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Our center offers the latest cutting edge treatment for adults and children and has an extraordinary track record in the care of people with epilepsy.

Epilepsy in Adults

What You Need To Know

Epilepsy is a medical condition that greatly impacts the lives of those with it. It is estimated approximately 2 million people in the United States have epilepsy. Fortunately, with the right treatment, many people are able to live a normal life with this condition.

To address the topic of epilepsy, one must define seizure. A seizure is a disruption of the normal electrical network in the brain causing the brain to issue aberrant signals to the rest of the body. This can manifest in many different ways. Often times, when we think of seizures, we think of whole body shaking and foaming at the mouth as commonly portrayed in movies. However, a seizure can also be much more subtle and manifest as a weird smell, feeling of déjà vu, and/or rising sensation of the stomach. Seizure is actually not a rare occurrence. Approximately 10% of the population in the United States will experience at least one seizure in their lifetime.

So now that we’ve defined seizures, what is epilepsy? Epilepsy is defined as having an unprovoked seizure and having a high risk of another unprovoked seizure (> 60% chance) without treatment. In the past, epilepsy was defined as having 2 or more unprovoked seizure but that definition was recently revised by the International League Again Epilepsy (ILAE) so that people who had only one unprovoked seizure but with high risk of a recurrent seizure can be included and treated.

The most common identifiable causes of epilepsy in adults living in a developed country such as the USA are stroke and brain tumor. Other less common causes of epilepsy includes parasites, meningitis, head trauma, neurodegenerative changes, and congenital malformation of the brain. It is not unusual for a cause of epilepsy not to be identified. In fact, less than half of epilepsy cases have an identifiable cause.

In order to figure out the cause of epilepsy, physicians will often image the brain and obtain an electroencephalogram (EEG). Imaging of the brain is done via magnetic resonance imaging (MRI) to look for things that can cause epilepsy such as stroke or congenital brain malformation. Computer tomography scan of head is less optimal but is acceptable in emergent settings or if MRI is contraindicated. An EEG evaluates the electrical activities of the brain to screen for abnormalities. EEG helps physicians determine seizure type and where in the brain the seizure originates. It is not uncommon for someone with epilepsy to have normal MRI brain and normal EEG. In such individuals, the abnormality is seen on EEG only at the moment they have a seizure.

The first line treatment of epilepsy is medication. There are over 20 different anti-seizure medications available in the USA and physicians choose anti-seizure medications based on the epilepsy type, possible interaction with pre-existing medications, and side effect profile. About half of patients can achieve seizure freedom with the first medication. An additional ten to twenty percent can achieve seizure freedom on a second medication. Ultimately, about two-thirds of patients achieve seizure freedom on just medication alone.   

For those who are unable to achieve seizure freedom on just medication alone, there are other options available. There is epilepsy surgery, which aims to identify the part of the brain that the seizures originate from (epileptic focus) and remove that part of the brain. Careful efforts are taken to make sure the epileptic focus can be safely removed without causing significant neurological problems such as weakness or language problems. For people who have failed multiple medications, epilepsy surgery is the best option for attaining seizure freedom. In the hands of an experienced epilepsy neurosurgeon, the risks of epilepsy surgery is small, especially when compared to the mortality risk of continued uncontrolled epilepsy.

Not everyone is a candidate for epilepsy surgery. Some people may not be candidates because their seizures do not have identifiable epileptic foci. Others may not qualify because the epileptic foci cannot be removed without causing significant neurologic deficits such as severe weakness.

For people who don’t qualify for traditional surgical resection due to epileptic focus being in a critical part of the brain, a more recent option is responsive neural stimulation (RNS). With RNS, the surgeon implants an electrode at the epileptic foci. The electrode is connected to a small device implanted at the skull. The device detects seizures and sends electrical pulses via the electrode to the epileptic focus help abort seizures. RNS reduces seizure frequency but is not meant to result in seizure freedom.

Another option beside RNS is vagal nerve stimulator (VNS). VNS is less invasive because it does not involve brain surgery. VNS can also be used in people whose epileptic foci cannot be identified. VNS is a device place under the skin below the clavicle. It sends an electrical pulse up at set intervals via a nerve that leads directly to the brain called the vagus nerve. Like RNS, VNS reduces seizure frequency but is not meant to result in seizure freedom. For those who either don’t qualify or do not want epilepsy surgery, VNS is a good option.

If you happen to witness someone having a seizure. Try to prevent them from falling onto the ground and slowly lower them safely onto the ground. Position them on their side. Do not put anything into their mouth or you may risk injuring yourself. Immediately call 911 and stay with the person until paramedics arrive. 

