Dr. Alfred Perry Bowles, Jr., M.D., FICS, FACS
Conemaugh Neurosurgical Associates
Q: Dr. Bowles, how was Teela first referred to you?
A: Well, she was referred to me because of having epilepsy, recurrent seizures that are medically refractory. Now, she’s had those seizures for many many years and the types of seizures that she has were partial complex seizures. So she, she fit a --- the seizures that she has were a very common description of epilepsy that’s recurrent and she had mesial temporal lobe epilepsy and the most common cause for mesial temporal lobe epilepsy is hippocampal sclerosis and, you know, we’ll talk about that on the film, and typically what happens with those types of seizures you have generally an aura, maybe a hallucination or a fear or something smells really bad.
Then there’s a brief stare or period of unresponsiveness and then as the seizure progresses you may have automatism or you’ll have unusual movement of your face, smacking, movement of the hands. That may last for seconds to a minute or two or three and then that’s the whole seizure and then afterwards as you --- after that period of time has --- has stopped, then you’ll be followed up with a period of confusion. We call that postictal confusion and you’re very tired and you may have this many times during the day. You may this periodically once a month and, you know, as the seizures become worse you’ll have them more and more often.
Now, with her, she had a situation where as a child she received a vaccination and she had an unusual reaction to the vaccination. So her brain swelled and when the brain swelling occurred there was a swelling of a very important part of the temporal lobe, the uncus. There’s a little uncal herniation, which caused some damage to the mesial temporal region, the uncus, amygdala, hippocampus. Those are the areas that were resected during surgery and that became the focus for her seizures, recurrent seizures, a seizure generator, and subsequently she’s continued to have these seizures despite multiple medications. She’s been on a number of medications and they just weren’t really doing the job.
If you have many seizures or seizures that are recurrent we call that epilepsy. Fortunately, most patients with epilepsy can have control of their seizures with medications. Sixty-seven percent of patients with epilepsy will have control of their seizures with medications. Another 30, maybe 40 percent of those patients may not have adequate control of their seizures with medications and those are patients who may be candidates for epilepsy surgery and probably the greatest number of patients with epilepsies where their seizures are pharmokinetic or medically retractory or medically refractory are patients with temporal lobe epilepsy and this is just what she had and so when we saw her we evaluated her through our comprehensive epilepsy program, which involves three primary phases of evaluation.
Phase I is the noninvasive diagnostic evaluation, which involves a history, physical examination, neuropsychological assessment, a number of brain imaging studies such as MRI, PET scan, MR spectroscopy, EEG and then also long-term EEG monitoring and so we had a number of tests that we obtained and probably the most important test that were able to help us localize where the seizures were coming from and what we might be able to do was the MRI, which showed that she indeed had mesial temporal sclerosis, which we’ll be able to show on the MRI a little bit later and when she underwent evaluation within our long-term epilepsy monitoring unit scalp electrodes were put on the scalp and then she was placed in a carefully controlled room, which has a video relay to it and as the scalp electrodes were attached to a 128-channel EEG.
So her brain activity is constantly monitored over several days and as we --- she was on multiple anticonvulsive medications. As we slowly decreased the medication doses over days we will then increase the chance for her to have a seizure that we can witness and control and record. So as the seizure develops we can record the brain activity right before the seizure occurred, as the seizure occurs and then after the seizure sort of dies down and as she’s having a seizure we can record it on video so we can correlate the type of seizure behaviorally that she’s having with the electrical activity.
So that’s what we did and we got a lot of information and most of the times we can get all the information with just that Phase I evaluation but in her case, when she had the seizure, it all appeared to come from the left side. It all appeared to come from the left temporal lobe but the --- she had brain --- we call it ictal and inter-ictal activity. The ictal activity is when the brain is having a seizure. The inter-ictal activity or the brain recording is when the patient is not having seizures but your brain recordings can still be irritable in the area where the seizures typically occur.
Now with her, when she had the seizure, it came from the left side and it correlated with all of her other, all of her other tests but she also had some activity on the right side, inter-ictal activity actually before she’d have the full blown seizure. So we wanted to make sure that her seizure focus was just on the left side and not somewhere else. So we had to take the next step further, Phase II, where we do more invasive monitoring of her brain activity. So what we did was we took the patient to surgery.
