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The University of Virginia Medical Center has a Level 4 epilepsy
surgery center, which is the highest designation assigned by the
National Association of Epilepsy Centers. What makes the program unique
is that Jeffrey Elias, M.D., the chief
epilepsy surgeon, conducts functional neurosurgery as well as
traditional epilepsy surgery, which means that he is uniquely suited to
perform stereotactic placement of electrodes for intracranial
monitoring.
Epilepsy surgery at UVa is integrated with the F.E. Dreifuss  Comprehensive Epilepsy Program to address all
surgical and nonsurgical diagnostic and treatment modalities. The
program offers the most advanced resources available to help patients
achieve remission of their seizures. This is a comprehensive program
not only in terms of the team approach to care, but also in the team’s
ability to apply every available diagnostic and treatment option.
Surgery as an Early Option
Epilepsy surgery has traditionally been viewed as a treatment of last
resort, but recent advances in the treatment of epilepsy offer the
possibility of a safe, effective cure and improved quality of life.
Patients should be considered for epilepsy surgery early in their
course of treatment to minimize the consequences of poorly controlled
epilepsy.
Testing
To determine actual suitability for surgery, the patient undergoes
comprehensive multimodality evaluations in two phases:
Phase 1 – Extracranial video/EEG monitoring in the hard-wired Epilepsy
Monitoring Unit (EMU); high-resolution MRI; ictal SPECT;
neuropsychological testing; Wada intracarotid amobarbital testing; and
other tests.
Phase 2 – Intracranial electrode placement, if needed, to localize
seizure focus to a small area; electrical stimulation cortical mapping;
intracranial evoked potential mapping; 3-D MRI reconstruction.
MRI of the brain with specially designed high-resolution sequences is
essential to identify structural abnormalities, which can be the source
of seizures.
Single photon emission computed tomography (SPECT) aids in localization
by identifying areas of altered perfusion in the suspected epileptic
focus. Inpatient intensive telemetry EEG monitoring with simultaneous
video recording is performed to capture seizures. The goal is to
confirm that the spells of interest are seizures, that they arise from
a single location and to further identify the exact electrographic
origin.
Neuropsychologic testing is performed on all surgical candidates to
localize areas of dysfunction, assess psychological health and
establish baseline neuropsychological functioning to help avoid the
risk of functional loss after surgery. When considering temporal
lobectomy, the intracranial amytal test (or Wada test) is performed to
identify hemispheric language dominance and whether the contralateral
temporal lobe is adequate to support memory function after surgery.
Types of surgery
All modalities of resective surgery are available, including temporal
lobectomy, focal cortical resections, lesion removal,
hemispherectomies, corpus callosotomy. Many different types of surgery
are now performed for refractory epilepsy, including anterior temporal
lobectomy, cortectomy, lobectomy, lesionectomy, hemispherectomy, corpus
callosotomy and multiple sub-pial transections.  Anterior temporal lobectomy is the most commonly
performed resective epilepsy surgery because “mesial temporal
sclerosis” is the most common single identifiable pathology associated
with epilepsy. Vagus nerve stimulation is also offered. Experimental
treatments are ongoing, including studies of deep brain (thalamic)
stimulation for epilepsy, gamma knife treatment of temporal lobe
epilepsy, and participation in ERSET (Early Randomized Surgery Epilepsy
Trial) sponsored by NIH.
Contact
For appointments, contact Jeffrey Elias,
M.D. or the Comprehensive Epilepsy Program at
434-924-5401.
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