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Epilepsy Outcomes of Surgical Treatment

Online Health Chat with Lara Jehi, MD

August 13, 2014

Description

Patients with epilepsy experience seizures that are difficult to control despite multiple medications. A successful epilepsy treatment should translate into a “good” quality of life and not simply be measured by seizure frequency. At Cleveland Clinic’s Epilepsy Center, we strongly believe the burden of epilepsy extends beyond a “seizure count.”

At Cleveland Clinic’s Epilepsy Center, we are integrating various measures of overall health with every patient encounter. During every outpatient clinic visit, we measure seizure freedom or frequency (how often are seizures happening) in order to determine whether treatment is controlling, or reducing, the occurrence of seizures and the extent of such an improvement.

The large number of epilepsy surgeries performed at Cleveland Clinic and the long duration of follow-up available on our patients allow us to accurately analyze our results and determine how well patients respond to surgery. Using modern statistical methods of analysis, the Epilepsy Center Team was able to determine that in the group of patients evaluated, 78 percent were completely seizure-free two years following temporal lobectomy, 66 percent were seizure-free five years following surgery and more than 50 percent remained seizure-free more than a decade later.

Some of the most important outcomes that the Epilepsy Team focuses on include (but are not limited to): improvement in quality of life in adult and pediatric epilepsy patients treated with medications or following surgery, seizure severity in adult and pediatric patients treated with medications or following surgery and long-term seizure freedom following epilepsy surgery.


About the Speakers

Lara Jehi, MD, is an epileptologist who treats adults with epilepsy at Cleveland Clinic's Epilepsy Center. Dr. Jehi received her medical degree at American University of Beirut Faculty of Medicine in Beirut, Lebanon. She completed her neurology residency at Cleveland Clinic in Cleveland, Ohio.

Dr. Jehi is board-certified in neurology and clinical neurophysiology with many clinical interests, including the medical treatment of epilepsy, epilepsy surgery and outcome analysis. She is the head of Clinical Research and currently leading efforts to broaden the spectrum of epilepsy management at the Cleveland Clinic Epilepsy Center to include social, psychological and quality of life aspects. She is also focused on research pertaining to appropriate selection of epilepsy surgery patients and defining predictors of seizure outcome following surgery.


Let’s Chat About Epilepsy Outcomes of Surgical Treatment

Moderator: Welcome to our chat with Cleveland Clinic epileptologist Dr. Lara Jehi. We are thrilled to have her here with us today to share her expertise about outcomes of the surgical treatment of epilepsy. Let’s get started with the questions.


SURGERY SPECIFICS

subcat2: What is the most common type of epilepsy surgery for patients and its success rate at Cleveland Clinic?

Lara_Jehi,_MD: The most common type of surgery at Cleveland Clinic is temporal lobectomy. More than 80 percent of patients are seizure-free for the first one to two years after surgery. More than half are still seizure-free a decade after surgery. Patients also see an improvement in their mood and quality of life.

mradam: Do you have to be awake for the surgery? If yes, how would my anxiety be managed? Where would the entry site be? Do you have to drill through the skull? How would the opening be sealed up?

Lara_Jehi,_MD: Typically (in more than 95 percent of the cases), patients are under anesthesia (asleep) for the surgery. In very rare situations, the patient needs to be awake for a portion of the procedure.

Answering your other questions requires me knowing more about your type of epilepsy and the expected surgery. There are many different types of epilepsy surgery and each has its own entry point, healing, etc.

mradam: How long would I be in the hospital for the surgery? Would I have to continue with physical therapy afterward? How often would I see my doctor after? Are there worries about infection or other complications from the surgery? How soon could I go back to work?

Lara_Jehi,_MD: Hospital stays vary in duration, but on average, patients go home within three to four days of the surgery. Usually, no rehab is required. Patients could return to work within four to six weeks of the resection. Exact numbers within these ranges again depend on the case and should be discussed with the surgeon doing the procedure.

Birgit: What is the recovery time for a patient undergoing epilepsy surgery? Is rehab or therapy also a part of the recovery process?

Lara_Jehi,_MD: The recovery time depends on the surgery itself. Most patients go home within three to four days, don't need rehab and are back to work within a few weeks. Rarely, rehab is needed, and in those cases, it may last for two to six weeks.

Jeriamy: I need to know if the reaction in your brain that makes you have seizures can be removed and if the surgery is fatal.

Lara_Jehi,_MD: Epilepsy surgery, depending on the case, can control seizures in up to 80 percent of patients. The mortality risk with surgery is 0.1 percent. The mortality risk from seizures is 1 percent every year. So, uncontrolled seizures are more life-threatening than the surgery itself. In fact, surgery was shown to increase the life expectancy by five years (i.e. people who have the surgery live five years longer than those who don't).

