The Level 4 South Texas Comprehensive Epilepsy Center at University Health System offers a wide range of advanced diagnostic and treatment options for patients young and old.
The numbers tell the story.
Nearly two-thirds of patients with epilepsy do well with medicines alone. But a patient whose seizures continue after the first one or two prescription medications has less than a 5 percent chance of becoming seizure-free with a third, fourth or fifth medication — alone or in combination.
The American Academy of Neurology recommends that these refractory patients be referred to a comprehensive epilepsy center. The South Texas Comprehensive Epilepsy Center, a collaboration between University Health System and UT Health San Antonio, sees a lot of them as the only Level 4 center in South Texas — and one of the largest and busiest programs in the country.
Charles Szabo, MD, Co-director of the South Texas Comprehensive Epilepsy Center, Professor of Neurology at UT Health San Antonio
“Based on the 20 to 25 surgeries we do each year, we’re probably in the top 15 percent nationwide among epilepsy surgery programs,” says Charles Szabo, MD, Co-director of the South Texas Comprehensive Epilepsy Center and Professor of Neurology at UT Health San Antonio. “In that sense it’s a pretty large program.”
The Center, which was established in 1995, has been growing steadily. The multidisciplinary team includes six epileptologists (neurologists with specialty training in epilepsy), two neurosurgeons, two neuropsychologists, two social workers, and a large and skilled support staff.
Besides seeing patients at University Hospital, the Robert B. Green Campus and UT Health’s Medical Arts & Research Center, the epilepsy team also staffs outreach clinics in Del Rio, Eagle Pass, Laredo and Harlingen.
Determining the cause
When a patient arrives for evaluation, a rigorous screening takes place to determine the type, severity and location in the brain of the seizures, and whether surgery might be an option.
“The monitoring we do in the hospital is really to figure out why people continue to have seizures — even though they’re receiving treatment with anticonvulsant medications,” says Lola Morgan, MD, Co-director of the Center and Medical Director of the Epilepsy Monitoring Unit at University Hospital and Associate Professor of Neurology at UT Health San Antonio.
Lola Morgan, MD, Co-director of the Center, Medical Director of the Epilepsy Monitoring Unit at University Hospital and Associate Professor of Neurology at UT Health San Antonio
The Epilepsy Monitoring Unit consists of 10 adult and four pediatric beds in the new Sky Tower at University Hospital. There, physicians have a range of sophisticated tools to determine where in the brain seizure activity is occurring.
That involves EEG video monitoring over the course of three to five days to observe and analyze the patient’s seizures. The patient’s medications are reduced or stopped to induce seizures under controlled conditions.
Technicians watch and record the brain waves and video images of the patients in their rooms to capture the seizure as it occurs. Staff monitors patients around the clock. That’s particularly important with children, who can be fidgety and restless while in bed for extended periods, says Linda Leary, MD, Associate Professor of Neurology at UT Health San Antonio, who oversees the pediatric epilepsy program.
EEG epilepsy video monitoring
“When children come here for video monitoring, an EEG tech is there all the time making sure the electrodes stay on the child’s head,” Dr. Leary says. “The tech can also move the camera if a child gets out of bed.”
Imaging studies, including anatomical MRI, PET and SPECT, are among the tools that can pinpoint seizure activity and determine if a lesion in the brain is the cause.
If a patient doesn’t have a lesion, or if a greater level of detail is required from an EEG, surgeons now have a method called stereotactic EEG, which is less invasive than previous methods and allows them to collect precise information by placing electrodes into the brain through 10 to 20 tiny holes rather than removing a section of the skull.
“You can put the electrodes right over the areas in the brain and pinpoint what needs to be resected,” says Alexander Papanastassiou, MD, Assistant Professor of Neurosurgery at UT Health San Antonio, whose expertise is the surgical management of epilepsy and movement disorders.
Furthermore, with implantation of subdural grid and strip electrodes, the functions of the brain can be mapped to see if it’s safe to resect.
When Surgery Is Indicated
If a patient is a surgical candidate, the first obstacle is usually fear.
