Innovative options for medically refractory epilepsy

Aug. 30, 2019

Anthony L. Ritaccio, M.D., a neurologist at Mayo Clinic in Jacksonville, Florida, answers questions about Mayo Clinic's approach to medically refractory epilepsy. The National Association of Epilepsy Centers rates all three Mayo Clinic campuses as Level 4 epilepsy centers — the highest rating, given to centers that provide the most-complex forms of intensive neurodiagnostic monitoring as well as extensive medical, neuropsychological and psychosocial treatment. Level 4 centers also offer a complete evaluation for epilepsy surgery and a broad range of surgical procedures.

What options can Mayo Clinic offer to the 40% of people with epilepsy whose seizures don't respond to medication?

Surgical resection is a potentially curative option, if the seizure origin site is identified. In addition to utilizing stereo-electroencephalography, we are able to use imaging and brain-mapping techniques developed at Mayo Clinic to make that determination.

How does Mayo Clinic identify eloquent tissue in patients undergoing resection?

We are proponents of awake craniotomy to avoid postoperative deficits. At Mayo Clinic in Florida, we perform on the order of 50 awake brain surgeries a year, for both epilepsy and tumor resection. We also have a unique intraoperative grid, developed at the Jacksonville campus of Mayo Clinic, that can surround small areas of the brain to identify seizure origin location. We are committed to constantly innovating devices to help make functional brain mapping more reliable, as described in Mayo Clinic Neurosciences Update, Vol. 16, No. 4, 2019.

What other technology is in development for functional brain mapping?

With a grant from the National Institutes of Health (NIH), we are studying an innovative mapping technology that avoids applying electricity to the brain. This passive functional mapping uses an electrode that has been surgically implanted in the brain to capture electrocorticographic broadband gamma signals. Broadband gamma activity has been shown to be a reliable indicator of neuronal activity directly underneath an electrode. We record that activity while the patient listens to some short stories, and while the patient is at rest. Analyzing that data allows us to passively map eloquent tissue.

What options are available for patients who aren't surgical candidates because the tumor focus is in eloquent tissue?

We have extensive experience with implanted neuromodulatory devices that detect abnormal electrical activity and interrupt seizures before patients experience them. Data from the devices is streamed to the cloud, which allows us to monitor our patients' seizures.

How does Mayo Clinic's multidisciplinary approach facilitate the management of medically refractory epilepsy?

Our neurologists, neurosurgeons and neuroradiologists work as a team to provide the latest imaging technology and surgical techniques. We have enormous collective experience evaluating people with intractable epilepsy for higher order therapies, both surgical and neuromodulatory. As a Level 4 center, Mayo Clinic is able to offer the panoply of services that these patients need.

What new insights and therapies are emerging for the management of headache disorders?

Our understanding of the biology of headache disorders is rapidly advancing. That, in turn, is leading to new therapies. In the last year alone, the Food and Drug Administration has approved new treatments that are effective and have low side effect profiles, including therapies targeting calcitonin gene-related peptide. Mayo Clinic was actively involved in designing clinical trials for these medications and analyzing the resulting data. In addition, our Neuroimaging of Headache Disorders Laboratory is using functional and structural MRI to identify subtypes of migraine. It's an exciting time to be able to care for patients with these conditions. In our practice, we like to empower our patients, validate their concerns and take a compassionate approach to care.

For more information

Quantifying neuroimaging: A revolution in patient care. Neurosciences Update. Mayo Clinic. 2019;16(4):1.

Laboratories: Neuroimaging of Headache Disorders: Todd J. Schwedt. Mayo Clinic.