Presentation_Mirza_Epilepsy Surgery

EPILEPSY SURGERY: A
HISTORICAL PERSPECTIVE
FARHAN A. MIRZA, MBBS
RESIDENT, DEPARTMENT OF NEUROSURGERY
5TH ANNUAL INTERNATIONAL EPILEPSY SYMPOSIUM
UNIVERSITY OF KENTUCKY
JUNE 4, 2016
NO FINANCIAL DISCLOSURES
ACKNOWLEDGEMENTS
OVERVIEW & OBJECTIVES
• DISCUSS THE ORIGINS OF EEG AND INTRACRANIAL MONITORING
• LIST PIONEERS IN THE FIELD
• RELATE THE HISTORY OF EPILEPSY SURGICAL PROCEDURES
HISTORY OF THE DISEASE
• Epilepsy was described as long ago as 2000 BC
• Accounts written in Akkadian, in ancient
Mesopotamia, talk of antasubba or miqtu, noting
the sporadic, ”jerky movements” and ”muscle
rigidity” observed in people who were thought to
have epilepsy.
• In the Ancient Hindu Medical text of the Sushruta
samhita (600BC), written in Sanskrit, symptoms of
“numbness (paralysis), convulsive contortions of
the limbs (Akshepa), anaesthesia, and various
kinds of pain (Sula)” are described.
• In Ancient Greece, symptoms such as ‘teeth
gnashing’, ‘convulsions’, and ‘screaming like a
horse, was, when appropriate, given the Greek
verb epilambanein (the term from which epilepsy
is derived), meaning “to seize, possess, or afflict.”
Oft too some wretch, before our startled sight,
Struck as with lightning, by some keen disease
Drops sudden: -- by the dread attack o’erpowered
He foams, he groans, he trembles, and he faints;
Now rigid, now convulsed, his laboring lungs
Heave quick, and quivers each exhausted limb,
Spread through the frame, so deep the dire disease
Perturbs his spirit: as the briny main
Foams through each wave beneath the tempest’s ire.
…………………………………………………………………………………
But when at length, the morbid cause declines,
And the fermenting humors from the heart
Flow back—with staggering foot the man first treads,
Led gradual on to intellect and strength
(III, 487, Good’s translation.)
Lucretius the Epicurean (c. 99-c.55 BC)
• Hippocrates suggested that Epilepsy was a
hereditary disease
• ‘On the Sacred Disease’ is the first book on
Epilepsy (400 BC)
• The disease continued to be known as:
- Disease of Hercules
- Sacred Disease
- Morbus Comitialis
Chaudhary UJ, Duncan JS, Lemieux L. A dialogue with historical concepts of epilepsy from the Babylonians to Hughlings Jackson: persistent beliefs.
Epilepsy Behav. 2011 Jun;21(2):109-14.
Trepanated skull from Chalaghantepe (Aghdam), 5th millennium BC.
Museum of History of Azerbaijan, Baku.
Trepanated Skull, Neolithic.
Ali R, Connolly ID, Feroze AH, Awad AJ, Choudhri OA, Grant GA. Epilepsy: A Disruptive Force in History. World Neurosurg. 2015 Dec 18.
Hughlings Jackson promoted a physical basis for neurologic pathology and shunned the appeal to a metaphysical basis of Epilepsy
Hans Berger - 1931
ORIGINS OF INTRACRANIAL MONITORING FOR EPILEPSY
• Since the 1880s, Sir Victor Horsley had been using direct cortical stimulation to guide
resections for epilepsy
• In 1929, Sachs, Schwartz, and Kerr first recorded activity from the surface of the human
brain.
• The strategy to perform basic neuroscience research using epilepsy surgery was
pioneered by Wilder Penfield and Herbert H. Jasper, at the Montreal Neurological
Institute
• The first use of stereotactic depth electrodes for the treatment of intractable seizures
dates to 1950, when E. A. Spiegel and H. T. Wycis recorded from and subsequently
lesioned the lateral thalamus in an attempt to relieve seizures. These and other early
studies emphasized the use of interictal recordings to guide resections.
Feindel W: Neurosurgery at the Montreal Neurological Institute and McGill University Hospitals. Neurosurgery. 39:830-839 1996 8880779
Penfield W, Boldrey E: Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain.60:389-443 1937
Weber M: History of the surgical treatment of epilepsy: from origin to MNI. Epilepsies. 19:91-95 2007
PIONEERS IN THE FIELD
Wilder Penfield & Herbert Jasper
• Jasper (1906-1999) joined the MNI in 1937 and introduced the technique of EEG
• Penfield (1891-1976) had been performing epilepsy surgery since 1928 at the MNI and with Jasper’s arrival
and contribution, MNI became a leader in pioneering epilepsy research and surgical advancement
• In 1941, Jasper and Kershman proposed a classification of epilepsy based on EEG waves.