Epilepsy is a debilitating condition if not well controlled. Imagine, not being able to swim alone or not driving because you never know when you will have a seizure. Aside from the impact on lifestyle, people with uncontrolled epilepsy also have a higher mortality rate than the general population. However, for those with well controlled epilepsy, they are usually able to live a normal life. Thus, helping people with epilepsy become seizure free is of utmost importance.

Infantile Spasms

What You Need To Know

Infantile spasms is a potentially devastating early-onset epilepsy that affects infants, typically between three and nine months of age.  Many cases of infantile spasms occur in children who are already have brain abnormalities, such as children with tuberous sclerosis, down syndrome, or brain injuries sustained as newborns.  However, in about one third of affected infants, infantile spasms occur for no known reason.

There are three first-line treatments used for infantile spasms. Most pediatric neurologists select one of these three as the initial treatment.

First, adrenocorticotropic hormone (ACTH) is a naturally occurring hormone that is made by the pituitary gland.  It stimulates the body to produce steroids.  There are several versions of ACTH available throughout the world -- in the US, physicians can prescribe a pharmaceutical grade purified ACTH for infantile spasms. ACTH must be given by injection into the infant's thigh twice a day for two weeks, and then gradually tapered over the next several weeks. There are significant side effects. Many babies become very irritable when taking this medication. It increases their appetite, and some gain weight during treatment.  ACTH can also increase blood pressure and, on occasion, lead to an increase in the size of the heart. These side effects fade after the medication is stopped.  

Second, oral prednisolone is a corticosteroid, which comes as a liquid.  This is the same medicine given for children with asthma attacks; although, for infantile spasms we use a higher dose for a longer period of time (usually several weeks). It can have the same side effects as ACTH, but these are usually less severe.

Third, vigabatrin is a medication that comes as a packet of powder, which can be disolved in water.  The major worrisome side effect of vigabatrin is loss of peripheral vision. This is uncommon.  Usually when vigabatrin is prescribed, the infant will also need to see an ophthalmologist to monitor for this potential side effect.  

Current evidence suggests that ACTH has the best overall response rate. The one exception is that for children who have infantile spasms due to tuberous sclerosis, vigabatrin seems to work better.  

First-line therapy works between half and three quarters of the time. If it fails, there is not good evidence to guide us on what to try next. Many physicians will switch to a different first-line agent. For example, if a child continues to have seizures after ACTH, the physician may try vigabatrin next. Rarely, a deficiency of vitamin B6 can cause infantile spasms, and many physicians will give infants this vitamin. Other physicians may try dietary therapy.  For example, there is a diet called "the ketogenic diet" that avoids carbohydrates and sugars.  This diet can lead to changes in how the brain makes fuel for itself, which can, in turn, reduce seizures.

In some cases, children with infantile spasms may have a subtle area of the brain which is abnormal, which is difficult to see on MRI scans.  Some physicians will order other kinds of brain scans, such as a PET scan (positron emision tomography), in order to look for these kinds of abnormalities.  This is important, because some infants benefit from epilepsy surgery to remove the abnormal area of brain. 

Epilepsy in Seniors

What You Need To Know

Causes and Testing for Epilepsy in Seniors:

People who develop epilepsy in their younger years may have it persist into the senior years.  Epilepsy while young may lead to epilepsy while old, but epilepsy while young does not lead to other neurological conditions while old, such as Alzheimer’s Disease, Parkinson’s Disease, or stroke. 

A first seizure in a senior citizen requires immediate medical attention and testing. This includes physician assessment; evaluation of lung, kidney, and liver functions; and looking for possible infections.  A surprise seizure in a senior also can be the first indicator of a new, serious brain problem.  Most of these problems can be diagnosed by pictures of the brain, such as CAT and MRI scans.  A brain wave test (electroencephalogram, EEG) can help classify and locate (in the brain) any seizure tendency.

With increasing age, certain brain problems become more common as reasons for epilepsy.  These include such things as brain tumors or blood clots on the brain (for example, subdural hematoma).  An MRI of the brain will be diagnostic in these cases.  A seizure also may be the first indicator of a stroke.  In the event of a stroke, other tests may be required, such as studying the blood circulation through the arteries of the neck.

At times it may be hard to tell a seizure from a fainting spell (syncope).  Elders are inclined to syncope due to heart conditions.  The doctor should review carefully all the seizure symptoms; note any symptoms that sound more like syncope; and review medications in use.  Some commonly used medications for high blood pressure (hypertension) may cause dizziness upon standing, and even cause syncope.  Testing of the heart rhythm (for example, with a Holter monitor), and testing of the heart structure and function (for example, with an echocardiogram), may be in order in selected cases.