Cathyb1955: What is your opinion on laser ablation to treat epilepsy, specifically a 1.5 cm right temporal lobe low-grade tumor causing focal seizures? Thank you.

Lara_Jehi,_MD: For the specific case of a right temporal lobe low-grade tumor, I would recommend surgical removal (traditional resective surgery) rather than laser ablation. In this situation, resective brain surgery offers a low complication risk coupled with a high success rate. Laser ablation has not proven to be better or even equivalent to resection for the treatment of epilepsy in the setting of a well-defined epileptic pathology such as a brain tumor.


CANDIDATE EVALUATION

loveitaly: I read in your profile that one of your special interests is surgery in patients with intractable seizures. Who are good candidates for these types of surgeries? What is the rate of success of these interventions? After the surgeries, is it necessary to continue taking the anticonvulsants? Are candidates patients with epilepsy only, or are patients with developmental delays such as cerebral palsy, intellectual disability, or non-ambulatory, nonverbal patients possible candidates, too? I commend you for your interest in this complicated field, especially in the aspects of social, psychological and quality of life that you are working on. Thanks for responding to my questions.

Lara_Jehi,_MD: Thank you for your interest. Patients need to fulfill two main criteria to be candidates for epilepsy surgery: 1) the seizures need to come from one spot of their brain; and 2) the spot in the brain needs to be one that can be removed without affecting vital functions such as language, memory, etc.

Rates of success depend on the location of the “seizure spot” and how much of the brain is removed. In general, at least half of the patients are completely seizure-free a decade or so after surgery. You can find more detailed outcomes in the Outcomes section of our webpage http://my.clevelandclinic.org/neurological_institute/epilepsy/treatments-services/treatment-outcomes.aspx.

Medications are usually reduced after successful surgery. The decision to stop them altogether is individualized depending on the case.

To have surgery, the patient needs to have epilepsy. Cognitive challenges are not a contraindication.

I hope I have addressed your various questions, and I am happy to answer any related to a specific case during a clinic visit.

Sarah: I understand patients undergo a pre-surgical workup that provokes seizures under close observation and determines which part of the brain generates seizures and can be safely removed. Can you tell me more about the pre-surgical evaluation?

Lara_Jehi,_MD: The test you describe is called a video-EEG evaluation. This is one component of a pre-surgical evaluation and usually occurs in a specialized Epilepsy Monitoring unit in the hospital, where a patient stays for three to five days. Other pieces of a pre-surgical evaluation include:

  • Getting a high-quality brain MRI to find any abnormal spots that can cause seizures. This is done for every patient considering surgery.
  • Getting some detailed pictures of the brain such as PET scan, or MEG or ictal SPECT. Those are special imaging studies that are only obtained in specific situations.
  • Sometimes, we also obtain a neuropsychiatric test to determine how surgery can affect memory or language.
  • There are additional tests that are again tailored to the individual case.

mradam: If a regular MRI and my video-EEG evaluation were inconclusive, are there other tests that could identify where my seizures are originating?

Lara_Jehi,_MD: Several other tests can be helpful, including:

  • A high-resolution (3-Tesla) brain MRI can show very subtle abnormalities that could be causing the seizures.
  • An ictal SPECT evaluation can be helpful: that is a video-EEG evaluation where a nurse waits with you in your room within the Epilepsy Monitoring unit to inject a special tracer in your IV line at the beginning of a seizure to "show a picture" of the spot that is triggering your seizures.
  • Other imaging studies such as a PET scan or MEG can be helpful.

The decision of which additional tests to do is typically made in our center after a detailed review of the original set of data (your regular MRI and VEEG) by a group of epilepsy specialists.

mradam: I heard from a friend who is a nursing student that there is a new type of SPECT test that is less invasive and does not require injection into an IV. Do you have more information on that?

Lara_Jehi,_MD: An ictal SPECT requires an IV injection. There are other newer tests, such as an MEG scan, that give some very helpful information without requiring an IV injection.


RESULTS REALITY

Katarina45: This is a very basic question and geared to the lay person. When you state “outcomes,” what does that exactly mean?

Lara_Jehi,_MD: It means how well does a procedure (in this case surgery) actually work? Outcome questions include: How often does surgery get rid of seizures? How well does it improve people's function? How can it affect their mood? Questions of this sort help us understand how well something works and how can we make it better.

Chicago65: How have results been for patients with interictal spikes coming from the posterior right temporal lobe? Also, how have outcomes been for patients with multiple seizure foci? Thanks.

