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Epilepsy is a brain disorder. Electrical signals in the brain misfire, causing seizures. Medicines can help control seizures, but they don’t always work.

Jorge Gonzalez-Martinez, MD, PhD, FAANS, is co-director of the UPMC Comprehensive Epilepsy Center. He is also the director of the Epilepsy and Movement Disorders Program. We asked him how epilepsy surgery makes life without seizures possible for people with a diagnosis of epilepsy.

What Is Treatment-Resistant Epilepsy?

If you have epilepsy, your doctors will give you medicine that may control your seizures for a while. For some people, though, these medications may not ever keep you seizure-free. When you have tried two or more types of medicine that don’t control your seizures, doctors say your epilepsy is treatment-resistant (intractable).

This is a turning point, says Dr. Gonzalez-Martinez. It’s unlikely you’ll become seizure-free with more medicines. “This is when benefits and potential risks turn in favor of surgery,” he says.

Treatment-resistant epilepsy is about how many medicines a person tries. It’s not about how long you’re taking medicine. There’s no reason to keep trying new medicines after the second fails, he says.

“With time, seizures tend to get worse. There are many things, like driving, that you may be missing out on in your life by waiting,” he says.

Is Epilepsy Surgery Right for Everyone?

Experts use your health and personal history to determine if epilepsy surgery is the best treatment option. For instance, take a child having severe seizures, Dr. Gonzalez-Martinez says. “After they fail two medicines, they should be rapidly considered for surgery.”

But, surgery may not be right for a 75-year-old with seizures and heart and lung issues. “The risks of surgery are higher when compared with other patients,” he says. “These facts must be considered.”

In order to be a candidate for surgery, you must:

• Continue to have uncontrolled seizures after trying two medicines.
• Have seizures that doctors can pinpoint to a specific brain area. For instance, this may be a part of the frontal lobe, temporal lobe, or occipital lobe.
• Have seizures in a part of your brain that surgeons can safely remove. For example, taking out some areas of your brain can impact language, movement, or vision. If your seizures come from one of those important areas, surgeons may not be able to remove that part of your brain.

Knowing where seizures start in the brain is critical. But surgeons must also find out how much brain tissue they can remove (resect) without changing how your brain works. “These questions are very important,” Dr. Gonzalez-Martinez says.

Benefits and Risks of Epilepsy Surgery

Epilepsy surgery’s biggest pro is the hope of living seizure-free. But there are some risks. Your surgeon will talk with you about how surgery may affect your:

• Movement.
• Language and speech.
• Quality of life.

Some people need a larger part of their brain removed. “A large resection makes surgery riskier,” Dr. Gonzalez-Martinez says.

“Our goal as epilepsy surgeons is to make you seizure-free with minimal manipulation of the brain,” he says. “Every aspect is tailored to the patient. We want to make you seizure-free without affecting your quality of life.”

Understanding Where Seizures Occur

Before surgery, experts may use a robotic-assisted stereo-electroencephalogram (EEG) to watch your brain’s electrical activity. This helps doctors find the precise place where seizures occur. During stereo-EEG, surgeons place thin wires (electrodes) into your brain to map your seizures.

Experts use a robotic system called ROSA® to create a 3-D image of your brain. Your surgeon uses the robotic arm to access brain tissue and place electrodes through tiny holes in your skull. They use these images to map your seizures and plan epilepsy surgery.

An expert neurology team works together to find where your seizures come from. They then create a tailored surgery plan to treat them. “That’s the value of analyzing data along with neurologists, neurosurgeons, neurobiologists, and neuropsychologists,” Dr. Gonzalez-Martinez says.

Types of Epilepsy Surgery

Today, neurosurgeons have several options for epilepsy surgery. These advanced methods help surgeons access problem areas in your brain to reduce surgery’s impact on the healthy parts of your brain.

Epilepsy surgery types include:

Brain resection

In a resection, surgeons create an opening in your skull to access the brain. You may have:

• Lesionectomy. Surgeons remove areas of damaged tissue (lesions) that may be causing seizures.
• Lobectomy. Surgeons remove part of the specific area in your brain (lobe) where seizures occur.

Disconnection surgery

Your surgeon operates on the nerves that send signals through your brain. This surgery disrupts the signals, reducing seizures.

Endoscopic epilepsy surgery

Surgeons use a thin, flexible tube with a camera (endoscope) to access brain tissue. The camera goes through small holes in your skull. This speeds healing.

Your surgeon may also use the endoscopic endonasal approach (EEA). They insert an endoscope into your nose and sinuses to reach your brain.

Laser interstitial thermal therapy (LITT)

Laser interstitial thermal therapy is sometimes called LITT or laser ablation. In LITT, surgeons use intense light beams to destroy brain tissue that causes seizures.

Experts make a small hole in your skull. Using MRI images, they guide a laser fiber through the hole to target parts of the brain with light.

Device implantation

Your surgeon opens your skull and implants a device. It may be electrodes or a neurostimulator. These devices help smooth out the electrical signals in your brain and control seizures.

What Happens After Epilepsy Surgery

Recovery from epilepsy surgery varies based on the type of surgery. Open surgery can take 4 to 6 weeks to heal.

Some people may need to take medicine after surgery. “The goal is to stop medicine completely, but there’s a process to it,” Dr. Gonzalez-Martinez says.

You may notice some changes in your memory or in how you move. With brain mapping, surgeons can often predict these changes. Typically, these deficits appear right away, Dr. Gonzalez-Martinez says.

As you recover, these changes may go away or improve. “Epilepsy surgery is extremely safe when well indicated,” he says. About 60% to 70% of people who have epilepsy surgery no longer have seizures after.