Epilepsy Surgery: An Alternative for Those Whose Seizures Can't Be Controlled
Cleveland_Clinic_Host: Epilepsy is one of the most common neurological disorders, affecting up to one percent of the population in the United States. Plus more than 45,000 children ages 18 and younger are diagnosed with epilepsy every year. Overall, medication can control seizures in 60 to 70% of epilepsy patients. For those whose epilepsy cannot be controlled with anticonvulsant medication, or experience intolerable side effects from anticonvulsants, there are other options available, including epilepsy surgery.
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 the majority of cases. In a minority of cases, seizure frequency is markedly reduced.
The Cleveland Clinic Epilepsy Center is one of the largest and more comprehensive epilepsy programs in the world for the evaluation and treatment of epilepsy in both children and adults. More than 300 patients with medication-resistant epilepsy undergo surgical procedures annually at Cleveland Clinic Epilepsy Center. The center is one of the few medical centers in the country that has been instrumental in using 3-D mapping to pinpoint the focus of seizures and improve surgical outcomes. The Epilepsy Center was also the first in North America, to introduce SEEG, a minimally invasive technique, which is a more precise and less invasive approach to localizing seizures.
William E. Bingaman, MD, is Vice-Chairman of the Neurological Institute and Head of the Section of Epilepsy Surgery at Cleveland Clinic in Cleveland, Ohio. Dr. Bingaman’s clinical interests are in the surgical treatment of adult and pediatric epilepsy, with special interest in hemispheric epilepsy. He also is interested in spinal surgery and maintains a busy clinical practice in close collaboration with the Department of Neurology via the Comprehensive Epilepsy Center.
He is an active member of many professional organizations including the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Epilepsy Society, the Ohio State Neurosurgical Society and the Council of State Neurosurgical
Societies. Additionally, Dr. Bingaman holds leadership positions in several national neurosurgical organizations including Member-at-Large board member of the Congress of Neurological Surgeons, Vice Chairman of the Council of State Neurosurgical Societies, board member of the American Neurosurgery Political Action Committee and Past President of the Ohio State Neurosurgical Society.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. William Bingaman. We are thrilled to have Dr. Bingaman here today for this chat. He is the Vice-Chairman of the Neurological Institute and Head of the Section of Epilepsy Surgery at Cleveland Clinic. Dr. Bingaman, let’s begin with some questions.
g: Is surgery an alternative in all types of epilepsy or in special types only?
Speaker_-_Dr__William_Bingaman: No. Surgery is appropriate mainly in patients with focal epilepsy that is resistant to medication. Focal epilepsy means that the seizures arise from one part of the brain.
Palliative surgical options do exist for patient with generalized epilepsy. These include vagal nerve stimulation, corpus callosotomy and deep brain stimulation.
Christo-Cam: Can an SEEG reveal lesions or focal points that an EEG or MRI cannot? In the case of a child with a normal MRI but 2 abnormal EEGs with a variety of non-centralized seizure types, what is the best "next step"? SEEG?
Speaker_-_Dr__William_Bingaman: In pts who have non-localized seizure activity with normal MRI scan, SEEG is a safer alternative to subdural gird evaluation.
mbnuss: Have you had success controlling Epilepsy through surgery when the seizure is in the Occipital Lobe?
Speaker_-_Dr__William_Bingaman: Yes. Overall the success of epilepsy surgery depends on whether or not there is a lesion present. A lesion is a non-specific term for any abnormality in the brain tissue. In general, when the lesion is present we can stop the seizure 70-80% of the time.
The special circumstance that involves the occipital lobe is that it is the area that controls vision and is thus considered eloquent brain. Therefore, the limiting factor in occipital lobe surgery is how much vision the patient is willing to lose.
darvik: Have you witnessed any insurance companies refusing to authorize MEG or SEEG diagnostic testing in order to determine a patients candidacy for surgery?
Speaker_-_Dr__William_Bingaman: We have not seen insurance companies refuse the pre-operative workup of patients with epilepsy in an organized or consistent manner.
darvik: Sorry for a vanity question, but how much hair is shaved if I need a SEEG, Intracranial EED, and ultimately resection surgery (if I am a candidate, of course).
Speaker_-_Dr__William_Bingaman: For subdural electrode evaluations, all the hair is clipped. For SEEG procedures similarly, the entire head is clipped. For resective surgery, it varies from surgery to surgery.
eudora: Can you speak to the Cleveland Clinic's experience in surgeries of the left temporal lobe with no lesion present?
Speaker_-_Dr__William_Bingaman: For non-lesion temporal lobe epilepsy, our experience has been most successful when patients are implanted with electrodes to better define the region within the temporal lobe where the seizures start.
The left temporal lobe is special because of the memory and language function within it, and therefore the less tissue removed, the better the functional outcome often is.
The use of invasive electrode recording often allows us to tailor the temporal lobectomy to improve both the seizure-free outcome and the functional outcome.
