Online Health Chat with Imad Najm, MD and Jorge Gonzalez-Martinez, MD
November 28, 2012
Epilepsy is one of the most common neurological disorders in our country, affecting approximately 2.5 million Americans of all ages and backgrounds. Remarkable advances in the diagnosis and treatment of epilepsy have been made in recent years. The success of epilepsy surgery is measured in terms of the operation’s impact on seizure control and improvement in quality of life. Successful surgery eliminates seizures in many patients. For others, seizure frequency is markedly reduced.
Ten years after epilepsy surgery, 68 percent of Cleveland Clinic patients who have undergone temporal lobe resection (removal of tissue)—the most common type of epilepsy surgery—continue to be seizure free. Significant improvement in lifestyle and social interactions also may occur.
New and increasingly effective surgical strategies are continually being developed, which could open up surgical treatment options for more epilepsy patients. For both children and adults, Cleveland Clinic provides state-of-the-art diagnosis and treatment in a caring environment.
The process to decide whether you are a candidate for surgery involves a thorough medical history and physical examination, including brain wave monitoring and other tests. The goal is to identify a specific source of seizures in your brain that can be safely removed without affecting important brain controlled functions.
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On Cleveland Clinic
The multidisciplinary Neurological Institute at Cleveland Clinic is a leader in treating and researching the most complex neurological disorders, advancing innovations such as epilepsy surgery, stereotactic spine radiosurgery, interstitial thermal therapy for brain tumors and deep brain stimulation. Annually, our staff of more than 300 specialists oversees nearly 175,000 outpatient visits and performs more than 9,500 surgical/interventional procedures.
Cleveland Clinic has one of the largest, most comprehensive programs in the world for the evaluation and medical and surgical treatment of epilepsy in children and adults . The Cleveland Clinic Epilepsy Center is committed to delivering world-class care for patients with epilepsy by providing excellent clinical management and the use of state of-the-art diagnostic and therapeutic techniques and approaches. We perform clinical and translational research to improve the knowledge and treatment of epilepsy, and strive to train world-class academic epileptologists and clinical neurophysiologists.
U.S.News & World Report's ‘America's Best Hospitals’ survey has consistently ranked the Cleveland Clinic's neurology/neurosurgery, psychiatry, pediatric neurology/neurosurgery and rehabilitation programs among the best in the nation.
Adult neurology and neurosurgery at Cleveland Clinic is ranked fifth nationally and is top-ranked in Ohio by U.S.News and World Report. Pediatric neurology and neurosurgery is ranked third in the nation and is top-ranked in Ohio by U.S.News and World Report.
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To make an appointment with Dr. Najm, Dr. Gonzalez-Martinez or any of the other specialists in the Epilepsy Center at Cleveland Clinic, please call 216.636.5860 or 866.588.2264. You can also visit us online at clevelandclinic.org/epilepsycenter
About the Speakers
Imad Najm, MD, is Director of Cleveland Clinic's Epilepsy Center at the Cleveland Clinic Neurological Institute, Division of Neurosciences. Dr. Najm is board certified in adult neurology, with an added qualification in clinical neurophysiology. He completed his fellowship in epilepsy after a residency in neurology at Cleveland Clinic. Dr. Najm completed his internship at Sacre Coeur Hospital after medical school at Saint Joseph University Faculty of Medicine in Beirut, Lebanon. Dr. Najm’s specialty interests include medical and surgical management of adult and geriatric epilepsy, malformations of cortical dysplasia, basic mechanisms of epilepsy and post-traumatic epilepsy. He has conducted numerous research projects on the topic of mechanisms of epilepsy and malformations of cortical dysplasia.
Jorge Gonzalez-Martinez, MD, is a neurosurgeon with Cleveland Clinic’s Epilepsy Center and a member of our biomedical engineering team. Dr. Gonzalez-Martinez completed his fellowship in functional and epilepsy surgery at Cleveland Clinic and a fellowship in stereotaxis and neuro-oncology at Wayne State University-Detroit Medical Center, in Detroit. He completed his residency in neurosurgery at Cleveland Clinic and at University of Sao Paulo Hospitals and Clinics in Brazil, where he also completed medical school. His specialty interests include epilepsy surgery and medical treatment of epilepsy in children and adolescents, general neurosurgery, brain malformations causing epilepsy, brain tumors, mechanism of epileptogenesis and vagus nerve stimulation among many other topics.
