Gonzales-Martinez, MD, PhD, professor of neurosurgery andrology, director of the epilepsy surgery and movement surgery and co-director of the Epilepsy Center at the University of Pittsburgh Medical Center talks about an alternative to treating epilepsy seizures.
Since we’re doing a story about epilepsy surgery, our viewers have probably heard the term. But could you just give me a quick overview to put this in context? What is epilepsy? And do you know what causes it?
GONZALEZ-MARTINEZ: Yeah, so epilepsy is a syndrome, which means that a lot of different diseases can cause epilepsy is a disease that is causing – that causes seizures. And the reason why patients are having seizures is because the neurons, the cells inside the brain, they have abnormal activity and for whatever reasons, they start spiking. They started activating themselves and then that will cause seizures. And those patients, they have several of those events during their lifetime. It can happen in children. It can happen in adults. And the severity will vary. It can – we can have patients that will have perhaps one seizure a year. We have patients that we have a thousand seizures a day. So, again, this is – it’s why we call this syndrome, because it’s a bucket where there are several other types of diseases, and it’s very variable.
What’s the impact on the quality of life for a patient who has a lot of seizures? Could they be having deficits in other areas?
GONZALEZ-MARTINEZ: Absolutely. Seizures, epilepsy is a very debilitating, disease. Again, there are economic burden. And there are social burdens and there are all sorts of complications that the patient may have. So, for example, the life expectancy of patients with epilepsy are probably five times less than a normal person because they are involved in accidents. They can have a car accident. They can burn themselves when they’re cooking. They can fall in hit their heads or having other injuries. In addition to that, again, it’s a disease that causes limitations from a social aspect. The problem with epilepsy is that I never know if I have epilepsy. I never know when I would have a seizure. I can look completely normal, but I never know if during this interview and we have a seizure, I would never know if by going to a restaurant with my friends or with my family, I would have a seizure and get into a very difficult situation. So what happened is people starting narrowing their social activities. And they stay more and more and more at home because they’re afraid of having seizures in public. And as you can imagine, seeing this can cause a huge, social limitation for those patients and a social burden. From an economic point of view, those patients, they can – many times, they cannot attend colleges. They cannot finish their educations. They cannot have appropriate jobs and good job opportunities because they’re having seizures. So it’s a very complex disease that can cause medical problems, social problems and economic problems. Unfortunately, we have approximately three point five million people in the United States with epilepsy.
Are there treatments prior to surgery that are effective for patients?
GONZALES-MARTINEZ: Yeah. So, yes, the main treatment, the main initial treatment for patients with epilepsy is medication. So always those patients, when you are diagnosed with epilepsy, the first line of treatment is and anti-seizure meds. And in general, most of those patients will have control of their seizures with anti-seizure medication. I would say probably 50 to 70 percent of those patients, We have a completely successful control of seizures with medication. The problem is what happened with the 30 percent and 40 percent of patients that cannot have seizures, control with medication. And that’s where surgery plays a big role in trying to control those seizures.
For patients who get to the point with a surgery is their best option, what has been the gold standard, the way the surgeons have performed the procedure?
GONZALES-MARTINEZ: Yes. So, again, as I mentioned to you, there are a whole variety of different epilepsies. But for this conversation, perhaps we can narrow what is the most common epilepsy, which is temporal lobe epilepsy. So let’s suppose the patient with the temporal lobe epilepsy. A temporal lobe is an area in the brain that is just behind my eyes. If the patient has temporal lobe epilepsy, which is the most common type of epilepsy, the first line of treatment is medication. If they fail, surgery is an alternative. And in general, the standard way we perform those, the surgical procedures is through a craniotomy, is through this call. What we do, we make in general an incision that has a shape of a question mark just in front of the ears, right or left, depending on which temporal lobe is responsible for seizures. And we are going through the scheme, through the muscle, and then we remove portions of the skull so we can expose the brain. And then we do what we call a temporal reception will remove portions of the temporal lobe. And finally, the hippocampal formation, that is the man responsible for the seizures.
And, what is the recovery like when you have a craniotomy, you have the full brain surgery?
GONZALES-MARTINEZ: So the procedure in general takes three to four hours. They stay in the hospital two or three days recovering from surgery. They go home. The stitches come out after 10 days. But for full, full recovery, we are talking about six weeks.
What are some other options, other ways that the doctors who perform the surgery the last eight years?
