Epilepsy is a common brain disorder. When it comes to epilepsy, most people are not unfamiliar with it and spontaneously associate it with the horrific scene of a seizure: a sudden scream to the ground, eyes rolled up, foaming at the mouth, twitching limbs, and unconsciousness. And in this day and age, when technology is quite advanced, many people give epilepsy a superstitious tinge. In fact, epilepsy is a common brain disease, and the above-mentioned condition is only one type of seizure. Epilepsy is common because of the number of people who suffer from it. According to the latest statistics from the World Health Organization, the prevalence of epilepsy ranges from 5 to 11,2 per 1,000 people, or 5 to 11 epileptics per 1,000 people. There are an estimated 50 million patients worldwide, and at least 100 million people have experienced a seizure in their lifetime, with 2 million new cases each year. Epilepsy can affect everyone from newborns to the elderly, but is more prevalent in children, adolescents and the elderly. There are no geographical differences in epilepsy. In China, a rough estimate of 5 million people are affected by this disorder. Therefore, epilepsy is a great danger to society, and a very conservative estimate by the World Health Organization indicates that 1% of the global economic burden caused by disease is due to epilepsy. It is common because all causes of brain lesions can lead to epilepsy, including head trauma, brain tumors, cerebrovascular disease, encephalitis, and so on. Those with a clear cause are called symptomatic epilepsy and are often named with a specific cause, such as traumatic epilepsy, post-infarction epilepsy, etc. Of course there are many patients who cannot be traced to a specific cause, which we call cryptogenic or primary epilepsy. Some people say that epilepsy is a disease of the poor, and this statement is highly biased. This is because there is no difference in status between rich and poor people with epilepsy. Some emperors, scientists, and artists throughout history have suffered from epilepsy. Epilepsy is even less associated with the gods. Epilepsy is simply an abnormal expression of brain function. Therefore, the World Anti-Epilepsy League and the newly established Chinese Anti-Epilepsy Association in China have been working to promote the idea that epilepsy is only a disease of the brain, like hypertension and diabetes, and is a chronic and treatable condition, and to remove the discriminatory mentality towards people with epilepsy. The most important thing is to make sure that you have a good understanding of the problem. The most important thing is that it is not just a matter of the brain. Human activities are rich and varied, not only completing basic biological behaviors such as eating and drinking and sexual behavior, but also engaging in creative activities all the time, such as reaching the moon and exploring the ocean floor. How does the brain perform these functions? Electricity! The brain is an electrical organ. The brain is composed of tens of billions of nerve cells, which are interconnected and built into a neural network that even the most advanced computers can never match. The most important messengers that constantly run in the neural network to transmit information are electrical signals. We speak, sing, jump, and other activities and various perceptions such as visual and auditory, none of which leave the coordinated and orderly electrical activity of the brain. When the brain is injured for various reasons and abnormal overdischarge occurs, it can cause seizures. However, in epileptology, there is a conceptual difference between seizures and epilepsy. Sometimes seizures can occur in normal people under special circumstances such as excessive shock and high fever, but an occasional seizure or a seizure in the acute phase of a brain disease is not usually diagnosed as epilepsy. Epilepsy is a chronic condition caused by recurrent abnormal discharges in the brain. Therefore, epilepsy has the following characteristics: (1) recurrent – meaning that at least 2 or more seizures are required to be diagnosed as epilepsy; (2) stereotyped – meaning that seizures are different from the variable form of seizures caused by psychiatric factors, and each seizure has a stereotyped form; (3) temporary – meaning that each seizure usually lasts from a few seconds to one or two minutes, usually less than 3 minutes, and only in very special cases do continuous seizures occur. (3) Transient – each seizure usually lasts for a few seconds to one or two minutes, usually less than 3 minutes. What we usually call “epilepsy” is only one form of seizure, but in fact there are many different forms of seizures. Each patient’s seizure pattern is determined by the location, extent, and electrical propagation of the abnormal foci in the brain. For example, some patients have seizures