Let’s Chat About ‘Is Epilepsy Surgery Right for Me? New Advances in Epilepsy Surgery’
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic epilepsy experts Imad Najm, M.D. and Jorge Gonzalez-Martinez M.D. We are thrilled to have them here today to discuss epilepsy and the latest surgical options. Let’s begin with some of your questions.
Diagnosis of Seizure Types
jeanneb: Are atonic seizures considered partial seizures?
Dr_Najm: Atonic seizures could be partial seizures, but sometimes they could be part of what we call generalized epilepsy. A determination of the cause and type of epilepsy causing your atonic seizures requires a video EEG (electroencephalogram) evaluation in the Epilepsy Monitoring Unit. This is important because, if these seizures have failed control with medications and they were shown to be partial, there may be a possibility of epilepsy surgery that may result in seizure control.
jeanneb: What are the primary symptoms and seizure types seen from the left temporal side of the brain?
Dr_Najm: Symptoms include rising abdominal sensations (the ‘so-called’ abdominal auras) smell sensations, sensation of fear, feeling of déjà vu and other associated symptoms.
The signs of temporal lobe epilepsy are as variable, but typically consist of staring, lip smacking, stereotypical repetitive hand movements, and, at times, chewing and swallowing salivation.
As you may have guessed, it is very hard to determine with a high degree of certainty the type of epilepsy from simply observing the seizures. Therefore, it is necessary to have further evaluation with various techniques that include video EEG (electroencephalogram) evaluation, MRI (magnetic resonance imaging), PET (positron emission tomography), SPECT (single photon emission tomography) and MEG (magnetoencephalography).
m0h1t: I have been an epileptic patient for two years and have recently shifted from Lamictal® 100 mg and Depakine® 1000 mg daily to Topamax® 100mg and Depakine® 1000 mg daily. Is the dose that I currently take of Depakine® Chrono 1000 mg and Topamax® 100 mg safe?
Dr_Najm: As long as you do not have any side effects from taking the two medications, the doses you are taking are not supposed to lead to any problems. As a matter of fact, many of our patients do take much higher doses of both medications, but you have to keep in mind that each patient tolerates a certain dose of a particular medication.
jeanneb: What are the long-term effects of anti-seizure medications when a patient is uncontrolled and does not qualify for surgery?
Dr_Gonzalez-Martinez: Long-term effects can be related to memory loss, loss of concentration, difficulty walking, and so on. A follow-up with an epileptologist is needed to ensure good levels of medication while avoiding the side effects.
m0h1t: Is a is a combination of Topamax® 100 mg and Depakine® Chrono 1000 mg daily a good dose for epilepsy?
Dr_Najm: Yes. If seizures recur on these doses, both medication doses could be increased.
Neurosurgery Evaluation and Surgical Outcomes
jeanneb: Are there specific types of seizures that have a better outcome from surgery?
Dr_Gonzalez-Martinez: Yes, surgery is better for focal epilepsy and seizures that don't involve eloquent areas of the brain, i.e., areas with important functions for everyday life such as speech, motor control and vision.
jeanneb: What areas of the brain do not qualify for neurosurgery?
Dr_Gonzalez-Martinez: In general, areas with high function like the brain stem, basal ganglia, and speech and motor areas are generally not candidates for neurosurgery.
mrrenneisen: With a frequency of two seizures in one year, would surgery be a consideration, or do you recommend staying the course on oral medication, increasing dosage or adding another medication?
Dr_Gonzalez-Martinez: It depends on how the seizures are affecting your quality of life. In some patients, this can be an indication for further treatment.
musicnote: How do I know if I am a candidate for epilepsy surgery?
Dr_Gonzalez-Martinez: In order for you to be a candidate for epilepsy surgery, you need to have focal epilepsy—meaning the seizures are coming from a single area in the brain. You also need to be medically refractory. This means you should have tried at least two different types of epilepsy medications without significant results—meaning they were unable to control your seizures. Once you meet these criteria, surgery may be an option.
nyst: Can surgery cure my epilepsy?
Dr_Gonzalez-Martinez: It depends what type of epilepsy you have. In general, surgery has the opportunity to completely stop the seizures, but it all depends on what type of seizures you are experiencing.
mrrenneisen: I am presently working. After a period of four years with no seizures, I have had several seizures in the last year. I feel I need to explore the possibility of surgery. How much time away from work would I need to plan to have an initial evaluation to find out if I am a candidate for surgery?
Dr_Najm: The evaluation would require 10 to 15 days. This obviously depends on the tests that we would need to do. I suggest that you call our Cleveland Clinic Epilepsy Access Coordinator Lauri Stegman at 216.445.0601.