• In 1950, Penfield reported his success in anterolateral temporal resections in a series of 68 patients
• In 1952, Penfield and Baldwin published a classic monograph describing their technique for anterolateral
temporal lobectomy including the hippocampus and amygdala. They reported that the most frequent
pathologic abnormality in two of three of their cases was an atrophic lesion termed incisural sclerosis.
Jasper HH, Kershman J: Electroencephalographic classification of the epilepsies. Arch Neurol Psychiatry. 45:903-943 1941
Penfield W, Flanigin H: Surgical therapy of temporal lobe seizures. Arch Neurol Psychiatry. 64:491-500 1950
Penfield W, Baldwin M: Temporal lobe seizures and the technique of subtotal temporal lobectomy. Ann Surg. 136:625-634 1952
Frederic Gibbs & Percival Bailey
• Frederic Gibbs’ (1903-1992) long research career was devoted to the understanding and treatment of epileptic
phenomena and closely associated with the development of EEG
• In the early 1930s Gibbs developed a thermoelectric blood flow probe and with William Lennox
• By 1934 Gibbs became a pioneer in the field of EEG while working at Harvard with Hallowell Davis and Lennox, and
the first to convincingly record and report EEG findings in epilepsy and states of altered consciousness.
• In 1947 the first non-lesional temporal lobe excisions based on EEG localization were performed in these patients
and by 1948 anterior temporal lobectomy had become their procedure of choice.
• Gibbs and Lennox received the coveted Lasker Award among other honors as pioneers in establishing the modern
era of epilepsy diagnosis and treatment.
• Percival Bailey and Ernest Gibbs reported a series of 25 patients from the University of Illinois program who
underwent temporal resection guided by EEG, at the same time that Penfield & Jasper had reported their findings
Bailey P, Gibbs F: The surgical treatment of psychomotor epilepsy. JAMA. 145:365-370 1951
ORIGINS OF EPILEPSY SURGICAL PROCEDURES
18th Century Trepanation Instrument Set
Engraving of trepanation by Peter Treveris (taken from Hieronymus Braunschweig's Buch der Cirurgia. Hantwirckung der Wundartzny 1497).
Epilepticus Sic Curabitur (“the way to cure an epilepticus”)
Epilepsy treatment from the surgical atlas Cerrahiyetül Haniye (Imperial surgery), 15th century
Lady Diana Ladino, Gary Hunter, José Francisco Téllez-Zenteno. Art and epilepsy surgery. Epilepsy & Behavior 29 (2013) 82–89
The cure of folly or The extraction of the stone of madness
The surgeon (Painted in 1555)
Lady Diana Ladino, Gary Hunter, José Francisco Téllez-Zenteno. Art and epilepsy surgery. Epilepsy & Behavior 29 (2013) 82–89
Ali R, Connolly ID, Feroze AH, Awad AJ, Choudhri OA, Grant GA. Epilepsy: A Disruptive Force in History. World Neurosurg. 2015 Dec 18.
Sinha S, Danish SF. Neurosurg Clin N Am. 2016 Jan;27(1):27-36. History and Technical Approaches and Considerations for Ablative Surgery for Epilepsy.
• The earliest epilepsy surgeries performed in the late 1800s and early 1900s
were targeted toward neocortical seizure foci, based on anatomic features
• In 1886, Sir Victor Horsley performed what would now be considered
lesionectomies with excellent results
• At the same time, Wilder Penfield at the MNI expanded the use of surgical
resection of seizure foci, primarily in the temporal lobe
• In 1951, Percival Bailey and Fred Gibbs at the University of Illinois
Neuropsychological Institute reported their results of temporal lobectomy
for psychomotor seizures guided by EEG findings.
Penfield W, Jasper H: Epilepsy and the Functional Anatomy of the Brain. 1954 Little, Brown Boston
Connolly PJ, Cohen-Gadol AA, Spencer DD. Milestones in epilepsy surgery since 1849. In: Spencer D, ed. Operative Epilepsy (in press).
Chaudhary UJ, Duncan JS, Lemieux L. A dialogue with historical concepts of epilepsy from the Babylonians to Hughlings Jackson: persistent
beliefs.Epilepsy Behav. 2011 Jun;21(2):109-14.
Surgical Pioneers
Hippocrates (460 BC)
‘The Sacred Disease’, Trepinations
Guy De Chauliac (1363), Pare (1561)
Percival Pott (1713-1788)
First described underlying brain damage in skull fxs
Jean Louis Petit (1674-1750)
Trepinations to treat underlying cause of
convulsions
Baron Larrey (1829)
Described a case of surgical cure
Sir Astley Cooper (1758-1841)
W.C. Wells (1812)
First to describe futility of elevating a depressed
skull fx for prevention of seizure activity
Benjamin Dudley (1828)
Professor of Surgery at Transylvania University
Lexington, Kentucky
5 cases of traumatic epilepsy, 3 ‘cures’
Billings (1861)
‘The surgical treatment of epilepsy’
Samuel Gross (1872)
4 cases, 1 ‘cure’
Horsley (1886)
Krause (1893)
Surgery for Jacksonian Seizures
Sinha S, Danish SF. Neurosurg Clin N Am. 2016 Jan;27(1):27-36. History and Technical Approaches and Considerations for Ablative Surgery for Epilepsy.
