In this episode, we talk with our guest Dr. Nilesh Kurwale who is an epilepsy specialist based out of Pune, India.

Dr. Nilesh helps us understand Epilepsy Surgery as a treatment approach. He covers different types of epilepsy surgeries i.e. curative and palliative surgeries. We discuss risks associated with epilepsy surgeries.

Dr. Nilesh highlights his counseling approach and rationale behind epilepsy surgery. Finally, we discuss the financial costs associated with epilepsy surgery.

Visit  http://www.drstories.com to hear and learn more from top surgeons and doctors.

Learn more about Dr. Nilesh Kurwale at:
https://www.rxoom.com/pune/doctor/dr-nilesh-kurwale-neurosurgeon

Transcript

Benefits and types of epilepsy surgeries

A talk with Dr. Nilesh Kurwale.

Speaker: Mr. Vivek
[0:00]

Hello, welcome to Dr. Talks. This is your host Vivek. Here we chat with the best doctors about diseases and conditions they treat. Our guest today is Dr. Nilesh Kurwale. Dr. Nilesh Kurwale is a neurosurgeon who specializes in surgical treatments of epilepsy. He’s head of Bajaj Allianz center for epilepsy at Deenanath Mangeshkar hospital, Pune. He consults at top hospitals for complex epilepsy surgeries. Dr. Nilesh is an expert in the evaluation and treatment of epilepsy and is not responding to medicine. Due to his extensive experience, passion and focus on epilepsy cure, Dr. Nilesh is recognized as one of the top epilepsy surgeons in India and he treats both Indian and international patients. Welcome Dr. Nilesh.

Speaker: Dr. Nilesh
[1:04]

Good morning. Thank you for inviting me to Dr. Talks.

Speaker: Mr. Vivek
[1:08]

Today to start with, I would request you to share your background in medicine with us.

Speaker: Dr. Nilesh
[1:13]

I am actually a practicing neurosurgeon. I finished my residency at All India Institute of Medical Sciences way back in 2009. And then after practicing for like four or five years of general neurosurgery, I completed my fellowship in epilepsy surgery, and I started focusing on epilepsy surgeries for the last five years now. After finishing my fellowship at All India Institute and Jefferson Institute, I came back to Deenanath Mangeshkar hospital and started a small unit for epilepsy surgeries, which is now a good high volume center as of now. So I have been focusing exclusively on epilepsy surgeries for the last four years.

Speaker: Mr. Vivek
[1:58]

In our last podcast we discussed epilepsy, its treatment in general. Can we focus today specifically on epilepsy surgeries?

Speaker: Dr. Nilesh
[2:07]

Yeah, that would be a great idea Vivek.

Speaker: Mr. Vivek
[2:10]

What are epilepsy surgeries?

Speaker: Dr. Nilesh
[2:13]

Just to understand about epilepsy surgeries. Our brain is made of small electrical circuits. So when there is a structural malformation, it causes a short circuit somewhere in that electrical circuit millenia. So when we find out that area, where the short circuit is generated, we would want to take that part out or repair that short circuit. And that is what the idea of epilepsy surgeries is. For simple example, if you have a switchboard in your room, out of many switchboards one switch is giving the short circuit, which is causing the tripping. And that’s exactly what epilepsy is in a normal brain scenario. And the idea of epilepsy surgery is similar to repairing that switch.

Speaker: Mr. Vivek
[3:26]

Oh, that’s a nice analogy. It helps a layman to understand epilepsy surgery in a much better manner. When do you consider patients for epilepsy surgeries?

Speaker: Dr. Nilesh
[3:39]

So basically, whenever epilepsy is diagnosed, we always start with medicines, because most of the epilepsies are self limiting. They can cure by themselves. But when two or more drugs fail, and still you continue to have seizures and your doctor keeps on adding drugs. So you are labeled as a drug resistant epilepsy meaning drugs are not controlling your epilepsy. When drug resistance is established, it means that further addition of drugs is not going to help you. And there are very limited sets of drugs. Also drug resistance to control epilepsy suggests that there is a very high possibility of having some structural malformation in your brain. So, then we consider the patient for surgical intervention. To simplify in terms whenever the drugs fail, when two or more drugs fail after adequate trial, and you still continue to have epilepsy, I think you should explore the possibility of surgical intervention or at least evaluation, if there exists any structural malformation which can be removed.