PIZZAFACE36: WHAT ARE YOUR THOUGHTS FOR STEM CELL TREATMENT FOR EPILEPSY?
Speaker_-_Dr__William_Bingaman: Stem cell treatment for epilepsy is in its infancy, with really no scientific data available.
PIZZAFACE36: WHAT COULD BE COMPLICATIONS OF A LOBECTOMY AND ARE ANY PERMANATE?
Speaker_-_Dr__William_Bingaman: Complications of epilepsy surgery include the general risks of craniotomy, such as infection and bleeding - which are fortunately low, as well as more specific risks based on the part of the brain where we are working.
These risks should be discussed individually with your surgeon.
Temporal lobectomy is the most common adult surgical procedure that we do and, in general, carries a risk of peripheral vision loss and memory/naming difficulties.
PIZZAFACE36: WHAT'S INVOLVED IN MEMORY/NAMING DIFFICULTIES? WOULD I FORGET I TOOK MY MEDICINE OR ATE - OR ANYTHING I DID?
Speaker_-_Dr__William_Bingaman: Left temporal lobe is often associated with difficulties with short term memory and memory of names. Surgical removal of the left temporal lobe will aggravate this pre-existing memory condition in a small subset of patients, as most of these patients have already adapted to their memory loss. This is not something that alters their lifestyle.
The memory loss may be bad enough to interfere with remembering to take medicine, etc.
Diagnostics Tests for Epilepsy Surgery
darvik: I have cortical dysplasia in the right side of my brain. This is according to my epileptologist at UCI Dr Howard Kim. So far, we've done a contrast MRI and video monitored EEG. What additional tests are needed to pinpoint my epigenetic zone and determine if I am a candidate for surgery?
Speaker_-_Dr__William_Bingaman: A PET scan is often done. Depending on the anatomy of the malformation, invasive recordings with invasive electrodes may be necessary to define the tissue that needs to be removed and the function of that tissue.
The basic workup for surgery requires a patient who has epilepsy that does not respond to medications. Once that has been determined, patients undergo video EEG monitoring, MRI scanning, PET scanning, neuropsychological testing and evaluation by an epileptologist and an epilepsy surgeon.
Here at Cleveland Clinic, patients would also see our behavioral health specialist, interested in epilepsy.
eudora: Please supply information on SEEG. How is it done and how much less invasive is it? Which patients are best candidates for SEEG?
Speaker_-_Dr__William_Bingaman: Dr. Jorge Gonzalez-Martinez is the epilepsy surgeon here that does SEEG. SEEG stands for stereoelectroencephalography. This involves a method of inserting electrodes into the brain to identify seizure onset and it is based on a patient's type of seizure, electrical characteristics of the seizure, and anatomy.
It is less invasive than the more widely used subdural electrode technique. Its limitations are based on the less desirable ability to map brain function. It is mainly used in patients who have non-lesion epilepsy - meaning that the brain is normal on imaging.
The main risk to the technique is bleeding during electrode insertion which is 1:100 cases.
We are doing this procedure on patients 2 years of age and older.
flukster: Hello, Dr. B! (you are doing this on Bethany's BD:) Our ques. is concerning the SEEG procedure. Could you explain it & tell us how successful it has been in cases like Bethany's? Thank you & YOU ARE THE BEST!!
Speaker_-_Dr__William_Bingaman: Say hello to Bethany and Happy Birthday. The SEEG information that we just discussed would be applicable to Bethany. One of the beneficial aspects to SEEG is that we can cover a wider area of the brain less invasively. We are in the early phases of SEEG at the Cleveland Clinic. The technique involves implanting the electrodes, monitoring the patient in the EMU, and recording seizures. The electrodes are then removed, often right at the bedside and surgical resection of the seizure focus when appropriate is done at a later date.
I do not know the up-to-date statistics on how successful the procedure is, but my observation is that we are likely too early in the program to make definitive conclusions.
eudora: Why is SEEG just now being done in the US? Hasn't it been done for many yrs in France?
Speaker_-_Dr__William_Bingaman: Yes, it was developed in France in the 1970's and has found a niche in France and Italy where it is widely used to study patients with epilepsy. It has not found a similar niche in the US due to concerns about cost, availability of subdural recordings. There has also been some long-standing disagreement between American and European schools of thought concerning the onset of epilepsy and how best to evaluate it.
Many US Center implant electrodes into the brain with a different technique called stereotactic depth electrode implantation. This technique implants electrodes in a similar manner from patient to patient.
SEEG allows us to implant electrodes into each patient with an individualized and customized fashion.
Christo-Cam: Is this suitable for non-centralized, cryptogenic childhood epilepsy?
Speaker_-_Dr__William_Bingaman: No, SEEG would not be suitable.
Christo-Cam: Are there any particular types of seizures that surgery is more or less successful in treating?
Speaker_-_Dr__William_Bingaman: Epilepsy associated with an abnormality in the brain is most successfully treated by surgery.
darvik: How long does monitoring and evaluation take and how soon after can surgery be done?
