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Brain, Nervous System and Mental Conditions

Epilepsy

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There are many effective treatments for epilepsy. Most children with epilepsy lead normal lives with seizures that are well controlled. Some children may stop having seizures with treatment. But finding the treatment for epilepsy that will work best for your child may take a long time, and your child might need many tests. Your child’s treatments must be tailored to fit their needs, so your child’s healthcare team will work to make sure they know everything they need to know before recommending treatment.

The best treatment for your child may be medicine, nutritional therapies, surgery, technologies such as the vagus nerve stimulator or a combination of treatments. Knowing the kinds of seizures your child has will help your child’s healthcare team understand what the best kind of treatment may be.

For almost all children, the first and most effective treatment is medicine. More than a dozen medicines treat epilepsy. Most people with epilepsy can control their seizures with just one kind of medicine. Our epilepsy team has access to many medications, including some new medicines that are available to children who take part in clinical trials.

If medicine does not work, your child’s healthcare team may suggest trying a ketogenic diet. The team may also investigate other factors that might affect your child’s condition. They may look at your child’s general health and nutrition. They may also look at patterns of seizures in relation to your child’s sleep, or other biological rhythms, like your child’s breathing. The team may also try to find out if certain things trigger your child’s seizures. Once a complete treatment plan is in place, seizures can be controlled in most children (about 70%).

About three or four out of every 10 people with epilepsy have frequent seizures that medicines cannot control. Frequent, uncontrolled seizures can be harmful. They can interfere with development and learning. If seizures last longer than 30 minutes, they can even permanently damage a child’s developing brain. For some children, side effects from some medicines for epilepsy are a problem, and they cannot take them. Or the medicine may interfere with normal learning and development. If medicine does not control your child’s seizures, or if they cannot take the medicine, your child’s neurologist may refer them for a neurosurgery evaluation.

Surgery for Epilepsy

Our neurologists and neurosurgeons work with you to find the best treatment for your child. We think about several factors when deciding if your child is a good candidate for surgery. Children may benefit from surgery if they have:

  • Ongoing seizures even though they take or have taken antiseizure medicine
  • A specific area in their brain (a focus) that doctors can find that causes seizures
  • Affected tissue in the focus area that can be removed safely (surgery is designed to avoid damage to speech and movement)
  • Intolerable side effects from medicine
Mesial temporal sclerosis

Mesial temporal sclerosis (scar of brain tissue has been removed)

The surgeries we do to help children with epilepsy include:

Temporal lobectomy

A temporal lobectomy is the most common epilepsy operation for adults and teens. We consider this surgery if your child has a small, non-cancerous (benign), slow-growing tumor in the part of the brain called the temporal lobe. We also consider using it if your child has abnormal brain tissue (mesial temporal sclerosis or cortical dysplasia).

Often, we can control your child's seizures by removing the affected area. If necessary, the neurosurgeon may remove the entire temporal lobe. For well-chosen patients, this surgery stops seizures in more than half (up to 70%) of people who get it. Another 10% to 20% of patients may have better seizure control, although seizures do not go away entirely.

Resection of epileptic focus (outside the temporal lobe)

In some cases, we can remove (resect) the tissue causing the seizures. This is possible if your child’s seizure focus is in a particular area of the brain only and that area is not necessary for functions like speech or movement.

Resection of epileptic focus

After the scar and the seizure focus is surgically removed

Before this operation, doctors must find the focus of seizures in your child's brain. They must also map the areas of your child's brain that control functions like speech and movement.

Your child may have surgery to place electrodes on the surface of the brain. Doctors monitor your child for about a week in Seattle Children’s Video and EEG Monitoring Unit. The neurosurgeon and neurologist can then plan to remove the area of your child's brain that is affected.

The electrodes also help doctors map out the parts of your child's brain that control speech and movement. Sometimes, we can map a teenager's brain during surgery. During the surgery to remove electrodes, we wake your teen up and ask them to help us with the mapping. This is only needed if the surgery is very close to parts of the brain critical for language.

If our findings show that your child is a good candidate, we operate. After this operation, more than half (up to 65%) of well-chosen patients have either many fewer seizures or no seizures at all.

Hemispherectomy/hemispherotomy

Both of these surgeries treat seizures caused by an entire side (hemisphere) of the brain area that controls many complex processes — the cerebral cortex.

Many medical centers, including Seattle Children’s, no longer remove the tissue that causes these seizures. Instead, we disconnect the tissue between these two sides of the brain. This procedure is called a functional hemispherectomy. The terms functional hemispherectomy and hemispherotomy describe different versions of the surgery. In general, this type of operation is shorter and causes fewer complications than older versions of the surgery, in which all of the tissue in a hemipshere was taken out.

