Specific expertise and intensive counselling

If a medicinal treatment has no results or if the patient experiences unacceptable side effects, epilepsy surgery may be a treatment option. Condition is that a very extensive structural and functional brain examination shows that an explicitly described area of the brain causes the seizures and operation of this area can be performed without damage.

Patients for who epilepsy surgery is an option are registered with the Working Group Epilepsy Surgery. This working group consists of specialists from the epilepsy centres and from specialists employed at academic hospitals where this type of brain surgery is performed.

The preliminary examination to determine whether a patient indeed is eligible for brain surgery is extensive and a heavy burden for the patient. That is why extensive information, intensive counselling and continuous monitoring of the physical and mental condition of the patient form part of the trajectory. At any moment the decision can be made that the process will not be continued. Either because it has become clear that an operation is not an option after all or because the patient is not able to continue with the process. The preliminary examination, four phases, takes about one year and a half.

The non-invasive Phase 1 examination takes in the epilepsy centrenfor the most part place. It may include MRI examination (3 Tesla), seizure registration examination, neurophysiologic examination, examination of the visual field, PET scan, MEG examination and functional MRI. The aim is to first define the epileptogenous zone, the area of the brain that has to be removed surgically to render the patient seizure-free. Secondly, the neighbouring exquisite cortex areas for sensory perception, locomotion, sense of touch, language functions and the memory are identified. These areas may not be affected by the surgery.

The invasive Phase 2 examination further defines the epileptogenous zone and the exquisite cortex areas. The examination may include blood vessel examination, Wada test and depth registration (intracranial registration). The invasive surgery required will be performed in an academic hospital. The patient will stay in the epilepsy centre for the subsequent measurements and registrations. If required, there will again be an imaging examination in combination with a (simultaneous) function examination.

Phase 3 includes the brain surgery. The brain surgery will be performed in an academic hospital.

In the aftercare phase, Phase 4, the epilepsy centre will supervise the patient. The psychological and social supervision of the patient after surgery, adjusting the medication policy and - if applicable - considering alternatives in the event of a negative surgery result form part of the aftercare. Even in the event of a positive result, the mental recovery in particular may make this phase intensive and time-consuming.

More information can be obtained from A. Colon, neurologist / clinical neurophysiologist (Heeze location); L. Wagner, neurologist / clinical neurophysiologist (Oosterhout location).

If a medicinal treatment does not work or if the patient suffers unacceptable side effects and epilepsy surgery is not a treatment option, the ketogenic diet may contribute to reducing the severity of the seizures and/or the frequency of the seizures.

The diet consists of fat enriched food with few carbohydrates and a regular quantity of proteins. The body misses the carbohydrates and starts to burn fat. About one-third of the patients following the ketogenic diet benefit from it. Kempenhaeghe utilizes the so-called MCT diet. In addition to a very well thought out diet of normal foodstuffs the patient receives a special fat emulsion. Patients fed through a PEG tube receive the classical form of the ketogenic diet in powder form.

The ketogenic diet is not suitable for, for instance, patients with fatty acid oxidation disorders and/or related disorders, for patients with a long QT syndrome or other arrhythmia, for patients with hyperlipidemia and hypercholesterolemia, for patients with diabetes mellitus or hyperinsulinism and for patients with a serious chronic disease of the liver, kidneys or pancreas. 
 
The ketogenic diet starts with an admission of one to two weeks in the epilepsy centre. As soon as possible the supervision will take place on an outpatient basis, first after six weeks, when all goes well every three months. Periodically a laboratory test and ECG registration are also performed.

After, as an indication, two years the diet is ended. The application of the treatment method is intensively supervised by a neurologist, dietician, epilepsy nurse and paediatrician.

More information can be obtained from Dr D. Lambrechts, neurologist (Heeze location); G.Graveland, neurologist (Oosterhout location).

If a medicinal treatment does not work or if the patient suffers unacceptable side effects and epilepsy surgery and the ketogenic diet are not treatment options, the Vagus Nerve Stimulation (VNS) may contribute to reducing the severity of the seizures and/or the frequency of the seizures.

Stimulating the nervus vagus reduces epileptic seizures with about 30% of the patients. The seizures may also become less severe and have a shorter duration. In addition, VNS may improve the quality of life in various respects which will make VNS users feel better.

Kempenhaeghe plays a role in selecting patients for Vagus Nerve Stimulation. The surgery needed to insert the stimulator takes place in an (academic) hospital with special qualification in VNS implants. Adjusting the VNS is done in the epilepsy centre, in principle through visits on an outpatient basis.

Children and adults can be treated in this manner provided that their physical condition allows the surgery. A neurologist and an epilepsy nurse are involved in the treatment trajectory. 

More information can be obtained from Dr M. Majoie, neurologist (Heeze location); L. Wagner, neurologist / clinical neurophysiologist (Oosterhout location).