Treatments for Epilepsy in Seniors:

After only one seizure, there may be no more seizures, so the decision to treat with an antiepileptic medication needs to be made after a discussion of the risks and benefits between the patient and the doctor.  If several seizures have occurred, that is “epilepsy”, and in most cases treatment is indicated.  If a decision to treat is made, it will mean long-term daily anti-epileptic drug (AED) medication usage.  AEDs reduce, and in many cases eliminate, the chances of seizure recurrence.  However, AEDs do not take away the brain’s underlying tendency to produce seizures in the first place.  Therefore, any potential future decision to stop AEDs (after a prolonged seizure-free period) again needs careful consideration of risks and benefits between the patient and the doctor.

There are many medications which work well against seizures, both in the young and the old.  There is no one drug which is superior to other drugs for seniors.  Some AEDs come in formulations which allow them to need to be taken only once each day.  Since many elderly also take many other different medications, a once-a-day AED schedule may be appealing.  Furthermore, for the same reason of multiple medications in use, drug-to-drug interactions need to be watched for.  For example, there can be important and unpredictable interactions between warfarin (Coumadin, a common blood thinner used with atrial fibrillation of the heart rhythm) and phenytoin (Dilantin).  Patients on both these medications require frequent blood test monitoring to ensure safety.

Long-term use of some of the older seizure medications (for example, phenytoin and phenobarbital) has a tendency to reduce the density of bones (in severe cases, leading to osteoporosis).  With advancing age, osteoporosis also occurs at an increasing frequency among women (with or without epilepsy), particularly after menopause.  Low bone density may lead to broken bones (fractures) due to falls, and falls may occur more frequently among the elderly due to any number of other problems with the brain, muscles, joints and skeleton.  Bone density can be measured with a simple and widely available x-ray test; bone density needs to be monitored regularly in these patients.  In the event osteoporosis, changing to a newer antiepileptic medication should be considered.

Rarely, seizures are not stopped by medications.  Under those circumstances, neurosurgery on the brain to remove the source of seizures can be undertaken.  There is no universally agreed upon upper age limit for epilepsy surgery.  However, the increased surgical risks due to increased occurrence of body illnesses with age (such as heart, lung and kidney disease) need to be weighed against excellent surgical outcomes, in discussions between patient and doctor.

An alternative surgical treatment for epilepsy is the implantation of a vagus nerve stimulator.  This device is placed just under the skin of the chest, and an electric wire reaches to and stimulates the vagus nerve in the neck.  This usually reduces the seizure rate by half.  There are no drug interactions, and no side effects like dizziness, with this electrical device.  Therefore, this should be considered a good option for seniors.

Conclusions:

While there are many similarities between seizures and epilepsy in younger and older individuals, there also are significant differences between these age groups.  Medical attention to the special details of epilepsy in seniors, however, should yield excellent results.

Patient Story

This is a work of fiction serving an educational purpose. Names, characters, places, events and incidents are used in a fictitious manner, based on past patient cases. Any direct resemblance to actual persons, living or dead or actual events is coincidental. 

Edward is 83, and he has been living with epilepsy for 70 years.  He still lives in his own apartment and takes care of many of his own day-to-day needs, with a little help from his nephew, who lives next door.  No cause for the epilepsy ever was found.  He is retired from his work in the garment industry (clothing pattern printing).

The seizures have become more mild over the years.  In the past they were falls. staring, and vocalization.  Now the seizures are short spells where he just does not respond when spoken to.  These happen only several times per year.

Like many older patients, he has been taking an older seizure medication, phenytoin.  Changing medication to a newer drug may be better, or may be worse; so changes are made only when really needed.  For Edward, changes had not been “really needed” for decades.

Over the years, Edward has run into several of the problems common among people with epilepsy as they get older.  Heart surgery was needed in 2006, and also prescribing the common blood thinner, warfarin, was needed at that same time.  This required frequent blood tests because phenytoin and warfarin affect each other’s activity in the body.  With close monitoring, this medication combination was used safely.

Long standing use of phenytoin increases the chances of low bone density (osteoporosis).  This increases the risk of a broken bone in the event of a fall.  Bone density can be measured by a safe and quick x-ray test.  Edward’s bone density is normal.  He has in fact fallen, but never broke any bones.

When a few additional seizures were noted recently, the phenytoin dose was increased.  This led to dizziness.  The phenytoin dose was decreased again, and another seizure medication, levetiracetam was prescribed in addition to the phenytoin.  This new supplemental medication led to excellent seizure control, no new side effects, and no drug interactions.  The prognosis for Edward is excellent, with many more rewarding years expected still to come.

