Epilepsy Questions and Answers

Q: What is epilepsy? What is seizure?
A: Seizure is the hallmark symptom of epilepsy. Epilepsy is the disease—or diagnosis—that a patient will get once examine by a neurologist. Typically, you are diagnosed with epilepsy after two or more seizures that occur twenty-four hours apart without any provoked factor or any cause causing seizure. It is possible for a patient to be diagnosed with epilepsy after one seizure depending on the imaging of the brain and the brain wave study (which studies the function of the brain).

Q: How many people are affected with epilepsy and who can be affected?  
A: Anyone can develop epilepsy. According to national data, about 3.4 million people are diagnosed with epilepsy nationwide: three million adults and 470,000 children.

Q: What are the main types of epilepsy?
A: There are two common types of epilepsy: 1) focal epilepsy, where seizures start from one region or side of the brain, and 2) generalized epilepsy, where seizures are bilateral and involve the majority of the brain. 

Q: What is the first line of treatment for epilepsy and who is involved in the treatment plan?
A: Antiseizure medications are the first line of treatment. According to studies, almost half of patients with new, onset epilepsy can be controlled with one medication. Regarding treatment, your neurologist will coordinate the treatment plan with your primary care physician.

Q: What is the treatment plan if the patient fails antiseizure medication?
A: Traditionally, a patient is given a second medication to see whether that can control the seizures. According to studies, about a third of patients who are diagnosed with new, onset epilepsy are drug-resistant, which means the chance of seizures being controlled (for at least one year) is not high. In that case, your neurologist would discuss whether other measures, such as epilepsy surgery, should be considered. 

Q: When should epilepsy surgery should be considered?
A: If the patient has already failed two appropriately chosen anti-seizure medications, the chance of being seizure-free becomes less likely. At this time, the option of epilepsy surgery should be considered. 

Q: How long does a patient need to stay on a medical treatment plan before it’s determined that it’s not working?
A: There is no specific determination as every patient is different. However, if patients are surgical candidates, the sooner the surgery can be completed, the better patients will do. 

Q: Are there circumstances where medicine is skipped in favor of surgery?
A: In certain instances where the seizure was provoked due to a lesion or brain mass, surgery may be the primary form of treatment before trying a second antiseizure medication. 

Q: What is epilepsy surgery?
A: Epilepsy surgery involves resecting regions of the brain responsible for the seizure. Because each surgery is specific to the individual patient, each resection is tailored to the patient based on a case-by-case scenario. The surgeon will confirm resection doesn’t cause any functional deficits, such as loss of vision, speech or motor functions (i.e., the brain resection should not be taking place in a region that are essential to a patient’s day-to-day activities. 

Q: Is there any other test needed to do before the epilepsy surgery?
A: A patient will go through several required tests before the final epilepsy surgery. First, the patient will be evaluated to specifically identify the type of seizure. To record a seizure safely, the patient will elect to be admitted to the Epilepsy Monitoring Unit at the University of Pittsburgh Comprehensive Epilepsy Center. Based on the seizure and subsequent brain imaging, further neuroimaging testing such as magnetoencephalography, FDG-PET scan, or functional MRI’s may be necessary. In some cases, further localization of the originating seizure region might be needed; if this happens, the patient will need to complete the invasive deep electrode recording. 

Q: How does the epilepsy surgery process work at UPMC?
A: UPMC is the home of the Comprehensive Epilepsy Surgery Clinic. When a patient is first referred to UPMC for epilepsy surgery, cases are reviewed by a nurse navigator (412-647-9335). Cases are then immediately reviewed by a neurologist that specializes in epilepsy surgery. If the patient is thought to be a candidate for epilepsy surgery, they will be scheduled in the comprehensive epilepsy surgery clinic where they will be seen by a neurologist and neurosurgeon in the same visit. If a patient is not ready and further testis are needed, they will be seen by neurologist first to determine the next necessary steps.  

Q: If a patient is seeing a non-UPMC neurologist and is seeking surgical intervention, would they come directly to UPMC Department of Neurological Surgery or would they need to be evaluated by a UPMC neurologist?  
A: If a patient is self-referred or received a referral from a non-UPMC neurologist, the patient will still need to schedule an appointment through a nurse navigator (412-647-9335) so the comprehensive epilepsy surgery clinic can weigh in on necessary care in the peri-operative period. The patient will still remain in the care of your current neurologist during this period.  

Q: What data is needed for a referral? 
A: The EEG data (in CD or test result) and MRI data (in CD) should be sent to the comprehensive epilepsy surgery clinic before coming to the clinic. 

Q: Apart from resection are there any other surgeries available?
A: When surgery is not possible because the regions or seizure-origin are too close to parts of the brain responsible for motor functions—or if there are multiple regions with seizure activity—surgery will not be possible. In the case of a non-surgical resection candidate there are other options. One of them being neuromodulation. Neuromodulation is typically used for patients with medically refractory epilepsy. 

Q: What are the hesitancies expressed by patients when exploring surgical options (complications, nervous about brain surgery, etc.)?
A: Most hesitancies expressed typically deal with feeling nervous about a big operation, which is a completely valid and understandable. Some hesitancies are due to the time commitment needed to complete necessary testing prior to surgery as well as recovery. 

Q: Is there any option for laser surgery?
A: When the brain regions responsible for seizures are very small, we can attempt a minimally invasive technique such as laser ablation.

Q: What does “success” look like on medication? Seizure free? Manageable? Is it up to the patient to determine the desired "quality of life"? Or would their neurologist recommend surgery?
A: This largely depends on the patient. Ideally, this would be seizure freedom. However, being seizure-free can involve side effects from medications. If indicated, surgical resection is the gold standard for seizure freedom as this will often come with a medication reduction as well as being seizure-free.  

Q: What type of follow-up is needed after surgical intervention?
A: After surgery, there will be several follow-ups with the neurosurgical team. If a patient had a resection, they will be seen after two weeks for immediate post-operative wound check. After six weeks, they will come back in for another follow-up with additional imaging. After that, they will be scheduled for a six-month follow-up and a one-year follow-up. If a patient received a neuromodulation device for epilepsy, they will be seen at two weeks for an immediate post-operative wound check. The patient will then be seen at around six months. The rest of your visits will be handled by neurology for device management.