Blog #155: Robot-assisted brain surgery at Canada’s London Health Sciences Centre provides hope for people living with epilepsy.

 

Since 2011, my monthly epilepsy blog followers (LanceFogan.com) have reviewed several blogs touching on the efficacy of epilepsy surgery on improving epilepsy—often cures result. Specialized epilepsy neurosurgical centers evaluate each candidate and if the seizure focus can be localized with various test procedures, and if it is determined that surgery on that focus would be safe without debilitating side-effects, e.g., speech problems, motor, sensory or visual complicating deficits, highly successful outcomes are routine.

Review my most recent epilepsy blogs on epilepsy surgery: blog #145 Aug. 25, ’22; blog#121, Aug 25, ’20, and blog #89, Dec 26, ’17.

 Bryan Bicknell, the CTV News Reporter, on June 23, 2023, reported that a neurosurgeon at the London Health Sciences Centre in London, Ontario, Canada, became the first to perform deep brain stimulation with a robot!

Neurosurgeon, Dr. Jonathan Lau, reported that all three of these robot procedures he has done since January 2023, have been successful. All went home a day or two after the procedure. He likens it to implanting a pacemaker for a bad heart.

“This is the same idea. People with epilepsy have a predisposition to having seizures, so they have irregular rhythms in their brain in terms of electrical activity. So, the same principle applies. An irregular rhythm there, so we put electrodes in the appropriate spots with the aid of the robot which is less intrusive than surgery. The electrodes can restore function and prevent seizures.” Lau said it was almost by accident that he and his team at University Hospital decided to employ it for this specific use.

“It was actually a fairly routine day when we decided, ‘Okay, because we don’t have the other options let’s use the robot.’ So, we inquired a little bit and it turns out nobody had done this for this indication in Canada,” he explained.

Epilepsy is one of the most common neurological disorders in the world, affecting one percent of the population, more than 300,000 Canadians. And not only is there a stigma around the disease itself, but Lau said there’s also a stigma attached to the very surgery to improve life for those living with it. Brain surgery can seem scary, but Lau said new technologies actually make it safer.

“With things like robotic assistance, with improvements in imaging, the risks of the procedure are much, much lower, and it’s just raising that awareness,” he said. Lau added that robot-assisted deep brain stimulation surgery is a treatment for some patients who would not otherwise be considered for surgery. 

This is another road you might consider if your epilepsy is uncontrollable.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

 

Blog #148: EPILEPSY AND SEVERE ABDOMINAL PAIN

Belly pain is a common complaint primary care doctors deal with. A specific cause often can’t be determined. Psychological and emotional causes are considered when your doctor cannot identify a cause. But, don’t exclude a physical cause that can’t be detected. As I have often told my patients, “Medicine is the practice of an art. Doctors really have too few answers and doctors can cause lots of problems.” So, follow-ups and gathering more information often reveals the correct diagnosis.
Episodic belly pains can suggest epilepsy known as ABDOMINAL EPILEPSY. This phenomenon is rare. In a large series of patients with epilepsy only 2.8% (24 of 858) experienced pain of any sort (headache, facial and body pains on one side) but only 3 of these 24 patients had belly pain: severe and sharp “like a knife”. ¹ I personally considered this possibility, especially in children. Some people with this condition have no other features of epilepsy, i.e., no altered consciousness or movements such as lip-smacking seen in complex partial seizures, exaggerated swallowing, shaking nor incontinence during the episode. A case described by physicians at the Mayo Clinic contained both elements of episodes of pain and epilepsy. Many physicians and patients can be confused by this combination of symptoms. ²
A person had no known risk factors for epilepsy except for a fall at age 4. He lost consciousness associated with the fall. That same year he experienced his first seizure: he initially complained of belly pain, ran out of the house and had a convulsion. EEG then showed no diagnostic etiology for the seizure, and he was given no antiepileptic medications (AEM). At age 20 he had another convulsion and carbamazepine was prescribed. When non-compliant the patient discontinued his AEM and more convulsions occurred. Additionally, the patient complained of recurrent episodes of central abdominal pain since childhood up to 10 times some days; he could go a month without these pains. The pain would last seconds to hours.  Multiple examinations with endoscopes peering into his intestinal tract were unrevealing. A diagnosis of irritable bowel syndrome was proposed. At times the pain was so severe he contemplated suicide.
Because of no altered consciousness nor convulsions his carbamazepine dosage was reduced at age 32. He then had a complex partial seizure preceded by belly pain which lasted throughout the seizure. He then consulted with a neurologist who recognized the recurrent episodes of belly pain as possible epileptic phenomenon. He was hospitalized and studied with EEG and video monitoring. Several complex partial seizures were recorded. Before each seizure onset he reported mid-belly pain. EEGs showed an epileptic focus in the left frontotemporal region. MRI showed scarring in the inner side of the temporal lobe, i.e., mesial temporal sclerosis, a common abnormality found in complex partial seizures. Specialized EEGs identified the abnormal focus. It was surgically removed and he has remained free of seizures and episodic belly pains for 5 years, 3 without AEMs. ²
Other researchers found these belly pain seizures associated with parietal lobe and frontal lobe origins.
In my past blogs, surgical removal of brain epileptic foci is beneficial, often curative, and safe (see my blogs #143 and blog #114 at website LanceFogan.com)
 