“That’s a common misperception — not just among the patients, but among treating physicians who are not specialists in epilepsy,” Dr. Papanastassiou says. “People overestimate the risk of surgery and underestimate the risk of epilepsy. The typical risk we have is about a 1 percent chance that we’ll permanently hurt the brain. But what’s interesting is, that’s about the same chance as somebody dying or having a serious injury from epilepsy each year.”
Linda Leary, MD, Associate Professor of Neurology at UT Health San Antonio
Dr. Leary agrees. “There are two sides to it. Epilepsy surgery can seem terrifying. On the other hand, the long-term decline that you can see in children with continued, uncontrolled seizures is terrifying as well.”
Patient education is a big part of what physicians and staff at the Center do. Not only do patients and family members learn about their particular condition and options, but also about the brain itself. Dr. Papanastassiou explains to patients the cortical association areas, in which various parts of the brain are able to contribute to a particular task. If one of those parts is surgically removed, the other parts can take over those duties.
If patients are concerned about cutting hair for epilepsy surgery, Dr. Papanastassiou says almost all surgical procedures can be done with hair-sparing techniques.
Surgical resection is the “gold standard” for the treatment of medically refractory patients who don’t respond to medications, Dr. Papanastassiou says. Cure rates in those who are good candidates for surgery are in the range of 50 to 70 percent for temporal lobe epilepsy, and about 30 to 50 percent for neocortical epilepsy — “which means epilepsy outside the temporal lobe,” Dr. Papanastassiou says.
“That might not sound amazing, but when you start comparing them to less than 5 percent (the chance of success with a third or subsequent medication), it’s pretty amazing,” he adds.
Some patients may be candidates for a less-invasive laser ablation technique that is a significant improvement over earlier ablation procedures. Part of the improvement is the availability of magnetic resonance thermography, which is an MRI that not only provides the anatomical makeup of the brain, but can measure temperature — making it safer and more precise.
While the laser ablation is best suited for patients with smaller lesions, it’s very good for lesions that are deep and small — which makes them hard to reach in open resection, Dr. Papanastassiou says.
For patients who aren’t candidates for surgery or who continue to have seizures after surgery, neurostimulation is an option. Vagus nerve stimulation uses a pacemaker-like device that sends impulses to the brain through the vagus nerve that passes through the neck.
A newer option is the Neuropace RNS device, which uses implants in the brain to detect the onset of a seizure and then stimulate the brain to interrupt it.
Children With Epilepsy
Some children have epilepsy syndromes at a young age, but their symptoms can resolve after puberty. Others may have hard-to-treat seizures that can affect their cognitive abilities over time.
And some may not have epilepsy at all.
The South Texas Comprehensive Epilepsy Center offers a range of surgical options for complex epilepsy patients.
“Sometimes what we’re doing is evaluating children who have strange spells and people aren’t sure if they’re seizures,” Dr. Leary says. “So some of our monitoring is oriented toward just trying to figure out if it’s epilepsy or not, and guide appropriate treatment.”
Children and adolescents also have unique psychosocial needs.
“There certainly are challenges as far as children progressing in school and remembering the information that’s presented if they’re having frequent seizures,” Dr. Leary says. “With adolescents, sometimes the downside isn’t the seizures. It’s the fact their parents don’t let them do things because they’re afraid they’ll get hurt. A driver’s license is huge.”
“Kids have a lot more plasticity in the brain, so especially if they have a large malformation of cortical development, the best time to address it with surgery is early on when they have the most plasticity,” Dr. Papanastassiou says. “And the earlier a kid can get to a comprehensive epilepsy center, the sooner we can figure out if he or she can benefit from surgery.”
The Center works closely with community neurologists, who can arrange to have their patients admitted to the Epilepsy Monitoring Unit.
“We offer referring physicians the opportunity to evaluate their patients, giving feedback to help them provide more effective medical care to their patients,” Dr. Szabo says. “Or, if the patient turns out to be a good surgical candidate, we can offer further evaluation of the risks of surgery so the patient, caregivers and neurologists can decide on the best therapeutic approach.”
To learn more about the South Texas Comprehensive Epilepsy Center, visit universityhealthsystem.com/services/neuroscience/epilepsy or call 210-358-1587.