Pediatric Epilepsy Surgery
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
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.
What epilepsy surgery is
Why children
Epilepsy surgery is a planned operation after months of careful testing, never an emergency. Families make the final decision with full information.
The team
| 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
| 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 |
Drug resistance is the moment to ask about surgery. Referral to an epilepsy surgery center should not wait years.
When the diagnosis needs checking
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
| 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 |
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.
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 |
| 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
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
Is it safe
How safe is stereo-EEG?
| 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.
| 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 |
- 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
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.
| Technique | Seizure-free | Shunted hydrocephalus |
|---|---|---|
| Lateral peri-insular | 80 percent | 11 percent |
| Vertical parasagittal | 80 percent | 11 percent |
| Both | Excellent results, similar safety | Comparable |
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
| 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?
When the focus cannot be removed
Palliative surgery aims to reduce the number and severity of seizures, especially drop attacks that cause injuries.
| 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
Risks
| 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).
| 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
After surgery
Rehabilitation
| 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
| 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 |
Not every child who is evaluated will be offered surgery. The evaluation still clarifies the diagnosis and treatment.
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
| Phase | Included | Priced separately |
|---|---|---|
| Evaluation | Video-EEG, MRI, PET, neuropsychology, conference | Genetic testing, SPECT |
| Surgery | Neurosurgeon, anesthesia, navigation, monitoring, pathology | Stereo-EEG, second operations |
| Hospital | Intensive care and ward stay as planned | Extra days, inpatient rehabilitation |
Comparing quotes
Compare quotes for the same tests and operation, and check that video-EEG days, neuropsychology and follow-up are included.
| 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 Specialist Dr. Fırat ATEŞ, Pediatric Health and Diseases.
Medically reviewed by
Specialist Dr. Fırat ATEŞ
Pediatric Health and Diseases
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