Epilepsy Surgery: An Underutilized Option for Uncontrolled Epilepsy

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab and psychiatry.

Glen Stevens, DO, PhD: Epilepsy affects about 3.4 million Americans. And for those of whom, more than two appropriately prescribed medications fail to control their seizures, surgery is a viable option. However, data continues to show that surgery is significantly underutilized with this patient population. In this episode of Neuro Pathways, we're discussing the state of epilepsy surgery and its value in the care of individuals with uncontrolled epilepsy. I'm your host, Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's neurological Institute. And joining me for today's conversation is Dr. Bill Bingaman. Dr. Bingaman is a neurosurgeon and director of the Epilepsy Surgery Program in Cleveland Clinic's Charles Shor Epilepsy Center. Bill, welcome to Neuro Pathways.

Bill Bingaman, MD: Thank you, Glen. It's a pleasure to be here.

Glen Stevens, DO, PhD: So historically, epilepsy was believed to be a demonic possession, and trephination was done for religious and spiritual reasons, with evidence dating back to surgeries 3000 BC, besides getting the evil humors out, let's start with the brief history in the evolution of epilepsy surgery to get to where we are today.

Bill Bingaman, MD: Yeah, so trephination, you make a burr hole in the skull, and this was done 5,000 years ago. Wasn't very successful. Interestingly, there was an American neurosurgeon at University of Kentucky who tried trephination, making a burr hole, didn't really work. Really, the modern epilepsy surgery started in 1886, a guy named Sir Victor Horsley and William McCune operated on a patient who had a traumatic brain injury, I think from a horse and buggy accident. And he had very typical. They operated on, took the skull fragment out of the brain, and cured the guy's epilepsy, which is pretty remarkable if you think about it in the 1880s, considering all the lack of instrumentation and antisepsis and everything else. And it really started from there. Most of the epilepsy surgery we do nowadays has a significant dependence on technology.

Bill Bingaman, MD: And whether you like neurologists or you don't like neurologists, for epilepsy surgery, we need the neurologist, right? They do 90 percent of the work. And so EEG, which Forster and Altenburg in Germany kind of brought around, ECoG, electrocorticography. This all happened in the '20s, '30s. Penfield and Jasper started to map the brain and stimulate the brain, which is how we learn about what the brain does. And then in really from the late '30s to the '50s, temporal lobe surgery, which happened in your neck of the woods, up in Montreal, at the Montreal Neurologic Institute. And so I owe a lot to them. I'm old enough that when I started here, Hans Luders was the director of the epilepsy program. He and Joe Hahn started it in 1978, and started putting grids and electrodes in people, doing invasive monitoring to map seizure onset.

Bill Bingaman, MD: The trick has always been, where are the seizures coming from? Is there a focal starting point? Where are they spreading to. And how can you safely remove that part? That's the whole trick. And unfortunately for epilepsy, we just don't have that definition. We don't have an easy way to map the epileptogenic. But Hans is the reason I'm in the game. He grabbed me one day and said he wanted me to do the epilepsy surgery as an opening came up, and here I am. I've been doing it since the mid-'90s. We've seen a lot of changes in that time. Imad Najm is now our director. Technology has come. It's funny, we were talking the other day, when I graduated from medical school, a powerful computer was a Mac SE with a 40 megabyte hard drive, and now we've got more power on our phones. And so technology's really made a huge difference for us.

Glen Stevens, DO, PhD: So why do you think that more patients aren't referred for surgery, that we just keep pushing more and more medications?

Bill Bingaman, MD: Yeah, it's a good question. Really, it's the question nobody can answer. And this has been true my entire career. We've not seen a bump in the numbers at all. I think there's a dichotomy as to who takes care of these patients. Often it's a family practice doc or a pediatrician or a general practitioner or an internist, and not a neurologist. And then I think there are some neurologists who are a little bit, just may not be aware of how safe epilepsy surgery is. Because the patients that we're operating on are desperate.

Bill Bingaman, MD: As you know, most patients, you start them on one medicine and the seizures stop and they're really never surgical candidates. And so I think it's just a problem with knowing who to refer, where to refer. There's probably certainly some regionalization of the availability of epilepsy surgery, so that if you're in the middle of the country, it may not be all that available up in the northern... You get up into the Dakotas, there aren't... Montana, it's not so available. So I think a combination of factors. People like you, influencers in medicine, in the social media, are what we need really to start talking about epilepsy.

Glen Stevens, DO, PhD: Epilepsy surgery is not epilepsy surgery. I'm sure there's a lot of variations. Talk to me a little bit about some of the different types of surgical procedures that you would do or other devices that you may utilize.

