Pediatric epilepsy surgery treats children whose seizures continue after two medicines have failed, by removing or disconnecting the brain area where seizures start or by reducing them with vagus nerve stimulation. Careful testing with video-EEG, MRI, PET and neuropsychology decides who will benefit. At Biruni Hospital in Istanbul, our epilepsy team plans each operation at a joint conference and follows children as medicines are reduced and development catches up.
About This Department
Pediatric Neurosurgery
When two seizure medicines have failed, a third rarely brings control. Epilepsy surgery can stop seizures and let a child's development catch up.
Pediatric epilepsy surgery treats children whose seizures continue despite medicines by removing or disconnecting the brain area where seizures start, or by reducing seizures with a stimulator when the source cannot be removed. Drug resistance shows early. In a prospective study of newly diagnosed epilepsy, 47 percent of patients became seizure-free with the first medicine, and far fewer did so with each medicine after that (Kwan and Brodie, New England Journal of Medicine, 2000). Surgery then changes the picture. In a randomized trial of 116 children and adolescents with drug-resistant epilepsy, 77 percent were seizure-free one year after surgery, against 7 percent of those who continued medicines alone, with better behavior and quality of life (Dwivedi and colleagues, New England Journal of Medicine, 2017). This page explains drug resistance, who is a candidate, the presurgical evaluation, stereo-EEG, resection, hemispherotomy, surgery in infants, stimulation options, risks, recovery, and how families from abroad arrange pediatric epilepsy surgery at Biruni Hospital in Istanbul.
77
Percent of children seizure-free one year after surgery in a randomized trial
7
Percent seizure-free with continued medicines alone in the same trial
80
Percent seizure-free after hemispherotomy in pooled data from 825 patients
Free
Review of your child's EEG and MRI by our epilepsy surgery team
Curative surgery removes or disconnects the area where seizures start. Palliative surgery, such as vagus nerve stimulation or corpus callosotomy, reduces seizures when the source cannot be removed.
Why children
Children's brains are still developing, and frequent seizures and high doses of medicine slow learning, language and behavior. Stopping seizures early gives the developing brain the best chance to catch up and to take over functions from the affected area.
Epilepsy surgery is a planned operation after months of careful testing, never an emergency. Families make the final decision with full information.
The team
Who plans pediatric epilepsy surgery
Specialist
Role
When
Pediatric neurologist and epileptologist
Diagnosis, medicines, EEG interpretation
Throughout
Pediatric neurosurgeon
Surgery and invasive monitoring
After testing
Neuroradiologist and nuclear medicine
MRI, PET, SPECT
Evaluation
Neuropsychologist
Memory, language, development
Before and after surgery
Drug-resistant epilepsy
Seizure freedom with successive medicines, 470 untreated patients
Medicine
Seizure-free
Note
First medicine
47 percent
Most who respond do so here
Second or third medicine
14 percent
Fewer with each step
After failure of the first for lack of effect
11 percent
Low chance with further medicines
Epilepsy is drug-resistant when two well chosen and well tolerated medicines, at proper doses, have failed to stop seizures. One third of children with epilepsy reach this point, and the chance of control with further medicines is small (Kwan and Brodie, 2000).
Drug resistance is the moment to ask about surgery. Referral to an epilepsy surgery center should not wait years.
When the diagnosis needs checking
Fainting, sleep disorders, reflux in infants and non-epileptic attacks can all mimic seizures, so video-EEG monitoring records the events and confirms what they are before any surgical decision is made.
Earlier is better
Every year of uncontrolled seizures has a cost.
Children with drug-resistant epilepsy fall behind at school, lose skills they had gained, sleep poorly, carry the side effects of several medicines and face injuries and, rarely, sudden death in epilepsy, while their families organize life around the next seizure, and the evidence shows that children operated on earlier, when the brain is most able to adapt, gain more in development than those operated on after many years. International guidelines recommend referral to an epilepsy surgery center as soon as two medicines have failed.
Referral is not commitment to surgery.
Who is a candidate
Common causes treated with epilepsy surgery in children
Cause
Typical operation
Seizure-free rates
Focal cortical dysplasia
Resection of the dysplasia
High when completely removed
Low grade tumors, such as DNET and ganglioglioma
Lesionectomy
Among the highest
Hippocampal sclerosis
Temporal lobe surgery
High
Hemispheric conditions, such as Rasmussen, stroke, hemimegalencephaly
Hemispherotomy
High
Tuberous sclerosis
Resection of the leading tuber
Selected children
1
The key question
Whether the seizures start in one area of the brain that can be removed or disconnected without unacceptable loss of function.
A visible lesion on MRI that matches the seizure pattern and EEG gives the best chance of seizure freedom. Children with a normal MRI can also be candidates after more detailed testing.
Children with seizures arising from both sides or from the whole brain, as in some genetic epilepsies, are not candidates for removal surgery, but may benefit from stimulation or callosotomy.