To understand the procedures, it helps to know that the brain has two halves, the right and left hemispheres. Two groups of children with epilepsy may benefit from either a hemispherectomy or hemispherotomy:

  • Children with many seizure focus areas located throughout one hemisphere of the brain
  • Children whose areas of seizure focus are spread throughout the entire hemisphere

These surgeries may benefit children with:

  • Sturge-Weber syndrome
  • Rasmussen's encephalitis
  • Hemimegalencephaly
  • Extensive cortical dysplasia
  • Extensive porencephalic cysts

During surgery, your child's neurosurgeon disconnects the affected hemisphere from the rest of the brain by cutting the electrical nerve pathways. The goal is to prevent seizure activity from spreading. Afterward, about 70% of carefully selected children may be seizure-free. About 20% may have fewer seizures.

Many people are concerned about the effects of this surgery. Sometimes, a child's brain function will move to the healthy side of the brain before or after surgery. If important parts of their brain must be cut, children experience notable changes.

After surgery, your child may be weak on one side. This weakness may be permanent. As a result, we limit this operation to children who:

  • Have severe seizures that greatly limit quality of life
  • Are already weak on the affected side because of the underlying brain illness, such as a stroke

After surgery, most children need to stay in the hospital for rehabilitation. This helps them improve or manage weakness.

Corpus callosotomy

The corpus callosum is a bundle of fibers connecting the right and left sides (hemispheres) of the brain. A corpus callosotomy involves cutting this bundle to prevent seizures from spreading from one hemisphere to the other. Neurosurgeons do this by cutting the front (anterior) two-thirds of the corpus callosum.

This surgery may be helpful if your child has seizures that do not involve a specific area of brain tissue that we can remove. Often, it helps children who have "drop-attack" seizures. That is, the child’s muscles suddenly contract and they fall down or collapse forward in a chair.

After surgery, about 70% to 80% of children may have fewer drop-attack seizures. If your child's seizures aren't reduced enough, sometimes neurosurgeons recommend a second operation.

Laser ablation surgery

If a patient is a good candidate, minimally invasive MRI-guided laser ablation surgery can provide an alternative with fewer side effects than open surgery. Read more about laser ablation surgery for epilepsy.

 

An Inside Look at Laser Ablation Surgery

Dr. Jeffrey Ojemann, director of epilepsy surgery at Seattle Children's, explains this cutting-edge treatment for epilepsy.

Vagus nerve stimulator

Some children are not candidates for epilepsy surgery because:

  • Their seizures begin in several brain areas (they have multiple foci)
  • Their seizures spread (generalize) to both sides of the brain
  • After trying several medicines, they still do not have good seizure control

The vagus nerve stimulator is an alternative to brain surgery.

The vagus nerve starts in the brainstem. From there it goes down the neck and into the chest. The vagus nerve stimulator delivers a small, on-and-off electrical current to the vagus nerve. This helps prevent seizures.

The vagus nerve stimulator is about the size of a small cookie. Neurosurgeons put it under the skin on the left side of your child’s chest, near the armpit.

During surgery, your child's neurosurgeon puts in (implants) the stimulator. The neurosurgeon moves wires attached to the stimulator to the left vagus nerve in the neck region. After the area heals, your child's neurologist turns on and sets the device.

Both you and your child can turn on the vagal nerve stimulator yourselves. If your child senses the start of a seizure, you can place a small, hand-held magnet over your child’s body at the spot where stimulator is located. This can prevent the seizure from starting.

Doctors don’t know exactly how the stimulation affects a child’s seizures. But about half of people with a vagal nerve stimulator reduce their seizures by more than 50%.

The vagal nerve stimulator is only for 12 years old and older. Its battery needs changing every several years. This requires a simple outpatient or day surgery.

Other Epilepsy Treatment Options

Ketogenic diet

Neurologists sometimes use the ketogenic diet to lessen or stop a child’s seizures. In general, it includes eating foods high in fat and low in carbohydrates and protein. It also limits the amount of liquid your child can drink.

A ketogenic diet is very complex. Children on it should always be under a doctor's care. To learn more about how the ketogenic diet works, please talk to your child’s neurologist.

Who Treats This at Seattle Children's?

Should your child see a doctor?

Find out by selecting your child’s symptom or health condition in the list below:

Summer 2014: Good Growing Newsletter

In This Issue

  • Understanding the Power and Influence of Role Models
  • Legal Marijuana Means Greater Poisoning Risks for Children
  • Why Choose Pediatric Emergency Care?

Download Summer 2014 (PDF)