Epilepsy is a chronic neurological condition that affects more than 2.5 million Americans. Uncontrollable seizures plague these patients’ lives. Until now, the only treatments were drugs and major surgery, but new therapies are on the horizon.
Jeff Martig suffered from seizures for 20 years that would strike anytime and anywhere!
“I was having about 30 a day.” Martig told Ivanhoe, “I would feel a sensation in my nose and then my left side of my face would twitch, and then I would start gasping for air.”
Jeff had surgery to remove part of his brain. Doctors at the Cleveland Clinic are studying less invasive ways to stop seizures. They’ve used an experimental technology called SEEG on almost 300 patients.
“It’s a technology to help us in locating, knowing where, where is the area in the brain, where the seizures may be coming from.” Imad Najm, MD, Director of the Epilepsy Center at the Cleveland Clinic told Ivanhoe.
Electrodes in the brain record seizure activity. Once the area is identified, doctors can use lasers to ablate it instead of major surgery to remove it.
“So without making any major changes, we remove the electrode, we put in another probe, we ablate the focus and we put it back.” Dr. Najm explained.
Another advance is the recently FDA approved responsive neuro-stimulator. The device is implanted in the skull and records electrical activity in the brain. When it detects a seizure, it delivers electrical pulses to intercede.
“For the first time, we have a device that is smart enough to record, detect and do something about the seizure on the spot.” Dr. Najm said.
New ways doctors are helping patients like Martig live seizure-free!
“I’m a brand new person. It’s amazing!” Martig said.
Patients with epilepsy should try medication first, but studies show between 40 and 50 percent continue to experience seizures or suffer major side effects. The neuro-stimulator device was approved for seizures last November.
Dr. Najm says patients who aren’t typically candidates for surgery may be eligible for this device. He says the laser therapies are still considered experimental.
EPILEPSY: Epilepsy is a chronic condition that affects the human brain and can cause seizures. Most people with epilepsy suffer from more than just one type of seizure and may have other neurological problems. Epilepsy is diagnosed when a person has more than two seizures that aren’t caused by a known medical condition. An epileptic seizure occurs when there is an excess of abnormal neuronal activity in the brain. Epilepsy is different from a seizure in that a seizure is a single event, whereas epilepsy is a disease that can cause multiple seizures in a particular timespan. (Source: www.epilepsy.com)
CAUSES: There is no single identifiable cause for approximately half of all who suffer from epilepsy. In others, epilepsy can be traced to a few known factors such as genetics, head trauma, prenatal injury and brain conditions. When brain conditions like a tumor or stroke cause damage to the brain, it can lead to epilepsy. Some cases of epilepsy can also be caused by developmental conditions like autism. (Source: www.mayoclinic.org)
TREATMENTS: To control the symptoms of epilepsy, many patients turn to anticonvulsant medications. Some common drugs used to treat epilepsy are Valium, Mysoline and Zarontin. When prescribing the drug, doctors must take into account the frequency and severity of the patient’s epileptic seizures. Generally, these medications control the symptoms of epilepsy in 70 percent of patients. (Source: www.webmd.com/epilepsy)
NEW TECHNOLOGY: The newly developed SEEG test uses electrodes in the brain to identify the source of epileptic seizures. Once the source is identified, doctors use lasers to remove the problem area. On top of this new test, a new device called a Responsive Neuro-Stimulator can actually use electrical pulses to stimulate the brain and eliminate a seizure before it ever starts. Neurologists implant the device into the skull which can detect and record the brain’s EEG. If symptoms of a seizure begin to occur, the stimulator sends electrical pulses to disrupt the activity. (Source: www.epilepsy.com)
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Imad Najm, M.D., Director, Epilepsy Center at Cleveland Clinic talks about new less invasive ways to stop seizures.
Dr. Najm: In our department we’re seeing much more epilepsy patients coming to Cleveland clinic and we don’t think it’s because there is an increase in the number of patients with epilepsy, but rather that there is some increase in awareness about the options for patients who have a diagnosis of epilepsy.
Explain the advantage of using the new laser technique and how it works together with SEEG.
Dr. Najm: Laser basically is a big type of light that uses lots of heat on a particular area of the body. It’s delivered through a small electrode, like a small cylindrical device that is very thin and could be a fraction of an inch in diameter that’s inserted through a small burr hole in the skull. Targeted into the computer assistance is the area of the brain that we need to ablate or to heat up and destroy. The big advantage of it is that we don’t need a big surgery or a big opening in the skull in order to remove or resect a particular area of the brain. In the case of epilepsy, that’s where the epilepsy itself is coming from. We can also define the area that we now ablate or remove very clearly without all of the potential complications from what we know as standard neurosurgery. SEEG, stereo encephalography, is a technology that is a natural treatment. It’s a technology for us to help in locating and knowing where the area is in the brain where the seizures may be coming from. The principle here is to make burr holes in the skull and introduce encephalography to record seizure or brain wave activity which is called EEG, electrical encephalography, from various areas in the brain and try to find out where the seizure focus is. We think these could be very complementary. For example, if we see a particular area deep inside the brain where the seizures are coming from, through the electrode of SEEG we can know exactly how to get to that region because we have the computer coordinates of where it is in the brain. We can pull the electrode that is recording and insert the probe that is delivering the laser heat, remove the electrode, put in another probe, ablate the focus and put it back.
They tell me this is something a patient will recover a lot quicker from as opposed to a surgery where you have to open up the entire skull.
Dr. Najm: Absolutely. I think one of the bigger advantages is that the patient would not undergo a craniotomy, an opening in the skull. They will just have one small burr hole, a very tiny fraction of an inch made in the skull and a probe inserted, then pulled back. Most times the patient can go home either later in the day or the next day.