We had to remove --- make an incision, remove the bone, open up the dura and instead of having those electrodes that record the brain activity placed on the scalp we put them on the brain and we put electrodes on the brain and depth electrodes in the brain. We closed her back up, awoken her and then we carefully monitored her in our long-term epilepsy monitoring unit and there those electrodes are much more sensitive. So when a seizure occurs we know exactly where it’s coming from. There’s no guesswork and indeed she had the seizure and we were able to correlate the location of the seizure to the left side.
The other very advantageous part that we’re able to do with those scalp and depth electrodes is we’re able to do cortical mapping. Now, one of the other considerations for the temporal lobe; when we do temporal lobe surgery for epilepsy we want to remove that part of the brain which is causing the seizures but we want to do it in a safe way and we don’t want to damage anything that’s very important to her. The temporal lobe can be a little tricky because the temporal lobe, as most of the brain, does important work.
What we find is that the temporal lobe in this instance is particularly important for speech and memory but, you know, say for example most people the speech occurs on the left side and in most people the memory may occur from both sides. So we had to --- before we did this we had to do a Wada Test to see if we can identify which side the speech came from and which side the memory came from. With the Wada Test, W-A-D-A, before we did our surgeries we found that her speech was indeed on the left side but her memory is on the right.
So that means that we can do our resection and not be too concerned with damaging memory but there is a concern with damaging speech. So I think it’s important for us to know where the speech is in relationship to the brain that’s causing the seizures and we’re able to determine that by cortical mapping. Now, when I put all of the electrodes on the surface of the brain and in the brain, when the patient was taken back to the unit and after we’re able to record a seizure, we then disconnected some of the connections and reattached to a special box.
It’s called an Ojemann Cortical Stimulator and then what we did was we’re able to stimulate each electrode with a small current and by stimulating each electrode we’re then able to determine where the speech function is and while the patient’s awake, you know, we’ll have them read a story and then we --- I apply a very very small current and if that’s the speech center then she won’t be able to speak and so I was able to map the whole function of the brain where the motor strip, sensory strip and the speech center was and indeed while indeed the speech center was in the temporal lobe but behind the area of our resection or the area that we would need to remove.
So with that information, with the information of the EEG and with the information of the cortical mapping, we then took her back to surgery, reopened the incision, removed the electrodes and then preformed a very specific tailored temporal lobectomy with microscopic guidance and in that instance we were able to remove the temporal lobe, the outside portion, and then we’re able to remove the inside portion. We call that the mesial temporal area, the uncus, amygdala and hippocampus.
That’s the area which really causes the seizures and we’re able to carefully remove that with the microscope and special instruments, cavatronic ultrasonic surgical aspirators, to carefully remove the tissue but preserve all of the important brain tissue and we’re able to successfully do that and she’s done real well after surgery. She not only doesn’t have any more seizures but her mental functioning is much better. She’s much brighter. She’s much more responsive and now that she doesn’t have these seizures to further damage her brain she’s a much happier patient, much happier person.
Q: How are you now able to help epilepsy patients with this new technology?
A: That, you know --- we have --- neurosurgery advances by leaps and bounds and we make use of the technology that we have to improve outcome for our patients. Probably --- epilepsy surgery probably started with Penfield many many years ago because he was the first one, first surgeon --- he was actually trained by Dr. Cushing who was the father of the neurosurgery and he was the first one to put an electrode on the brain and have the electrode recordings guide where the resection should be. Well, it’s advanced a lot since then.
Probably since the latter part of the 80s and 90s we began --- there was a surgence or resurgence of epilepsy programs where under an umbrella many specialists will come together and try to figure out the best way to treat our patients with refractory seizures, those patients who may be candidates for epilepsy surgery, and with the specialists we try to identify what types of seizures the patient may be having, where the seizures are coming from and in essence what type of surgery may benefit our patient.
So we’ve been able to do that and the epilepsy centers have grown in number and grown in sophistication particularly within the 90s and in the 2000s and now, with this multi-disciplinary approach and with the advent of so much technology we are now able to carefully remove certain areas of the brain, those brain --- that part of the brain which causes the seizures.