Genetic testing is part of the evaluation, because some genetic epilepsies respond poorly to surgery, while others, such as tuberous sclerosis, can respond very well.
The presurgical evaluation
Tests in the presurgical evaluation
Test
What it shows
Duration
Video-EEG monitoring
Records seizures and where they start
Three to seven days
Epilepsy protocol MRI, 3 Tesla
Small lesions, dysplasia
One hour, sedation for young children
PET scan
Areas of lower brain activity
Half a day
Neuropsychological testing
Memory, language, development
One to two days
Medicines are reduced during video-EEG monitoring under close supervision so that typical seizures are recorded. A parent stays with the child throughout.
Further tests in selected children
Test
Purpose
When
Functional MRI
Maps language and movement areas
Older children who can cooperate
Ictal SPECT
Blood flow during a seizure
Normal or unclear MRI
Magnetoencephalography or high density EEG
Source localization
Specialist centers
The epilepsy surgery conference
1
One decision
Neurologists, neurosurgeons, radiologists and neuropsychologists review all results together and recommend surgery, further testing or continued medicines.
Written recommendation
Families receive a written summary that explains the expected chance of seizure freedom, the risks to movement, vision, language and memory, and the alternatives.
Stereo-EEG
When non-invasive tests do not show exactly where seizures start, or the area lies close to important functions, thin electrodes are placed into the brain through small holes in the skull. Seizures are recorded over one to two weeks, and the electrodes are then removed.
Is it safe
How safe is stereo-EEG?
Serious complications such as bleeding or infection occur in a small share of children. Electrodes are planned with three-dimensional imaging to avoid blood vessels, and the procedure is done under general anesthesia.
1
Stimulation mapping
While electrodes are in place, gentle electrical stimulation maps movement, language and vision, so the surgeon knows which areas to protect.
Stereo-EEG at a glance
Step
Timing
Note
Electrode placement
Under general anesthesia
Small holes, no large opening
Recording
One to two weeks
Medicines reduced
Removal
Short procedure
Sometimes with thermocoagulation of the focus
Removing the seizure focus
Complete removal of the seizure focus gives the highest chance of seizure freedom. The surgeon removes the abnormal area while protecting nearby functions.
Types of resective surgery
Operation
What is removed
Used for
Lesionectomy
The visible lesion and a margin
Tumors, cavernomas
Focal resection
The dysplasia or epileptic area
Focal cortical dysplasia
Temporal lobectomy
Front of the temporal lobe and hippocampus
Temporal lobe epilepsy
Multilobar resection
Parts of several lobes
Larger malformations
The operation takes four to six hours under general anesthesia, with neuronavigation, the operating microscope and, near critical areas, monitoring of movement pathways. Children stay one night in intensive care and go home after five to seven days.
Laser ablation through a small hole treats deep, small targets in selected children.
Thermocoagulation through stereo-EEG electrodes treats some small foci and hypothalamic hamartomas.
Open resection remains the standard for most lesions.
The removed tissue goes to the neuropathologist, who confirms the cause and guides the outlook.
Hemispherotomy
1
Disconnecting one half of the brain
When seizures arise from one damaged hemisphere, the surgeon disconnects it from the rest of the brain while leaving most tissue in place.
Children who already have weakness of one side and loss of half the visual field from the disease lose little further function, and the healthy hemisphere continues to develop.
Hemispherotomy in 25 studies, 825 patients
Technique
Seizure-free
Shunted hydrocephalus
Lateral peri-insular
80 percent
11 percent
Vertical parasagittal
80 percent
11 percent
Both
Excellent results, similar safety
Comparable
Hemispherotomy suits conditions such as Rasmussen encephalitis, perinatal stroke, hemimegalencephaly and Sturge-Weber syndrome. In pooled data, four in five patients became seizure-free with either main technique (Cossu and colleagues, Journal of Neurosurgery, 2022).
Children walk after hemispherotomy, in most cases with a limp, and the hand on the affected side keeps limited fine movement.
Surgery in infants
Operating in the first months
Epilepsy surgery in the first six months of life, 158 infants
Outcome
Result
Note
Seizure-free overall
65.6 percent
Hemispherotomy 71 percent, focal surgery 58 percent
Complications
27.7 percent
Hydrocephalus most frequent
Medicines reduced
85.9 percent
Discontinued in 21.5 percent
Is our baby too young for surgery?
Age alone does not rule out surgery. Infants with severe epilepsy from a hemispheric or large focal lesion lose development every week seizures continue. Surgery in the first months is demanding and belongs in experienced centers, and developmental gains were seen mainly in infants who became seizure-free (Makridis and colleagues, Seizure, 2022).
Infants need specialist pediatric anesthesia, blood replacement planning and intensive care, which our pediatric intensive care unit provides.
When the focus cannot be removed
Palliative surgery aims to reduce the number and severity of seizures, especially drop attacks that cause injuries.
