October 22, 2019
When Joe Dwyer met epileptologist Patrick Landazuri, MD, at The University of Kansas Health System, he'd had uncontrolled epilepsy for 17 years and was experiencing up to 100 small seizures or auras each day. People with epilepsy are familiar with auras, a feeling or movement that tells them a seizure is starting.
"I'd get tingling sensations on the right side of my body," Joe says. "I'd be driving and feel it start to come on."
During the seizures, Joe's body would become uncontrollably rigid, and he would stand straight up. His right arm would tense, and his right hand would tighten into a fist. He would make unusual movements with his whole body. Each seizure lasted about 30 seconds. The unpredictable episodes were both dangerous and embarrassing.
Joe, a Kansas City, Missouri, resident, lost his driver's license and his warehouse job. The losses were devastating for him and his fiancée, Samantha, who together care for 6 children.
Left frontal lobe seizures
After seeking treatment at a local hospital, his general neurologist referred Joe to The University of Kansas Health System for further evaluation. The health system is home to Kansas’ only Level 4 Comprehensive Epilepsy Center, where a team of specialized epileptologists diagnoses all types of epilepsy and offers the most advanced medical and surgical options.
"We met Dr. Landazuri, and he was on it," Joe says.
Dr. Landazuri diagnosed Joe, then age 36, with left frontal lobe seizures. After reviewing his MRI together, it was determined his epilepsy was caused by a congenital abnormality called cortical dysplasia.
"When Joe's brain was forming, the cells migrated abnormally and ended up in the wrong place," Dr. Landazuri says.
An awake brain surgery
Dr. Landazuri collaborated with neuropsychologist Caleb Pearson, PsyD, at the health system to conduct a variety of tests, including functional MRI, to maximize the safety and success of Joe's surgery. Electrodes inserted inside and around the dysplasia tracked seizure activity. The results showed the abnormal tissue was in between the parts of the brain that controlled the right side of Joe's face and his speech. Surgery would be highly challenging, but possible given the epilepsy team's expertise in treating epilepsy and its interdisciplinary approach to customizing treatment plans.
A team of epileptologists, neurosurgeons, neuroradiologists, neuropsychologists, nurses and nuclear medicine experts reviews each patient's case to collaborate on treatment strategy. For Joe, the team recommended an awake craniotomy, a surgical procedure in which Joe would spend time alert and interacting with Dr. Pearson.
"Most centers in the Kansas City area wouldn't touch this kind of surgery," Dr. Pearson says. "People like Joe who go to doctors outside of our health system are told there is nothing to be done. They are left to experience a life of epilepsy. Our deep expertise and collaborative style give patients more advanced options, even those with complex conditions."
A 15-hour team effort
Joe's procedure took place in July 2018. Dr. Landazuri, Dr. Pearson and neurosurgeon Jennifer Cheng, MD, worked together. While Dr. Cheng performed the surgery, Dr. Pearson continuously assessed Joe's language function, mapping speech function as he conversed with Joe, asking him to repeat words and phrases so the team could confirm the abnormal area of the brain could be safely removed. Dr. Landazuri monitored Joe's brain electricity to ensure the brain stimulation did not trigger a seizure as well as evaluate for any epileptic brain tissue that remained. Dr. Cheng made a small, question mark-shaped incision on the left side of Joe's scalp, then slowly and delicately worked her way to the dysplasia to remove it.
The surgery lasted 15 hours, with Joe alert for about 6 of those hours – the longest period of patient alertness in Dr. Pearson's experience. Twice Dr. Cheng paused for the team to perform an intraoperative MRI (iMRI) to obtain real-time images to assess how much of the problem tissue remained mid-procedure and fine-tune plans to continue the surgery. The health system has the region's only iMRI adjacent to the operating suite. This allows the patient to be safely moved for imaging mid-procedure.
"It was a marathon," Dr. Pearson says. "We let Joe rest and tested his language repeatedly. He was an extremely tough guy and our true hero. He was an active participant in his own surgery."
Joe discounts his role and admits to talking himself out of the surgery several times before going through with it.
"I tip my hat to Dr. Cheng and the whole team," Joe says.
He went home the next day with normal speech and facial movement.
A second surgery
An MRI following Joe's surgery revealed a speck of abnormal tissue remained, a possibility the team had anticipated given the difficult location of the lesion.
"We decided to wait and monitor Joe," Dr. Landazuri says. "We hoped we had removed enough of the problematic tissue that Joe might only have auras."
For 9 months, Joe remained seizure-free. But one day in March 2019, he was building a privacy fence in his backyard and experienced a seizure. He believes the physical activity may have triggered it.
"Dr. Landazuri was quick to respond," he says. "He presented me with the options. I thought about it and decided to have a second surgery."
Joe had a second procedure in August 2019. This time, Dr. Cheng used minimally invasive laser ablation to destroy the remaining abnormal tissue. Post-surgery brain scans showed no trace of the dysplasia. Joe was discharged the next day with continued normal speech and facial movement.
Life without seizures
Since the second procedure, Joe has been seizure-free. Dr. Pearson believes this is highly encouraging.
"When a seizure occurs, it can recruit other parts of the brain, so those parts of the brain also become epileptogenic," Dr. Pearson says. "Conversely, the longer Joe lives without having a seizure, the more likely he is not to have another one."
If Joe remains seizure-free for several more months, Dr. Landazuri will clear him to return to work and begin driving.
"I've been to many doctors, and the doctors at the health system are the greatest," Joe says. "The nurses are the best. If I ever go to a hospital again for anything, the health system is where I’m going."