Now, of course, you have to have training and experience, you know, extra experience with neurosurgery in order to be able to do this epilepsy work but again, with the experience, understanding of the anatomy and utilization of our technology, technology such as a microscope, technology such as image-guidance where we can help --- we can utilize a computer to help guide us where our resection should be, help with special instruments where we can carefully remove the tissue microscopically and remove the tissue and distinguish the bad tissue from the good tissue or the normal brain.
Q: Talk a little bit about how those anti-seizure medications can effect someone with epilepsy.
A: Well, you know, the situation is --- to have seizure is not a good thing. I mean there’s many different types of seizures that you can have but if you --- it’s more than just being dependent upon somebody else. It’s more than just not having a normal life because you can’t do anything because you never know when your seizures are going to occur but to have seizures are bad because if they’re not controlled they can damage the brain. They can have the seizure focus enlarge.
You can go into status epilepticus and damage your brain and die but probably another very important thing is patients with epilepsy, the death rates are probably two to three times higher than the normal population and we have this syndrome called sudden --- sudden death and patients with epilepsy, they have sudden death at a significantly alarming rate that no one really understands. So to have, to have seizures are not a good thing. We have to do whatever we can to control those seizures.
Now, with epilepsy most patients’ seizures are controlled with medications. A lot of them are controlled with maybe one or two medications, maybe 60 to 70 percent of them, but you do have a lot of patients whose seizures aren’t controlled with medications or patients whose seizures are controlled have to be on a lot of medications and medications of significant doses that can be toxic to the patient. So a lot of these strong medications can hurt the patient. They can interfere with the way they’re able to think. They can interfere with their ability to act.
They can interfere with their energy level and, you know, taking medications, even if they control the seizures, can be bad because of the variety of side effects that can occur. So if we’re ever in an opportunity to remove the seizure focus it’s always going to be beneficial because we don’t have the --- we don’t have the brain that causes seizures and we can often times eliminate those medications that can be detrimental to the patient in order to try to control the seizures.
Q: Where was this particular patient’s problem centered?
A: Our patient had mesial temporal lobe epilepsy, which meant that the seizures that were occurring came from the temporal lobe. Now, in our patient’s case the seizures came from the left temporal lobe. This is half of the brain, the bottom part of the brain that’s been removed, the frontal lobe, parietal lobe, occipital lobe, temporal lobe and then this is the brain stem.
Now, what we needed to do we localized that the seizures came from here and they not only --- this is the outer part but they came more from the inner part and that’s where we have to do the carefully planned surgery and that’s why it’s so meticulous. So with all of our testing we’re able to show that the seizures came from the deep part. Now, what’s important about it is that this part of the brain here is important for speech. All right. So when we do our resection we don’t want to damage this area.
Now, with, with our Phase II evaluation, with the strips on the brain and strips --- and depth electrodes in the brain, we’re able to apply small electrical current to the brain and stimulate the brain and we’re able to localize and identify the speech center being here. We’re also able to identify the motor strip and the sensory strip but we’re able to identify the speech center being here so even if we did our resection here we would be safe. Now, when we did our surgery using a microscope and specific surgical equipment we carefully resected the lateral part, the outside first and once we removed the outside part we had access to the inside part.
Okay. And the inside part --- it’s not going to be able to show it very well. Hold on a second. We --- now, if you can see this inside part is very very close to the brain stem. All right. Now, let’s take that out. In essence what we have to remove is the inside part and that’s the part that is the seizure generator, this inside part.
Now, just for medical terminology the uncus, amygdala and hippocampus and those are the critical areas that we have to remove in addition to the outside portion in order to be able to control those seizures and one of the, one of the difficulties is, is that, as you’ll see, this area of the brain is very close to this part of the brain.