Speaker: Mr. Vivek
[4:52]

What are the investigations needed before proceeding to epilepsy surgery.

Speaker: Dr. Nilesh
[4:57]

So basically whenever the drug resistance is diagnosed, I mean your drugs are not controlling the epilepsy and you continue to have seizures. So we will find out the source area of these epilepsy. So the first and foremost crucial investigation is video EEG wherein you will be admitted and your seizures AND EEG will be recorded under camera. So video EEG will give a fair idea of what part of your brain is producing these kinds of seizures and are the same and do they mean those clinical characteristics of diseases. So with this video EEG, you’re answering the electrical data set, which gives you an idea of the broad part of the brain which is producing seizures. Second is Three Tesla focused MRI. So when we do MRI and see it in a holistic manner in the context of video EEG findings, we will be able to find out the structural abnormality. MRI gives us structural details of your brain. So, electrical datasets come from video EEG and structural data that come from the MRI. The third investigation needed is a neuro psychological investigation which gives the functional detailing of your brain or what exact deficit Do you have, which are not possible to delineate in day to day life. So this is a detailed evaluation. So this is a third data set which is a functional data set. And the last part of the data set is a PET scan, which uses glucose utilization of your brain. So the malformation part of the structure malformed part is supposed to have a bad glucose utilization by the brain. So, it will give you glucose. So, the fourth data set is glucose utilization always is also called a nuclear data set. So, these four data sets are acquired during the pre surgical evaluation. And they are reviewed in a holistic manner not in isolation. So, once all these data sets match or all the data sets are pointing towards the same part of your brain, which is probably producing these kinds of epilepsy or seizures you are having. Then the next question to be answered is whether removal of this part of the brain will produce any new neurological problems in your brain or to you, or like losing a hand or losing a memory or losing a vision. So, as you understand only 20% of the brain is an eloquent brain, rest all is a backend brain. So most of the time the answer is no. Meaning that removal of that part is not going to produce any fresh onset neurological deficit. So once the answer of this question is yes. Then we proceed further with epilepsy surgery. So basically we acquire four or five data sets to answer the relevant questions about proceeding up for epilepsy surgeries.

Speaker: Mr. Vivek
[8:32]

So if I understand well, the four data sets enable a doctor to pinpoint the location of the brain from where the epilepsy is emerging and based on that the surgery is planned. Right?

Speaker: Dr. Nilesh
[8:46]

Exactly. And also it gives you an answer, whether the removal of that part is safe or not .

Speaker: Mr. Vivek
[8:54]

Great, and depending on that, What are different kinds of epilepsy surgeries?

Speaker: Dr. Nilesh
[9:00]

Yeah, so epilepsy surgeries are also broadly divided into two types. One is a curative surgery, meaning we are looking at a cure here from epilepsy and the other part is a palliative surgery meaning that probably we may not aiming the cure because brain damage is very high or very huge or both parts of the brain but the current condition of the patient is so bad that we should make him better and surgically it is possible to make him better. So these are called palliative surgeries. So typically, when we identify the focus and all our seizures are coming from the same part, we call that patient suitable for curative surgery. Meaning that if you remove that part, we are likely to aim at a cure and we will probably not have epilepsy in our lifetime again, as well as we may stand a chance of drug freedom as well. But these are the curative surgeries and curative surgery is typically is resection of some malformation like mesial temporal sclerosis, tumor, arteriovenous malformation or a gliosis. So basically, there is a substrate or there is a malformation identified and we want to remove it. The other part becomes palliative surgeries, so palliation means in the damage are the malformed parties on both the hemispheres or at multiple levels. Like the example, suppose you have a perinatal insult meaning the babies do not cry after birth and they have a huge insult and the brain do not get oxygen at that time and brain we will have insulted both the hemispheres both the sides of the brain, then we cannot remove both the sides of the brain simultaneously the at that time we will have to go ahead with a palliative surgery we will have to explain to the parents that we cannot go ahead and remove both the parts to curative surgery is not possible. So we go ahead with a palliative surgery. So these are the two types of surgeries. curative surgery versus palliative care. Palliative surgery has great outcomes in the form of it reduces the disabling seizures to the tune of like 90-95%.