1.  Young GB,Blume WT. Painful epileptic seizures. Brain. 1983; 106 (pt 3):537-554.
2.  Eschle D., Siegel A. and Wieser H-G. Epilepsy with severe abdominal pain. Mayo Clin
3.   Proc. 2002; 77:1358-1360.
 
Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His emotionally hard-hitting family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in a recent Publishers Weekly, New York Times Book Review and the Los Angeles Times Calendar section. DINGS teaches epilepsy and is now available in eBook, audiobook, and soft and hard cover editions.
 

Blog #145: Epilepsy Patient Passes Driving Test After Brain Surgery

  

Several of my previous 144 monthly blogs on LanceFogan.com dealt with brain surgery as a chance to improve, or even cure, epilepsy in those whose epilepsy is poorly controlled. (See Blog # 89 December 26, 2017: Surgical Removal of Seizure Foci in Your Brain to Cure Poorly Controlled Epilepsy is Safe!; Blog # 101 February 26, 2019: Epilepsy—Fit to Drive?; Blog # 114 January 26, 2020: Epilepsy Surgery in Childhood and Long-Term Employment Is Encouraging.; Blog # 121 August 25, 2020: If Your Seizures Aren’t Controlled Epilepsy Surgery Is Safe and Really Can Help).

 

The greatest chance to cure your uncontrolled epilepsy is by successfully removing the seizure focus surgically.

My clinical experience has shown that there is so much that can physically alter the brain anatomically by surgery and by unintended trauma that surprisingly results in undetectable, or barely detectable, changes in a patient’s mental and physical capabilities. I have examined people who have been shot in the head, the bullet entering one side traversing through parts of the brain and exiting the other side of the head sparing sensitive brain areas. When neurosurgeons and neurologists perform specialized types of EEGs and imaging scans anticipating epilepsy surgery, sensitive parts of the brain can be identified and avoided.

The BBC on-line service recently reported that a man with epilepsy says he finally has independence. A surgical procedure removed his epilepsy focus and he then was able to pass his driving test.¹ The 40-year-old man had the brain operation eight years ago. Government rules meant the computer programmer from Birmingham was unable to take his driving test unless he was seizure-free for two years. But twice since learning to drive he had a seizure, setting him back each time and then Coronavirus lockdowns led to further delays. But eventually he was able to take the test and since passing, plans to take his young family on regular camping trips.

The man said he never thought he would be able to drive after living with epilepsy since childhood. But he underwent lesion resection, which involved inserting electrodes into his brain to detect electrical activity and carefully removing abnormal tissue.

Discuss possible epilepsy surgery with your neurological caregivers.

