About one-third of epilepsy patients have a disease that is considered drug-resistant, meaning they have failed at least two medications. For these individuals, neurosurgical procedures offer the best chance of bringing their disease under control.
Remarkably, the average time it takes for someone with drug-resistant epilepsy to be referred to a neurosurgeon is 20 years in the United States. Although current surgical approaches are already good, researchers at Brigham and Women’s Hospital are focused on developing treatments for patients with drug-resistant disease that are more effective and less invasive. Neurosurgeons at the Brigham and Woman’s Hospital hope to raise awareness about the success of these procedures, with the goal of delivering disease relief to more patients.
“Epilepsy has extremely negative effects on a person’s quality of life and in some cases can even lead to death,” says John David Rolston, MD, PhD, director of Epilepsy Surgery and of the Mapping & Engineering Neural Dynamics Laboratory at the Brigham and Woman’s Hospital. “More medicines are not always the answer, but there is a lot of fear among patients and even their providers about surgery.
“In my lab, we want to improve these surgeries by lowering the risks. This has the benefit of making them less frightening as well as making the risk-benefit ratio more appealing to patients who are hesitant.”
Enhancing the Effectiveness of Implanted Devices
One surgical approach that can relieve many patients involves the placement of neuromodulating, or brain-stimulating, devices. This technique may be used when it’s not possible to remove the part of the brain where the seizures originate due to the proximity to a crucial part of the brain, such as the language area or the hand motor-control area.
“The problem is that neuromodulation is only helpful in three out of four patients, so my lab is spending a lot of time trying to redesign this technique for those patients,” Dr. Rolston says.
Among the research studies that aim to boost the effectiveness of neuromodulation implants, some use imaging, including MRI, to better understand the brain circuits involved in epilepsy. Current clinical trials are using this imaging and a better understanding of natural brain variability to optimize the positioning of electrodes in the brain. Dr. Rolston is optimistic that the trials will be able to capture a better share of responders to this treatment.
Patients may also be monitored over longer periods of time before the placement of these devices so that their surgeons can gain as much information as possible about where the seizures are starting. This is done by temporarily implanting electrodes in the brain, allowing for real-time brain monitoring.
Minimally Invasive and Robot-assisted Approaches Improve Patient Experience
Robot-assisted surgery has also improved the placement of these devices. “The robot is incredibly accurate for positioning devices deep into the brain, with accuracy within the millimeter,” Dr. Rolston says. “By incorporating robotics, we hope to make these procedures safer, more efficient, and more reproducible, and to ultimately create a better experience for the patient.”
Another surgical technique that can be effective in treating epilepsy is laser ablation. As Dr. Rolston notes, “The laser can melt away the parts of the brain that might be causing seizures or other problems.”
The laser enables a minimally invasive approach in cases where an open craniotomy would have been standard in the past. Rather than requiring a piece of the skull to be removed, the laser can destroy the tissue through a hole in the skull only about the diameter of a pencil.
Here, too, robotic assistance can enhance treatment accuracy. “The precision that we get from the robot combined with the minimally invasive use of the lasers is a really powerful combination,” Dr. Rolston says.
Focused ultrasound, which requires no incision and treats the brain with soundwaves, can provide relief not only for patients with epilepsy but also those with essential tremor or Parkinson’s-related tremor.
“This is really neurosurgery 2.0, where we are able to do completely incisionless therapies,” Dr. Rolston says. “And we’re only scratching the surface of what these treatments can do.”
Active investigations are also exploring the use of focused ultrasound for brain tumors and to treat conditions like addiction and obsessive-compulsive disorder.
Advantages of a Multidisciplinary Team
The Brigham offers a wide range of treatment options for neurosurgery patients, no matter what their diagnosis is.
“A major reason patients should consider the Brigham is that we have access to all these new technologies along with a great deal of expertise with older, more standard surgical approaches,” Dr. Rolston says. “In addition, we work in an environment where everybody is focused on taking these techniques to the next level. This makes a huge difference for every patient who comes through our doors.”
Outside of clinical trials, the Brigham is focused on developing better support for doctors working in the community in making treatment decisions, including raising awareness about options for patients with drug-resistant cases of epilepsy and other neurological diseases. These treatment-decision tools could use the medical records system and machine learning to help providers identify which patients might benefit from a neurosurgical consultation.