Epilepsy and Seizures

This series is built on a Jivo Masterclass delivered on June 29, 2025, by Dr. Dinesh Rattnani, Senior Director of Neurosurgery, Neuro Critical Care and Spine Surgery at Max Super Speciality Hospital, Noida. The session was organized for Jivo Healthcare's network of doctor partners across Africa, and it addresses a question referring physicians ask constantly: at what point does a patient with seizures stop being a medication problem and become a surgical one.

Epilepsy is common. Drug resistance is the exception.

Epilepsy is a chronic condition caused by repeated seizures, themselves the result of a burst of uncontrolled electrical activity in damaged brain cells. Most patients respond to medication: 60 to 70% become seizure-free on standard antiepileptic drugs prescribed by a physician or neurologist. The remaining 20 to 40% do not, and this group, not the condition as a whole, is who epilepsy surgery is built for.

Defining drug resistance before considering surgery

Dr. Rattnani draws a firm line before a patient is even labeled drug-resistant. It requires a minimum of two antiepileptic drugs, given at their maximum allowed dosage, with seizures still occurring. Before that label is applied, every modifiable trigger has to be ruled out: stress, sleep deprivation, alcohol use, hormonal changes, illness, fever, flashing lights, physical exertion and dehydration. Only once those factors are excluded and seizures persist does drug-resistant epilepsy become a genuine diagnosis, and only then does a surgical workup make sense.

Why concordance between the scans decides the outcome

The workup rests on three tools: EEG to trace where the electrical discharge originates, MRI to find a structural cause, and video EEG, which admits the patient for 24 to 48 hours to record brain activity and physical behavior simultaneously during an actual seizure, since a routine EEG only captures 5 to 15 minutes. The result that matters most is concordance: whether the seizure pattern, the MRI finding and the EEG focus all point to the same location. Good concordance, for instance a right temporal lobe abnormality on MRI matching a right temporal EEG focus, predicts an excellent surgical outcome. Discordance, where the imaging and the electrical signal disagree, makes surgical planning far more difficult and often requires additional intraoperative mapping.

Three surgical approaches, not one

Once a patient qualifies for surgery, Dr. Rattnani groups the options into three families. Resective surgery removes the abnormal tissue directly, most often for mesial temporal sclerosis, a tumor, a scar from a prior head injury, or damage from a lesion near the motor cortex. Disconnection surgery, including hemispherectomy and corpus callosotomy, does not remove tissue but severs the pathways that let a seizure spread from a focal point into a generalized one. Neuromodulation, using vagal nerve stimulation or deep brain stimulation, changes the electrical behavior of the nervous system itself rather than removing or disconnecting anything, and is the fallback when imaging shows no operable lesion at all.

The rest of this series works through each of those decisions in turn: how to refer a patient for the right workup, what resective and disconnection surgery actually involve, how neuromodulation works when there is no lesion to remove, the real complication and success rates behind these procedures, how antiepileptic drugs are managed after surgery, and the multidisciplinary team that has to sign off before any of it happens.

This article is based on a Jivo Masterclass session conducted by Dr. Dinesh Rattnani, Senior Director - Neurosurgery, Neuro Critical Care & Spine Surgery, Max Super Speciality Hospital, Noida. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording

Looking for a neurosurgery consultation or a second opinion on epilepsy surgery? Get in touch with the Jivo team