Who are the main candidates for this and for SEEG?
Dr. Najm: At the Cleveland clinic we started using SEEG in 2009 as a technique. Since then, we are close to around 300 cases we’ve done over the last five years. During this period we learned quite a bit about who could benefit from an SEEG. Some of the patients who would benefit from the SEEG, we already knew from the beginning and some new types of patients with epilepsy, we are learning that SEEG may be very helpful to them. In general, SEEG is very good in any patient who is suspected to have epilepsy coming from one single area of the brain. We do not know exactly where the area is and the MRI scan of the brain is normal. SEEG could be very helpful because it could sample multiple areas in the brain in a very less invasive way, without any major complications, to try to pinpoint the area in the brain that is epileptic. If we help those patients who we could not touch from a surgery standpoint, we would use the brainwave recording and see epileptic activity coming from the left and right. In these situations we could not do much with them because we could not put electrodes in the majority of cases in both sides. With SEEG we can sample the left side of the brain and the right side of the brain almost at the same time. It gives us a huge advantage to hopefully locate the areas of the brain where the seizures are coming from and ultimately help these patients. Another type of patient who could be helped with SEEG is someone with lesions and scars. That’s potentially irritating to the brain and could lead to seizures and epilepsy, deep inside the brain. All the methods that we used here, in particular in North America and at Cleveland clinic, we used electrodes on the brain after a craniotomy but we could not cover the deeper areas. Now we’re using the SEEG technology and perfecting it like our neurosurgeons have done over the last five years. We’re able to sample the brainwave electrical activity from deeper areas of the brain and therefore enhance our ability to locate where epilepsy is coming from in deeper areas of the brain.
Now back to laser, what kind of success are you seeing with the laser technique?
Dr. Najm: It’s too early for us to make any major statement about it at this stage. We just have less than a handful of cases that we’ve done so far here. So it’s too early for us to judge the long-term results. But so far the statement or the statement I can make is that laser is safe. we didn’t have any complications and the lesion that is created or the ablated area in the brain that we accomplished is exactly what we intended to do. As for earlier results from a seizure standpoint we have some hope that at least in a couple of the patients there is a decrease in the number of seizures, although at this stage we cannot make a big statement about complete control of seizures. We’re waiting for more time and certainly more patients.
And any other advances on the horizon that show promise in treating seizures?
Dr. Najm: I think the biggest excitement has been over the last six to twelve months, the NeuroPace device. NeuroPace is the responsive neurostimulator. This responsive neurostimulator is a pacemaker of the brain that is inserted through a small area in the skull and there are electrodes that are touching a particular area of the brain deep under the surface where we think the seizures are coming from. This device continuously records EEG brain waves and has special software that will detect if a seizure is occurring. When it does, there is an automatic electrical stimulator that will go and stimulate to ablate or abort a particular seizure from continuing. That’s the principle. This is exciting because for the first time we have a device that is smart enough to record, detect and do something about the seizure on the spot. We are very hopeful that technologies based on responsiveness and detection will deliver treatment based on an event that’s occurring and spot it and detect it. That will open the horizon for us not only to deliver electricity in the future, but to deliver medications on demand and meet the seizure on demand.
And with the neurostimulator we’re seeing patients that weren’t able to get surgery before?
Dr. Najm: Absolutely, a person who has a very clear focus in an area where speech is generated; taking out or removing the epileptic area there will result in loss of speech. The neurostimulator will be a very good option because it does not ablate or destroy the epileptic area. It controls epileptic activity when it happens. When it’s not happening it won’t interfere with the brain function that is speech. Some other patients who may benefit from the responsive neurostimulator are those patients who have multiple foci or multiple areas in the brain that are epileptic. It’s very tough to do epileptic surgery to remove all of them. These are situations where these patients can benefit from the responsive neurostimulator. Some type of patients are patients of what we call temporal lobe epilepsy, where the foci or the areas of epileptic activity are both in the left and the right hippocampi and hippocampus is in the area of the brain that supports memory. We cannot do surgery to take both hippocampi because it would lead to amnesia which is forgetfulness and inability to make any new memories. In this situation we think it’s a very good idea to put electrodes on both sides of the brain in both the hippocampi and let the device analyze and respond to any seizures that’s occurring either left or right or both.
And any recent research on the cause or who might be getting epilepsy?
Dr. Naji: A lot of research is done in epilepsy, obviously not enough because we still have far to go before we come up with some better understanding of it. I think the most exciting type of research that is being done is that we are now following up patients with time and looking at the molecules and at the genetic changes in the patient’s brain and models of epilepsy. What we’re seeing now is that epilepsy is not static. That means it’s not a disease that happened at a certain time and it’s not going to progress. We are now documenting what we all suspected hundreds of years ago, that epilepsy is a progressive disease. It’s getting worse with time. What are the implications of this knowledge or this renewed validation of previous statements about epilepsy? The aggressive nature of epilepsy means that we need to control seizures and epilepsy as soon as we can. We need to do it preferably with medications but if medications don’t work we should definitely try to ask ourselves if a surgical option is a valid one or not. That’s why we encourage patients, families, people who have loved ones who have epilepsy or suspected epilepsy to make sure they accept nothing but complete seizure control and if this is achieved with antiepileptic medications then that’s wonderful. But usually 70 percent of these patients have achieved seizure control with medications. If seizure medications fail to control seizures, then surgical options should be strongly encouraged and done if the patient is a good candidate. If surgery is not doable, there are newer options which are quite exciting. I’m sure in the future we’re going to come up with better ways to treat most epilepsy.
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