Epilepsy is a disorder of repeated, unprovoked seizures more common in young children than in adults. Most children’s seizures will be controlled without surgery; however, when medication is not enough to manage a child’s seizures, our caring and experienced pediatric neurosurgeons at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital may be able to offer surgical options to treat epilepsy that include resection, corpus callosotomy, and more.
At our Comprehensive Epilepsy Center, experts use the latest technology to diagnose epilepsy, determine the location of the seizures’ origin in each patient’s brain, and tailor individualized treatment plans. Our pediatric neurosurgeons work as part of a team that includes pediatric epileptologists, pediatric neurologists, neuroradiologists, psychologists, and more.
A pediatric seizure can be an alarming event, and a suspected seizure should be investigated by a medical team. There are many potential causes of pediatric seizures besides epilepsy, including fever, meningitis, a metabolic imbalance, exposure to a toxin, head injury, or a tumor or other lesion. Sometimes no cause is ever determined. It is estimated that 10 percent of people will have a seizure during their lifetimes. Only one to three percent of people have epilepsy.
Epilepsy is a disorder of repeated seizures. There are many different types of epilepsy, with different causes, extents, and effects. In general, there are two major types: generalized epilepsy, in which seizures affect the entire brain, and partial (or focal) epilepsy, in which seizures begin in a specific portion of the brain.
Generalized epilepsies have no defined area in the brain from which the seizures originate. There are two varieties of generalized epilepsies. One is idiopathic, in which the brain behaves normally between seizures. The other variety of generalized epilepsy is symptomatic, in which a clear structural abnormality contributes to the seizures.
Types of seizures caused by generalized epilepsy include:
- Absence, or petit mal, seizures: These seizures are characterized by a brief lapse in awareness that lasts a few seconds and causes the person to stare or have twitches in the eyelids or face muscles. These seizures, which may occur up to hundreds of times a day, commonly begin before age two and end after childhood.
- Tonic-clonic, or grand mal, seizures: These seizures are characterized by a sudden and complete loss of consciousness and a stiffening of the arms and legs that causes the person to fall (called the tonic phase) before a rhythmic jerking (called the clonic phase) begins. When the seizing does not stop, it may become a status epilepticus seizure. This uncontrolled seizing requires immediate medical attention to prevent brain damage or death.
- Tonic seizures: These seizures are similar to tonic-clonic seizures, but are not followed by the rhythmic jerking of the clonic phase.
- Myoclonic seizures: These generalized seizures involve very brief, lightning-like jerks of any part of the body without a loss of consciousness.
- Atonic seizures: People with these seizures experience a sudden loss of muscle tone resulting in collapse, sometimes head first, into the ground.
In partial (focal) epilepsy, seizures begin at a specific point in the most highly developed parts of the brain. Often defined by their point of origin, types of partial epilepsy include frontal lobe epilepsy, occipital lobe epilepsy, temporal lobe epilepsy, and parietal lobe epilepsy.
While the electrical activity of a focal seizure begins in a localized area, the seizure can spread and become a generalized seizure. Seizures caused by partial (focal) epilepsy include:
- Complex partial seizures (psychomotor attacks): These seizures often begin with an aura, or a neurological warning, such as a sense of fear, an unpleasant smell, or change in perception. After the aura, consciousness may be altered; speech may stop and the person may perform automatic repetitive movements such as chewing, swallowing, hand fidgeting, or purposeless movement from place to place.
- Simple partial seizures: These seizures typically affect the motor or sensory areas of the brain, causing jerking movements in the hand or facial muscles, or sensory symptoms such as flashing lights or a buzzing sound–but not an alteration in consciousness.
Seizures can cause a wide variety of symptoms, including strange sensations, changes in behavior or emotions, muscle spasms, convulsions, or a sudden loss of awareness or consciousness.
Epilepsy diagnosis can be challenging, but it is critical to get the diagnosis right. At the Columbia Comprehensive Epilepsy Center, our specialists use state-of-the-art tools and techniques to do just that.
The most common technique used to diagnose epilepsy is the electroencephalogram, or EEG. In this test, carried out in our 6-bed Epilepsy Monitoring Unit, small metal discs placed on the surface of the scalp record electrical activity from the brain. Sometimes a diagnosis of epilepsy can be made even while the brain is operating normally. At Columbia Neurosurgery, video-EEG telemetry (vEEG) is also available. In this test, a prolonged EEG is conducted, and a video recording is made at the same time. The vEEG can help make a definitive diagnosis of epilepsy, determine the type of epilepsy, and–if the seizures are partial seizures–determine in which part of the brain they arise.
Other tests include the imaging scans Computed Tomography (CT) and Magnetic Resonance (MRI) imaging. These scans use different methods to visualize the brain’s structures: CT scans use X-rays along with a computer, and MRI scans use magnets and radio waves along with a computer. CT or MRI scans may show whether there is a structural problem causing the epilepsy: a tumor, a vascular malformation, hydrocephalus, or other anomaly.
Still other tests reveal how the brain works. Not how it looks, like the tests above, but what parts of it are working at what time. These “functional tests” include positron emission tomography (PET), single photon-emission computerized tomography (SPECT), and functional MRI (fMRI). PET measures how much fuel each area of the brain uses, and SPECT makes a map of blood flow through the brain. fMRI also measures the brain’s blood flow and oxygen levels, while providing an MRI picture at the same time. These functional tests can be especially useful prior to or during surgery. They help define vital regions of the brain and limit the risks associated with removal of the epileptic zone.
Some individuals may have a minor brain injury, present since birth, or an inherited tendency toward having seizures. Sometimes, head trauma, meningitis or encephalitis at an early age produces scarring of the brain that can cause seizures. But in most children, no specific cause of epilepsy can be found. It is unknown why the developing brain is more prone to seizures than the adult brain.
As many as 1 in 10 people will have a seizure during his or her lifetime.
When children have epilepsy that is difficult or impossible to control with medication, they are at increased risk of physical injury during a seizure, adverse effects from antiepileptic drugs, disruption of family life, and impairment of learning and attention. Any or all of these factors, accompanied by concerns about quality of life and future development, may lead a family to consider surgery.
There are three main categories of pediatric epilepsy surgery. In one type, called resective surgery, the “epileptic zone” causing seizures is removed. Depending on the type and extent of removal, such a procedure may be classified as a lesionectomy, lobectomy, or even hemispherectomy. A second type of surgery is the cutting of the connection between the two hemispheres of the brain. Called a corpus callosotomy, this procedure prevents seizures that start on one side of the brain from spreading to the other side. Finally, implanting a device that sends electrical impulses to the brain can even out the uncontrolled electrical activity associated with seizures. Vagus nerve stimulation is a well-known example of this type of surgery, and provides effective relief for many patients.
In the past, surgical treatment for epilepsy was considered only after a long period of seizures and multiple medication trials. Today, individuals with intractable epilepsy can be identified earlier. A surgical evaluation will often be considered when a child has not responded to two or three antiepileptic medications. There is accumulating evidence that surgically curing epilepsy at an early age may provide a better quality of life.