Melanie Cole, MS (Host): Welcome to GW Hospital HealthCast, an informative health podcast from the George Washington University Hospital. I'm Melanie Cole. And joining me today is Dr. Mohamad Koubeissi. He's a professor and Interim Chair in the Department of Neurology and Rehabilitation Medicine, and he's the Director of Epilepsy Center at the George Washington University School of Medicine and Health Sciences. And he's affiliated with the George Washington University Hospital. He's here to tell us today about epilepsy surgery, and what's exciting in that department.

Dr. Koubeissi, thank you so much for joining us today. I'd like you to speak to us about epilepsy surgery and the trends and how that's changed over the years. Have we been doing epilepsy surgery on people for 20 years? Less? Tell us a little bit about how that's all gone together.

Dr Mohamad Z. Koubeissi: The history of epilepsy surgery dates back to centuries ago. But the first good epilepsy surgery, when I say good, I mean the one that targeted the lesion that indeed caused the seizures occurred in the 1860s in England by Forrester, who worked closely with one of the most renowned epilepsy specialists in modern history, who's John Hughlings Jackson. They did surgery related to tumors or other lesions, which caused seizures and they reported good outcomes.

If you look at the first decade of the 20th century, in 1905, Harvey Cushing did some epilepsy surgery also. And interestingly, he was a pioneer in the sense that he did awake surgery for brain mapping. What this means is the patient would first go under anesthesia and then they would do the craniotomy, which is removal of the bone in order to expose the brain area that needs surgery. Then, they will use local anesthesia and wake the patient up from anesthesia so that they can communicate with the patient and when they stimulate the brain, they will assess the response. This way, they can figure whether a specific brain region is important for speech or movement or the like. So, the history of epilepsy surgery dates to more than a hundred years ago. But in the modern era, it has gained a lot of momentum because of, first, the proliferation of expert centers across Europe and the United States, and the technology that has facilitated the procedures.

To be a little bit more specific in France, in the '50s and '60s, they started to use something called stereotactic EEG implantation, which means if you have a patient with a seizure focus that cannot be localized using non-invasive means such as regular EEG, imaging, and what have you. Then, you can put needle-like electrodes deep in the brain tissue on one side or both sides, and these will traverse the skull and go to target specific areas that the surgeon and the neurologist decide could be the culprit. This kind of monitoring was paralleled in North America by something we call subdural electrode monitoring, which is instead of putting needle electrodes within the substance of the brain, the electrodes are placed directly on the surface of the brain, also through a neurosurgery, which provides a lot better recordings from the brain itself, and it also facilitates brain mapping. This way, the neurologist can tell not only where the seizures come from, but also whether the neighboring areas are crucial for an important function such as language, speech, movement, and the like.

All these technologies have increased the utility of epilepsy surgery. And in more modern eras, which we will talk about in the past decade or so, there have been other technology that has made the surgery faster, more accurate and less invasive and less painful. And these are in particular using robots for insertion of the intracranial electrodes, but also using laser ablation to ablate neural tissue, brain tissue, that is believed to be the cause of the seizures. And instead of doing a craniotomy, removal of the bone and removing parts of the brain tissue, all the surgeon needs to do is to put a needle-like object targeting the specific region that produces seizures and burn it by laser. And the patient can go home the following day with little or no pain.

Melanie Cole, MS: Wow. That was a comprehensive answer, doctor. Thank you so much for that. What an exciting time in your field. So, speak about the primary goals. You've given us a lot to think about, about the way it's evolved over time and the different current surgical options that are available to discuss with a provider. What are the goals for someone who is living with epilepsy? How does this determine and control the quality of life for them?

Dr Mohamad Z. Koubeissi: The main goal, and this should be in the mind of any clinician who treats epilepsy, is to achieve two things, no seizures and no side effects. If the patient has no seizures, but they are overburdened by the adverse events of anti-seizure medications, that's not the goal. If the patient can tolerate the anti-seizure medications without any side effects, but they still have seizures, that's also not the goal. The goal is to achieve no seizures and no side effects. It's important to have an overview about the whole path that an individual with seizures goes through therapeutically to know what options they have. But before I go into that path, and I will start with the first seizure, I want to make sure that the main take-home message for our patients is that epilepsy surgery is not a last resort, and it's not something that will make people suffer from cognitive impairment, or coma, or paralysis, or anything of that sort. The way we do surgery today is very, very safe with very, very minimal rates of complications, and the outcomes are a lot better than continuing to try different anti-seizure medications.

With this, I will go through the whole journey of an individual with seizure. After the first seizure, the patient comes to the clinician. And the clinician will have to decide whether the seizure was provoked or unprovoked. Provoked seizures can occur if somebody has, let's say, all of a sudden a metabolic disturbance, their sodium is low, their sugar is low because they took some insulin, they had a car accident, had trauma and they had a seizure, they had a stroke, or they are taking a medicine that is known to increase the chances of seizures, such as bupropion or Wellbutrin, among numerous others. If this is the case, meaning if the seizure is provoked, it will not necessitate any treatment. The only management is to refrain from whatever was the inciting trigger.

On the other hand, if the seizure is considered unprovoked, then it counts towards the definition of epilepsy. Epilepsy is defined as two or more unprovoked seizures that are more than 24 hours apart. It's also defined as only one unprovoked seizure in the presence of a preexisting condition that is known to significantly increase the chances of a second and a third seizure. If the definition of epilepsy is met, then the treatment should commence.

