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Advanced Procedures Inform Surgery to Stop Epilepsy

Epilepsy patient Judy Hodge.

April 25, 2019

Judy Hodge was beyond grateful to reach her 5-year milestone as a Hodgkin lymphoma survivor, but she didn't pause to celebrate for long. Instead, with the cancer in remission, Judy turned her focus to the next chapter in her health journey: She was ready to get her epilepsy under control.

A wife of 28 years, mother of 3 and grandmother of 3, Judy began to experience seizures in 2000.

"I would have multiple seizures in the course of a single day," she says. "They were draining. I would lose awareness and come back to myself with terrible headaches. I didn't have any warning that a seizure was coming on, and afterward, I didn't know that I'd had one."

The seizures stopped Judy from working or driving. But at age 57, what Judy wanted most was to spend time with her family and be a central part of her grandchildren's lives.

"I felt like I was missing out a bit," she says. "I had 3 beautiful grandbabies, 2 boys and a girl. I couldn't stay with them alone, and I couldn't carry them up or down stairs. I had these limitations at a point in my life that I didn't want to miss out on precious time."

Judy had tried many different medications without reaching seizure freedom. While her cancer treatment went well, her seizures seemed to worsen afterward, occurring in clusters. She experienced full-blown tonic-clonic seizures, but also "interseizures," partial seizures that were less visually dramatic to bystanders, but just as disorienting to Judy.

"My husband said I would start to stare and mutter," she says. "I really wanted to put the seizures to a stop."

An innovative approach

While also managing her cancer treatment, Judy connected with epileptologist Patrick Landazuri, MD, of The University of Kansas Health System. He is part of the expert team that leads the health system's Level 4 Epilepsy Center, the only one of its kind in the state of Kansas.

Dr. Landazuri felt Judy to be an excellent candidate for brain surgery that could stop her seizures once and for all. But first, he needed to further understand where in the brain Judy's seizures occurred so he could better communicate a neurosurgical plan. A new technology, the ROSA® robotic surgical assistant, could help determine this in less time and at lower risk to Judy than traditional invasive monitoring. The technology was on its way to The University of Kansas Health System.

"Depth electrodes are millimeters-sized electrodes that can be safely inserted into a patient's brain to identify seizure-causing brain tissue," says Dr. Landazuri. "For patients like Judy, this is the standard of care. The ROSA optimizes electrode insertion. Our epilepsy physicians are thankful to work with gifted neurosurgeons trained in the most advanced techniques. The collaboration helps us confidently discuss surgical options with patients."

The ROSA includes a software system to support surgical planning and a robotic arm that streamlines placement of depth electrodes to track brain activity and help doctors pinpoint the source of seizures.

"The ROSA allows us to accurately, efficiently place depth electrodes into the brain in a minimally invasive manner, says neurosurgeon Jennifer Cheng, MD. "We can complete this procedure in about half the time as a traditional surgery. This reduces risk to the patient, as time under anesthesia is shorter and recovery is faster."

"I knew the electrodes would give us the information we needed to consider a surgery, but I waited awhile before I had them placed," Judy explains. "As I talked with my doctors, I learned about the ROSA technology, which would soon be available. It would cut the procedure time in half, down to 3 or 4 hours from 6 to 8 hours. It was less invasive. I thought those were good reasons to wait."

On October 23, 2018, Judy became one of the health systems first patients to undergo ROSA surgery for depth electrode placement. After the placement, she was hospitalized for several days while the electrodes recorded seizure activity. This was followed by careful electrical stimulation of the identified seizure area to ensure no vital function such as speech was located in that part of the brain. The findings allowed Judy's epilepsy team to plan a safe surgery to remove the brain tissue causing her epilepsy. Judy had that procedure – a tailored frontal lobe resection – days later.

Contributor to her own care

A crucial member of Judy's multidisciplinary team was Judy herself. She remained awake during the surgery – called an awake craniotomy – and interacted with fellowship-trained neuropsychologist Caleb Pearson, PsyD.
Prior to the surgery, Dr. Pearson had worked with Judy to perform a functional MRI, creating a detailed map of her brain function. He studied and recorded the areas of her brain responsible for functions including memory, problem-solving, language and visual-spatial skills. The completed map then served as a guide for surgeons, as did Dr. Pearson's interaction with Judy during the surgery.
"It's not unusual for a patient to wake up quite nervous and scared, but Judy was neither," Dr. Pearson recalls. "We talked about the surgery. We talked about her family. The functional map and Judy's involvement enabled us to be confidently aggressive in removing brain tissue."
In contrast, he explains, surgeons who lack the data provided by the functional brain mapping have no choice but to perform surgery very conservatively. This protects brain function, but may not allow for all of the abnormal tissue to be removed, leaving the patient to continue experiencing problems.
Interaction with Judy enabled Dr. Pearson to monitor surgeons' proximity to functional centers in Judy's brain. He supported the surgical team in removing the most possible abnormal tissue with the least possible impact to Judy's cognitive and functional abilities.
"We had the data to perform a larger resection, which will give Judy a better outcome," Dr. Pearson says.

A hopeful future

Another week or so later, Judy was home again, resting and rebuilding her strength.

"We're very hopeful that Judy is seizure-free," says Dr. Landazuri. "We will follow Judy closely for years to come. Given how well her surgeries went, we are very optimistic."

"I've been ready to figure out the source of the seizures and have surgery to stop them," Judy says. "My 3 kids were all in sports, and I loved every minute of that time with them. My grandkids will be there soon, and I don't want to miss out on their lives."

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