Options when resection is not possible
Option
How it works
Best suited for
Vagus nerve stimulation
A stimulator in the chest sends pulses to the vagus nerve in the neck
Generalized or multifocal epilepsy
Corpus callosotomy
Divides the connection between the two hemispheres
Drop attacks
Ketogenic diet
Changes brain metabolism
Several epilepsy types, alongside surgery
Vagus nerve stimulation
In a meta-analysis of 480 patients with Lennox-Gastaut syndrome, 54 percent had at least half as many seizures with vagus nerve stimulation added to medicines (Dibué and colleagues, Acta Neurologica Scandinavica, 2021). The device is implanted in a one to two hour operation and adjusted in the clinic over months.
Risks
Risks of epilepsy surgery
Risk
Depends on
How we reduce it
Weakness or visual field loss
Area operated
Mapping, monitoring, careful planning
Language or memory change
Dominant temporal or frontal surgery
Functional mapping and testing
Infection, bleeding, hydrocephalus
Extent of surgery
Standard precautions, follow-up scans
Some deficits are expected and accepted in advance, such as weakness after hemispherotomy in a child who already has it. In the Indian trial, hemiparesis occurred in 26 percent, almost all after planned hemispherotomy (Dwivedi and colleagues, 2017).
1
Weighing the risks
Uncontrolled epilepsy carries its own risks, including injuries, developmental delay and sudden death. We set out both sides of the balance.
What families should expect
Area
Usual course
Follow-up
Seizures
Most stop at once, a few in the first weeks
Seizure diary
Mood and energy
Tiredness for weeks
Gradual return
Development
Gains over months to years
Neuropsychology at one year
Seizures after surgery
A few seizures in the first days after surgery do not mean failure. Seizure freedom is judged after one to two years.
After surgery
Children stay in intensive care for the first night and walk within days. Most go home five to seven days after resection and seven to ten days after hemispherotomy.
1
Medicines
Seizure medicines continue unchanged for at least one year. If the child remains seizure-free, the neurologist reduces them step by step, and many children stop them completely.
Rehabilitation
Follow-up after epilepsy surgery
Visit
Timing
Tests
Wound check
Ten to fourteen days
Clinical
Neurology review
Three and six months
EEG
Full assessment
One year
MRI, EEG, neuropsychology
Physiotherapy, occupational therapy and speech therapy start in hospital and continue at home where needed.
School, sleep and family life
Life changes when seizures stop.
Children sleep better, think more clearly as medicine doses fall, return to school with fewer absences and take part in sports and activities that seizures had made unsafe, while parents sleep through the night for the first time in years, and the family stops planning every outing around the risk of a seizure, so our psychologists and social workers help families adjust to this new life as well as to the challenges of recovery.
Development keeps improving for years.
For families from abroad
Typical stays in Istanbul
Phase
Duration
Note
Presurgical evaluation
One to two weeks
Video-EEG, MRI, PET, neuropsychology
Stereo-EEG, if needed
Two to three weeks
Separate admission
Surgery and recovery
Two to three weeks
Fitness to fly after wound check
Send previous EEG reports and video recordings of seizures, MRI images on disc, the list of medicines tried with doses, and any genetic results. A short phone video of a typical seizure helps the team more than any description.
1
Length of stay
Families planning evaluation and surgery in one trip should expect four to six weeks, or two trips if the conference recommends further tests.
Not every child who is evaluated will be offered surgery. The evaluation still clarifies the diagnosis and treatment.
2
After you return home
Seizure diaries, EEG and medicine changes continue with your local neurologist, and our team reviews progress by video and message.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Flying with epilepsy
Children with frequent seizures can fly with a medical letter and rescue medicine in hand luggage, and we prepare both before each flight.
Cost
What a quote for pediatric epilepsy surgery covers
We quote the evaluation first, because the type of surgery depends on its results. A second quote for surgery follows the conference recommendation, before any operation.
Comparing quotes
Compare quotes for the same tests and operation, and check that video-EEG days, neuropsychology and follow-up are included.
Factors that change the quote
Factor
Effect
Example
Need for stereo-EEG
Extra admission
Normal MRI
Type of surgery
Length of operation and stay
Hemispherotomy
Device
Implant cost
Vagus nerve stimulator
References
Dwivedi R, Ramanujam B, Chandra PS, et al. Surgery for drug-resistant epilepsy in children. N Engl J Med. 2017;377(17):1639-1647.
Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl J Med. 2000;342(5):314-319.
Cossu M, Nichelatti M, De Benedictis A, et al. Lateral versus vertical hemispheric disconnection for epilepsy, a systematic review and meta-analysis. J Neurosurg. 2022;136(6):1627-1637.
Makridis KL, Atalay DA, Thomale UW, et al. Epilepsy surgery in the first six months of life, a systematic review and meta-analysis. Seizure. 2022;96:109-117.
Dibué M, Greco T, Spoor JKH, et al. Vagus nerve stimulation in patients with Lennox-Gastaut syndrome, a meta-analysis. Acta Neurol Scand. 2021;143(5):497-508.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Ömer DOĞRU, Pediatric Hematology and Oncology.