Epilepsy in Sports

What You Need To Know

A concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Immediately following a concussion, an athlete is usually advised physical and cognitive rest till post-concussion symptoms abate. The athlete then enters a stepwise return to play protocol. Premature return to play risks a second concussion, second impact syndrome, exacerbation and persistence of post-concussive symptoms. 

Sports and Epilepsy:

Sport is important not only in normal healthy populations, but also in persons with medical illness, physical or mental disabilities. Active participation in sports is beneficial physically and psychologically. The main concern in sports for persons with epilepsy is safety.

Why are people with epilepsy restricted from some sports?:

Rationale is that the occurrence of an untimely seizure during certain sporting event has the potential for causing substantial injury and bodily harm both to the patient with epilepsy as well as fellow athletes and even spectators.

Example: if a person with epilepsy has a generalized convulsion or a complex partial seizure while skydiving: he shall not be able to deploy his parachute and a fatal accident can occur

  • person with epilepsy taking part in an automobile racing event suffers a seizure while making a bend at speeds in excess of 100mph
  • person with epilepsy suffers a seizure while taking part in a swimming meet
  • person with epilepsy suffers a seizure while bicycling
  • person with epilepsy suffers a seizure while horseback riding
  • person with epilepsy who is indulging in contact sports such as boxing, karate, kick-boxing, muay thai boxing, American football, ice-hockey, wrestling, judo
  • person with epilepsy suffers a seizure while skiing down a steep hill
  • even things more mundane such as having a seizure while running on a treadmill, while playing tennis, while jogging outside have the potential to cause bodily harm to the patient and others

But are these restrictions and fears actually based on scientific evidence or are they unfounded? Which sports are safe and which are not? Could indulgence in some sports make seizures potentially worse Vs. could some sports actually be beneficial for people with epilepsy (physically and psychologically)? Can vigorous physical exercise provoke seizures?

Exercise and seizures:
One reason that people with epilepsy have been traditionally restricted from certain sports is the fear both in the patient and the treating physician that exercise especially aerobic exercise may exacerbate seizures. Some studies have shown an increase in interictal discharges during or after exercise. Most frequently these patients have generalized epilepsies. At least some frontal lobe and temporal lobe seizures are clearly precipitated or at times solely occur during exercise suggests that these are a form of reflex epilepsies. A number of physiologic mechanism by which seizures may be provoked by exercise have been postulated. These include hyperventilation with resultant hypocarbia and alkalosis induced by exercise. Another possible mechanism which is postulated to cause exercise induced seizures is hypoglycemia. This usually causes seizures after exercise in diabetic patients. Other mechanisms which have been postulated for exercise triggered seizures include the physical and psychological stress of competitive sports and potential changes in anti-epileptic drug metabolism. Exercise is a complex behavior and involves not such the motor system and the motor cortex but also involves other domains such as attention, concentration, vigilance and presumably some limbic networks which mediate motivation, aggression and competitiveness. Hence it is possible that patients who have temporal or frontal lobe epilepsy may on rare occasions have seizures triggered by exercise.

There is some limited evidence that exercise may in fact be protective and have physical, physiological and psychological benefits in patients with epilepsy. Electroencephalographic studies have shown that inter-ictal epileptiform discharges either remain unchanged or may decrease during exercise so there is some hint that exercise may actually raise the seizure threshold.  Regular exercise also influences neuronal and hippocampal plasticity by upregulation of neurotropic factors. There is further evidence to suggest that regular physical exercise can improve the quality of life, reduce anxiety and depression and improve seizure control in patients with chronic epilepsy.

What sports are off limits for people with epilepsy?
No sport is completely off limit for a patient with epilepsy. Key though is proper supervision to reduce the potential for injury. There are some sports such as skydiving, automobile racing, swimming in the open seas and horseback riding which should be avoided by patients with epilepsy. Other sports can be enjoyed by patients with epilepsy but one should remember that they all have the potential to result in bodily harm if seizures occur when the patient is not supervised or if he is not wearing protective head and body gear.

