Approximately 70% of people with epilepsy find their seizures can be controlled with medication. It is usual for a person with epilepsy to have tried at least two anticonvulsant medications at suitable doses before it is considered that medication may not be completely effective for seizure control.

For this group of people, it may be worth considering epilepsy surgery.

Deciding to have surgery for epilepsy is a big decision. The assessment process can take more than a year and treatment (in most cases) will involve major brain surgery.

Our consultants

Nilesh Mundil

What we do

Resective surgery

There are various causes of epilepsy, and for many people, the cause is unknown. Some people however, have a structural abnormality in part of their brain, which could be the cause. This could be something they were born with, such as scarring, or an area that did not develop properly. Alternatively, it could have developed in later life. As part of the assessment process, you will have a scan to see if the abnormal epileptic activity in the brain that occurs during a seizure starts in the same area as the abnormality. Resective surgery would involve removing this part of the brain.

Being considered for resective surgery

You could be considered for resective surgery if

you've tried several anti-epileptic drugs but they have been unsuccessful or unsuitable
your seizures arise from one localised area of the brain
your ability to function normally would not be affected by operating on this area of the brain, and the surgeon can get to this area without causing further damage to any other parts of the brain
you have a good chance of becoming seizure free after surgery
you do not have any other medical problems that would make you unsuitable for surgery.

Benefits of resective surgery

Resective epilepsy surgery aims to improve quality of life for patients and their families. Around 70% of people who have resective epilepsy surgery become seizure free. A further 20 to 25% of people find their seizures are greatly reduced. A small number of people will not benefit. Our complex assessment process gains as much information as possible about the chance of success, and identifies specific risks to each individual.

Risks of resective surgery

Any major operation requiring an anaesthetic carries risks. There are many different types of epilepsy surgery, and as everyone is different, until the tests are completed we cannot be specific about what the risks are to each patient. The most common type of operation is on the temporal lobe of the brain. In general, the risk of death is less than 1%. There may be a persisting neurological deficit in up to 2 to 3% of people, such as weakness in the opposite side of the body to the surgery. With this type of operation there may be a small loss of vision in the upper outer corner, again on the opposite side. This is not usually noticeable but may affect your ability to drive. There can also be deterioration in memory. All of these risks are discussed in greater detail in our booklet on epilepsy surgery. Please contact us if you would like a copy.

Functional procedures

If the area is not removable, it may be possible to affect the way a part of the brain works without removing any brain tissue. Vagal nerve stimulation is an example of this type of surgery.

Alternatives to surgery

If surgery is not suitable, your condition will continue to be managed by medication. The consultant neurologist in the epilepsy surgery team is experienced in managing medication and may be able to suggest changes to improve the control of your seizures. However, it is worth remembering that with each new medication, the chances of your seizures becoming completely controlled becomes less.

Issues to think about

What are your reasons for considering epilepsy surgery? Take some time to think about what would change in your life if your seizures improved. It may help to write things down.

Surgery for epilepsy aims to improve your quality of life by reducing the number of seizures you have, and hopefully stop them all together. It can take time to get used to not having seizures, and improvements in self-confidence and self-esteem will not happen overnight. It will take time, and you may require additional help and support.

If you hope to regain your driving licence, remember, even one minor seizure a year will prevent you from doing this. If resective surgery is successful, and you are seizure free, damage to your vision caused by the surgery, which is not noticeable in everyday life, may still mean you are not eligible to drive.

Some people consider surgery because they want to stop taking daily medication. After surgery, most people will not stop taking medication completely. If you are seizure free after one year, the consultant may advise reducing the amount of medication you take; but it is likely you will continue to take some form of drugs for the foreseeable future.

If surgery is not an option

Assessment for surgery is a complex process and the epilepsy surgery team take many factors into account when making a decision. If the results of the investigations show that surgery would not be the correct treatment choice for you, this decision would not have been made lightly. We will try to keep you fully informed during the assessment process and encourage you to ask questions as you go along. Although it may not be possible to give you an answer until the assessment is completed, wherever possible, we will try to warn you during the assessment process if it looks like your chances of being offered surgery are low.

The consultant neurologist will invite you to an outpatient appointment where the results of the tests will be discussed, along with the reasons why surgery is not suitable for you.

It may be that your seizures start in more than one place, or that the chances of becoming seizure free are very low. Alternatively, where your seizures begin may mean an operation would leave you with new problems.

Sometimes the risks of the surgery may outweigh the potential benefits, therefore further attempts at drug treatment are recommended. This does not mean that surgery cannot be re-considered at a later date if all other options have been tried and the risks of surgery are thought to be justified.

If surgery is an option

Surgical assessment process

To identify which patients are suitable for surgery, each patient will undergo an intensive assessment process. Tests may include an EEG, a detailed brain scan, video telemetry (involving a week long stay in hospital) and assessment by a psychologist and psychiatrist. Find out more about the tests and investigations we carry out.

The epilepsy surgery team meet to discuss the assessment results of patients every fortnight. You will be offered an appointment with the consultant and depending on the test results, the options will be:

Surgery is not a suitable option
Surgery can be considered
Further tests are required

Outlined below are some of the tests that the epilepsy surgery team may need to perform during your assessment for surgery.

These are used less commonly, and not all patients will require them.

FMRI (functional magnetic resonance imaging)

Patients usually undergo this as an outpatient. This procedure is a modified MRI Scan. FMRI can produce images of areas of the brain that are 'activated' while you are carrying out a specific task. These areas of activation are linked to increased blood flow in those areas of the brain. This helps us identify which areas are involved in functions, such as speech and movement, so we can understand how surgery may affect these functions.