Speaker_-_Dr__William_Bingaman: For SEEG, the typical hospital stay is one week and surgery, when appropriate, is scheduled in a couple months.
For subdural electrode evaluation, the average length of stay is 14 days, and both surgeries are performed during the same hospitalization.
SEEG: Availability & Outcomes
Christo-Cam: Is the Cleveland Clinic the only hospital doing SEEG right now?
Speaker_-_Dr__William_Bingaman: There are hospitals in France and Italy, but to the best of my knowledge Cleveland Clinic is the only hospital in the United States doing SEEG in the way it is described in Europe.
eudora: How many epilepsy surgeries does the Cleveland Clinic perform annually? Where does this rank nationally?
Speaker_-_Dr__William_Bingaman: About 350-400 annually, at Cleveland Clinic. Based on the US News and World Report, we are one of the top in the nation.
flukster: How many SEEG procedures have you done on adults @ CCF?
Speaker_-_Dr__William_Bingaman: We have done 25 to date. We started the program at Cleveland Clinic in March 2009.
Christo-Cam: What are the remission rates, post-surgery?
Speaker_-_Dr__William_Bingaman: Seizure free outcomes vary according to different pathologies and locations of the epilepsy. A general number is 70-80% of patients are seizure-free at 1 year following surgery.
This success declines over time so that at 5-10 years after surgery, 50-60% of patients remain completely free of seizures.
annnow: That figure factors in variances not related to the "success" of the surgery, I'm assuming?
Speaker_-_Dr__William_Bingaman: Can you rephrase this question?
annnow: What I mean is, a portion of that 40-50% who have had seizures were not compliant with treatment.
Speaker_-_Dr__William_Bingaman: Medical intractability prior to surgery means that an adequate trial of anti-convulsant medicines has been attempted.
Non-compliance with prescribed therapies would be a reason for exclusion for consideration from surgery.
After surgery, as the length of time increases without seizures, some patients do become non-compliant with medications and some patients may be weaned from medication under the supervision of the physician.
You are correct that the 40-50% of patients that have recurrence of seizures do so when stressed, ill, or after not taking their medicine.
Bi-temporal Epilepsy & Surgery
RJ: I have complex partial seizures. I have a primary focus on my right temporal lobe and have developed a mirror focus on the left side. Are there any new surgical developments that might make surgery a possibility for me?
Speaker_-_Dr__William_Bingaman: The diagnosis of bi-temporal epilepsy is difficult because patient's often do not respond to medications and both temporal lobes cannot be removed surgically.
For this difficult group of patients, surgical evaluation should begin with non-invasive video EEG to document seizures coming from both temporal lobes. Even when scalp EEG recordings show this, a small number of patient's will still have seizures arising from one temporal lobe and quickly spreading to the other.
This gives the false appearance of bi-temporal seizure onset. For these patient's, we will often implant depth electrodes into both temporal lobes to prove or disprove seizures arising from both temporal lobes.
If seizures do arise from both temporal lobes, there is a procedure called NeuroPace, which essentially is direct cortical stimulation of the temporal lobes.
This may be effective in reducing the seizure burden. This procedure is investigational at the present time and likely will not be available for implantation for several years.
Medical Treatment for Epilepsy
megabrain: What is your stand on vitamin B6 and its role in seizures.
Speaker_-_Dr__William_Bingaman: I would refer to the medical epitologist for this answer.
Christo-Cam: How many different anti-convulsant drugs should a child with epilepsy try before trying surgery?
Speaker_-_Dr__William_Bingaman: There are several papers in the literature that suggest if two medicines fail to control the seizures, additional drugs will also fail to work. There are approximately 20 anti-convulsants on the market, and an adequate trial of all of these medicines could take up to 10 yrs.
In children, neurocognitive development is often affected by ongoing seizures and it becomes important to stop the seizures for more normal development to occur.
Remember that all of these pts have a 0% success rate with medical treatment.
Therefore, pediatric epileptologists are aggressive at recommending surgical evaluations in young patients.
PIZZAFACE36: I ALREADY HAD A CONSULT WITH THE SURGEON. WOULD IT BE WRONG TO ASK FOR ANOTHER ONE TO MAKE SURE WE UNDERSTAND EVERYTHING AND ALL THE RISKS?
Speaker_-_Dr__William_Bingaman: I believe that people should get a second opinion for every significant problem they face, including epilepsy treatment.
Cleveland_Clinic_Host: A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. William Bingaman is now over. Thank you again Dr. Bingaman for taking the time to answer our questions about epilepsy surgery as an alternative when seizures cannot be controlled.
Speaker_-_Dr__William_Bingaman: Thank you.
- To make an appointment with William Bingaman. MD or any of the other specialists in our Epilepsy Center at Cleveland Clinic, please call 216.444.5559 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/epilepsy
- A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult
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This chat occurred on November 10, 2009.
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