Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole and joining me, we have a panel today with Dr. Timothy Quezada. He's a Neurologist and Director of Stereo EEG at AHN and Dr. Alex Whiting. He's a Neurosurgeon and the Director of Epilepsy Surgery at AHN. They're here to highlight new surgical options for epilepsy for us today. Doctors, thank you so much for joining us and Dr. Quezada, I'd like to start with you. Give us a little overview of drug resistant epilepsy, how common it is and how it has evolved over the years as we get more understanding of this disease.

Timothy Quezada, D.O.: So drug resistant epilepsy is a condition in which somebody has epilepsy or a seizure disorder that continues despite the use of medications. And we've drawn pretty clear lines on what defines despite the use of medications. It's failure of two medications to control the seizures. The medications can either be sequential, so one medication then the other, or they can be at the same time.

But regardless, if a patient continues to have seizures, despite these two medications, that is labeled as drug resistant. And I think the progress in that realm, especially with the definition, has been important in that we know that somebody that is labeled as drug resistant or that meets that criteria for drug resistant should be worked up for epilepsy surgery.

They should be evaluated at a level four epilepsy center, which is the highest level of accreditation for an epilepsy center. We know that patients that are drug resistant are unlikely to respond to a third anti-seizure medication, let alone a fourth or a fifth, and so they need to be evaluated for other non medication options.

The treatments for drug resistant epilepsy, which we'll get into, have expanded quite a bit in the last few years, and we'll spend, I'm sure, quite a bit of time talking about what those treatments are, but really just getting an awareness of not just what drug resistant epilepsy is, but where patients should go for evaluation and what options are available is really important.

Host: Well, it certainly is and thank you so much. And Dr. Whiting, as Dr. Quezada said, I'd like you to expand now on when we consider surgical interventions for epilepsy and how have these surgical indications evolved over time to apply epilepsy surgery to more patients; and while you're telling us this, I'm asking you a lot of questions at once, but speak a little bit about some of the new surgical options out there. The therapies that a patient would have to have failed to be considered for surgical intervention and the parameters for identification of patients who will benefit from these types of surgeries.

Alex Whiting, M.D.: So, it's actually become relatively cut and dry when we should be referring patients for surgical evaluations. Most major bodies like the American Academy of Neurology, the American Epilepsy Society, they recommend that you get a surgical evaluation once you've tried two drugs and you continue to have seizures.

There are so many drugs available at this time to treat seizures that sometimes patients can get caught in a cycle where they just keep trying new medicines over and over and over again. Unfortunately, most of the data would show that once you fail two medicines, the chance of the third one, the fourth one, the fifth one being successful is pretty low.

So, because of that, most major bodies at this point recommend that once you've failed two drugs, you do get a surgical evaluation. And as Dr. Quezada mentioned, they recommend that's done at a level four epilepsy center like we have here at Allegheny Health Network. The earlier we intervene when somebody has that drug resistant epilepsy, someone who's failed two medicines and still has seizures, the better we usually do at fixing it.

There's a really nice paper from a few years ago where they split patients up and they looked at people who had a surgical intervention within five years of meeting that criteria of failing two medicines and people who waited more than five years. And you were twice as likely to be cured of your epilepsy if we got to you within five years.

So, it's a lot like heart disease or atrial fibrillation, things like that, the longer you have that problem, the more it teaches the rest of your body to have it. We say epilepsy begets epilepsy. So the longer you have seizures, the harder it can be to cure or treat. So we do like to see patients early, once they have failed those two medicines.

And obviously that was a couple questions. The question about what, is new and what has changed. We could probably talk all day about that. In the last 10 years alone, the amount of different interventions and surgical treatment options we have has really exponentially increased. It used to be the only real option we had for patients, not that long ago was basically to do a resection, to cut a part of the brain out. And we certainly still do that sometimes because that gives some patients a chance at a cure, but we have plenty of other options including neuromodulation, stereoelectroencephalography, vagus nerve stimulation, deep brain stimulation, all these things I think we're going to talk about today that have really changed the landscape and they've made it so that pretty much any patient with medically refractory epilepsy, these people that have tried medicines and are still having seizures, has a reasonable surgical option.

And many of them can be minimally invasive and leave you exactly the way you are. So, I think that's what we're going to talk about today.

Host: Well we definitely are and thank you for that. Dr. Quezada, speak a little bit about stereoelectroencephalography, how that's changed our ability to understand a patient's epilepsy. Tell us about it.