Speaker: Mr. Vivek
[12:08]

Oh, that’s a huge success rate. And the two broad classifications of surgeries for epilepsy are curative and palliative. Are there further sub classifications within each of these classifications?

Speaker: Dr. Nilesh
[12:22]

Yeah, but that becomes more of a technical jargon. But I would put it as, if you are considering curative surgeries then curative surgeries can be of two types again, that is resective surgery, meaning you’re taking out that part of the brain completely. That is resection. And one more surgical type is disconnective surgeries. Now disconnective surgeries means that the part to be taken out is a big although it is damaged. It is big. So we cannot take out that complete part because then there will be a big cavity inside the brain. So, in that case what we just do is we cut the wires only and leave the part there. So, these are called as disconnective surgeries and typically disconnective surgery the names are hemispherectomy or TPO disconnection or a frontal disconnection. So, these are disconnective curative surgeries where the part of the brain which is abnormal is big and we cannot take out the entire part. So the curative surgeries are resection and disconnection. So now the same goes for palliative surgeries. Now palliative surgeries can also be of two types. One is direct brain surgeries wherein you are cutting the brain. So that name is corpus callosotomy were in wicked, the band which connects the two hemispheres that is one surgery. And the other also the hemispherectomy can also be used as a valid use of series and the other part of the palliative surgeries in neuro modulation. Now neuro modulation means implanting a device like a pacemaker, what we call typically for heart is a pacemaker, which sets the heartbeats. So, similarly, here we have vagal nerve stimulation devices, second is responsible mouth stimulation devices. Third is deep brain stimulation devices. So, basically these are the implants which we put inside the brain on the vagus know, which keep on stimulating the brain in a positive way. So as to reduce the seizure frequency and improve the mood of the patient. So, this is called neuro modulation. We are modulating the brain or we are modulating the electrical circuits of the brain. So, there are advantages and disadvantages of both. So I will cover this in our next topic.

Speaker: Mr. Vivek
[15:09]

What are the typical complications arising out of epilepsy surgeries. Are they safe?

Speaker: Dr. Nilesh
[15:16]

Yes. So, I would like to address it in a very different manner rather than stating it in a simple way. So, basically, epilepsy surgeries are quality of life improvements surgeries so they are not typically life saving surgeries. What we see in case of tumors or strokes, where you do operate upon the brain to save life. Epilepsy surgeries are quality of life improvement surgeries. So by definition of quality of life improvement surgeries, we have to be very specific that the mortality of these procedures should be less than 1%. To give an example, the total knee replacement which is done for osteoarthritis is also a quality of life surgery. So the mortality rate in this surgery is less than 1%. On similar terms, although it is a brain surgery, the mortality of epilepsy surgery is less than 1%. Typically it is one in 500 if I want to quote it, so these are very safe procedures, although they involve the brain so because we have a common understanding that brain surgeries are difficult brain surgeries are complicated, brain surgeries mortality is huge. That is because we have been witnessing the brain surgeries which are being done for the life saving purposes, and life saving purposes surgeries will always have a greater mortality. Because we’re in an emergency situation. Epilepsy surgeries, on the contrary, are very well planned, very well executed, and they require a lot of gadgets to make the procedure safe. So basically the mortality of epilepsy surgery is less than 1% or one in 500. I will put it this way. Now, secondly, why are we requiring these kinds of data sets? Why are we not only operating with MRI? This is because we want to make the procedure safe, because these are quality of life surgeries. So, basically, the chances of acquiring new neurological deficits during surgery inadvertently or unknowing is less than 2% I would say less than 2% which is again very high in your conventional neurosurgery that is tumor surgery or other stroke surgeries. So, again, we do so much of work up or so much of assessments before epilepsy surgery, that we are very well equipped in knowledge understanding of the function at which part is to be removed, so as to make this surgery very safe to satisfy the definition of quality of life improvements. So, to give you gist they are very smooth surgery with a mortality of one in 500. And the chances of acquiring new deficits unknowingly, is less than 2%.

