California Pacific Epilepsy Program: Results-Oriented Treatment for Seizure
With advanced medical therapies and surgical options, the California Pacific Epilepsy Program offers hope and support to patients whose epilepsy is not responsive to standard anti-seizure medications.
Freedom from seizures can create greater opportunities and a brighter future for patients and their families. Our mission is to assist our epilepsy patients in achieving their optimal wellness by providing personalized and comprehensive care for epilepsy and epilepsy-related problems. We accomplish this by using the latest diagnostic technology, appropriate surgical treatment options, and prescribed medications to give our patients an all-inclusive epilepsy treatment program.
To further augment our epilepsy capabilities, on-site basic research studies give our patients access to the most advanced technology and treatments available. We directly apply new laboratory findings to clinical use and facilitate patient participation in appropriate clinical trials and testing.
Medications can control the majority of recurrent seizures. Recurring seizures impact the patient’s quality of life. Many have difficulty with employment and social interactions, and increased medical care costs requiring more medical resources than those whose epilepsy is controlled. For select patients whose recurring seizures are not controlled by medications, surgery may be an option.
Surgery for epilepsy can take many forms. Temporal lobectomy is the most common procedure performed for refractory epilepsy. The vagus nerve stimulator is an implanted device that can lead to better seizure control. Implanted brain stimulators are emerging as a promising therapeutic alternative. Seizures sometimes arise as a consequence of a brain lesion such as a brain tumor or a brain blood vessel malformation. Lesion removal, with or without the aid of epilepsy surgery techniques, is often indicated for both lesion elimination and seizure elimination. Surgery is not for everyone and certainly not for those whose seizures are completely controllable with medications.
Health care professionals, primary care physicians, and, in particular, neurologists will usually refer difficult epilepsy cases to a comprehensive epilepsy center. Patients whose seizures are not controlled by medications make up the vast majority of referrals to centers such as the California Pacific Epilepsy Program. To determine which patients are candidates for epilepsy surgery, a series of studies are performed to select the most appropriate candidates. A less common, but still important reason, for referral to a comprehensive epilepsy center is to gain a clear description of the epilepsy type.
The tests performed at a comprehensive epilepsy center help patients, referring doctors, and the epilepsy specialists understand the best treatment options for their patients. A high-field-strength MRI scan done with specific protocols is a critical test to look for structural abnormalities. Standard EEG and long-term Video EEG monitoring determine the zone of electricalonsets of seizures.
Image: Lateral skull film of patient with implanted grid and strip electrodes for seizure monitoring.
Subdural strip, grid, or depth electrodes are sometimes necessary for the localization or lateralization of seizures. The Wada test (intracarotid sodium amytal injected sequentially into the right then left common carotid arteries) is used to determine language lateralization and helps predict the ability of each hemisphere to support memory function. Neuropsychological tests evaluate the patient’s cognitive abilities and help physicians understand which brain regions may be malfunctioning as a result of epilepsy. Less commonly used tests, such as SPECT and PET scans, are also available to help localize the seizure condition. The California Pacific Epilepsy Program uses all of these studies to select the patients most likely to benefit from epilepsy surgery.
One common surgically remediable epileptic condition is temporal lobe epilepsy. Such patients typically suffer from medically refractory complex partial epilepsy. Not all patients in this category will develop secondary generalized seizures. The MRI scan may show scarring of the temporal lobe’s hippocampus and surrounding structures, known as “mesial temporal sclerosis.” Video EEG recordings would show lateralized temporal lobe interictal spikes and seizure onsets from the sphenoidal or lateral temporal electrodes. Neuropsychological tests would likely indicate lateralized deficits, suggesting poor function of the involved temporal lobe. Wada testing would help the team understand the hemisphere that supports language and the ability of the opposite hemisphere to support memory function. Removal of the diseased temporal lobe, temporal lobectomy, is safe and frequently performed. Temporal lobectomy is usually the best alternative for medically refractory complex partial epilepsy arising from a diseased temporal lobe. The combined surgery risk is about 4%. The success rates for excellent seizure control or seizure freedom are 80-95%.
Patients may not be candidates for tissue resection to control epilepsy if the diseased brain is located in the eloquent cortex, if the seizures come from both sides of the brain, or if previous surgery has failed to control the epilepsy. The California Pacific Epilepsy Program participates in promising new investigational research in the field of responsive neural stimulation with the NeuroPace Responsive Neurostimulator (RNSTM) System Pivotal clinical trial. The surgeon implants electrodes into the diseased areas of the brain. The electrodes are then attached to the implanted RNS device. The device records brain activity and senses when a seizure is about to occur. A small, subthreshold counter-stimulation is applied to abort the seizure activity before it propagates into a full seizure. To date, the California Pacific Epilepsy Program has the nation’s largest clinical experience with the use of this device.
Vagus Nerve Stimulator
The vagus nerve stimulator is an alternative surgical treatment for epilepsy not responsive to medications and not treatable by surgery to remove tissue. This device stimulates the brain indirectly through the vagus nerve’s connection to the central nervous system. About 50% of the patients implanted with this device will respond by improved seizure control and/or lessened severity of seizures. The device is implanted as an outpatient procedure and severe complications from the use of this device are very rare.
Vascular malformations, benign or malignant brain tumors, and other structural lesions can cause epilepsy. If the comprehensive workup for epilepsy reveals such a condition, surgery is usually recommended for removal of the lesion. Long-term follow-up data indicate that improved seizure control rates can be obtained in these cases if epileptic cortex surrounding the lesion is removed at the same time as the lesion removal surgery. The techniques for identification and removal of epileptic tissues are a safe and useful adjunct to the standard neurosurgical procedures used to remove these lesions.
The success rates are high for surgical treatments of medically refractory epilepsy conditions. Patients can be referred to comprehensive epilepsy programs such as the California Pacific Epilepsy Program for an evaluation to determine the best options. Physicians work with the referring physicians to optimize care and improve quality of life for patients with epilepsy.