Bill Bingaman, MD: Well, we have resective surgery, which is typically applicable for somebody who has a focal onset in an area of the brain that can be safely removed. Somebody shows up with a scar in their hippocampus, and have failed a couple of medicines. We take out the hippocampus, and 65 percent are seizure-free long term. Now, if I sold you a car and said, "There's a 65 percent chance that car is going to start when you get home," you might not try it. You might not buy that car. But for these patients, they're really at a 0 percent chance of anything working. So that's typically the resective candidate. And there's all types of resections, from temporal lobe, extratemporal lobe, hemispherectomies, multi-lobe, depending on what it is in the brain that's causing it, and where in the brain it is.

Bill Bingaman, MD: There's a group of patients that we've seen more recently called non-lesional, meaning their MRIs are normal. We don't really have a good explanation, but they have a focal epilepsy. So we're using implantation of electrodes into the brain using robotic assistance and stereotactic encephalopathy, SEEG electrodes to sort of try to map their epilepsy. And the advantage to that electrode over the type Hans did back in the late '70s, those electrodes in the late '70s, we'd lay on the surface of the brain, but they couldn't map seizures, measure brain activity from the hippocampus. They couldn't measure seizures from the mesial hemisphere, from the deep sulci. SEEG can do that. So it's been pretty popular, and it opens up the door for all those patients who have non-lesional epilepsy, where typically our results, any surgical result, is 30 to 50% seizure free. But again, these are the patients that have failed everything. So it's opened the door for those patients. We've seen more and more of the non-lesional as every tertiary center has.

Bill Bingaman, MD: Then we have palliative surgery. So, hey, we don't think we can stop your seizures, but we have the vagal nerve stimulator. We have neuromodulation, RNS, the NeuroPace, deep brain stimulation, all of which has come in the last 10, 15 years, to really make it so that everyone's a, if you think about it, everyone's a surgical candidate once they fail a couple of medicines. And the trick then is just to be able to tell them what their chances are to become seizure free, because people want to be seizure free so they can drive, so they can work, so they can take a bath or a shower by themselves without fear of drowning. And really, a big one is, I don't want to take medicine or I want to take less medicine. That's a huge thing.

Bill Bingaman, MD: And then finally, we have, the laser probably is a more recent development, laser ablation as they use in the brain, really developed for the brain tumor patients. This has the ability to create small ablations in the brain, depending on whatever the pathology is that's causing the epilepsy. So it's found some use in epilepsy surgery as well. So I think we think about palliative. We think about resection. We think about ablation with all the modern tricks that are available.

Glen Stevens, DO, PhD: Yeah. I can certainly talk on a personal level, and that is that we've sent a number of our brain tumor patients for surgery, understanding of course, that if they have a malignant tumor, that surgery will not cure it. And we've sent them for epilepsy-based surgeries, not tumor resective surgeries per se, because they may be different things for patients that are on multiple medications. And they're obviously a very carefully selected group of patients, but in general, their quality of life is significantly improved by being on less medication and having fewer seizures.

Bill Bingaman, MD: Yeah. It's a powerful disease. It doesn't usually kill you. It can, but it doesn't usually. But it does really limit your independence and your ability to fit in with society, which is important. And the medicines don't just affect the epileptic brain. They affect the entire brain, all the neurons. And so they really have quite a few side effects. People don't like it.

Glen Stevens, DO, PhD: So Bill, back in the old days, we used to a lot of Wada on patients, do you still do those? Has it kind of gone by the wayside?

Bill Bingaman, MD: Again, I only do 10 percent of the work. So the neurologist, the people like Dr. Kotagal and Dr. Nair, Dileep Nair, and Dr. Najm, they do the Wada. It's not used as much as it is because it's an invasive test, requires an angiogram, 1 percent chance of stroke. But it's an effective test. The functional MRI now has largely replaced it for most patients. We're also doing TMS. Dr. Nair is doing transmagnetic stimulation, identification of language. The Wada has the ability to do some memory testing, crude memory testing as well. The functional MRI, there is a memory component. We've not developed that so well here. And so if memory and language is an issue, we typically will do a Wada, but I bet you, we do less than 10 a year now. When I first started, everybody got one.

Glen Stevens, DO, PhD: Can you talk about the role of the MEG in surgery?

Bill Bingaman, MD: Yeah. So the MEG is, it measures magnetic fields associated with the electrical activity of the brain. And they're very small. So it's a well-insulated room. You wear a helmet, kind of like the Gamma Knife helmet, or a big space helmet. And it measures magnetic fields. And so it's more sensitive in picking up some of the changes associated with epilepsy. It's a way of measuring the irritation in the brain in between seizures, just like interictal EEG. And the nice thing about is that you can map that pretty closely onto an MRI scan for magnetic source imaging. And it's just a different way

of looking, I think, at that picture. We do MEG, we do SPECT, we do PET, we do EEG, invasive EEG, and then try to put that all together. I think you've had Irene Long on in the program. She talks about multimodality imaging and is one of those unique individuals that knows how to bring a hundred different file formats together and display it in a useful way.