Speaker: Mr. Vivek
[18:35]

That’s so wonderful to know that epilepsy surgeries are safe surgeries. But just to add perspective to it, can you also share what are the odds of getting cured after epilepsy surgeries?

Speaker: Dr. Nilesh
[18:48]

Yes. So basically, the odds are the chances of getting cured depends on what type of epilepsy surgery you’re performing or what type of substrate you are having so typically for substrate or the disease like a mesial temporal sclerosis, the chances of getting cured is almost to the tune of 80% meaning eight out of 10 people will never have epilepsy again. And four out of 10 people will never have to take drugs, meaning the other four which are not having seizures, but will have to take one medicine for a long time. So that is for mesial temporal sclerosis. The similar outcome goes for the procedures like hemispherectomy and dysplasia which are small and frontal. Yes. So basically they depend on the pathology to pathology or what kind of structural malformation you have and what surgical strategy we are taking for these things. But if roughly I want to put it I would say it is 80% meaning I will have to operate upon 10 patients to cure eight patients. We don’t know which two patients are going to fail, but still 80% of the people will be cured from epilepsy from their multiple drugs which they are taking and they will be back again to normal life. So that would be for curative surgery. Same goes for hemispherectomy or other curative surgeries. Now if we look at palliative surgeries, again by definition of a palliation surgery like a corpus callosotomy or neuro modulation, they are aimed at reducing the disabling seizures. Disabling seizures means just to give an example there is something called as Lennox Gastaut syndrome or head drops. So atonic seizures patients will keep falling, if he is standing he will directly slump to the ground and then they will have all the marks of injury to the chin or a forehead or all the bony prominences and they will keep falling multiple times every day. So if you do corpus callosotomy on these patients, the chances of getting no falls again is 95%. Meaning callosotomy cures your disabling fall, but it doesn’t take care of your minor seizures. So that’s why the metrics by which you measure the success in palliation surgery is the percentage reduction of disabling seizures. So, I would say the success rate of Callosotomy In reducing disabling seizure is 90%. And similar lines neuromodulation will have a success rate closer to 50 – 60%. In terms of this reduction in the disabling seizures. So I think this addresses the complete spectrum of epilepsy surgeries and their cure rates.

Speaker: Mr. vivek
[22:07]

All right, and till now we have covered about epilepsy surgeries in detail. What are the types? What are the success rates? Now let’s look at some of the factors which you must be discussing with your patients, while the patients or their relatives or their caregivers are weighing about epilepsy surgeries, right. So when you talk to your patients, what is the rationale you give for epilepsy surgery?

Speaker: Dr. Nilesh
[22:36]