 

1)    Epilepsy Patient Passes Driving Test After Complex Surgery. https://www.bbc.com/news/uk-england-birmingham-62568014. Aug 16, 2022.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in a recent Publishers Weekly, New York Times Book Review and the Los Angeles Times Calendar section. DINGS teaches epilepsy and is now available in eBook, audiobook, and soft and hard cover editions.

 

 

 

 

 

 

 

 

 

   

 

Blog #121: IF YOUR SEIZURES AREN’T CONTROLLED EPILEPSY SURGERY IS SAFE AND REALLY CAN HELP

I have addressed epilepsy surgery before in several of my 120 monthly epilepsy blogs published at LanceFogan.com since 2011. Evidence is overwhelming that epilepsy surgery, if you are a candidate, is safe and can be tremendously beneficial in reducing, or even, curing your epilepsy.

 

The chief research officer and epilepsy specialist at Cleveland Clinic, Lara Jehi, MD, detailed the patient-centered pros and cons associated with epilepsy surgery, as well as the stigmas related to it. “Even before you put a patient through the surgical testing, neurologists have to identify if they’re a surgical candidate. The most cost-effective option is to send them to get that evaluation.” Jehi hopes that her study can help demystify some of the preconceived notions that surround epilepsy surgery. NeurologyLive /www.neurologylive.com/videos/lara-jehi-md-pros-and-cons-of-epilepsy-surgery.

 

A recently published study that evaluated costs found epilepsy surgery was cost effective ($328,000) compared to medical management ($423,000) in surgically eligible patients and more effective (measuring Quality Adjusted Life Year of 16.6 vs. 13.6 QALY) than medical management in the long run. The quality-adjusted life year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived.¹

 

The data has potential to raise eyebrows within the epilepsy community, and ultimately sway more patients to not only get the surgery, but to at least have their own surgery-eligibility evaluated. Dr. Lara Jehi feels that patients don’t fully understand the benefits that come with epilepsy surgery. She encourages those eligible to at least consider surgery knowing their less-than-effective anti-seizure medication will probably not improve their quality of life.

 

“There are a lot of fears out there. Some justified, but some due to misperception and misinformation that may stop someone from getting to the point of looking at brain surgery.” Jehi provides insight on the truth behind the stigmas related to epilepsy surgery and whether patient fears are legitimate. In the above video Jehi discusses moms worried about weeks long hospitalizations for testing, other family responsibilities during that time; time off work; relatives with past complications due to other types of surgeries.

 

Her study results confirm the positives of surgery. Epilepsy surgery is underutilized and not recommended to a large number of patients by their neurologists despite multiple studies proving its effectiveness and long-term benefit with drug-resistant temporal lobe epilepsy. Jehi hopes that her study can help demystify some of the preconceived notions that surround epilepsy surgery.

 

1. Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Cost effectiveness of surgery for drug resistant temporal lobe epilepsy in the US. Neurology. Published online July 8, 2020. doi: 10/1212/WNL.0000000000010185

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

 

 

Blog #98: Highlights from the Epilepsy Symposium: University of Southern California. September 15, 2018

Ten percent of the American population will have at least one seizure in their lifetime and one in 26 Americans will develop epilepsy; epilepsy is diagnosed when more than one seizure occurs. Americans with epilepsy number 3.4 million, 65 million people world-wide have epilepsy. There are 48 newly diagnosed cases/100,000 population each year.