An FMRI scan is carried out while you perform a task and again while you are at rest. The procedure will be explained to you before you go into the scanner and the staff will give you instructions during the scan through an intercom.

For example, to determine the area related to hand movement, you will be asked to tap the fingers of one hand for about 10 seconds, then lie still for the next 10 seconds, and then tap your fingers again for the next 10 seconds. This pattern will be repeated several times during the scan. It is very important to keep very still throughout the whole scan. There may be other tasks you are asked to perform, to help us locate the areas related to language and memory.

The sodium amytal (WADA) test

It is very important for us to know where the speech and memory areas are in your brain, so that we can understand how surgery may affect these functions. Occasionally, we do not obtain enough information from the initial tests carried out by the neuropsychologist, and we may need to perform a more invasive test.

This involves using a short acting drug (sodium amytal) to put one side of the brain to sleep at a time. This allows the neuropsychologist to test the function of each side of the brain separately. You will be awake during the procedure and the effects of the drug only last for 5 to 10 minutes. The medication is injected into the vessels of the brain via a tube that has been inserted up to your neck from the artery at the top of your right leg. This is done under local anaesthetic. You will also have an EEG performed at the same time to monitor your brain activity. Once the sodium amytal has been injected, the neuropsychologist will show you objects and pictures and ask you questions to determine how well your language function and memory are working with half your brain asleep. Once the test is finished you will return to the ward. You may stay overnight in hospital for observation and go home the following day.

Intracranial monitoring

EEG and video telemetry recordings use electrodes attached to the surface of the scalp. For most people this provides sufficient information. Occasionally, it is not possible to determine the exact location of the epileptic discharge using scalp electrodes. In this situation, the surgeon may have to insert special electrodes to lie on the surface of the brain, or place the electrodes into the brain tissue itself.

This is only necessary in a small number of people. It will involve an operation to insert the electrodes, and you will require a day or two to recover from the operation before we start recording. The recording will be similar to the video telemetry you will already have had. The electrodes will be attached to the equipment as before, and you will be able to move around the bed space as normal. The surgeon will have stitched the electrodes securely during the operation and your head will remain bandaged during the recording to ensure a good connection and to prevent infection. The recording will take several days, and once completed, you will return to theatre within the next few days to have the electrodes removed.

If the decision has been made that epilepsy surgery would be a good choice for you, this will be carried out at the same time as removing the electrodes.

Before and after your surgery

Before surgery

Preparing - work and finances

Surgery for epilepsy is a big step, so you need to prepare for it carefully.

If you work, tell your employer that you are expected to need three months to recover. You will also need to consider what will happen financially. If you are working, check that your employer will pay you sick pay while you recover and until you are back at work.

If you receive benefits, consider what will happen if you become seizure free. While nothing would happen immediately, in the long term you may no longer qualify for benefits you received in the past. It is important to consider your options - would you want to return to work, or further education? We understand that these choices can be daunting, and will be happy to discuss them with you.

Job Centres will have a disability employment advisor, who can give advice and support on returning to the workplace.
The Citizens Advice Bureau can advise you on benefits.

Accommodation for relatives

After surgery

Going home

In the first few days after surgery, you will gradually increase how much you can do. Most people go home after seven days. Patients usually go home on their normal medication regime, and this will continue unchanged for at least the first year. Very occasionally, some people develop side effects from their medication after surgery. If needed, we will change your medication before you leave hospital.

Remember to gradually increase how much you do both physically and mentally over the next few weeks. It is normal to have good and bad days. Some people have headaches, but these will reduce with time. The specialist epilepsy nurse can help if you have any questions.

On returning home, most people will be able to do everything for themselves, such as washing and dressing, but will find they get tired very easily. You will need to rely on friends and family for support, and gradually build up how much you can do. The surgical team will discuss with you your plans for recovery, but if you have specific concerns, such as living alone, or caring for small children please let us know.

If you work, when you return it will probably be tiring. We suggest that you start part-time, and gradually build back up to your normal hours over several weeks. The epilepsy nurse will be happy to contact your employer if you, or they, have any concerns.

Follow up after surgery

The epilepsy nurse can give you advice after you go home. We will make an appointment for you to see the neurosurgeon around six to eight weeks after you leave hospital. Over the next six months, the neurologist, neuropsychologist and liaison psychiatrist will give you appointments for review. You will have a repeat MRI scan, and most patients will also have their vision checked. Wherever possible, several appointments will be arranged for the same day to limit the number of visits you need to make.

We will continue to review you at regular intervals over the next few years.

Emotional reactions

Each person copes differently with having surgery. If the operation is successful, experience has shown it can take people a long time to get used to life without seizures. Remember, you have lived with your epilepsy and the difficulties that it brings and you and your family will need to go through a period of re-adjustment after the operation.

Emotional reactions are quite common. Some people can develop temporary depression after surgery, and we encourage you and your family to be aware of this. The depression will usually resolve by itself or can be helped with a short course of medication. Very occasionally it may require a hospital admission for treatment.

You may find that becoming more independent, and being faced with choices such as returning to work, learning to drive or starting a family can be stressful. Allow yourself time to recover at your own pace and try not to put pressure on yourself to make changes too soon. If you have any specific aims after surgery, discuss this with the epilepsy surgery team before your operation, who will be able to assist you in forming a plan to achieve your goal.

We encourage you to talk through how you are feeling with your friends and family. If you, or your family are finding things difficult, please let us know. We are here to help.

Epilepsy surgery