WORLD / Health
Epilepsy surgery: Underused but rising
(AP)
Updated: 2007-05-22 14:20
WASHINGTON - The research is persuasive: When drugs don't completely
control epilepsy, surgery often can - and the sooner it's tried, the
better.
Neurosurgeon Dr. P. David Adelson, right, and Dr. Brian Jankowitz, senior
neurosurgical resident at the Children's Hospital of Pittsburgh, operate
on 2-year-old Alex Seman Tuesday, May 1, 2007. [AP]
Yet while children are going under the knife at younger ages, epilepsy
specialists are struggling to get that message to tens of thousands of
adult patients.
"Surgery used to be thought of as a last resort. Now we don't think that
anymore," says Dr. Deborah Holder, a neurologist at Children's Hospital
of Pittsburgh.
"In my perfect world, we'd take care of everybody when they're young."
Almost 3 million Americans have epilepsy, periodic electrical storms
inside the brain. When circuits misfire fast enough, a seizure results.
Many are born with it, but epilepsy can develop at any age, particularly
after injury to brain cells such as head trauma, meningitis or a
mini-stroke.
Up to 30 percent of patients have intractable epilepsy: Medicines don't
prevent all their seizures, or they cause intolerable side effects. Many
are candidates for surgery, cutting out the abnormal brain tissue that
sparks seizures. At leading centers, up to 80 percent of surgery
recipients become seizure-free, with few complications.
And improved technology is allowing surgeons to better pinpoint the bad
spot and remove less brain tissue - half as much as the most common
epilepsy surgery removed just a few years ago, says Dr. P. David Adelson,
a neurosurgeon at the Pittsburgh children's hospital.
Between 3,000 and 5,000 of the operations are performed annually, up from
1,500 in the early 1990s, estimates Dr. Robert Gumnit of the University
of Minnesota, who heads the National Association of Epilepsy Centers.
However, 100,000 to 150,000 epilepsy sufferers are considered surgery
candidates. Most have two to five seizures a year despite medication, and
have been told to live with it - instead of being sent to an epilepsy
center that specializes in complicated cases, says a frustrated Gumnit.
That may not sound like many seizures, but it means the people can't
drive or perform certain jobs.
"It's not the burning issue it ought to be," adds Dr. Jerome Engel of the
University of California, Los Angeles.
There is a major push to get youngsters, especially those with severe
epilepsy, to the operating room sooner.
Why? If two medications fail to control epilepsy - at any age - there's
only a slight chance a third will help, recent research shows. Worse,
years of seizures can harm a child's development, sometimes permanently.
A Cleveland Clinic study in the journal Pediatrics this month is among
the first to examine surgery on children younger than 3, and found that
even among patients that young, earlier surgery predicted a better chance
of normal development.
Consider 2 1/2-year-old Alex Seman of Wampum, Pa. He has a condition
called tuberous sclerosis that triggers epilepsy through abnormal brain
growths. Despite four medicines, his arms and legs would flail with
seizures several times a day. Brain monitoring uncovered several dozen
mini-seizures daily, too, presumably the reason his language skills were
about a year delayed.
"It's like listening to your cell phone with static coming through," says
Pittsburgh's Adelson, who operated on Alex earlier this month. "The goal
was to cure it before he even knew he had it."
Preparation was the hardest part, says Alex's father, Mike Seman. Doctors
performed a sort of pre-brain surgery, implanting electrodes directly
onto the surface of Alex's brain. For a week, he was monitored by video
as those electrodes mapped the source of his seizures - and his parents
went through lots of bubbles and Barney videos keeping him quiet.
Weeks after doctors removed a chunk of his brain, Alex is seizure-free so
far, and his parents say his perky personality has reappeared.
Not everyone is eligible for surgery. Seizures may originate in a spot
that can't be removed safely. Their options:
Major studies are beginning to see if implanting an electrode that emits
a low-level electrical current could zap the bad brain tissue and stop
seizures as they form. Called deep-brain stimulation, it's already used
to control tremors in Parkinson's disease.
Doctors also sometimes implant a "vagus nerve stimulator," which delivers
tiny shocks to a nerve in the neck that in turn signals the brain. It
doesn't cure epilepsy like surgery can, but can reduce some patients'
seizures.
Also under study is beaming the seizure spot with radiation, using a
technique called the Gamma Knife.
Janet Rickey of Arlington, Va., chose standard surgery even though
doctors warned the problem spot was right next to the brain region that
controls movement of her left side. But at age 47, seizures that began at
7 were steadily worsening, and drug after drug failed. When testing
recorded 120 full-blown or mini-seizures in a week, surgeons at
Georgetown University Hospital agreed to try.
Rickey did wake up with partial paralysis; it took a month to move her
left leg. Three months later, she still walks with a cane, but is gleeful
that her seizures have plummeted.
"Every day I could count on having a seizure, and now I can count on them
stopping," she says.
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