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simple seizures one year following treatment, and reported increase in visual field deficits
and the unknown long-term risk of radiation. The ROSE study, a randomised multicentre
trial, is presently taking place comparing surgery and gamma knife in medial temporal lobe
epilepsy. Other forms of anatomical lesioning, such as with a laser, are presently being
investigated. The advantage of these techniques is their immediate effect.

Neuropace RNS™
The RNS neurostimulator is a programmable, battery powered, microprocessor-controlled
device that delivers a short train of electrical pulses to the brain through implanted leads. The
stimulator is designed to detect abnormal electrical activity in the brain and respond by
delivering electrical stimulation to normalise brain activity before the patient experiences
seizure symptoms. The neurostimulator is implanted in the cranium and connected to one or
two leads that are implanted near the patient’s seizure focus. The device monitors the patient’s
electrical activity by connection to an implanted strip electrode on the brain surface. In theory
the device can be taught to recognise the onset of a patient’s seizure and the data from its
phase III study is presently under review by the FDA.

Paediatric epilepsy surgery

The role and importance of the multidisciplinary meeting in determining surgical suitability
and surgical strategy has already been stressed. In the case of children this means that
neurophysiologists, neuropsychologists, neuropsychiatrists, and neurologists must have
specific experience in managing children with intractable epilepsy. A dedicated paediatric
service is also vital in the peri and post-operative periods. Surgery should be carried out in a
paediatric centre and, to ensure the safety and well-being of the patient, the services of a
paediatric neuro-anaesthetist are paramount. There are very specific anaesthetic
requirements, particularly when electrocorticography is required, and the anaesthetic
technique employed should be carefully selected.

Furthermore, when dealing with cortical dysplasia, blood supply to the dysplastic area may
be extremely abnormal with intra-operative blood loss becoming a critical issue. This is the
case particularly in patients with hemimegalencephaly, in whom the dysplastic hemisphere
may have a grossly disorganised blood supply and venous blood loss during the procedure
can pose a very significant hazard.

Many patients with severe, refractory epilepsy suffer from delayed neurological development
and also impaired psychosocial adaptation and behaviour. For this reason many patients
undergoing epilepsy surgery remain in the care of the paediatric epilepsy services despite
being above the age of sixteen. The skills of the paediatric team are therefore also of benefit
to young adults. Sympathetic management from a medical and nursing standpoint is essential
to ensure that the experience of the hospital admission and surgical intervention is as smooth
and as atraumatic as possible.

Surgical follow-up

There are many facets of outcome from epilepsy surgery; seizure control, neuropsychological
development, neurological deficits, quality of life and psychosocial adjustment. It is
regrettable that many publications address the outcome following surgery after only a very
short time. Long-term studies of all patients are required, with a follow-up of at least two
years. It is also important to realise that seizure status may not necessarily indicate a good
outcome, and quality of life measurements are increasingly used to determine the efficacy of
surgical intervention. Some patients with long-standing epilepsy will have few improvements
in their quality of life. Over time epilepsy affects a patient’s pattern of behaviour and also
their social interaction; and these effects may be irreversible. This would suggest that earlier