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Epilepsy Surgery and Device Therapies

If your seizures cannot be controlled with medications, surgery may offer the best opportunity for you to achieve seizure freedom. At the University of Chicago Medicine, we offer advanced surgical and epilepsy device treatments that are not widely available, including new options for patients not previously considered candidates for surgery due to the location of their seizure source (such as near brain regions that control speech, movement or vision).

If we can pinpoint the origin of your seizures within the brain, what we call the "seizure focus," epilepsy surgery may work for you. We perform sophisticated, non-invasive source localization, which reduces the need for open surgical procedures during pre-surgical evaluation. This comprehensive testing helps our experts determine if surgery is an option and which procedure may have the best chance for success.

At the University of Chicago Medicine, we perform several different types of surgeries to treat epilepsy. They include:

Focal Resection

This procedure involves removing the portion of the brain where your seizures originate. For example, neurosurgeons remove a portion of the temporal lobe in patients with temporal lobe epilepsy. At the University of Chicago Medicine, we use comprehensive, non-invasive technologies to help localize the seizure origination site and determine if there is more than one origination site. This is important because focal resection is only effective if seizures consistently originate from one location in the brain.

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Visualase and Stereotactic Epilepsy Surgery

Stereotactic epilepsy surgery is minimally invasive and uses a three-dimensional coordinate system applied to the brain by attaching a frame to the head. With the help of sophisticated MRI, CT or PET imaging and ultrafast computers, any point in the brain can be safely reached with sub-millimeter precision. In combination with different technologies, the following approaches are used at the University of Chicago Medicine, offering minimally invasive ways to provide long-term seizure control and avoid the risks associated with open brain surgery:

Visualase MRI-Guided Laser Thermal Ablation

Visualase laser thermal ablation is a minimally invasive treatment that uses lasers to destroy seizure-causing lesions with pinpoint accuracy. After making a tiny hole in the skull about the size of a pencil, surgeons guide the Visualase laser applicator into the brain and to the seizure focus. Laser energy is used to heat and eliminate the abnormal tissue. During treatment, physicians view an MR image of the brain to monitor the laser's temperature, ensuring precise treatment while sparing healthy brain tissue. Only a single stitch is required to close the skin at the treatment area.

Visualase can be used safely and effectively in some patients with a single, well-defined seizure source, including those with medial temporal lobe epilepsy and hypothalamic hamartomas.

Because Visualase treatment does not require large incisions, patients typically spend less time in the hospital compared to open epilepsy surgical treatments.

Because Visualase treatment does not require large incisions, patients typically spend less time in the hospital compared to open epilepsy surgical treatments.
Pre- and post- laser ablation MRI images. Physicians use real-time 3-D images of the brain before, during and after the procedure to ensure the best results. Panel A shows a temperature map of the brain to help the surgeon gauge the desired laser temperature. Panel B shows the probe in place at the seizure source. The orange patches in the red circles in panel C indicate where the seizure source was destroyed with the laser.
  • Radiosugery, which can aim radiation in a single treatment session to destroy an epileptic focus using a linear accelerator (radiation therapy machine).
  • Radiofrequency lesioning, which can be applied to thermally destroy an epileptic focus via a small probe.

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NeuroPace Responsive Neurostimulation System (RNS)

Preventing Seizures Before They Start

The NeuroPace Reponsive Neurostimulation System (RNS) is a breakthrough device designed to prevent seizures before they start. The small, battery-powered system is implanted in the skull, just under the scalp. Wires, called leads, are connected to the NeuroPace device and placed in or on one to two brain regions where seizures originate. When the device detects abnormal brain activity, it responds in real time to deliver short bursts of electrical stimulation to stop the seizure. Patients typically do not feel the device working.

Neuropace RNS systemThe NeuroPace Responsive Neurostimulation System, shown alongside a pencil and dime to demonstrate its size.

RNS treatment is available to people who cannot have resection surgery or laser ablation. RNS may be an option for many people previously not considered candidates for epilepsy surgery, such as those with a seizure focus in a critical part of the brain (near speech, vision or movement centers) or those with more than one seizure focus. This is because RNS therapy does not remove brain tissue and the leads can be placed in or on more than one brain region.

Because the neurostimulator records brain electrical activity over time, our physicians use this information to get a better understanding of your seizures and to program the device to be more effective.

Within one year of being treated with RNS, patients report up to a 44 percent reduction in seizures, and a 60 percent reduction in seizures by year three. Patients typically continue to take epilepsy medications, although in some cases, dosages are reduced or a specific medication is no longer necessary.

Unlike vagus nerve stimulation (VNS), RNS is not associated with a higher risk for voice changes, hoarseness or shortness of breath.

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Vagus Nerve Stimulation (VNS)

Some patients find relief from seizures with vagus nerve stimulation (VNS), an effective alternative to traditional surgery. In this minimally invasive procedure, your surgeon will implant a small device in your chest wall that sends electrical pulses to the vagus nerve in the neck. The goal is to block the faulty brain messages that cause seizures. The device is programmed to give stimulation at regular intervals, alternating between periods of stimulation and no stimulation. New versions of the VNS can also detect seizures when they start, and stimulate the vagus nerve during the seizure.

Research shows that about 30 percent of people treated with VNS experience major improvement in seizure control. Another 30 percent experience some improvement. Most patients who undergo VNS must continue on epilepsy drugs, but some can reduce their dosage.

VNS is an attractive option when a seizure focus cannot be identified, or when there are more than 2 seizure foci.

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Hemispherectomy

Hemispherectomy is a treatment we don’t often recommend. It involves removing almost all of one hemisphere, or side, of the brain. It can be a very successful procedure, but it is never a first option for treatment. We usually only perform it in newborns and children whose brains are capable of compensating for the removal of so much tissue.

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Laser Corpus Callosotomy

The goal of corpus callosotomy surgery is to interrupt the pathway by which seizures spread. If the pathway is interrupted, the seizure cannot spread to other parts of the brain. This surgery does not remove parts of the brain. Instead, the surgeon will cut the large bundle of fibers that connect the two brain hemispheres. This fiber bundle is called the corpus callosum. There are two types of corpus callosotomy procedures. One cuts only part of the fiber bundle (a partial callosotomy), and the other severs the entire bundle (a complete callosotomy).

The University of Chicago Medicine is pioneering the use of lasers to cut the corpus callosum. With this technique, the corpus callosum is stereotactically targeted and then cut with a use of a laser.

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Subpial Transection

Other similar techniques, such as multiple subpial transections, can also be considered if a seizure focus overlaps with areas of important brain functions such as language, motor skills and sensory ability. Multiple subpial transections is a surgical procedure we sometimes use for patients who have well-localized epileptogenic areas that can’t be resected because they are too important to overall brain function. The goal of the procedure is to sever fibers that are likely responsible for spreading seizure activity while preserving the fibers that control the necessary brain functions. This technique allows a small area of the brain to seize, but does not allow the seizure to spread and cause overt symptoms.

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