GONZALES-MARTINEZ: So the what I just described to you, the craniotomy, is traditionally the most standard in more traditional ways of performing this operation. There are other techniques now. Most recently, there is something called laser abrasions where we can put a small laser catheter with a small opening in the skull and we can destroy or we can burn the areas in the brain that are responsible for the seizures. Again, the downside of the laser abrasions that we cannot completely treat the whole area, uh, then he should be treated. So we still the conventional approach offers better results than the alternative approach of the less invasive approach, such as the laser ablation. But this comes with a price. Again, in order to perform this very complete resection, we need to perform craniotomy. We need to open the skull. And most importantly, we need to remove areas in the brain that are not completely responsible for the seizures. So, we need to remove those areas in order to get access to the areas that we need to treat. And of course, the areas that we remove in May cause problems for the patients may cause additional morbidity, mainly memory and cognition, because we’re removing portions of the brain that, in fact, don’t need to be removed for the surgery. So this is the main limitations of the current standard approaches that we have for epilepsy.
Talk to me a little bit about what you and your colleagues are doing here at UPMC.
GONZALES-MARTINEZ: And so in order to overcome exactly this limitation, in order to – let’s provide a procedure that will have the same success rate of the standard procedure, but without the removal of external or additional brain tissue, and the only way to perform this is going through the front, through the face, because the areas that we need to remove the temporal lobe, the temporal lobe, the hippocampus and amygdala, they are located more anterior. And the only way to remove those areas without removing the light of areas is still going through the phase, so that’s the reason why here at Universal Pittsburgh, we join forces with a group we call the surgeons and EMT surgeons. And we develop this approach that goes that we perform the resections of the major structures of the temporal lobe through the face. This is a truly, minimally invasive procedure where there are no craniotomies, there are no openings in the skull. It’s something that goes completely without incisions through the sinus, which are spaces in the face. We open the spaces. We expose the areas that we need to remove. And with an endoscopic approach, we just remove the entire areas without touching the external areas that don’t need to be touched.
Now, I had heard of endonasal, going right through the nose. But what are you and your colleagues doing in addition or instead of the…
GONZALES-MARTINEZ: So we realize that the endonasal was the first alternative for this, but we realized that the endonasal itself will not give us the appropriate visualization of the structures. So we went a little bit later instead of going through the nose, we went through what we call the gingiva labial fold, which is inside the mouth. And then in that way, give us exactly the very direct approach that we need.
Can you walk me through the surgery for our viewers? Tell me, where do you where do you start? What’s the first step? And then when he takes over, what’s next?
GONZALES-MARTINEZ: Sure. Patients will come in the morning in the operating room. And they’ll be anesthetized. So, patient will be completely under anesthesia. So they normally takes for the the surgical time for the whole procedure around five hours. But for the patient, the perception is just one second. They close their eyes, open their eyes and surgery’s over. So what we do is initially the EMT team gets into the approach. They are responsible to making the approach to open, to give access to the temporal lobe. And this is the group led by Dr. Snyder. So Doctor Synder and his group, they will do the incisions inside the mouth. They will expose the signals. They expose the entire areas in a very delicate fashion until they expose to us, the areas that are responsible for the seizures, which is a temporal in the meta structures. That’s the point that myself and Dr. Garner, we take over and then we do the resection, which involves the amygdala, the hippocampus and the temporal pole. This whole process takes five around five hours. After we do that, we close all the layers, and then patients will be transferred to the ICU when they stay one night overnight and then they’ll be transferred to the floor and then they stay two or three days in the hospital recovering and they’ll be able to go home.
Doctor, you’re essentially doing the work through what is it called a cannula. Can you describe the the work that you’re doing and how much of the brain are you removing? Is it just a tiny little pinpoint or about how much…
GONZALES-MARTINEZ: Yeah, the instruments that – we use several instruments that are specifically designed for this approach. So there are cameras, cannulas seizures, bipolar calculators, dissectors. Everything is perfectly designed to really give us the possibility of removing through this narrow corridor. And also what’s very important is to visualize. So we’re able to see and exactly understand, what are the structures that we need to remove in the areas that we remove are little small areas. We are talking about perhaps, areas that we have a volume of knowledge, for example, or a very small areas, just the areas that we need to treat in order to stop the seizures.
And, I asked this before. I’m not sure if I asked it on camera though. The importance of being very, very precise. And just taking the minimal amount of brain tissue – can you speak to that.