Lara_Jehi,_MD: Outcomes with such an interictal spike localization actually depend on the type of surgery being contemplated and the pathology in question. Location of the spiking by itself doesn't really "drive" how well a patient does.

Multiple seizure foci reduce the chances of seizure-freedom to about 20 percent to 30 percent. These patients may be candidates for responsive neurostimulation (NeuroPace). An evaluation with invasive EEG is typically required to determine if a patient should have resective surgery or neurostimulation in this setting.

mradam: Why do seizure surgery outcomes show that 72 percent of adults are seizure-free at one year, but only 43 percent are seizure-free at 12 years?

Lara_Jehi,_MD: This is the topic of a lot of research. The current thinking is that some patients have a genetic or other predisposition for seizures and are at higher risk of their brain developing epilepsy over time. That is one of the reasons why we don't recommend completely stopping seizure medications after surgery, as this may uncover such tendencies.


MEDICATION MATTERS

mradam: If I were going to have the surgery, would I be weaned off the medications before it, after or not at all?

Lara_Jehi,_MD: You will continue to take your regular seizure medications until about six months after surgery. At that point, testing will be done to determine how successful the surgery was. Depending on the findings of the tests (mainly outpatient EEG), medications may be either continued or tapered down and reduced. In most cases, patients end up on a low dose of one medication within one to two years of surgery.

Mollie73: I had a right temporal lobectomy in July 2011. I have been seizure-free for 1 1/2 years (yeah!). My doctor hasn't made a big change in my medications yet. How do you feel about the generic medications?

Lara_Jehi,_MD: I don’t typically recommend changing to generic medications if a patient has been seizure-free. You just don’t want to take any chances in this situation and would rather continue what is working. Talk to your doctor about possibly reducing the doses of some of your medication, as that might be an option.


REVIEW REQUIRED

thornsnpetals: In July 2013, my brother, an engineer, was put on medical disability. In December in Milwaukee WI Hospital, they removed a piece of his skull and put electrodes in his brain. After three weeks, they could not pinpoint the origin of his seizures so they closed him back up. His cognitive skills, memory, emotions and knowledge seem worse than before the surgery and don't seem to be improving. He is like a very old man rather than a man in his 40s. We can't get clear information from him or his wife. Is this usual? What can we ask or do to help? I have given him computer games called Lumosity, if you are familiar with them.

Lara_Jehi,_MD: An adequate answer requires a detailed review of your brother's case, including the type of surgery that was done, any surgical complications and an assessment of his mood to rule out depression. Going through a long and extensive surgical evaluation can affect a patient's level of function either through a direct injury to the brain through a surgical complication, an insult to the brain from multiple recurrent seizures during the evaluation or from the psychiatric trauma of not ending up with a surgical hypothesis. It is impossible to know which of these factors is the cause without a more detailed review of the case.

Richie: I have suffered from recurrent seizures that are not stopped by medicine and have been diagnosed with epilepsy. Do you think I would be a good candidate for epilepsy surgery? Are there any other pre-qualifications for surgical candidates?

Lara_Jehi,_MD: You may be a candidate. I recommend you at least look into it to give yourself the best chance of getting rid of these seizures. "Looking into it" should start by seeing an epilepsy specialist at a center that does epilepsy surgery, such as Cleveland Clinic, to review the details of your case and arrange for the video-EEG evaluation we discussed earlier in this chat.

4niB10: I have frontal lobe epilepsy and have taken medications for years to control my seizures. It seems medication therapy is becoming less effective in controlling my seizures and I’m feeling defeated. Where should I go from here?

Lara_Jehi,_MD: You should get an evaluation for epilepsy surgery as soon as possible. We have recently shown that particularly for frontal lobe epilepsy, early surgery is essential to get rid of seizures (http://www.ncbi.nlm.nih.gov/pubmed/?term=simasathien+jehi). I suggest that your next step should be to make an appointment with an epilepsy specialist within the Cleveland Clinic or anywhere else that does epilepsy surgery.

Moderator: We want to offer you a chance to follow-up with our specialists to get answers to your questions on epilepsy treatment options. To schedule a same-day consultation, please contact us toll-free at 866.588.2264 or by email at epilepsy@ccf.org.

mradam: Does that mean the same-day consultation would be over the phone?

Lara_Jehi,_MD: A consultation requires a clinic visit. Phone calls are insufficient to provide any definitive information.

Moderator: For further information about a consultation, please email epilepsy@ccf.org.