Surgery Success Rates
mrrenneisen: What is your success rate with surgery for temporal lobe seizures, as well as the nature of complications and likelihood of an undesirable outcome from surgery?
Dr_Gonzalez-Martinez: The resulting seizure control from surgery varies from 60 percent to 70 percent. Complications related to surgery in the temporal lobe are two to three percent.
jeanneb: Out of the 68 percent success rate in brain surgery enabling patients to be seizure-free, is this for a specific type of seizure? Do the majority of patients who have grand mal seizures benefit from brain surgery?
Dr_Najm: Different types of epilepsy with different locations in the brain may respond differently to epilepsy surgery. For example, patients who suffered from epilepsy arising from the temporal lobe and a very well defined lesion shown on MRI do much better after brain surgery than patients exhibiting seizures arising from functional areas of the brain and with normal MRI.
Medical studies show that patients who have a history of more that 20 grande mal seizures in their lifetime prior to surgery do slightly worse than patients who have fewer grand mal seizures or no grand mal seizures at all.
mrrenneisen: What are the criteria to consider surgery as a successful at the 60 to 70 percent range? Can you describe what is considered a complication?
Dr_Najm: We consider success in epilepsy surgery when seizures are fully controlled —either on or off anti-epileptic medications.
Complications are variable. They include bleeding, infection, stroke, loss of function, headaches and so on.
jeanneb: Is the 68 percent seizure free rate after surgery, the percentage that is shown on your website, based on patients with specific types of seizures?
Dr_Gonzalez-Martinez: Yes, they are based on temporal lobe seizures.
Neurosurgery Techniques and Recovery
suzieQ: My 30-year-old daughter is scheduled for surgery with Dr. Martinez on December 11 for epilepsy. What can I expect? Will she be normal, i.e., minus the seizures, after surgery? We have been praying really hard. How long will her recovery be? How many of these surgeries do you do per year?
Dr_Najm: Epilepsy surgery is safe if performed in the right setting by an experienced surgeon such as Dr. Gonzalez. Besides the expected postoperative recovery issues, we shouldn’t expect any major complications. Dr. Gonzalez may have already let you know about or will be sharing any additional information about any complications that are specifically associated with the type of surgery your daughter will be having. We are very proud of our surgeons and their records in performing epilepsy surgeries for many years.
coleen: Can you please tell me if techniques have improved since 1987, so that the post-surgery headaches aren't quite as debilitating as they were following my lobectomy? Dr_Najm: Many new techniques have been introduced for both the evaluation of patients with epilepsy and their treatment. This includes major improvements in the EEG (electroencephalogram) video evaluation, MRI (magnetic resonance imaging) accuracy and PET (positron emission tomography) scan. In addition, newer techniques have been introduced, such as magnetoencephalography (MEG), ictal SPECT (single photon emission tomography), functional MRI and stereoelectroencephalography (SEEG). For more information and updates, please check our website at www.clevelandclinic.org/epilepsycenter
plato: What exactly is a resection? Is the hippocampus cut in to separate sections?
Dr_Gonzalez-Martinez: Resection means the removal of a specific area in the brain. The hippocampus is not cut into separate sections; it is completely removed.
mrrenneisen: If your hippocampus is removed, how does that affect your memory?
Dr_Najm: It all depends on the side, and presence or absence of scarring in the hippocampus. If the seizures are arising from a scarred hippocampus, there is little or no impact of surgery on memory. If the seizures are starting from a normal-looking left hippocampus and in the setting of good memory, memory may be affected.
Grid Implants for Focal Point Identification
chelsea: My brother has left temporal epilepsy. He has about five to eight complex partial seizures per day. Occasionally, he also experiences other unusual seizures. He has no control, even with medications. The doctors have been unable to find the focal point. All they can say is that it is in the left temporal region, and possibly in his hippocampus. The doctors want to implant grids for a week and run tests to, hopefully, find the focal point. Can you tell me about grid implants, and what can to expect with these?
Dr_Najm: At Cleveland Clinic, the implantation of grids requires a craniotomy (skull opening) and replacement of electrode grids directly on the brain. Immediately after the implantation, the patient is sent to an intensive care or post-anesthesia care unit and then transferred to the epilepsy monitoring unit for seizure recording and mapping. Shortly after surgery, the patient may experience a headache and have swelling of the face.
At Cleveland Clinic we frequently evaluate patients with suspected MRI negative left temporal lobe epilepsy with either a combination of subdural grids and depth electrodes or our new technique of SEEG (stereoencephalography). The depth electrode implantation will allow a sampling of the activity in the hippocampus, which is a structure we try to spare if the MRI is normal.
