When Elton, a young Albanian architect, couldn’t find treatment for his disabling seizures in Albania, he traveled 500 miles to Austria to meet with Massachusetts General Hospital (MGH) Epilepsy Service Director Andrew J. Cole, MD.
Dr. Cole, in Austria on a business trip, felt Elton was a good candidate for surgery and brought his case back to his colleagues in Boston.
After sophisticated imaging revealed a lesion in Elton’s left temporal lobe, Dr. Cole and a clinical team of epileptologists, neuroradiologists, neurosurgeons and neuropsychologists recommended a resection. Because the lesion was in the dominant hemisphere, decision making around whether to include the adjacent hippocampus in the resection was complicated.
"Many specialists are involved in every case and bring greater insights and knowledge than any single practitioner can offer," says Dr. Cole.
Ultimately after careful mapping of language and memory function using functional MRI and Magnetoencephalography, intra-operative hippocampography, a technique pioneered at MGH was used to guide the decision to spare the hippocampus.
Six months post-surgery, Elton is back in Albania and seizure-free (see video). "With epilepsy surgery, we don’t declare victory for at least a year, but his seizures have stopped and his prospects look favorable," says Dr. Cole.
Sophisticated Imaging Technologies Improve Diagnosis and Treatment
Sophisticated imaging capabilities at MGH have made it possible to identify the cause of seizures in 60 to 70 percent of cases and, as a result, prescribe more effective treatments. Patients are often referred by regional and national epilepsy centers for specific imaging studies not available elsewhere such as high-resolution (7 tesla) MRI and magnetoencephalography (MEG). Other imaging capabilities include spectroscopy, and functional imaging using MRI, SPECT and PET scanning.
"New imaging technologies have been a game changer in epilepsy diagnosis. We have developed very specific epilepsy imaging protocols and know how to analyze imaging modalities to optimize the chances of finding a cause. It’s now possible to identify lesions and disorders of brain development that are not obvious in routine scans," says Dr. Cole.
This more precise imaging has changed outcomes for many patients like Elton. One longtime patient, a young lawyer with left temporal lobe seizures that were not adequately controlled, was initially rejected as a candidate for surgery because his low-grade tumor was located in the left frontal operculum and insula, areas of language cortex that are typically off limits due to concern for language function.
The development of diffusion tensor imaging, which allows assesment of white matter tracts connecting anterior and posterior speech ares, much of it at the MGH Martinos Center for Advanced Imaging, allowed the epilepsy team to reconsider surgery. DTI in this man clearly demonstrated that critical white matter tracts were displaced by the tumor, allowing surgery to remove the tumor without causing disconnection of language cortex and a resultant conduction aphasia. Following surgery, his seizures have been greatly reduced in both frequency and severity.
Advanced Care for All Patients
Certified by the National Association of Epilepsy Centers as a Level 4 center — defined as having the capabilities to provide the most intensive testing, more extensive treatment and complex epilepsy surgery procedures — the MGH Epilepsy Service can address the most complex, challenging cases. "We live by the motto ‘if you don’t get an answer here, you won’t get it anywhere." says Dr. Cole.
The Epilepsy Service welcomes patient referrals – including candidates for clinical trials — from neurologists and primary care physicians and also provides remote consultations (see below).
Referring Patients to the MGH Epilepsy Service
Most MGH Epilepsy Service patients are referred by neurologists and primary care physicians. Dr. Cole recommends referring patients who meet any of the following criteria:
- Their seizures do not readily respond to medications.
- The cause of their epilepsy is unknown.
- They have a complex medication regimen which might benefit from a second opinion.
- They might benefit from an evaluation using targeted imaging optimized for epilepsy.
- They might benefit from participating in a clinical trial and having access to novel therapies (see below).
When working with patients from referring physicians, "we make it a priority to communicate clearly with physicians in a timely fashion," says Dr. Cole. "We prefer to work in close partnership with neurologists and primary care physicians and provide ready access to patient information."
MGH Epilepsy Service physicians also share their expertise through e-consults, which include reviewing patient records using electronic data transfer, and telemedicine consultations, which use videoconferencing to provide follow-up evaluations for patients who can’t get to MGH due to geography or debilitating symptoms.
For information about clinical trials that are recruiting patients, go to: http://www.massgeneral.org/neurology/research/epilepsy.aspx. To refer patients, contact Clinical Research Coordinator Samantha Donovan at firstname.lastname@example.org or 617-643-4617.
Future Prospects Hold Promise
In recent years, a number of new epilepsy medications have been approved and others are undergoing clinical trials. Most recently, the NeuroPace implanted responsive neural stimulator (RNS) device received FDA approval based on a multicenter clinical in which MGH enrolled 7 patients (see related article). In the coming years, Dr. Cole expects "continued progress, with improvements in diagnosis, the development of new drugs and devices, and insights from scientific research, especially genetics, reshaping how we think about the disease."