caused by abnormal discharges in a part of the brain called the amygdala, and the seizures may be characterized by olfactory hallucinations and smelling a particular odor. The patient is clear-headed during such seizures. This is medically known as a limited seizure, where the EEG only records a partial discharge in the brain. The usual term for epilepsy is grand mal seizures, or tonic clonic seizures, when both sides of the brain discharge at the same time during an EEG. Pediatric seizures are also known as petit mal seizures, in which only a dazed state is observed. Because of the variety of seizure forms, seizure classification is an important task for epileptologists. Specifically for each patient, correct classification is associated with rational treatment. 3. Can epilepsy be treated with surgery? A woman, 40 years old. She had seizures since the age of 10. The seizures started with indescribable discomfort in the upper abdomen, rising toward the head, followed by blurred consciousness and movements such as smacking of the mouth and groping for pockets with both hands for a few seconds to half a minute, after which she could not recall but felt tired. In the beginning, the treatment with medication was effective, but in the past 7-8 years, it seems that all kinds of medication did not work for him, and he went to many large hospitals and some Chinese medicine clinics in China for treatment, but all of them failed time and again. In the past six months, the seizures were very frequent, up to 4-5 times a day, and the memory gradually deteriorated, and the patient almost completely lost the ability to work. The patient visited our department six months ago and was given a special sequence and special scanning method of magnetic resonance scan and video EEG recording, which was determined to be medial temporal lobe epilepsy syndrome, caused by sclerosis of the right hippocampus. Surgery was performed. After surgery, the patient has been seizure-free, his memory has improved significantly, and he has been living as a normal person. This is a typical case of a patient with psychomotor seizures, sometimes misdiagnosed as psychosis. The site of the seizure was in a structure in the brain called the hippocampus. In terms of surgical treatment of epilepsy, this case should be a simple case, and a lot of experience has been accumulated in surgical treatment at home and abroad, which can cure more than 80% of patients and make another few cases significantly better and worthy of surgical treatment. A large amount of information has shown that surgical treatment for epilepsy is effective. In selected cases, surgery can cure 80% of patients; for epilepsy caused by a focal lesion in the brain, such as tumors and vascular malformations, the surgical cure rate is 95%. In 80 cases of intractable temporal lobe epilepsy, the patients were divided into two groups, 40 cases in each group, one group was treated with medication and the other group was treated with surgery. 4. Is epilepsy surgery safe? Scientifically speaking, epilepsy surgery, like other surgeries, is not 100% safe. The safety of any treatment is relative, and we cannot talk about the risks without the efficacy. The chance of postoperative bleeding and infection is less than 1% and is curable; the chance of reversible limb weakness in the early postoperative period is less than 0.5%. In one hospital in the United States, patients waiting for epilepsy surgery were scheduled for a year later, and the doctors divided the patients who had surgery in the first three months and those who were treated with medication only into two groups. In fact, the surgical conditions are now quite good and the risk of surgery is very low. In addition, it is important to recognize that surgery is the only treatment that specifically targets the epileptogenic focus, just like chemotherapy for tumors. What patients with epilepsy are considered for surgery? From the etiological point of view, some seizures can be traced to a clear cause such as brain tumor, vascular malformation, etc., which is called symptomatic epilepsy or secondary epilepsy; some patients cannot be traced to a clear cause, which is called cryptogenic epilepsy or primary epilepsy. Currently, due to the development of diagnostic techniques, more and more patients are found to have seizures caused by some kind of lesion in the brain, and many patients previously diagnosed as so-called primary epilepsy are found to have symptomatic epilepsy. Therefore, the etiological examination should not be neglected for every patient with seizures. Under current conditions, it is advocated to perform at least one general magnetic resonance scan, and if tumors or vascular malformations are found, early surgical treatment should be considered. The results of domestic and international studies show that 70% of all patients with epilepsy can be