I remember a 30-year-old math teacher who had complex partial seizures. He was considerably distressed by his seizures, which occasionally embarrassed him in front of his class at school. His seizures did not respond to trials of the usual medications, and he went through a presurgical evaluation. To our surprise, his seizure focus turned out to be in the left temporal lobe, despite the fact that he had good mathematical and verbal abilities. He underwent a partial left anterior temporal lobectomy.

Unfortunately, the patient suffered a serious postoperative complication, one that was rare in my experience. A left posterior temporal hematoma developed at the margin of the resection, extending into Wernicke’s area. Consequently, the man became profoundly aphasic. In addition, his complex partial seizures persisted.

The members of the medical care team, including me, were devastated by the complication, as was the patient. Nevertheless, he threw himself fully into rehabilitation and his speech improved substantially. He moved to the South, where, he said, “people talk slow anyway.” He gave up teaching mathematics because he lost most of his mathematical and computational skills. He earned an income by selling insurance.

One year after the man’s surgery he returned to our institution because he was still having seizures. Naturally, we were reluctant to attempt any invasive procedures, but at the patient’s request we put aside our distress over the previous complication. We felt obligated to see if anything could be done to help him, so we began by reviewing his current symptoms and then proceeded to EEG monitoring. Testing showed that his seizures were originating from remnants of the left posterior hippocampal area. After much intense discussion and the patient’s extensive encouragement of the medical team (sometimes such encouragement flows in the reverse direction), we reoperated. This time the patient had no complications. Later, he went back to the South to live.

Three years later, our follow-up indicates that the patient is seizure-free and leads a full and independent life. His aphasia is not evident in casual conversation. He believes that his medical experience overall was extremely worthwhile and says that he would do it again in a moment.

I had a similar experience with an 8-year-old-boy. He had cortical developmental anomalies that gave rise to a catastrophic seizure syndrome. He underwent surgery on his left frontal lobe at another institution, which resulted in postoperative hemorrhage and no improvement at all in his seizures. His parents had educated themselves about epilepsy and its treatments to a degree unusual even for parents of severely challenged children, who often know more about epilepsy than their doctors do.

The child’s parents wanted us to take another look at him. We therefore implanted a subdural grid over the left frontal region. The grid showed his seizure focus to be in the left premotor area, approximately 1 to 2 centimeters anterior to the primary motor cortex. Because their child had recurrent status epilepticus and had required medication doses high enough to cause major behavioral problems, his parents and the medical care team decided to perform another resection.

When he awakened from surgery, the child was densely hemiparetic on the right side. Although some degree of postoperative weakness had been expected, a dense hemiparesis had not. Again, the medical team lost considerable sleep over the complication and spent a very difficult week hoping that the boy’s strength would return and that the seizures would not. After about a week the child began to show some return of tone in his right leg, and by the end of the following week he was able to walk independently with a limp. From that point on, further recovery proceeded rapidly.

Two years later the boy appears normal. He is seizure-free and off antiepileptic medications. His prognosis for continued seizure control appears good; the pathology report showed dysplastic cortex that did not extend beyond the margins of resection. This diseased tissue was undetectable on the magnetic resonance imaging scan of his brain, even on retrospective review.

These two episodes have taught me that seizure surgery, particularly high-risk procedures, can be a roller coaster for patients and families, as well as for the medical care team. In such situations we have to be cautious and to balance the risks dispassionately. Although we must try to empathize with our patients, we cannot let our emotions interfere with our decision-making. Sometimes, when the situation looks darkest, time will turn things around and the value of the treatment and the wisdom of our decisions will emerge.

The Brainstorms Healer: Epilepsy In Our Experience edited by Steven C. Schachter, M.D. and A. James Rowan, M.D., Raven Press, 1998, Lippincott Williams & Wilkins