RAAAY3: My son was in Cleveland Clinic for a workup for surgery. I got the written report and on the EEG side. It said: location right front temporal max f8t8 60 % discharge and location left front temporal f7t7 30 % discharge and right and left occipital; 10% discharge the octal SPECT test showed symmetric tracer retention in the cerebral cortex, subcortical gray matter and cerebellum, by vis using z score of more than 2 as significant hyperperfusion potential sites of seizure activation are identified in the following cluster area 1. left anterior to mid temporal lobe, left superior insula dr impression interictally has multi regional epileptiform discharges in both temporal regions, indecent, maximum on noted over the centroparietal vertex and evolving better over left front temporal region. The seizure semiology ws bilaterally asymmetric tonic seizures with no clear lateral. What does all this mean? Does he look like a candidate for surgery? Is it on one side or both?

Lara_Jehi,_MD: The meaning of all these tests should be discussed in a clinic visit with your son's epileptologist. We usually review all these tests in a "patient management conference" where your son's doctor and all remaining epilepsy specialists, neurosurgeon, radiologist, etc. get together to discuss the findings and decide as a group if he can have surgery or not. If you don't have an appointment with your son's epileptologist to go over these results, please call his or her office and make one.

RAAAY3: We do have an appointment on September 15 at Cleveland. I am wondering by reading this if his seizures are on both sides of the brain or is it suggesting one over the other. No medication seems to be helping. I was told it can take three to five years before they consider surgery. It will be three years this Fall. This medical language is difficult for me to understand.

Lara_Jehi,_MD: This medical language is, indeed, difficult to understand. Also, the decision about surgery requires a combination of tests and pieces of information beyond what you have in your question. That is exactly why we don't recommend looking at each test individually and we don't give a determination about being a surgical candidate or not until after the patient management conference. Your doctor on September 15 will have the bigger picture after reviewing these and the several other tests that your son had. So please, make sure you make it to that appointment.

Rick: I had one grand mal seizure in 1980. I have had complex partial seizures from the right temporal lobe since. I have tried several medications and still have seizures. I’ve had a few less over the years since1980, but have had a lot of side effects from so much medication I take daily. I have had tests to see if I am a candidate for surgery, and was told I was, but after having seizures for 34 years, I was told it would only be about a 50/50 chance it would be successful. This doesn't seem very good odds, considering I have no insurance to pay for such a surgery.

Lara_Jehi,_MD: Your exact chances of success will require a review of some additional information, such as findings on your brain MRI and your video-EEG evaluation. These will need to be reviewed before we determine if it is indeed 50/50 or higher or lower.


OPTIONS OPEN

golfpro: I am considering VNS (vagal nerve stimulation) treatment to control my seizure activity. I'm wondering if the normal outcome is to continue prior drug therapy, or does the VNS eventually eliminate the need for all or most of the drugs?

Lara_Jehi,_MD: VNS is a "palliative" epilepsy treatment. That means it helps with seizure control, but does not get rid of seizures. Patients who get a VNS may see a reduction in frequency of their seizures (meaning they may have fewer seizures), but typically continue taking seizure medications. Other such "palliative" options include additional medications or a ketogenic diet or responsive neurostimulation. The only option currently available that can eliminate seizures is brain surgery. I would encourage you to investigate that possibility first with an epilepsy specialist. If you are not a candidate for surgery, then a VNS may be considered as a second choice.

Moderator: We want to offer you a chance to follow-up with our specialists to get answers to your questions on epilepsy treatment options. To schedule a same-day consultation, please contact us toll-free at 866.588.2264 or by email at epilepsy@ccf.org.

dbob: Earlier this year I read about a new FDA-approved device called the NeuroPace RNS System for use in people with epilepsy whose seizures can’t be controlled with medication or surgery. Does Cleveland Clinic offer this and if so, can you tell me more about how this system works?

Lara_Jehi,_MD: NeuroPace is a very interesting new treatment that was recently FDA approved. Cleveland Clinic offers it. The process starts by seeing one of our epileptologists in the outpatient clinic for an office visit. The epileptologist will then review all of the prior evaluations and tests that you had and then determine your candidacy for NeuroPace after presenting this information in a "patient management conference," as described earlier in the chat.


GENERAL INFORMATION

cindy4hope: Can migraines be related to epilepsy? I had epilepsy brain surgery in 2002, and I have been seizure-free since the surgery; however, I have had a few auras. I now have chronic migraines. Is there any relation?

Lara_Jehi,_MD: Some patients do get chronic headaches after surgery. This is called post-craniotomy headache, and they can either resolve within a few weeks or become a chronic issue. If you need help with management of the headaches, I recommend an evaluation in a headache clinic.