satisfactorily controlled with medication, and the other 30% have poor results with medication and are intractable or drug-resistant epilepsy. All patients with intractable epilepsy should be evaluated as candidates for surgical therapy, and those suitable for surgical treatment should be screened for surgical treatment. At present, only a trial of drug therapy can prove whether the epilepsy suffered by the patient is intractable. However, the problem is that there are many antiepileptic drugs on the market and new drugs are constantly being introduced, so it would be difficult to try all of the current drugs and the new drugs that are constantly being introduced, as well as different combinations of these drugs, for a lifetime. In the past 20 years, there has been significant progress in the surgical treatment of epilepsy, recognizing a number of surgically treatable epilepsy syndromes for which surgical treatment should no longer be the last option, emphasizing early surgery for these epilepsy syndromes, because these epilepsy syndromes are generally not well treated with medication and surgical treatment has a fairly high cure rate of 75% – 90% or more, in addition to surgery In addition, surgery is too late to wait until the patient has severe intellectual memory impairment, and even if the seizures are controlled, it does not significantly improve the patient’s quality of life, and the surgical results become worse. Therefore, surgical treatment should be considered for these epilepsy syndromes once some first-line drugs such as sodium valproate, carbamazepine, and phenytoin sodium do not work well. Surgically treatable epilepsy syndromes include (1) medial temporal lobe epilepsy caused by hippocampal sclerosis; (2) epilepsy caused by isolated intracerebral lesions such as vascular malformations and small brain tumors; (3) hemiplegia with epilepsy in infancy and childhood due to lesions in one hemisphere such as large penetrating malformations or Rasmussen’s encephalitis. (3) Falling seizures often seen in Lennox-Gastaut syndrome, etc. 6. What tests should be done before epilepsy surgery? A detailed preoperative evaluation is performed before epilepsy surgery. First of all, the doctor should ask the patient and his relatives about the seizure history and medication, so that it is clear that medication is not effective and that the epilepsy is intractable. Then video EEG monitoring is performed. The video EEG is performed while the patient is hospitalized, and the EEG is recorded while the patient is videotaped in real time, which can be done for 24 hours or even days, recording to the patient’s seizures, so that the seizure performance and where the seizure discharges start during the seizure can be frontally analyzed. Another routine test is a high fractional rate MRI scan, which can detect small lesions in the brain, but epilepsy surgery is different from general brain surgery in that the lesions shown on the MRI are not necessarily the ones causing the epilepsy, and a combination of seizure type and EEG is needed to determine where the epileptogenic focus is located. Sometimes these tests are not sufficient and electrodes may need to be placed directly on the surface of the brain and deep within the brain for EEG recording to determine this. Other tests such as SPECT and PET are also useful in some complex cases. Therefore, the preoperative examination may vary from case to case. At present, the provincial hospital has hardware comparable to that of developed countries in Europe and the United States in the preoperative evaluation of epilepsy, such as long-range video EEG monitoring equipment, high-resolution MRI, SPECT, PET, etc., and neurosurgery has accumulated considerable successful experience in the surgical treatment of epilepsy. 7.What are the current epilepsy surgeries? (1) Excisional surgery, which is to remove the epileptogenic foci causing epilepsy, is the most ideal surgical procedure, provided that the epileptogenic foci can be found and are located in unimportant parts of the brain and do not cause functional impairment after excision. (2) Palliative surgery, including corpus callosotomy, multiple subchondral transection, and vagus nerve stimulation, are procedures aimed at altering the electrical propagation or electrical activity of the epileptogenic focus and reducing the degree of seizures or the type of disabling seizures. For example, in a patient with multiple seizure types, one of which is prone to falls and injuries, a corpus callosotomy may be chosen to alleviate the fallogenic seizures. The main channel for information exchange is the corpus callosum, a cable-like structure that connects the two hemispheres. Cutting off part of the corpus callosum can interrupt the transmission of epileptic discharges from one hemisphere to the other. The corpus callosum can only reduce seizures and not cure