You've tried just about everything to get the seizures to stop.
For months, you've been on more than two types of anti-seizure medications with maximum dosages — and your seizures are still out of control.
Your epilepsy has been diagnosed as intractable, meaning the drugs aren't working. So, your doctor recommends surgery. You may hear words such as "resection," "lobectomy" or "craniotomy."
The good news is that you may have other options; alternatives to major surgery that may help control your intractable epilepsy.
Getting Under Your Skin
The RNS, or responsive neurostimulation system, may sound like something out of a sci-fi movie, but it's designed to control seizure frequency - kind of like a wearable device that collects health data and course corrects for seizures.
This advanced type of neuromodulation therapy that anticipates and overrides epileptic seizures is a technology that was pioneered by Brian Litt, MD, of the Penn Epilepsy Center.
It's approved for people over age 18 and has been shown to reduce seizures in those who have frequent and debilitating seizures.
It's relatively new, but it's been in development for nearly 15 years. The US Food and Drug Administration (FDA) approved the system in November 2013.
Yes, this is still brain surgery. But it's not a resection where a part of the brain is removed. The procedure may take anywhere from two to five hours with a hospital stay of up to three days.
Once the device is implanted, the Penn Neurosciences team — including neurologists and surgeons — allows it to collect data for two weeks with no stimulation. Then, data collection continues with an eye toward fine-tuning settings around the spurts of stimulation on seizure patterns.
Patients can also collect data at home using their own programmer, which behaves like a mini computer. They then transmit information to their physician via the internet.
Kathryn Davis, MD, MTR
The device holds promise, but it's not a cure. "It's a palliative device," says Kathryn Davis, MD, MTR, neurologist and medical director of the Epilepsy Monitoring Unity at the Penn Epilepsy Center. "About 65% of patients have shown a meaningful improvement in clinical trial."
The hope is that it will give new options to people with intractable epilepsy, who otherwise had no other choices.
Pinpointing The Problem
Still feeling like an implant is just a little too invasive? There are other options.
Laser technology called Visualase® MRI-guided laser ablation is where a laser beam zeroes in on a problem area of the brain that may be causing the seizure and literally burns it out.
Again, this is still brain surgery, but it's far less invasive than a resection and offers shorter recovery time.
This usually requires "burr holes, which are just small holes in the skull," Dr. Davis says. "We feed the laser catheter in, and it's done right in the MRI suite."
"And they'll be conservative: Do a little bit, go back and check to see what the extent of the burn was, and extend it if necessary. And then the patients usually go home the next day," explains Dr. Davis.
In a standard resective surgery, patients would usually have a hospital stay of three or four nights.
Who stands to gain?
Visualase is a less invasive way to treat temporal lobe epilepsy, which is the most common type of epilepsy in adults.
Dr. Davis adds that it is best suited for patients who "have clear hippocampal sclerosis on their imaging."
Hippocampal sclerosis, also called mesial temporal sclerosis, occurs when scar tissue forms in parts of the temporal lobe when nerve cells in the brain die.
This is a fairly new procedure, so there is still more to learn about its effectiveness. Visualase received US Food and Drug Administration clearance in 2007.
As of December 2014, more than 1,000 cases using Visualase ablation technology had been performed.
"We don't have long-term outcomes for these patients," Dr. Davis says. But her patients have been very receptive to it.
And if it doesn't work? Then, it may be time to consider open surgery.