SURGICAL PROCEDURES
• Standard temporal lobectomy
• Selective Ammygdalo-hippocampectomy
• Stimulation procedures
• VNS
• RNS
• Extra temporal lobe epilepsy surgery
• Lobectomy
• Multilobar resection
• Lesionectomy
• Anatomic Hemispherectomy
• Disconnection Procedures
• Multiple Subpial Transections
• Corpus Callosotomy
• Functional hemispherectomy
• Radiosurgery
Epidural/Subdural Electrodes
• History of use is traced back to
Penfield and Jasper
• Grid
• Strip
• Foramen Ovale
• First developed in 1985
• Most useful in mesial temporal
lobe epilepsy with inability to
lateralize on phase I testing
Standard Temporal Lobectomy
• Penfield and Jasper, alongwith Bailey and Gibbs are the pioneers of
this operation
Engel J, Wiebe S, French J, et al.: Practice parameter: temporal lobe and localized neocortical resections for epilepsy—Report of the Quality Standards Subcommittee
of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons. Epilepsia. 44:741751 2003
Spencer S, Huh L: Outcomes of epilepsy surgery in adults and children. Lancet Neurol. 7:525-537 2008
Engel J, Wiebe S, French J, et al.: Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the Quality Standards subcommittee of
the American Academy of Neurology in association with the American Epilepsy Society and the American Association of Neurological Surgeons. Neurology. 60:538547 2003
Jeha L, Najm I, Bingaman W, et al.: Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy.Neurology. 66:1938-1940 2006
Selective Amygdalohippocampectomy
• Niemeyer was the first to describe selective transcortical
transventricular amygdalohippocampectomy (STTAH) in 1958
• This technique was further refined by Yasargil, Wieser who suggested
a transsylvian approach to the medial temporal structures
Clusmann H, Schramm J, Kral T, et al.: Prognostic factors and outcome after different types of resection for temporal lobe epilepsy.J
Neurosurg. 97:1131 2002
Goldstein LH, Polkey CE: Short-term cognitive changes after unilateral temporal lobectomy or unilateral amygdalo-hippocampectomy for the relief of
temporal lobe epilepsy. J Neurol Neurosurg Psychiatry. 56:135 1993
Multiple Subpial Transections
• Morrell and Whisler developed MST and by 1999 had treated more than
120 patients at Rush Epilepsy Center in Chicago
• Subpial transections are traditionally performed approximately every 5 to
10 mm along the length of each gyrus within an epileptogenic region.
• These transections are thought to divide the fibers connecting adjacent
regions of the cortex while leaving the projection fibers in and out of the
region intact.
Benifla M, Otsubo H, Ochi A, et al.: Multiple subpial transections in pediatric epilepsy: indications and outcomes. Childs Nerv Syst.22:992-998 2006
Blount JP, Langburt W, Otsubo H, et al.: Multiple subpial transections in the treatment of pediatric epilepsy. J Neurosurg.100:118-124 2004
Mulligan LP, Spencer DD, Spencer SS: Multiple subpial transections: the Yale experience. Epilepsia. 42:226-229 2001
Morrell F, Whisler WW, Bleck T: Multiple subpial transection: a new approach to the surgical treatment of focal epilepsy. J Neurosurg. 70:231-239 1989
Corpus Callosotomy
• First performed in the 1940s by Dr. William P. van Wagenen
• Roger W. Sperry won the 1981 Nobel Prize for Physiology and Medicine for
his work on split-brain characteristics of callosotomy patients
• Indicated in patients with drop attacks and generalized epilepsy with rapid
spread
• Concerns of surgical morbidity and disconnection syndromes have made
stimulation procedures first line Rx generalized seizures before considering
corpus callosum section.
Madsen JR, Carmant L, Holmes GL, et al.: Corpus callosotomy in children. Neurosurg Clin N Am. 6:541-548 1995
24Téllez-Zenteno JF, Dhar R, Wiebe S: Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis.Brain. 128:1188-1198 2005
Hemispherectomy/Hemispherotomy
• The first anatomic hemispherectomy was done for glioma surgery by Dandy in
1928
• The first hemispherectomy for infantile hemiplegia and seizures was done by
Mckenzie in 1938
• An important step in the evolution from large resection to large disconnection
occurred with development of the technique of functional hemispherectomy,
introduced by Rasmussen and further described by Mathern
• The modern transition to nearly exclusively disconnective techniques started in
1992 with different approaches developed independently by Schramm,
Delalande, and their colleagues including perisylvian techniques, vertical
parasagittal hemispherotomy and the transsylvian transventricular keyhole
procedures.