Yeah, that would be an interesting thing to speak about. And I like to talk about it more often than any of these technical terms. So when I say that, we are selecting you for epilepsy surgeries, or we are probably putting you through a pre surgical evaluation for epilepsy surgeries, we must talk about rationale. So when we make this decision, you’re already on multiple drugs you are having multiple seizures. So the patient is having multiple seizures, maybe every day, maybe week, maybe every month, or maybe he’s having clusters meaning four or five seizures come in a cluster and the patient has to be admitted. And then this is the condition, patients come to us asking for or seeking for some help. So many of the patients are not convinced with a thought or with an idea of opening up the brain. And they are very reluctant and they have been never told that a surgical strategy exists for this disease. And then we will have to talk about rationale so when I say look, there are only two ways We treat your epilepsy, either we go for a surgery, if we don’t go for a surgery and continue on the best medical treatment you are having. So you are anyway having this kind of best medical treatment for the last four years, five years, sometimes 10 years before coming to us. So let us have two options, two groups divided one is surgery, we do surgery, or we don’t do surgery and continue the best medical treatment possible. So now let us take one by one chances. Now the first thing is seizure freedom, or the odds of getting cured, or the odds of getting your seizures controlled with best medical treatment in this subpopulation subset is just less than 5%. I mean, addition of any further drug is not going to cure you more than 5% chance. On the contrary, surgery has a chance of 80% I mean, eight out of 10 people will be cured. There is a huge gap between the medical treatment versus surgical treatment in terms of seizure control rates. So that’s the biggest factor. The second factor is the chance of drug freedom or you might not have to take the drug. So if we go for a surgery, there is a 40 to 50% chance that you will not have to take the drug again. Drug freedom, however, in a best medical form best medical treatment, you’re choosing to take medical treatment for lifelong because the structural malformation will not be cured by your medicine. Medicine is just trying to control your seizures, the root cause is not being addressed. So we’ll have to take these medicines lifelong so here is the chance of drug freedom versus lifelong continued drugs or third parties, the complication of drugs or side effects of antiepileptic drugs. When you take one antiepileptic drug for a long time, that is fine. Generally they do not have typical pain. But when you combine more than three or more antiepileptic drugs, they have a huge panel of side effects like mood effects, your bone health goes down, it affects your liver, it affects your kidneys it affects your bone marrows. So there are a plethora of side effects of antiepileptic drugs when they are taken in large doses. And for a long number of days, a long number of years i could say. So, here surgery offers you a chance of when you go for a surgery and a similar problem is that your complication or side effect profile of the drug goes down by a huge magnitude. On the contrary, when you choose the drug treatment, you are accepting those kinds of side effects and you will have to keep visiting your doctors again and again every two months, every three months, then you will keep on going to the hospital again and again for status or multiple major seizures or a cluster. So, nothing is going to change. Now, the fourth point is quality of life when you achieve certain people or when you achieve seizures freedom after surgery. When you achieve seizure freedom, your cognitive profile improves. The patients’ understanding improves, you can go back to school, you can take education, you are eligible for employment, you are again go back to school, societal fabrics and assimilate inside. Here on the contrary, when you are an epilepsy patient under treatment who continues to have epilepsy, your cognition goes down over a period of time. And the side effect profile of antiepileptic drugs in a large doses is also the similar lines that your cognition goes down. Cognition meaning attention, memory, understanding the context or the social connect, all these things comes under a cognitive umbrella. So this goes down over a period of time. So here we are choosing to keep you back through surgery to a mainstream profile. On the contrary, if you do not choose to go for surgery, then you continue on drugs and continue to suffer. Now, let’s come to a financial part. When we come to the financial part, what is said is the amount of money you’re spending for maintaining the drugs for three or four drugs, multiple doctor’s visits, traveling, everything comes together. This is like you do a surgical expenses at the cost of three years maintenance of this patient, meaning if you choose to treat with the best medicines possible in three years time, the amount you spend, you can spend that amount at one go and you will be seizure free. So the breakeven between the continued medical management and the surgical cost at this point of time happens within three years. This is the break even point So it’s like paying a EMI for a lifelong or just three years EMI at one go as a down payment and you’re free and you’re cured. I normally put it in this context. Now, the last point and the most important point is what people see is epilepsy surgery. People are afraid of dying or death or major complications. Now, let me tell you, the chances of death in best medical treatment is one to 1.5 percent per year, meaning drug resistant epilepsy if you choose a cohort of a hundred people who have drug resistant epilepsy and follow them for five years. In five years, seven to eight people will die out of 100 in a drug resistant, uncontrolled drug resistant epilepsy. Now here in surgery, the chance of dying is just one in 500. So there is a definite survival advantage by surgery. Surgery is safer than continued medical management in case of drug resistant epilepsy with uncontrolled seizures, although it appears contrary, because of your ignorance. So once we tell all these factors and rationale of undergoing surgical procedure, most of the people will agree that the surgery should be undertaken.

Speaker: Mr. Vivek
[31:40]

Rightly said Doctor, it’s very nicely put forward the rationale about epilepsy surgeries and just to add to it, how much is the hospitalization needed for the surgery?