Pdob: Neither the American Association of Neurological Surgeons nor the Epilepsy Foundation appears to compile data regarding which medical centers are doing the highest volume of epilepsy surgeries; what specific surgeries are being performed where; and data relating to surgical outcomes. Can you recommend a source for this information? And if not, how can patients make the best choice about where to go for surgical evaluations and, potentially, epilepsy surgery itself?

Lara_Jehi,_MD: Unfortunately, there is no centralized source of this information. You may find some additional information at the website for the National Association of Epilepsy Centers at http://www.naec-epilepsy.org/. This will at least give you an idea of the centers that do qualify as epilepsy surgery centers. You may then inquire directly with them or through their websites about their surgical volume and their outcomes. Typically, high-quality surgical centers are transparent about their outcomes data and can readily provide this information. You can learn about some of our outcomes at Cleveland Clinic by clicking on this link http://my.clevelandclinic.org/neurological_institute/epilepsy/treatments-services/treatment-outcomes.aspx or checking our yearly Outcomes Book (found on the Cleveland Clinic Epilepsy Center's website).

mradam: Thank you for taking the time to answer my questions! If I can make a suggestion for the future, is it possible to present this chat in video as well as text format? This would be much easier for patients who struggle with reading and visual comprehension to understand.

Moderator: We have just started doing video chats and I will pursue this request for you. We will be doing another chat about epilepsy in November. Check chat.clevelandclinic.org for the scheduled date yet to be determined.


Closing

Moderator: I am sorry to say that our time with Lara Jehi, MD is now over. Thank you, Dr. Jehi, for sharing your expertise and your time with us today to answer questions.

Lara_Jehi,_MD: Thank you for taking the time to chat with me today.


For Appointments

To make an appointment with Lara Jehi, MD, or any of the other specialists in Cleveland Clinic’s Epilepsy Center, please call 216.636.5860 or toll-free 866.588.2264.

If you would like to learn more about the benefits of choosing Cleveland Clinic for epilepsy care, visit us at clevelandclinic.org/epilepsycenter.

For More Information
On Epilepsy and Epilepsy Surgery
Here is some information about epilepsy and epilepsy surgery that may help to clarify some common questions. You may also visit clevelandclinic.org/health.

Who Should Be Evaluated for Epilepsy Surgery?
http://my.clevelandclinic.org/disorders/Epilepsy/hic_Who_Should_Be_Evaluated_for_Epilepsy_Surgery.aspx

Epilepsy and Seizure References
http://my.clevelandclinic.org/disorders/Epilepsy/hic_Epilepsy_and_Seizure_References.aspx

MyEpilepsy IPad Tool
Cleveland Clinic now offers a free educational interactive iPad tool, MyEpilepsy, that allows you and your physician to effectively manage your epilepsy. The interactive app gives you the ability to keep a daily record of your seizure activity, provide a record and reminder of all medications, manage appointments, track progress and access educational information on treatment options and how to manage seizures. Download MyEpilepsy to your iPad at clevelandclinic.org/epilepsycenter.

On Cleveland Clinic

In the Epilepsy Center, Cleveland Clinic has one of the largest, most comprehensive programs in the world for the evaluation and the medical and surgical treatment of epilepsy in children and adults. Our goal is to help patients and their loved ones manage the disease in order to enjoy fuller, more productive lives.

Our team of dedicated physicians, health care professionals and support staff participate in the evaluation and treatment of our epilepsy patients who come to Cleveland from across the country and around the world.

Pediatric and adult neurologists; neurosurgeons; neuroradiologists; nuclear medicine physicians; nurse specialists; pharmacists; physical, occupational and speech therapists; dietitians; neuropsychologists and psychiatrists; educational counselors and social workers; and an array of scientists and technologists all work together to offer individualized care to adults and children.

Cleveland Clinic’s Epilepsy Team:

  • Diagnoses and treats more than 10,000 patients with epilepsy each year
  • Delivers highly specialized care for adults and children in state-of-the-art facilities for evaluating patients for and performing epilepsy surgery
  • Provides state-of-the-art diagnostic approaches and therapies
  • Has established comprehensive research programs for testing anticonvulsant drugs and monitoring blood drug levels, as well as other research to advance epilepsy treatment for adults and children
  • Trains the most promising future academic pediatric and adult neurologists, epileptologists, neurophysiologists, educators and other specialists interested in epileptology
On Your Health

MyChart®: Your Personal Health Connection is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 8+\66.915.3383 or send an email to: mychartsupport@ccf.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.


Contact Information

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2014. The Cleveland Clinic Foundation. All rights reserved.