Pediatric Epileptologist at the Cleveland Clinic Epilepsy Center, Elia Pestana Knight, MD, talks about treating Epilepsy
Interview conducted by Ivanhoe Broadcast News in 2023.
What causes epilepsy?
Pestana Knight: Epilepsy is a disease of the brain. The reality is that the causes of epilepsy could be anything that upsets the brain where we see it in the case of tumors, a stroke, intracranial bleedings, the sequel of any traumatic brain injury, or since the windows don’t see genetic disorders, and other epilepsies that are considered in the intermix of genetics and the influence of the environment. The expression of epilepsy is seizures, and there are many varieties of seizures.
Traditionally, how was it treated?
Pestana Knight: Traditionally, epilepsy has been treated with antiseizure medications. Over the decades, the number of antiseizure medications has progressively increased to meet the needs of those in which the older traditional drugs have no work and to reduce drugs that produce side effects as a consequence of the patient taking it. Today, we have more than 20 antiseizure medications.
What are traditional surgical treatments for epilepsy?
Pestana Knight: Sometimes when the epilepsy is focal, meaning it originates in a specific area of the brain, whether we see a lesion or not, the epilepsy can be treated with epilepsy surgery.
Finding where the lesion is in the brain can be difficult. Why?
Pestana Knight: Some patients have obvious lesions in the brain. Malformations, the sequel of stroke or traumatic brain injury or infections. However, some patients have very small malformations that we cannot see with the naked eye. One example of that is the button of the sulcus dysplasia.
Can MRI and CAT scans always pinpoint exactly where it is?
Pestana Knight: Oftentimes the brain MRI can show larger lesions that we can find by looking at the study with our naked eye. The head CT is not the best test for diagnosing epilepsy and that is why it is not used for epilepsy purposes today.
What happens to the patient when you can’t pinpoint the lesion?
Pestana Knight: When we can find the lesion, we resort to a number of tests that can help us decide if we are looking at focal epilepsy and from what part of the brain this epilepsy is occurring. Those tests are the electroencephalography. This is a noninvasive test in which the patient will come to the hospital, and we recall the activity of the brain when the patient is awake and asleep. We recall any abnormal brain that indicates that the patient may be having epilepsy. This is typically known as interictal activity. And we also record the typical seizures. Typical seizures are very important in deciding what part of the brain the seizures are coming from. Sometimes we must use other tests such as the Magneto Electron Cephalography. Is a test different from the EEG because we have the capability to find sources of epilepsy that are deeper in the brain. Sometimes we have to do other metabolic tests such as depositor emission tomography, also known as PET. The PET will highlight the area in which we think that the epileptic activity is being generated in the brain. There is another test that we use very frequently, that is the expect. The except what will help us to decide is from where the seizures are starting, and what structures of the brain are involved in the network of generating the symptoms of the seizures. Sometimes we need to use a specialized MRI to find smaller lesions. This is the case of the 70 MRI. The 70 MRI means that the size of the magnet is a seven Tesla is a very strong magnet. They have a very good resolution in creating pictures of the brain for the physician to look at.
Now there’s the seven Tesla MRI, what is it?
Pestana Knight: The most common MRI used today for the diagnosis of small lesions and bigger lesions in epilepsy is a three-Tesla MRI. There are other techniques that are being developed to help improve the accuracy of the interpretation of the three Tesla MRIs. The three Tesla MRIs have a magnet size that is three Tesla. The seven Tesla MRI, the magnet is more powerful and is a seven Tesla MRI. That’s how these two scanners are different. There is a problem with using the seven Tesla as a day-to-day brain scanning because the patient must not have any metal in the body because this could disrupt the functioning of the scanner and be harmful to the patient. One condition to use the 7T is the body could not have any kind of screws or staples, etc.
Tell me about Gabi, the patient we interviewed.
Pestana Knight: I met Gabi and her parents many years ago. As you know, Gabi is a delightful girl who started having epilepsy when she was of school age. Her seizures were very characteristic. She had typical seizures over the summer and all of the seizures began in the same spot on the brain. When we did all the studies that I mentioned before, there was a consistency in the information that the seizures were coming from the left front to the temporal area. The left front to the temporal area is a big area to have Gabi with any kind of surgery because we can simply not remove the whole frontal lobe and the left temporal lobe in her case because those are her dominant lobes for her language and for her ability to write and comprehend the spoken language. Over the years, we did multiple video electroencephalograms with repeated tests including, pets, spades, and make, and they told us to keep looking in that region. Gabi has medications that sometimes work for a short period of time. Some other medications that we used to treat her epilepsy gave her serious side effects of difficulty in her learning at school. Once she got to college and the seizure came back this time with vegans, I told to the parents, we need to start looking again in the brain. Gabi had a dental retainer which was a piece of metal that prevented us from going straight for the seven Tesla MRI. We all agreed to speak to the Gabi dentists and have that piece of metal removed. Gabi came to have a seven Tesla here at the Cleveland Clinic. They were on the way home when the radiology team told me, we had found the lesion that was responsible for Gabi’s refractory epilepsy. The lesion is called the bottom of the sulcus dysplasia. Is a very small malformation, and it was in the bottom of the superior frontal sulcus. With good luck, that lesion was far away from the areas of her speech. The surgeon, Doctor Bingaman, was very confident that he could remove this lesion successfully with a laser procedure. Gabi had her laser procedure, and she has been seizure-free and currently off medications. We are very proud of her accomplishments, and we are looking forward to hearing one day that she is graduating from law school.
Her life was challenging because?
Pestana Knight: I think that the best option of treatment for Gabi was her epilepsy surgery with a laser. We try more than six or seven different medications and none of them will give us prolonged seizure freedom. Sometimes we thought that Gabi was doing well for a year and then the seizure would come back. This will lead to escalation of the dose to the point of creating side effects. Then we had to change the medication to another medication because the seizure continued. This was the life of Gabi for many years. If we had not done epilepsy surgery, this would have been also the future of Gabi. With the sense of modern technology and the hardworking team that the family chose for the care of Gabi, we were able to change her future into what it is today.
How small was her lesion and where was it?
Pestana Knight: The bottom of the sulcus dysplasia that we found on Gabi was very small. No more than three to four millimeters small. It was really a tiny lesion that we could not appreciate in a seven-Tesla MRI.
Will it grow back? Will Gabi need to be checked?
Pestana Knight: The bottom of the sulcus dysplasia is a congenital malformation of the brain. Once you remove it will not grow back.
Anything we are missing?
Pestana Knight: Gabi is an incredible person. Soon after she had her epilepsy surgery, she decided to go to Machu Picchu, and she successfully was able to climb all the way up there. We hear all of the stories of people getting short of breath and having difficulties with altitude. She was able to get there with no difficulties. She went back to college. She graduated from college with honors. She has a fabulous internship this summer, and next step she’s going to law school.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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