Speaker: Dr. Nilesh
[31:52]

So typically, when we see a drug resistant epilepsy patient, we always perform the two sets of admissions, one needs one admission is needed for the pre surgical evaluation, meaning video EEG, MRI, PET scan and neuropsychological evaluation because these are tedious procedures. So, they normally take three to four days depending on your seizure frequency. So, you will be admitted for a video EEG and in the same time all the other investigations will be done and you will be discharged. Because to read this data, it takes us at least 10 to 15 days and then a multidisciplinary meeting will be organized on your data will be held for this analysis of this data and a plan will be arrived at that this is the plan which should execute in this patient. So once that plan is there, you will be called again for counseling purposes so that I explain all the facts and possibilities of epilepsy surgeries and then you’re again, allowed to go home and think about it. So this is a normal protocol for us and then we will schedule the admission for surgery. So typically, we will admit the patient one day prior to surgery to get the basic blood investigations or surgical fitness or pre anesthesia checkup. And once that is done, the surgery will be performed on the day and after that after seven to eight days, we will remove your sutures and let you go home. So typically the first admission will last for three to four days. And the next admission for a surgical admission will last for approximately around eight to 10 days depending on the surgical complications. I mean, there are minor surgical complications like infection and sometimes wound problems and that if they are the chances of all these complications less than one to 2% but still they are there. So apart from that the standard hospitalization is more or less in the tune of eight to 10 days. Depending on which surgery we are performing.

Speaker: Mr. Vivek
[34:03]

Post surgery, how long is the recovery period for the patient.

Speaker: Dr. Nilesh
[34:07]

So typically when we say that we removed your sutures and you’re going to go back home, it means from my side, this record is complete, and the kid can if he wants to, he can join school, or the person if he’s doing a job can join to work. But most of the time, this is unrealistic, and many people will want to stay home for another 10 to 15 days. So I would say that typically most of my patients stay home for one month, I mean, including surgery hospital stay, like after discharge, they will request leave certificate for at least two to three weeks for their recovery at home which is more or less a psychological one. But yes, that is the standard practice in our country. I mean, most of the people will want to stay at home for two to three weeks after surgery. But I would recommend them to join the work as early as possible. From my side, they can join work in two weeks.

Speaker: Mr. Vivek
[35:09]

Okay? And previously you shared that break even of the cost of epilepsy surgery in comparison to the ongoing medical treatment is three years. And I know it might be difficult to put a number, a specific number to the cost of epilepsy surgery. But just for the benefit of our audience, how much is the expense of an epilepsy surgery? And we need not go for any specific number, but to put some context around it.

Speaker: Dr. Nilesh
[35:37]

Yeah, sure. I would definitely want to do that. See, nowadays, most of the doctors or most of the neurologists would prefer newer anti epileptic drugs, over older ones, for the safety and cognition and all that stuff. So if you compare the cost You’re on two or three antiepileptic drugs minimum at times four or five. So, let us consider three as a mean number. So, most of the time people will spend around 2500 rupees every month for buying antiepileptic drugs and every three months they will have to visit a doctor to get some levels done, consultation fees, charges travel expenses, so, this cost comes around 4000 to 5000. So, if you have a cluster or a meaning of major seizures or status Epilepticus most of these people will have it common in this population. So, they will have to be admitted in hospital or emergency room visits basically, at least to take the emergency care services. So, all this cost roughly comes around 4000 to 5000 every month and we are not considering the job loss of one parent because one parent had to stay home to take care of this kid. So we are not even considering that. So, even the financial addition is to the tune of 5000 per month so that comes roughly around 60,000 per year. The cost of epilepsy surgery as of now, the pre surgical evaluation will cost you somewhere around 40,000 at specific institutes not everywhere and the cost of surgery is roughly around 2.25 lakhs or 2.5 lakhs all included. That includes medicines hospitalizations, surgical cause doctor fees consultations, everything included is 2.5 lakhs. So when I say the cost of pre surgical and evaluation and surgery that roughly rounds about three lakhs rupees, which is a semi private facility depends on again the choice is different for patient to patient about a ward and luxury and that’s a different story. But the meaning of the ballpark figure is around two and a half lakhs rupees. So when I say, do we want to pay an EMI for the whole life or you just pay three years of your EMI cost as a down payment and you will be free of seizures, The other advantage is a part. So only on a financial ground. This way is superior as a treatment to continued medical management.

