Question 1

How do you prevent neurological complications from dissecting brain tissue during epilepsy surgery?

Dr. Dinesh Rattnani · Accepted Answer

Follow the basic anatomical rules and do not breach the arachnoid plane. Use navigation in as many cases as possible and be very selective, with electrocorticography confirming the resection is complete. In the mesial temporal lobe, the anterior choroidal artery and the third nerve lie just medial to the correct surgical plane, so staying within that plane avoids most complications. Bleeding that is severe enough to cause panic is when surgeons are most likely to breach the arachnoid and lose track of the anatomy. The vein of Labbe must also be preserved during a temporal lobectomy, and dissection should not go medial to the tentorium.

Question 2

After hemispherectomy, does the patient still need antiepileptic drugs, and what happens to their function?

Dr. Dinesh Rattnani · Accepted Answer

Hemispherectomy does not mean removing the entire brain. It disconnects the frontal lobe from the temporal and parietal lobes, and from the occipital lobe, so a seizure starting at one focal point cannot spread and become generalised. It also does not mean the patient comes off antiepileptic drugs. It is reserved for very resistant cases, patients already on four or five drugs whose seizures continue regardless, and even then it is not a guaranteed cure. With continued medication, seizures can usually be brought under better control.

Question 3

How do you reduce the risk of paralysis on the opposite side of the body after hemispherectomy?

Dr. Dinesh Rattnani · Accepted Answer

The corticospinal tracts are not cut. The disconnection stays within the white matter, which is mostly sensory and is the pathway mainly responsible for the seizure activity spreading, so the motor pathways controlling movement are preserved.

Question 4

Is epilepsy surgery available only in India, and what complications can arise from it?

Dr. Dinesh Rattnani · Accepted Answer

Epilepsy surgery is not unique to India. It is practiced everywhere a neurosciences centre exists, including the US, UK and Canada, and is done at a minimum of 40 to 50 centres across India alone.

Question 5

What is the prognosis of epilepsy surgery, and what complications are associated with it?

Dr. Dinesh Rattnani · Accepted Answer

The complications are basically infection, bleeding and meningitis, along with weakness, hemiparesis, hemiplegia and memory loss. An equally important complication is the surgery simply not achieving the expected result, meaning the seizure frequency does not come down even though the operation itself went as planned. That specific outcome happens in roughly 5% of cases.

Question 6

As a layman with no medical background, if someone asks me for help, is my role simply to get an EEG and an MRI done and share the results?

Dr. Dinesh Rattnani · Accepted Answer

Yes. Get the EEG and MRI done, share the reports, and the surgical team will review them and advise from there.

Question 7

Which epilepsy cases actually need surgery, and can a teenager undergo it?

Dr. Dinesh Rattnani · Accepted Answer

The best candidates are cases with good concordance between where the seizure semiology points, what the MRI shows, and what the EEG confirms, for example a right temporal lobe abnormality on MRI matching a right temporal EEG focus. Temporal lobe epilepsy accounts for 70 to 80% of these good-responder cases, typically treated with temporal lobectomy along with amygdalohippocampectomy. Teenagers can absolutely undergo the surgery, but medical management is always tried first.

Question 8

What are the recommended antiepileptic drugs for a patient with a normal EEG and a normal MRI?

Dr. Dinesh Rattnani · Accepted Answer

Sodium valproate and levetiracetam both cover a broad spectrum and rank as the top two choices for most epilepsy types, including generalised tonic-clonic and atonic seizures. For focal seizures with secondary generalisation, carbamazepine is slightly preferred, though sodium valproate also works well. Lacosamide is a newer add-on drug, used alongside a first-line drug rather than as initial therapy. Perampanel is particularly useful when the epilepsy is related to a brain tumour or damaged brain tissue.

Question 9

Is robotic surgery used for epilepsy surgery?

Dr. Dinesh Rattnani · Accepted Answer

No, not at this centre. In neurosurgery, robotic assistance is currently limited to placing spine screws. No brain surgery is done with a robot here, though other centres may use it differently.

Question 10

What is the post-operative drug management for these patients?

Dr. Dinesh Rattnani · Accepted Answer

The drugs the patient was already on before surgery are continued unchanged for the first 10 to 15 days. After that, one drug is withdrawn at a time, slowly, rather than stopping everything at once. The patient is kept on at least one drug for about a year while seizure-free, and full withdrawal is only considered around the two-year mark, since these are patients who were having seizures despite medication before the operation.

Question 11

How does vagal nerve stimulation actually help control seizures?

Dr. Dinesh Rattnani · Accepted Answer

The exact mechanism is not fully understood, but the proposed explanation is that it is a parasympathetic stimulation. Stimulating the vagus nerve sends signals back to the brain, and the brain's electrical activity is reduced as a result. Deep brain stimulation works on a related principle: stimulating the anterior thalamic nucleus also reduces the spread of epileptic activity.

Question 12

What drug do you prefer, and is robotic surgery an option here?

Dr. Dinesh Rattnani · Accepted Answer

Sodium valproate is the preferred drug of choice. Robotic surgery is still not used at this centre for brain procedures.

Question 13

Is terahertz wave technology useful in managing epilepsy?

Dr. Dinesh Rattnani · Accepted Answer

This is not something familiar from current practice. Standard advice is to exhaust medical management first, and only refer for surgery once the patient is not responding to it.

Question 14

Are there advances that could make a patient seizure-free for the rest of their life?

Dr. Dinesh Rattnani · Accepted Answer

That is what everyone in this field is working toward, but it cannot be guaranteed. Sometimes it succeeds, sometimes it does not, and improving long-term seizure freedom remains a continuous, ongoing effort rather than a solved problem.

Question 15

Based on your experience, what has your success rate been for these surgeries?

Dr. Dinesh Rattnani · Accepted Answer

Around 80% of patients get a desirable result or at least a meaningful reduction in the antiepileptic drugs they need, though a seizure-free or drug-free outcome can never be guaranteed. In 90 to 95% of cases, the surgery at minimum does not make the patient worse. The overall goal is to improve the patient's quality of life from wherever it currently stands, not to promise a cure.

Question 16

This patient population needs a multidisciplinary approach. What about post-operative management and rehabilitation?

Dr. Dinesh Rattnani · Accepted Answer

Nearly all of these cases need a multidisciplinary team: a neurologist, a neurosurgeon, a neuropsychiatrist and a psychologist are all involved in assessment. If a complication does occur, the impact on quality of life can be serious, which is exactly why the case is discussed with neurology, neuropsychiatry and psychology first, and surgery only goes ahead once that team gives its approval.

Question 17

Is a funded scholarship available to come and observe brain surgery at your centre?

Dr. Dinesh Rattnani · Accepted Answer

There is no funded scholarship, since this is a private institution, but an observership can be arranged to come and see brain surgeries in person. Government institutions such as the All India Institute of Medical Sciences and Sree Chitra Tirunal Institute may have funded options worth trying separately.

Diagnosis & Management of Epilepsy & Seizures

Questions Doctors Asked Dr. Dinesh Rattnani