GONZALES-MARTINEZ: Absolutely. So this is the main advantage of this approach. The – this approach is all about selectivity. It’s hyper selective approach to treat seizures. So as opposed to what we had with a conventional approach that we need to expose larger areas in the brain and remove larger areas in the brain in order to just to get access to the areas that we need to treat. Now, we are having the surgery done just in the areas that we need to treat. So in the past, we used to remove a larger volume. Now we are removing small areas, as I said, size of an olive, perhaps the size of a cherry – very localized, very vocal. So what this brings is better outcomes in terms of better memory results after surgery and also associated with an optimal seizure outcome.
Because you haven’t had that full craniotomy, what is recovery like for patients that then this has been minimally invasive?
GONZALES-MARTINEZ: Yeah, pain is much less – the main factors here is pain, the need for blood transfusions, the need for extended ICU stays in the hospital. This all change. Again, this is a face approach, with brings much less pain, much less complications in terms of, blood transfusions, in terms of other types of complications that we can find in conventional surgery.
What’s your patient success rate so far? How are the patients doing with this approach?
GONZALES-MARTINEZ: So epilepsy is – it’s a complex pathology. And again, they’re having seizures for long periods of time. And we are not expecting all the patients will become seizure free. And we are not expecting that all the patients will become seizure free soon after surgery. So in order to really evaluate what is the success in terms of seizure outcomes, we need to follow those patients for for a long period of time. But regardless of that, I think this approach would bring us the possibility of treating the areas that we need to treat. There are no limitations. We are removing the areas that we intentionally once remove, and that is a success. And also the other success – and our vie is that this procedure can be done in a very safe way with minimal complication rate. So, of course, the final success will come with time.
How long have you been doing this procedure and is it done anywhere else in the country or the world right now?
GONZALES-MARTINEZ: We developed this procedure here at the University of Pittsburgh. We’ve been doing this for approximately one year.
Does there have to be any kind of FDA approval or oversight Because it’s a different procedure? Can you talk about it?
GONZALES-MARTINEZ: Not necessarily. Again, this is not an investigation, approach. This is a standard approach. We are using just different routes. So that’s why we’re not using any different devices or we’re not giving any other indications. So this is a standard approach, or using the standard techniques to treat epilepsy through a different route. But everything that we have so far is a standard of care.
Do you speak to me a little bit about the patient Joe before and after and how he was doing before what prompted, uh, his need for surgery and how he’s doing now?
GONZALES-MARTINEZ: Joe was having a lot of seizures before surgery. And the point that his medication was not helping the family was concern. He was concerned. He reached out to us. We understand, we studied his brain. We put together, the analysis of all the information that he had before, which includes the type of seizures that he’s having, the e.g. the other images. And we put everything together in something we call patient management conference here within our group. The Epilepsy Center here in Pittsburgh is fantastic in terms of putting having a very comprehensive approach for every single patient. So we got together in a group of more than ten, fifteen physicians. We come up with the conclusions that Joe’s seizures were coming from the temporal lobe, from the meta structures. And then we decided what type of role will perform the job. And we found that Joe would be probably a very good candidate for this hyper selective approach through the temporal lobe. So that’s what we did. And then finally, we discussed, Joe’s situation and proposal with Dr. Snyder and Dr. Gardner, and we indicate surgery for him.
How is he doing now?
GONZALES-MARTINEZ: He’s doing very well. Joe has been recovering well from from surgery. I saw him yesterday in clinic. To me, he looks fantastic.
Terrific. Is there anything I didn’t ask you, doctor, that you would want to make sure that people know?
GONZALES-MARTINEZ: I just want to emphasize how important it is to develop new approaches for epilepsy. Epilepsy is a severe disease. It’s under diagnosis in our country. We have a lot of patients that needs, uh, better treatment for this type of theology. I think this type of approach brings hope and brings an alternative for less invasive approaches. Many times patients are afraid of coming for surgery or to look for surgical treatment for epilepsy because the surgery is too invasive, because they are afraid of losing other functions, for example, like memory, cognition and other things. And they tend to stay at home and they tend not to look for treatments and they will continue to see the rest of their life. quality of life, they’re missing. So this type of approach brings the alternative that now we have a surgical approach that will provide you the chances for you to become seizure free, the chances for you to change your life, to improve your quality of life, but without the detrimental consequences of a larger procedure.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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