Speaker: Mr. Vivek
[38:32]

In terms of deciding the time of the surgery. Is there a criteria for how early a patient should go for it or the patient can wait for some time or it can be well planned?

Speaker: Dr. Nilesh
[38:45]

So typically, I would say epilepsy surgery is a well planned surgery. It is definitely not elective surgery. As I already explained, that patient is already suffering from seizures for three to ten years. Average around seven years before visiting us. So basically, they’re more or less settled with that epilepsy for seven, eight years. So, weeks difference is not going to definitely matter. Secondly, we require a lot of processing about the data. So when a pre surgical evaluation is done, we will have to work around it for almost like three to four weeks before concluding to a diagnosis. So once that is done, we will plan it well in advance of around 15 days to one month time. So this is a planned surgery. But at the same time, the plan surgery means this is a planning between pre surgical evaluation and surgery. So that gap roughly is around one to two months. But let me state it in a very different manner. So if a kid of three months or four months comes to us with a continuous ongoing seizure, then we do not even wait for six months or we cannot wait for six months because kids brain is a developing brain and more you lose on a developing time of the brain which is first two years. The first two years of the majority of the brain development happened in the first two years. So there is a different criteria for surgery emergencies in the first two years of life. So we consider it emergency whenever a patient comes with multiple seizures every day at three months, we generally operate within the next one month, taking all tapes and all the evaluations at a faster rate. And we counseled them that it would be done within one month. Do not wait for the child to grow for one year because then we lose the very crucial development period of nine months. So nine months out of two year means almost 50% of trainable Brain Age is lost. So the emergency type depends on surgery to surgery. At what age you’re presenting, what kind of epilepsy you’re having. But the idea is earlier the better we operate all the patients after they attain of body weight of five kilogram or three months of age, till any anything I mean like 40, 50 or 60 years old, the patient keeps coming for epilepsy, but the earliest ages three months we operate, we do not wait for the child to grow till one year or two years. So, that there is a very thin line to choose between the surgical risks and the losing the cognition and brain development. So, for me brain development is the essential and crucial most thing in deciding the surgical planning or in deciding the surgery. I will not want to Wait, just because surgical risk goes up from 1% to 2% in a kid for one year and lose all his cognitive abilities to epilepsy and not perform surgery. So, we are a little fast in deciding the timing of surgery. We always say earlier the better, infancy is the best thing because in earlier years, the chances of recovery of the brain is more. Brain is so plastic in nature that even if you produce deficits at the age of three months, by the time a child grows to two years, those deficits will be recovered, because the brain is developing. So other parts of the brain will learn that function and most of the time deficits don’t happen. So these are the advantages of offering surgeries to earlier infancy. So here I would say do not be afraid of subjecting the kid for surgical intervention early if the center is well geared up to treat infantile surgeries, because then you are actually gaining on the child’s cognitive development and the brain development, which is most important. So once the brain development is gone and you need to operate a child at two years, you’re going to treat only seizures and the brain development won’t come back. Once the child becomes autistic or secondary autism sets in, you can control only epilepsy, the autism will not regress. So that is the reason we say earlier the better.

Speaker: Mr. Vivek
[44:00]

That’s very helpful to know. And our discussion today helped us understand epilepsy surgery as a treatment approach. We also learned about different types of epilepsy surgeries both curative and palliative surgeries. And we learned about the complications involved during epilepsy surgeries. Another important aspect we discussed is which are related to hospitalization and rationale and costs associated with epilepsy surgeries. Overall, Thank you Dr. Nilesh, for sharing so much about epilepsy surgeries with us.

Speaker: Dr. Nilesh
[44:36]

Thank you. It was my pleasure to do so. And thank you really for arranging these Talks. These are really very important. Thank you.

Speaker: Mr.Vivek
[44:45]

Thank you, doctor. Dear listeners, please share and spread awareness about epilepsy surgeries and epilepsy in general by sharing this talk with Dr. Nilesh Kurwale. Cheers, till we meet next time.

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