Bill Bingaman, MD: And so that's helpful for us. We do that in the OR, but when you're sitting in a patient management conference, which is our large multidisciplinary group, neurologists, neurosurgeons, neuroradiologists, psychologists, psychiatrists, techs, et cetera, to talk about each case, there's a large amount of data. If you can show how to display that in a cool, interactive way, I think it really makes a difference for the patient.

Glen Stevens, DO, PhD: Yeah. And I'll just say that I've had the pleasure of coming to your multidisciplinary conference on several occasions. And for those that haven't had the opportunity, it truly is very interdisciplinary. Everybody gets an input to decide what really makes the most sense for a patient. I always think that the great news is there's a lot of epilepsy drugs out there now, versus when you and I started. In some ways, the bad news is there's a lot of epilepsy drugs out there since we started.

Bill Bingaman, MD: Yeah, sure.

Glen Stevens, DO, PhD: So it becomes easy for neurologists to say, "Well, let's try this new drug, let's try this new drug, let's try this new drug." And you're having patients failing 10 drugs before we decide, boy, their epilepsy's really not doing well, and we should refer them to surgery. So I guess my call would be earlier evaluation.

Bill Bingaman, MD: It could take 10 or 15 years probably to go through all the drugs on a fair trial. And it reminds me of last year, I saw a lady come up from Mansfield or Ashland, central Ohio. And she was in her late '60s. And she had hippocampal sclerosis, the most common adult epilepsy we see, our most successful patient from epilepsy surgery. She had a febrile convulsion as a baby. At 15, she started having seizures and seizing for 50 years. And she and her husband are sitting in my clinic and we're talking about temporal lobectomy, which we typically don't do on people in their '60s. Occasionally, but it's rare.

Bill Bingaman, MD: And I said, "Gosh, you had seizures for 50-some years. Why now? Why are you here now?" And she looked at me and said, "Well, I didn't know surgery was an option." And I said, "Well, how did you get here?" "I was watching the Indians game, and you guys had a commercial during the Indians game that said if you have seizures and they're not controlled by two medicines, go to a place where they do epilepsy surgery." And then there she was. I mean, that's unfortunately something that we still see, and it's, 50 years of uncontrolled epilepsy can really do a number on you.

Glen Stevens, DO, PhD: So Bill, we've had a nice foray through the field of epilepsy and the benefits of surgery. Any closing statements that you'd like to make?

Bill Bingaman, MD: We didn't really talk about the future of epilepsy surgery. And I occasionally have to give that talk. I get invited to give those talks. And I'm not a fan of those talks as I don't know how to predict the future too well. I think Yogi Berra had a saying about that. And I'm afraid that the future is going to be not surgical, right? So we figure out what epilepsy is and how it works, we should be able to figure out the genetics behind this. And it's coming, slowly. Dr. Najm does a lot of a cool genetic stuff. And then I think sooner or later we're going to have the ability to manipulate the genetics in the brain and the neuronal makeup. And I think that's going to maybe solve the problem. It's not going to happen while you and I are practicing, but I think that's where we're going.

Bill Bingaman, MD: The other exciting thing, and it's been true forever is, in the OR when patients have a seizure when we're doing an awake craniotomy, we'd spray the brain with cold water, and that stops the seizures. So theoretically, if we had a way to develop a reservoir that had ice cold water and could squirt it on the brain when the seizures started, I think the seizures would stop. But the problem is it's impossible to keep water that cold, and so the energy requirement to keep water that cold. So drug delivery into the brain, HIFU ultrasound is coming. It's here for movement disorder. It's coming for epilepsy. You can disrupt the blood-brain barrier, possibly drug delivery. I think all of those are exciting things that are going to happen in the next few years.

Glen Stevens, DO, PhD: Yeah. I'll just add a little point. And that is that we've actually started... We've treated now, I think five patients with low frequency ultrasound to disrupt the blood-brain barrier for our brain tumor patients. And we're giving them chemo, but certainly we could give any drug that's there.

Bill Bingaman, MD: Yeah, we're going to learn from you guys. Yeah. That's exciting stuff.

Glen Stevens, DO, PhD: Yeah. So we all hope to put you out of business. But I think in closing, we would say that if you have patients that have really failed a good effort of two medications, they should really be referred to a center that gives multidisciplinary care that includes surgical options for patients so that we can get them evaluated sooner rather than later.

Bill Bingaman, MD: I agree 100 percent.

Glen Stevens, DO, PhD: So Bill, hopefully this conversation encourages others to consider surgery as an option for patients with uncontrolled seizures. I'd like to thank you for joining me today. We've known each other for 30 years. It's always great to see you.

Bill Bingaman, MD: It's great to see you, Glen.

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