It's important also to mention that a lot of people who have paroxysmal episodes that are believed to be seizures or that resemble seizures may not have epilepsy. Epilepsy occurs when the seizure tends to often be associated with specific brain wave changes, but there are a lot of events that look like epilepsy that are non-epileptic, and these include physiologic ones like fainting or psychogenic ones, meaning sometimes psychological stress can manifest as events that may look like epileptic seizures, but they are a mere manifestation of emotional disturbance.

After the clinician characterizes the seizures, often during an epilepsy monitoring unit admission, and they know they are epileptic, and they know the patient meets the definition, then the first thing we start with is anti-seizure medications. Failure of two or more anti-seizure medications to achieve seizure freedom defines medical intractability . That means that the patient is pharmacoresistant. It means that the medications will have very slim chances of achieving seizure freedom, and it is at that point that we start our surgical evaluation.

Several surgical procedures can be done for treatment of epilepsy. And these include ones that are resective or ablative, which means where brain tissue is removed or is interrupted. And legionectomy is one of those, which means a specific lesion that is there. It could be a vascular lesion or an abscess or scar tissue, they can be removed surgically. Selective amygdala hippocampectomy is another where the amygdala and the hippocampus, which are brain structures that are deep behind the ear and the temporal lobe and are often the source of seizures, can be removed, all the way to what we call an atomic hemispherectomy, where a whole hemisphere, the half of the brain is disconnected and removed. And this occurs in some pediatric epilepsies that are very severe and that will not respond to any other interventions.

But what is very important in the modern era or what every epilepsy doctor now deals with on a regular basis are the novel techniques that have really changed the practice of epilepsy surgery. And namely, these are the stereotactic EEG implantation, especially using robots, and also the laser ablation, also called LITT therapy, which stands for laser interstitial thermal treatment for epilepsy. These are being done increasingly at numerous centers in the United States and are less invasive than previous procedures with excellent outcomes. If the patient is not a candidate for epilepsy surgery, there are still things that we can do, and these include neuromodulation, which means electrical stimulation, and we have devices that can be used for that purpose, including ones that stimulate the vagus nerve, which is a nerve that comes from the brain down through the chest and can be stimulated and its stimulation has been shown to reduce seizures in many epilepsies, but there's also electrical stimulation that can be done inside the brain.

And two FDA approved procedures include one where a specific brain region is stimulated called the anterior nucleus of the thalamus. And this has reduced seizures in many individuals. And the other one is called responsive neurostimulation, whereby electrodes are placed near an area that is believed to produce seizures. And then, whenever a seizure discharge is detected, the device will deliver specific electrical stimulation, hoping to abort and stop the seizure.

All of this is available to our patients today, but I still have to mention one other thing, which is diet therapies. For some pediatric epilepsies, diet therapies can achieve complete seizure freedom and can be superior to any treatment with anti-seizure medications, but that's not only for kids. There are accumulating data in adults that have demonstrated time and time again that specific diets, including, for example, the modified Atkins diet in individuals with seizures can reduce the seizure frequency significantly.

Melanie Cole, MS: Thank you for going over all of that so clearly, Dr. Koubeissi. As we wrap up, I'd like you to just speak to patients about your best advice, really, living with epilepsy. You mentioned diet because that is a really big thing that we're hearing about today. You went over all of the different surgical procedures. Speak about the multidisciplinary approach that is so important for people living with epilepsy and the different specialists that you work with at the George Washington University Hospital.

Dr Mohamad Z. Koubeissi: At George Washington University Hospital, we've had a level 4 epilepsy center for the past 12 years. Level 4 is the highest designation of epilepsy centers by the National Association of Epilepsy Centers. The highest designation is earned when an epilepsy center is able to offer all the available technology for treatment and management of epilepsy.

At GW, we do all kinds of epilepsy surgery. We offer diet therapies. We offer neuromodulation and device implantation. The journey of individuals with epilepsy can sometimes be easy, because many epilepsies will respond to the first or second anti-seizure medication and seizures will not affect the individual's social life or professional life, or cognitive status or psychological condition, but sometimes it can be difficult and the patient needs to go through different anti-seizure medications, but also surgical evaluation, and maybe diet therapy, and maybe neuromodulation.

The take-home message for my patients, and for any individual with epilepsy, is that please be open to discuss any treatment modality with your epilepsy specialist. Surgery is not something that will make people a vegetable as some describe it. It's not something that is a last resort and that is associated with, disastrous consequences. Surgery has been done in thousands and thousands of people. And when compared to continued medical treatment, it is way superior in its chances of achieving seizure freedom. In one controlled trial that was done 24 years ago in Canada, surgery resulted in 58% chances of seizure freedom compared to 8% for those who did not do the surgery and continue to try different regimens of anti-seizure medications.

We have more recent data showing seizure freedom rates of up to 70% and 80% and this is not something that medications can do after medications have already been tried and failed. It's important to keep an open mind and talk to your clinician about all the available options for you today. One may not work, the other may work. And if you're scared of pursuing the surgical path, please ask your clinician to put you in contact with individuals who have already been through that journey so that they can tell you about it from their own perspective.

Many of my patients who have achieved seizure freedom with epilepsy surgery, they come to my clinic volunteering to talk to future patients who may be eligible for the surgery and encourage them to undergo the surgery, because that's the only way for some people to achieve seizure freedom.

Melanie Cole, MS: Excellent advice. So educational. You're a great educator, Dr. Koubeissi. Thank you so much for joining us today. And for more information, please call 1-888-PATIENT for GW docs, or you can visit gwhospital.com. Thank you so much for joining us on GW Hospital HealthCast, an informative health podcast from the George Washington University Hospital.

Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any procedure. Please speak with your physician about these risks to find out if any procedures are right for you. I'm Melanie Cole. Thanks so much for tuning in today.