New patients in the Dartmouth-Hitchcock Epilepsy Center will have an initial evaluation with one of our doctors to determine the nature of the seizures and the best way to evaluate them.
Your doctor may order various tests to locate the exact cause of your seizures and determine the best treatment for you. You may be able to manage your epilepsy with medication or dietary changes, or we may recommend surgery. Testing usually happens in three phases:
- Phase 1: Preliminary tests: This testing is done to more clearly define your epilepsy. It is also used in preparation for surgery.
- Phase 2: Wada test: If phase 1 testing indicates that surgery may help you, the team will use the Wada test (developed by neurologist Juhn Wada) to evaluate whether you are a good candidate for surgery. It is also used in preparation for surgery.
- Phase 3: Electrode placement: If the epilepsy team determines that you need more detailed testing, they will recommend electrode placement to better determine where in the brain the seizures are happening.
Most forms of epilepsy can be treated with medications; however, about 25 percent of epilepsy patients continue to have seizures while on medication.
For such patients, the Epilepsy Center may recommend surgery, dietary changes, or a combination of therapies.
You may find that one treatment no longer works as well as it used to, perhaps because of pregnancy, insomnia, medications, or other issues. It is important to keep in touch with your doctor about your health.
Our ketogenic diet is intended for patients one year or older who have frequent seizures and who do not respond well to anti-seizure medications.
The diet is composed mostly of fats with small amounts of protein, carbohydrate, and fluids. Most patients find that they have fewer seizures on this diet, although results vary. The program starts with a three-to-five-day hospital stay, followed by regular appointments with the neurologist and dietitian.
Vagus nerve simulator
This device is an electrical generator implanted under the collarbone and connected by a wire to the vagus nerve in the neck.
Stimulating this nerve has proven effective in reducing some types of seizures. It can be activated by holding a magnet over the implanted generator.
If medication and other treatments are unable to control your seizures, your Epilepsy Center team may recommend surgery.
- Lobectomy: A lobectomy is the removal of part of the brain. Almost 80 percent of partial seizures in adults begin in the temporal lobes, which are located on both sides of the head just above the ears. A portion of one of the temporal lobes can be removed if tests consistently show that your seizures originate there. The success rate for becoming seizure-free after a temporal lobectomy is currently at least 90 percent. Your doctor may perform other surgeries such as removal of tumors, abnormal collections of blood vessels, and congenital lesions. Lesions and their surrounding tissue will be removed if monitoring shows that seizures begin in that area.
- Corpus callosotomy: During this operation, the doctor temporarily removes a portion of the skull to gain access to the brain. Nerve fibers that connect one side of the brain to the other, called the corpus callosum, are severed. This is done to keep seizures from spreading from one side of the brain to the other. No tissue is removed. This surgery is most helpful for grand mal seizures and drop attacks. Seizures are not usually stopped entirely by this procedure; however, the effects are generally less severe. Often patients may have a seizure on only one side or the other. The operation is done in two stages. In the first stage, the corpus callosum is severed two-thirds of the way. If this adequately controls seizures, then no further surgery is needed. If it does not significantly reduce the frequency and/or intensity of your seizures, then you will be evaluated for further surgery.
- Hemispherectomy: In rare cases, a patient may have extensive brain damage on only one side of the brain. That damage may produce uncontrollable seizures and paralysis on the opposite side of the body. During a hemispherectomy, the doctor removes all, or almost all, of one side of the brain. After this procedure, the remaining side of the brain may take over many of the functions of the part that was removed. However, some body weakness will persist.
- Hemispherotomy: This procedure is similar to a hemispherectomy, but instead of removing part of the brain, it is disconnected. A hemispherotomy can have certain advantages for some patients, particulary children.
Life after surgery
After surgery, you will be followed very closely by your medical and surgical team.
It is important that you tell the physician or nurse if you have any problems functioning in everyday life, or have trouble coping with a life without epilepsy. These are very important concerns, and our team can help you.
- The nurse coordinator will call you frequently to check on your progress and help with any questions or concerns.
- You will see your neurologist and neurosurgeon about four to six weeks after surgery, and have an MRI.
- Six months after surgery, you will be admitted to the hospital for a 24-hour electroencephalogram (EEG) with video monitoring and a second series of neuropsychological testing.
- Your team will follow up with you every three months for the first year, then every six months thereafter.
Risks from epilepsy surgery
Although epilepsy surgery is considered relatively safe, there are certain risks, which may include:
- Bleeding or infection at the surgical site
- Difficulty remembering or speaking certain words
- Minor vision loss or weakness opposite the side of surgery
- Risks associated with anesthesia