Vagus Nerve Stimulation
welsh: Can you talk about vagus nerve stimulation (VNS)? What can one expect with this therapy?
Dr_Gonzalez-Martinez: VNS is applied as a palliative measure to control seizures. It will not stop your seizures, and will only partially control them in 40 percent of patients. The surgery takes about an hour and has minimal complications. There are two incisions, one in the neck and one in the chest. A pacemaker is inserted together with an electrode that is connected to the vagal nerve. Electricity is applied to the nerve to help control the seizures. Patients usually return home in less than one day. Follow-up appointments to adjust the VNS are necessary.
Surgical Advances and Research
nikkim: Are there any new advances in epilepsy surgery techniques?
Dr_Gonzalez-Martinez: In the last 10 years, many new techniques have been developed in order to diagnose, localize and treat seizures. Examples are the SEEG (stereoencephalography), which is a new minimally invasive method to localize seizures that are located in deep areas of the brain. Another method of treatment is the laser ablation, which allows us to treat deep located seizures with a 1 cm incision allowing the patient to return home within one day in most cases.
lb16: My 21-year-old son had a SEEG (stereoelectroencephalography) done at Cleveland Clinic about a year and 1/2 ago. He had a rare complication from the surgery that was a brain bleed and swelling. His seizures changed from complex partial to secondary generalized tonic clonic seizures. If he were to consider surgery evaluation again, would you do intracranial brain mapping this time? From the SEEG they determined, but not definitely, that his seizures were coming from the temporal pole tip and/or the insula, which is inoperable. He is currently on Potiga® 1200 mg, Vimpat® 400 mg and Onfi® 20 mg. Where would you go from here? He still has seizures, and the longest time he has gone without a seizure is 25 days
Dr_Najm: Obviously, this is a tough situation for your son. Not knowing the exact details of the previous evaluation, complications and the results makes it very hard for me to comment more specifically on your question. However, I will be happy to review his records and get back to you and him. Please contact my office at 216.445.1107
jeanneb: In your opinion do you feel like someone that is uncontrolled and has been uncontrolled should be working?
Dr_Gonzalez-Martinez: Yes, but it depends on what type of work. Work that requires driving or operating heavy machinery is, in general, not recommended.
jeanneb: Would it be OK to work as a school teacher?
Dr_Gonzalez-Martinez: Yes, that should be fine.
jeanneb: Do you find that a majority of patients living with epilepsy work outside the home?
Dr_Najm: Yes. As we all know, epilepsy can affect any of us, and does not preclude any of us from living and functioning normally in society. Some of the most brilliant and most influential people in history suffered from epilepsy.
jeanneb: What is the best thing to do after a seizure to care for yourself?
Dr_Gonzalez-Martinez: If it's an isolated seizure, in general, a resting period of six hours is recommended. If it's a sequence of seizures, which are unusual to the normal pattern, patients should go to the ER.
mrrenneisen: Does your electrolyte balance affect your propensity for seizure activity?
Dr_Najm: It may. The major electrolytes that would decrease your seizure threshold (thereby, increase your seizure activity) include low magnesium, low sodium or low calcium.
General Questions and Comments
jrachvr: Dr Najm was part of my wife's surgery team in December 2009. To this date, she is still seizure-free and we had a baby boy three months ago. Thank you, Dr. Najm.
Dr_Najm: Thank you for your kind comments.
jeanneb: I appreciate these answers; I know that your team is one of the best in the nation. Based on my short experience with Dr. Najm, my daughter was treated by him at the Cleveland Clinic in Weston, Florida last year.
Dr_Najm: It is wonderful to get this type of feedback from wonderful people like yourself. Thank you.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic epilepsy experts Imad Najm, MD and Jorge Gonzalez-Martinez, MD, is now over. Thank you, Dr. Najm and Dr. Gonzalez-Martinez for taking your time to answer questions today about epilepsy and the latest surgical options for treatment.
Dr_Najm: Epilepsy surgery has become an accepted, safe and effective treatment option to help manage patients with difficult-to-control seizures. Epilepsy surgery should be considered in those patients who suffer from focal epilepsy, and who have failed to respond to at least two anti-epileptic medications. The pre-surgical evaluation should be performed at a highly specialized epilepsy center like Cleveland Clinic, since it does require a truly multi-disciplinary approach with access to the latest technologies for the mapping and removal of the epileptic focus.
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