which is scarring deep within the temporal lobe; and small malformations of cortical development that cause epilepsy. It is performed in the hospital with general anesthesia.
A surgeon uses MRI mapping to pinpoint the area of the temporal lobe that needs treatment and guides a tiny laser probe that heats up and destroys targeted tissue. Computer software monitors the temperature of surrounding brain tissue to avoid injury.
More than half of people who receive laser interstitial thermal therapy are seizure-free two years after the procedure.
Recovering from Laser Interstitial Thermal Therapy
The hospital stay after laser interstitial thermal therapy is one to two days. Doctors typically place a single stitch over the treatment area that later dissolves. Children are often back to daily activities within three to seven days. An oral steroid may be prescribed to manage headache from minor swelling.