epilepsy, but it is amazing that seizures are completely aborted in 5% of patients after corpus callosotomy. Vagus nerve stimulation was approved by the FDA in 1997 as a new treatment for epilepsy, primarily for patients for whom drug therapy is not effective and who are not candidates for surgery. In developed countries, a significant number of patients have been fitted with a vagus nerve stimulator, which has proven to be effective. However, this procedure has not been performed in China. The main reason is that the stimulator is expensive. In daily clinical work, when talking with patients and families about surgical treatment of epilepsy, one of the most common questions they ask is whether and for how long they need to take antiepileptic drugs after surgery. It is important to make clear that surgical treatment cannot be considered in opposition to drug therapy. In general, antiepileptic drugs should be continued for a considerable period of time after surgery. The first reason for continuing to take antiepileptic drugs is that most patients have been on a large number of antiepileptic drugs for a long time before surgery, and the body has become dependent and adaptable to the drugs. In addition, surgery mainly removes the most critical epileptogenic foci, but the brain of patients with long-term epilepsy has changed functionally as a whole, and there may be secondary epileptogenic foci. If the drug has no significant toxic side effects and is seizure-free for at least 1 year after surgery, dosage reduction and gradual discontinuation of the drug should be considered under the guidance of a physician. In large overseas epilepsy centers, we find that many patients have been seizure-free for many years after surgery and are advised by their physicians to stop taking their medications, but the patients still insist on taking them. 9. How to treat the problem of surgical failure Epilepsy, like brain tumors and many other brain diseases, has not yet been clarified by humans, and there are many unknowns to be further studied. The localization of the epileptogenic focus is based on clinical manifestations, imaging data, and electrophysiological examinations, etc. There is no examination method that can directly show the location and extent of the epileptogenic focus. In addition, the main goal of epilepsy surgical treatment is to improve the quality of life and the ability to work and learn, not to save or prolong life, and surgery should only be considered if it does not cause significant new neurological deficits. Therefore, more care should be taken in the preoperative evaluation and in making treatment decisions than in the treatment of some other surgical diseases of the brain. Unfortunately, even in some of the larger epilepsy centers with a long history of epilepsy surgery, a certain percentage of their current caseload of patients still have seizures that do not resolve after surgery. There are various reasons for this, some of which are overly conservative surgery, some of which are inappropriate localization of the epileptogenic focus, some of which are multiple epileptogenic foci, and certainly some of which are difficult cases to try to solve something for the patient from a surgical perspective. Some cases may require further surgery. The author had a patient with psychomotor seizures for more than 10 years, who had been taking a variety of drugs with poor results and had attempted suicide several times. Based on the seizure type and electrophysiological findings, temporal lobe epilepsy was considered, and an MRI scan showed a small tumor in the posterior part of the right middle temporal gyrus. In view of the fact that in some cases the seizures could be stopped by removing only the tumor, only the tumor was initially removed and the pathology was reported as ganglion cell tumor, which was benign. However, there was no change in the patient’s seizures after the initial surgery, and the patient was repeatedly given an anterior temporal lobectomy, with good postoperative results, and has been married and a mother of two children for more than three years now. In some cases, there are still seizures after surgery but they are significantly reduced. In some cases, the seizures may become less and less frequent until they stop completely, a phenomenon that the famous epilepsy surgeon Rasmussen called gradual cessation. Some patients may still require long-term medication after surgery, but in these cases, the preoperative medication is extremely ineffective, and after surgery, the seizures may be well controlled with only low doses of medication. Therefore, epilepsy surgery should not be too demanding, but should be approached sensibly. After all, this is a proven treatment method in developed countries, and the majority of epilepsy patients in China should also have the opportunity to receive this treatment method.