• The Communicable Disease Center (CDC) found the death rate for all Americans in 2017 was 844.0 deaths per 100,000 population or 0.84 percent.¹  This statistic is not that dissimilar to the 500 to 1000 deaths per 100,000 people with epilepsy that die each year. However, life-expectancy for people with epilepsy averages 19 years fewer than the general population. In 2014, SUDEP (sudden unexplained death in epilepsy) was listed as cause of death for only 2650 people. Death certificates don’t always list accurate causes of death, but SUDEP is thought to occur in one out of 75-150 Americans, or 30,000, of all ages with epilepsy annually (SUDEP is discussed in my blogs #13, #57 and #68), especially in those whose epilepsy is poorly controlled. Fifty percent of the epilepsy population have more than one seizure/year, i.e., their epilepsy is active and not in remission.
• One-third of the epilepsy population is NOT under the care of a neurologist, the physician-specialty that is more expert in caring for epilepsy patients.
• The greatest number of newly diagnosed patients with epilepsy currently is over 60 years of age, not the pediatric population (see LanceFogan.com blog #15).
• Pregnant women, and those who are considering getting pregnant, should take 400 micrograms of Folic Acid vitamin daily. Folic Acid can lower the incidence of nervous system and other malformations in the fetus. Verbal abilities in children of mothers on antiepileptic drugs (AEDs) who started daily Folic Acid at least four weeks before conception exceed verbal abilities the children of mothers with epilepsy not taking Folic Acid.²

GENETICS IN EPILEPSY:

• Genes that connect with actions of certain anticonvulsants (AED) are now being identified. If these genes are present in the patient a more effective AED can be chosen. Some of these effective medications are not even AEDs but medicines used for other diseases. To date, these genetic laboratories are rare. When two AEDs have been unsuccessful in controlling one’s epilepsy, genetic testing should be done. Genetic testing is expensive, but its use is growing and should benefit many uncontrolled patients. As of 2018, seventy percent of people with epilepsy have no identifiable cause. Genetic screening will probably result in many more identifiable causes.

SURGICAL EPILEPSY TREATMENT:

• Epilepsy is now considered a surgical disease. Epilepsy centers evaluate patients with sophisticated equipment. If an abnormal brain area can be located as the origin of seizures, 60-70 percent are cured of their epilepsy or markedly improved. As scary as brain surgery sounds side effects, as significant thinking, memory, motor or sensory problems, are uncommon. Nonetheless, surgical treatment is underutilized, probably because of fear and expense.

OTHER DEVICES AND TREATMENTS IN EPILEPSY:

• Vagus Nerve Stimulation: in use since 1997. Its effectiveness in decreasing seizures increases over time with its use independent of AEDs. Side effects include cough, hoarseness and shortness of breath because the vagus nerve stimulates these functions of the vocal cords and the respiratory functions. Usually an out-patient procedure.

·         Responsive Neurostimulator: a portion of the external skull surface bone is scooped out for a battery-powered computer (batteries need replacement every 3-5 years) to fit in this bone-bed, then covered with scalp tissue. Thin stimulators are placed into the area of the brain where the seizure originates via two small drill-holes through the skull. Whenever the apparatus detects the beginnings of a seizure the stimulator probes “fire.” This “short-circuits” and halts the seizure. Researchers believe cognition increases over time, probably because fewer seizures occur that interfere with thought. Over one-half of the patients decrease their seizure frequency by 60 percent.

Ketogenic Diet:

            Mostly reserved for intractable epilepsy. Not ideal for good surgical candidates. Effective across the age spectrum. In use since Mayo Clinic doctors in 1924 found this diet efficacious. It consists of 90% of calories from fat and only 10% from carbohydrates (sugars) and protein. The diet is safe and can be effective in children and adults. Ten percent of patients become seizure-free & 40 percent achieve more than 50 percent decrease in seizure frequency at one year. Forty percent remained on the diet at one year due to their successful control. Of 53 percent of the people who discontinued the diet, half was due to poor tolerance and half due to poor seizure control. Response to the diet may take a month to occur.

• Excellent response in most genetic and primary epilepsies (Juvenile Myoclonic, brain malformations and trauma, Dravet, West and Lennox-Gastaut syndromes, infantile spasms, tuberous sclerosis, and others). The ketogenic diet should not be used when certain other conditions exist, usually metabolic diseases.

1)   https://www.cdc.gov/nchs/fastats/deaths.htm 

2)     Husebye ESN, Gilhus NE, Riedel B, et.al. Verbal Abilities in Children of Mothers with Epilepsy. Neurology 2018: 91:e811-e821.

3)     A. Bergqvist in Epilepsy and the Ketogenic Diet; edited  by Stafstrom & Rho, 2004

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.