Children's Epilepsy Surgery

Temporal Lobe Surgery or Resective Surgery for Lesional Epilepsy

An example of surgery for epilepsy is a temporal lobe surgery such as a temporal lobectomy, which aims to control seizures originating from the temporal lobe. A temporal lobectomy is considered an option for patients with abnormal brain tissue, such as Focal Cortical Dysplasia, developmental tumor or mesial temporal sclerosis. In some patients with a small or deep area where the seizures are arising, a minimally invasive stereotactic laser ablation procedure can be an excellent and appropriate option.

Open surgery as well as selective removal of abnormal brain tissue is an appropriate solution, for instance, when the area to be removed is far too large and extensive for a laser ablation.

Similar principles apply when there is a defined lesion such as a cerebral cavernous malformation (CCM), arteriovenous malformation, tumor, or cortical dysplasia/brain malformation in other areas of the brain that are safe to remove or ablate in one stage.

In some cases, neurosurgeons can remove the tissue causing seizures in other areas of the brain. Resection (removal) is possible if a child’s seizures are caused by an area of the brain that does not control speech, movement or such critical function. This type of surgery may be done with open surgery or with stereotactic laser ablation.

For some types of epilepsy, localizing the precise area where the seizures are coming from may need a stepwise approach.

If it is not clear from the EEG, MRI, PET, MEG or other studies about the exact area where seizures are arising, two steps of surgery may be needed.

If the staged Phase 2 monitoring is recommended, in the first procedure, the epilepsy team plans the surgery carefully to determine where we need to study to determine precisely where the seizures are coming from. With this type of planning to get more information, neurosurgeons may use subdural grids or stereoEEG.

One choice may be place flat electrodes (subdural grids and strip electrodes) on the brain's surface or place thin electrodes into the brain. Stereotactic EEG (sEEG) electrodes are placed with the assistance of a surgical robot. At Lurie Children's, we use the ROSA, the stereotactic robot system for our neurosurgical procedures for precise placement of electrodes. For the next few days, the child is monitored by video and EEG in the 19th floor Epilepsy Monitoring Unit, where the electrodes record for seizures and give important information to make a detailed map of the area of the brain where seizures are coming from.

Based on this important detailed map of a child's brain and the seizures recorded, the epilepsy surgery team can make a plan for the next steps. Options to address the area of the seizure focus are:

• Surgical resection (removal) of the part of the brain if it is safe to remove
• Stereotactic laser ablation of the part of the brain causing seizures if it is small and if it is safe to laser. At Lurie Children's, our team uses the Visualase stereotactic laser ablation system.
• Placement of neurostimulation devices such as a Responsive Neurostimulator (RNS) if the area of the brain where the seizures are coming from is identified but it is not safe to remove that area of the brain. Neurostimulation allows the brain tissue to stay in place. Implanting a device helps send signals to the brain with the goal of decreasing seizures. For instance, in the case of RNS, the device records and "learns" a patient's seizure activity patterns, and in time aims to deliver signals to the brain to stop seizures even before they start.

It is important to reflect that, as recently as 10 years ago, patients who are now benefitting from these types of surgeries would not have been considered for surgery. Now, we have more and more options to offer hope for seizure control and for a better quality of life.

The Comprehensive Pediatric Epilepsy and Epilepsy Surgery Program is inspired, honored and grateful to be a part of our patients' and families' journeys.

At Lurie Children's, neurosurgery division chief Dr. Sandi Lam offers endoscopic hemispherotomy surgery, which is a minimally invasive approach to hemispherectomy or hemispherotomy surgery.

Seizures may come from an entire side, or hemisphere, of the brain. In these cases, the "bad" side of the brain is the cause of many seizures, and affects the function and development of other hemisphere, which is the only "good" side of the brain. In order to allow a child in these cases to stop seizing and allow the "good" side of the brain to develop to its full potential, it is necessary to disconnect the diseased, seizing side of the brain from the unaffected side, to prevent seizures from repeatedly spreading to the "good" side of the brain. In young children, neurological function from the diseased affected hemisphere can move over to the healthy side of the brain both before and after the surgery. Many patients benefit from physical therapy, occupational therapy, and speech therapy in a course of rehabilitation. A majority of children enjoy significant seizure freedom or seizure reduction and improvement after the procedure.

This surgery is typically done with minimally invasive techniques at Lurie Children's Hospital by our epilepsy surgery team headed by Dr. Lam. Options include endoscopic surgery, stereotactic laser ablation or open surgery.

The corpus callosum is a bundle of fibers connecting the right and left hemispheres of the brain. A corpus callosotomy involves separating these fibers to prevent seizures from spreading from one hemisphere to the other. Neurosurgeons do this by disconnecting the front two-thirds or the full length of the corpus callosum. This surgery may be recommended for a child with seizures that do not involve a specific area of brain tissue that can be removed. Specifically, this surgery can also help type of seizure typically referred to as "drop attacks" where children can fall and cause serious injury to themselves.

Vagal Nerve Stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) are all ways for implanted medical devices to modulate brain patterns with the goal of reducing seizure frequency or stopping seizures. The Lurie Children's Comprehensive Epilepsy Team runs a Neurostimulator Clinic for programming and follow-up, led by the Neurology Division head of Pediatric Epilepsy Dr. Joyce Wu and nurse practitioners Breanne Fisher and Amy Tennant.

The surgeries are tailored to each patient, with the choice of the implant device and the design of the surgery to be based on the best configuration to control seizures depending on where the seizures are arising.

Vagus nerve stimulators are placed with an electrode lead in the neck on the vagus nerve along with a small generator (much like the device for a pacemaker for the heart) at the front of the chest.

Responsive Neurostimulators are placed with targeted electrodes in the brain depending on where seizures are coming from in each individual patient, along with a small generator in the skull, which fits well within the contour of the head underneath the scalp.

Deep Brain Stimulators are placed with targeted electrodes in the brain, along with a small generator in the chest wall (much like the device for a pacemaker for the heart).

The neurosurgery and neurology specialists of the Comprehensive Pediatric Epilepsy Surgery programs work with patient and parent groups to understand the spectrum of epilepsy surgery options and also to understand how neurostimulators can help.

Intake into the Comprehensive Epilepsy Surgery Program is typically done through our Epilepsy Center’s physician referrals to assess the nature and origin of the seizures and to obtain or review all diagnostic data.

To schedule an appointment with one of our epilepsy neurology specialists (pediatric epileptologists), call our Epilepsy Center at 312.227.3540. Patient cases are organized and reviewed with input from our entire interdisciplinary team, including epileptologists, neurosurgeons who are pediatric epilepsy surgeons, neuroradiologists, neuropsychologists, and other specialists. Debbie Williams, RN is the epilepsy coordinator. 

To connect with Pediatric Neurosurgery specifically, please call 312.227.4220. Daisy Vazquez, APRN-NP, is the bilingual pediatric neurosurgery epilepsy surgery nurse practitioner who will help collaborate with the whole team through the process of comprehensive epilepsy surgery evaluations for personalized, high-quality information to evaluate the best treatments,  including surgical options. 

View some helpful resources and patient advocacy groups below: 

• Pediatric Epilepsy Surgery Alliance
• Deep Connections
• Epilepsy Foundation