~~“Epilepsy surgery, which is a new field of application for brain and neurosurgery, is a solution for epilepsy patients who cannot be treated with medication. This treatment method can be applied by a team composed of neurosurgeons, neurologists, neuroradiologists, psychiatrists and neurophysiologists experienced in epilepsy surgery. However, in terms of the costs of operations that require a multidisciplinary approach, there are problems in terms of accessibility to technical devices in the application of treatment due to commercial concerns by authorized persons. This causes disruptions in the treatment of a treatable disease.”
Approximately 30% of epilepsy patients, whose number reaches 750 thousand in Turkey, do not benefit from drug treatment. These patients, who could not be treated effectively until now, now have a new treatment opportunity. Epilepsy surgery gives very successful results for patients in this group. A multidisciplinary team intervenes in patients using all advanced methods in a scene reminiscent of operations in science fiction movies. This practice, which is considered quite new for surgery, is performed in only a limited number of centers in the world.
Epilepsy is a chronic disease that is known as epilepsy among the people and manifests itself with seizures. These seizures; It is a clinical picture that results from abnormal electrical activity of cells in the brain. We can divide epilepsy into two according to the seizure picture: general seizures and focal or focal seizures. General seizures are manifested by twitching of the arms and legs, salivation from the mouth, and incontinence of urine. We can divide focal seizures into two: complex partial seizures and simple partial seizures. In simple partial seizures, there may be only a small movement and then it stops. The patient remembers everything about that moment. In complex partial seizures, on the other hand, symptoms that seem more like a psychiatric disorder such as babbling, slurping or involuntary movements in the hand occur. But here the patient does not realize himself. Focal seizures are especially important for us in the surgical treatment of epilepsy. Because focal seizures are caused by a focus, it is more beneficial to intervene and remove. There is also the possibility that some focal seizures may affect the whole brain and turn into epileptic seizures. If the focal seizure is drug-resistant, then surgical intervention should be considered. Here, we can describe the drug resistance situation as follows; It is the situation in which the seizure continues and no result can be obtained despite the use of primary anti-epileptic drugs on the patient for 2 years, in high doses and in different combinations.
Whether the patient is suitable for epilepsy surgery is an issue that requires meticulousness. All patients referred for surgery in different ways should undergo brain magnetic resonance imaging (MRI), electroencephalography (EEG), and other nuclear medicine tests, which we call non-invasive tests. These are all painless diagnostic methods. Especially in patients with MRI, if there is a lesion in the brain and EEG shows the lesion, this patient is a candidate for surgery only for the removal of the epileptic focus. There is also a troubled group in epilepsy surgery. Here, the patient’s seizures originate from the right frontal part, he has seizures very often, but if there is no lesion there, then we apply more invasive surgical methods.
Disconnective Surgery
It is a surgical method consisting of procedures aimed at disconnecting the brain from each other. For example, by cutting the cortex right next to the speech center, we make boots that prevent the spread of electrical conduction towards the cortex. However, this process may not yield as successful results as extraction. Success is around 30-40%.
In recent years, we have been performing a pacemaker, called vagal nerve stimulation, in patients with drug-resistant epilepsy, which appears normal in brain MRI, no epilepsy focus can be detected, and can originate from any part of the brain.
In vagal nerve stimulation, electrodes are placed on the left vagus nerve with a 2 cm incision made in the neck. The subcutaneous electrode is extended under the collarbone, a pocket is opened and placed there, the battery and electrode are connected to each other. After 15 days, the battery and electrode open and start working. With this treatment, 50 to 70% of patients are able to reduce seizures. The history of this application in the world goes back to 1997. This method has a feature like this, the inserted battery warns for 30 seconds every 5 minutes. It can prevent seizures that may occur during this time, as well as reduce seizures that may occur before or after.
Here, a magnet, very similar to a clock, is placed on the patient’s arm to allow manual intervention in seizures. Some patients feel the seizure coming, we call it aura. The patient, who feels that the seizure is coming, can stop the seizure or reduce the duration and severity of the seizure by warning the battery. In a study conducted on approximately 10 thousand seizures, it was determined that this application stopped seizures by 86%.
Although the number of surgeries performed annually in Turkey in the field of epilepsy surgery has increased in recent years, it is still quite low. However, the number of patients waiting for epilepsy surgery is very high. From this point of view, adequate number of experienced epilepsy centers in accordance with the needs of our country should be expanded for treatment practice.