Timothy Quezada, D.O.: So stereoencephalography is a way in order for us as the neurologist to determine where their seizures are coming from. When we have somebody that has focal epilepsy, meaning it's coming from one or more particular spots within the brain, it can be really difficult for us through traditional testing to figure out where it's coming from.

You know, the brain's a big place. It can come from any number of places or multiple places at once. And with regular EEG, meaning surface EEG on your scalp, that signal of the seizure can be difficult to determine where exactly it's coming from deep tissue for example like the mesial temporal lobe, the cingulate cortex, the ventromedial frontal lobe. These places can't really be detected or the seizures from these places can't really be detected on surface EEG. We try to augment the EEG with MRI, with PET scans, with SPECT scans. We have all these non invasive ways to try to come up with a good hypothesis about where the seizures are coming from, but nothing beats measuring or detecting the seizure from the exact area of brain tissue itself. So, that's what stereo EEG does.

It's a minimally invasive surgery in which electrodes are passed directly into brain tissue, that's done with a good bit of planning, or a lot of planning, I should say, including an EEG prior, an MRI prior, all the things I mentioned before, blood vessel imaging so that it's done safely. And several of these electrodes are passed right into the brain at the areas where we think or we have good reason to suspect seizures are coming from.

Then we would send the patient to an epilepsy monitoring unit like we have here at AHN and have the patient have seizures. So we would see their seizures come directly from the brain tissue of interest and then we can make our best recommendations about what type of surgery is most appropriate for the patient. As Dr. Whiting said, whether it's neuromodulation, whether it's a minimally invasive laser ablation of targeted tissue, whether it's a small or even a larger brain resection, the SEEG is the starting point. It's the first diagnostic surgery in order to lead us to the therapeutic surgery afterwards.

Alex Whiting, M.D.: If I can add a little bit too as a surgeon, what I like the most about SEEG or stereoelectroencephalography is that it really changed the game in terms of what patients have to go through to get to that potential cure or treatment. It used to be we'd have to do these very big, very invasive surgeries, take off a big piece of bone to map

the brain. This surgery is so minimally invasive, you can barely see where we put the electrodes in. I mean, it's one little poke in the skin where each electrode goes in. That usually when they come back at their two week appointment, I can barely see where the incisions were. On top of that, it's an exceptionally safe surgery. The risk of something bad happening, a complication is about as low as most diagnostic procedures like angiograms. So, things that we take as diagnostic tests, that's how safe this is. I mean, I usually quote 1 percent as the chance of a complication. And on top of all that, just like Dr. Quezada mentioned, it has made us so much better at localizing exactly where the epilepsy is coming from, because we're actually putting the electrodes into the brain, so it's safer, it's better at finding the epilepsy, and it's incredibly minimally invasive. It's been a game changer we do a lot of it here at Allegheny Health Network now.

Host: That's absolutely fascinating and what an exciting time in your fields. It really, everything is moving so quickly. Dr. Whiting, I'd like you to expand on some of the new devices and implants being used to treat seizures. Tell us a little bit about some of those things that you're both doing.

Alex Whiting, M.D.: So, after we do the stereoelectroencephalography in a lot of these patients and obviously these are people who have had epilepsy and have failed medicine. And a lot of times they've lost hope that this is going to go away. We use the SEEG to map exactly where your epilepsy is coming from down to the millimeter sometimes.

And then we really have a lot of options now. So if you have epilepsy coming from a part of your brain that isn't doing very much in terms of being eloquent cortex or being something that's important to you. A lot of times we'll talk about taking that part out and hopefully curing your epilepsy or using a laser to ablate it in a minimally invasive way.

But for some patients, this isn't the case. For some patients, they have epilepsy coming from an important part of their brain. And if we were to do something to that part of the brain, they might be different afterwards. And ultimately our goal is to fix your epilepsy, but we want you to be exactly the same after surgery.

And it used to be we didn't have any options for those people. But now we have all these new devices. And they're the ones that fall into the stimulator category or the neuromodulation. One of them is called a vagus nerve stimulator. That's one that we place into the neck and it stimulates a nerve that goes to the brain.

Two of them, the response to the neurostimulator and the deep brain stimulators, those are ones where we actually put electrodes directly into the brain and connect them to a battery. Or in RNS's case, we actually connect them to a little computer that we implant into your skull. And what's nice about all these things, they don't change anything about the brain, so you're still you afterwards, but if we put those electrodes directly into the part of your brain causing the seizure and we hook it up to that little computer, that computer can learn over time where your epilepsy's coming from and get better and better at stopping it before it starts.