Cook SW, Nguyen ST, Hu B, et al.: Cerebral hemispherectomy in pediatric patients with epilepsy: comparison of three techniques by pathological
substrate in 115 patients. J Neurosurg. 100:125 2004
Theodore Rasmussen, William Feindel and Wilder Penfield at the 40th Anniversary of the MNI
Stereotactic Radiosurgery
• The first application of radiosurgery for
epilepsy surgery is attributed to Talairach
in the 1950s, who implanted radioactive
yttrium in patients with temporal lobe
epilepsy without a lesion.
• In 1980, Elomaa promoted the idea of the
use of focal irradiation for the treatment
of temporal lobe
Régis J, Rey M, Bartolomei F, et al.: Gamma knife surgery in mesial temporal lobe epilepsy: a prospective
multicenter study.Epilepsia. 45:504-515 2004
Elomaa E: Focal irradiation of the brain: an alternative to temporal lobe resection in intractable focal
epilepsy?. Med Hypotheses. 6:501-503 1980
• Irving Cooper pioneered
the use of DBS as chronic
therapy for epilepsy
• In 1973 their group
reported cerebellar
stimulation in seven
patients with intractable
seizures with virtually
complete control of
seizures achieved in four
of them.
Rosenow J, Das K, Rovit RL, et al.: Irving S. Cooper and his role in
intracranial stimulation for movement disorders and
epilepsy.Stereotact Funct Neurosurg. 78:95 2002
Davis R: Cerebellar stimulation for cerebral palsy spasticity,
function, and seizures. Arch Med Res. 31:290 2000
Vagal Nerve Stimulation
• Experimental use of VNS to treat epilepsy can be traced to the 1880s by
Corning.
• Zanchetti and colleagues showed that intermittent VNS reduced or
eliminated interictal epileptic events that were chemically induced in the
frontal cortex of cats.
• Based on these experiments, Zabara in 1985 proposed that if VNS could
desynchronize electroencephalographic activity, it might be effective in
attenuating epileptic seizures.
Henry TR: The antiseizure effect of VNS is mediated by ascending pathways. Miller JW Silbergeld DL Epilepsy Surgery: Principles and
Controversies. 2006 Taylor & Francis New York 624-629
Zabara J: Inhibition of experimental seizures in canines by repetitive vagal nerve stimulation. Epilepsia. 33:1005-1012 1992
• In 1988, the first epileptic patient
to undergo implantation of a VNS
therapy device became seizure
free
• Approved in 1997, vagus nerve
stimulation (VNS) delivered via
the implantable Neurocybernetic
Prosthesis (NCP) has become an
established method for treating
patients with medically refractory
seizures
Amar AP, Heck CN, Levy ML, et al.: An institutional experience with
cervical vagus nerve trunk stimulation for medically refractory epilepsy:
rationale, technique, and outcome. Neurosurgery. 43:1265-1276 1998
Mulligan LP, Spencer DD, Spencer SS: Vagus nerve stimulation for
intractable epilepsy: a review. J Clin Neurophysiol. 14:358-368 1997
Tecoma ES, Iragui VJ: Vagus nerve stimulation use and effect in
epilepsy: what have we learned?. Epilepsy Behav. 8:127-136 2006
Responsive Closed Loop Neurostimulation
• Early work on a closed-loop approach was performed in the Soviet Union
by S. A. Chkhenkeli’s group in the 1970s
• Gluckman and associates worked in vitro and showed that seizure-like
activity can be adaptively controlled with electric fields. Osorio and
colleagues implemented a working closed-loop system
• Records electrical activity from the brain and can be programmed with
seizure detection algorithms that trigger brain stimulation at electrical
signs of seizure onset. This responsive stimulation is intended to block
progression of the seizure
Chkhenkeli SA: Direct deep brain stimulation: a first step twoards the feedback control of seizures. Milton J Jung P Epilepsy as a Dynamic
Disease. 2003 Springer-Verlag Berlin
OUTCOMES
PROCEDURE
STL
60-80% seizure freedom
SAH
Improved Neuro-psychological outcomes
MST
71% for generalized epilepsy, 62% for complex partial epilepsy, and 63% for simple
partial seizures.
CC
Improves frequency of drop attacks with reduction in severity of GTCs
VNS
30-50% effective in providing a 50% reduction
Median reduction at 6 months 46%, 1 year 57%, 2 years 63%
RNS
Currently in study
SRS
65-85% seizure freedom at 2 years, limited data
DBS
Experimental
EVOLUTION