We have nerves and arteries and there enlies the real tricky part of the skill that’s required, the understanding of the anatomy, the utilization of the microscope and utilization of these special instruments that allow you to remove the tissue, the bad tissue, but preserve the good tissue and we’re able to remove it in such a way with a --- we call it tactile proprioception with special instruments that vibrates the tissue and vibrates --- and removes the tissue maintaining this very very thin peel barrier, which is a part of the layer of the brain that you can only see with a microscope and I’m able to do that just by feel, just by small little movements of the fingers that you really can’t see but all the input is going up through to my brain so I know exactly what I’m doing so that I can carefully remove this part and preserve this part and so that’s what we call a temporal lobectomy.
We’ll remove the outside portion and this very very important inside portion. Of note is that this part of the brain is important for memory but in --- we generally get it from both sides and in her case she got just about all of her memory from the other side. So we were --- we would be able to safely remove this bad part of the brain which are causing the seizures and do it in a way that would cause no damage to our patient.
Q: How important is the image-guidance and the technology that’s available?
A: With tailored temporal lobectomy we can further improve upon our surgical abilities in carefully removing this area of the brain and preserving perhaps this area of the brain with image-guided and what happens with image-guided we’re able to take an image of the brain with fiducials and we’re able to download that image with fiducials onto our brain lab intraoperative monitor and workstation and then with computer-like guidance we’re able to identify exactly where we’re supposed to be.
So in essence if I do --- if I start to work here I know just from experience that the --- this part of the brain, deep part of the brain, is very very close by but with an image-guidance I can actually see exactly where I’m at. So it takes a lot of the guesswork out of it. You may not need to have my years of experience. You may --- and even with my years of experience the computer even further increases my ability to do an even better job and so with this computer-like precision we can then carefully remove this area of the brain even better and again, that type of technology is only available at a few places.
Q:There’s only a few centers where you can get this kind of comprehensive epilepsy care. Is that right?
A: That’s right. You know one of the problems with the management of patients with epilepsy, the management of patients with seizures that need surgery, is the fact that we just don’t have enough of the resources around. You know, many --- 50 million people in the world have epilepsy. Two, three million people in the United States have epilepsy. So that’s a lot of patients who have seizures that aren’t controlled. Unfortunately, we just don’t have enough centers to treat all the patients with this problem and one of the things that happens is one; patients aren’t identified correctly.
They’re not diagnosed correctly that they have a problem that can be treated and two; even if they’re diagnosed the resources aren’t available. So luckily here in the State of Pennsylvania we have this program and the resources to be able to provide care for this very very difficult problem that in a lot of patients just is not treated.
Q: What do you think the prognosis is for this particular patient?
A: I think her prognosis is excellent because you’ve got to remember she --- she’s had these seizures for a very very long time and unfortunately it seems even the patients who make it to the epilepsy programs, if you take the average length of time the patients had symptoms before they had treatment it’s in years, 10, 20 years, and unfortunately that was her case, too, and because she’s continued to have the seizures, you know, it damaged --- you know, having seizures damages your brain and even with having these ongoing seizures it just made her completely dependent upon other people and it impeded her ability to really think, to be active, to do the things that she would really want to do.
Since surgery she’s a completely different person. She’s much more interactive. She’s much brighter. She’s engaging and right now she can make up everything she’s lost and I think she will with the right incentive and she’s very eager to do that. So I think her prognosis and her outlook is excellent. I think she’s going to do very well like she’s doing very well now.
Q: What would you say to someone who is considering epilepsy surgery about having it done at Memorial?
A: Well, I would say get the surgery done. Get the treatment done because you really need it. You shouldn’t deprive yourself of an opportunity to cure yourself of this devastating disease. Do you need to go to Pittsburgh? Absolutely not. Do you need to go anywhere else other than what we have here? No. Because we have all the technology. We have all of the expertise. We have the surgical expertise. We have the technical expertise and we definitely have the technology and also you got to remember that anytime that you have, you have to undergo complicated surgery or surgery of any type you need the support of your family.
So you’re going to need the support of your family. You’re going to need to have this done in an area that’s close to your family as well. It doesn’t make a whole lot of sense to go somewhere else which will take you away from your family. It doesn’t make a whole lot of sense to have your surgery done someplace else because you’re going to need to have your follow-up there. It makes every, it makes every bit of sense to have the surgery done here close to family, close to physicians who can take care of you.
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