 So these are patients that had no option before and now we have these wonderful options that do a really good job of controlling their epilepsy and sometimes ablating the seizures completely, getting rid of them. So, it is very exciting time because all of these patients who didn't have good options before have good options.

Host: Dr. Quezada, for other providers, when they're counseling their patients on this myriad of tools that you have in your toolbox, what do you tell them about continued epilepsy despite trying multiple medications for epilepsy that is refractory to these interventions? How do you advise that they counsel their patients?

Timothy Quezada, D.O.: I think I would just start by telling them that there's always hope, there's always something that we can do for this medically intractable epilepsy, and there may be things that have come around over the last few years which they may not fully understand or be up to date on. You know, I'm talking about providers or neurologists that don't practice epilepsy every day. And that's okay. We want them to be referred to a level four epilepsy center to see if they're a candidate for any of these interventions, whether they're devices, whether it's an open brain surgery, or even whether it's other medications. There's just a lot of options out there that didn't exist before.

And I don't think I've had anybody come here, that's medically refractory, that's wanted treatment that we haven't been able to find something for, whether it's a vagus nerve stimulator, or whether it's a medication or whether it's some other kind of surgery. I've never had anybody where we just couldn't offer them anything.

That would be an uncommon situation. And even more specifically with epilepsy surgery, the number of patients that qualify for epilepsy surgery is, you know, Dr. Whiting was explaining that number has grown substantially. It used to be that if your epilepsy came from the part of your brain that controls your motor function, well, there wasn't much we could do because we can't cut that out without leaving you weak on one side, and that's just not the case anymore.

I'm saying with multifocal epilepsy, where seizures come from more than one spot, and even for generalized epilepsy, where the whole brain is involved in the seizure network right away, there's options for all of these patients. So I guess, long answer here, but I would just say that for providers seeing medically refractory patients or for the patients themselves, not to give up hope, to seek high level epilepsy care at a level 4 epilepsy center.

Host: I'd like to give you each a chance for a final thought. So Dr. Whiting, the Epilepsy Center has a focus in engaging multidisciplinary teams to best treat patients. I'd like you to speak to other providers about what that means and why that multidisciplinary approach is so important for these patients.

Alex Whiting, M.D.: It's important because we take every patient's life and goals very seriously and we're not rushing into anything or jumping into anything. Every patient that gets recommended for any intervention, gets discussed at a multidisciplinary conference. And we spent a significant amount of time going through all their test results, talking about them, going through their neuropsychological reports, what their goals are.

And then we come up with a bunch of solutions. And then I will sit down with the patient or Dr. Quezada will sit down with the patient and we present what everybody came up with. And I think the era of you walking into a doctor's office and the doctor telling you what you need is thankfully over. Here at Allegheny Health Network, we're really just trying to meet your goals.

If your goal is to be seizure free and to be cured of your epilepsy, then we're going to work towards that goal. If your goal is to get them under control so you can go back to doing something you used to like to do and you can't do anymore, then we work towards that. And that multidisciplinary conference gives us the ability to bring everybody together, all the different specialists meet those goals.

Host: Dr. Quezada, last word to you. What would you like other providers to take away from this interesting episode, this podcast that we've discussed today and the Epilepsy Center at Allegheny Health Network?

Timothy Quezada, D.O.: I would like just everyone to know, to reiterate that there is treatment out there for all epilepsy patients. Epilepsy is a very common disorder. There's a lot of patients out there having seizures. And, we worry here that there's patients having seizures unnecessarily, that they're not being referred for the latest treatments out of misunderstanding that there's nothing that can be done for them, that they're feeling hopeless or lost.

We want them to just know that there are more answers out there than maybe they realize. We have a excellent team here at Allegheny Health Network from neurologists, not just me, other neurologists. We have Dr. Whiting at neurosurgery, who's very well trained specifically in epilepsy surgery. We have dedicated neuroradiologists that interpret advanced imaging, so MRIs and other things that can help diagnose epilepsy. We have neuropsychologists. We have just great technologists. We have a state of the art epilepsy monitoring unit, and we're here to serve the population around us, all those patients with epilepsy. So the biggest thing that I struggle with and I know Dr. Whiting has felt this way before too, is just visibility. It's just letting people know that we're out there and we're available and willing to help.

Host: Such a comprehensive approach, Dr. Quezada, and thank you so much. That is what we're here to do. So thank you both for coming on and sharing your expertise for other providers today. To learn more or refer a patient, please call 844 MD REFER. Or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network.

Please remember to subscribe, rate, and review this podcast and all the other AHN Med Talks podcasts. I'm Melanie Cole. Thanks so much for joining us today.