Concussion and seizures (post traumatic epilepsy): what is the link?
The link between concussion (closed head trauma) and seizures has been and continues to be closely looked at. The fear of concussions (minor head trauma) making seizures worse is the prime reason why people with epilepsy are discouraged from some sports such as tackle football, ice-hockey, boxing, mixed martial arts and wrestling. The human skull is quite resilient and the closed head trauma has to be significant for it result in seizures. Usually a concussion which results in prolonged loss of consciousness (some authors say more than 30 minutes) is graded as a significant head trauma. Minor bumps and bruises to the head do not cause seizures, do not increase the risk of future seizures and more importantly do not make chronic epilepsy worse. Seizures may occur immediately following a severe closed head trauma. Immediate post traumatic seizures by definition occur within 24 hours of the injury. They have also been referred to as impact seizures.  Early post traumatic epilepsy refers to seizures which occur about a week to 6 months after the injury. Seizures may occur as far out at 2 to 5 years after head trauma (late post traumatic epilepsy). Factors which increase the risk of post traumatic seizures/ epilepsy include severity of trauma, prolonged loss of consciousness (more than 24 hours), penetrating head injury, intra or extraaxial hemorrhage, depressed skull fracture and early post traumatic seizures.

Counseling patients:
Patients with epilepsy should be encouraged to exercise and take part in sports. My personal feeling is that no sport should be off limits to them with the exception of maybe sky-diving, river rafting and boxing.  The goal should be exercising and playing sports safely. Walking, running, cycling and yoga are great exercises which can be indulged in with little to no risks. I advise all my patients with epilepsy (especially those with poorly controlled epilepsy) to wear a Medic Alert bracelet or carry a card in their wallet. This is of immense help were a seizure to occur in the field (as for example when a patient is jogging or cycling and is not in the immediate vicinity of his or her home). Low risk recreational sports such as walking or running usually do not need a one is to one supervision if seizures are well controlled by history. Team sports such as volleyball, basketball, baseball and softball are popular sports which carry a low risk of injury. For cycling I advise my patients to wear a helmet and have their bikes fitted with lights and reflectors.  I also advise them to keep off from the busy city streets. “you do not want to have a seizure at the wrong place and at the wrong time”. Swimming is a great way to keep fit and also to meet and make friends. I feel many patients with epilepsy are discouraged from swimming due to an irrational fear of caregivers and physicians of drowning.  I advise my patients not to swim alone.  Most of the city pools have life guards and a polite request to them to keep a watch out goes a long way in reassuring both the patient and the caregivers. Swimming in the open seas is more risky.  I advise my patients to swim close to the beach under the watchful eyes of a life guard. Also having a buddy around helps, preferably someone strong enough to pull the patient out of the water if a seizure was to occur. The option of wearing a life jacket is underutilized. 

Treatments

Vagus Nerve Stimulation

What You Need To Know

Stimulation of the vagus nerve in the neck has been approved for the treatment of epilepsy by the US Food and Drug Administration since 1997.  Doctors and patients at the Weill Cornell Epilepsy Center were participants in research on this therapy, as far back as 1993.

For vagus nerve stimulation (VNS), out-patient surgery is performed to place a small pace-maker like device under the skin of the left chest.  A wire leads under the skin to the vagus nerve in the neck.  Low level electrical current is delivered to the nerve every few minutes.

Patients can self-activate extra stimulation, which is usually extra strength, when they feel a seizure coming on.  This is done by waving a magnet over the pacemaker.  The result typically is a less severe and shorter seizure, with less after effects.  A new model of stimulator also gives extra stimulation when it detects the increased heart pulse rate that occurs when a seizure happens.

VNS usually reduces the patient’s number of seizures by more than 50%, and usually less seizure medications are needed when on VNS.  It may take months of VNS therapy to see the maximum effects.  It is uncommon for the results of VNS to be “no seizures”, but it is also uncommon for the results to be “no improvement”.

VNS is in the lowest risk category for pregnancy.  VNS has no drug interactions and no sedative side effects.  These might be reasons to use it in specific patients.

The most common side effects are deepening of the voice and hoarseness every few minutes during stimulation.  This occurs because a branch of the vagus goes to the voice box.  The device battery lasts about 7 years, and a brief out-patient surgery is required at that point to implant a replacement device.

Patient Story

This is a work of fiction serving an educational purpose. Names, characters, places, events and incidents are used in a fictitious manner, based on past patient cases. Any direct resemblance to actual persons, living or dead or actual events is coincidental. 

Arnold first came to the Weill Cornell Epilepsy Center in 1997 at a teenager.  He has cerebral palsy with a paralyzed arm and weak leg, but otherwise was completely healthy.  However, he did suffer persistent seizures.

A Pediatric Neurologist had been his epilepsy doctor up until the teenage years.  In the past, seizures medications tried had been ethosuximide, primidone, phenytoin and phenobarbital.  By 1997, he had changed to carbamazepine and gabapentin, but those drugs were not working.

In 1997, the US Food and Drug Administration approved vagus nerve stimulation (VNS) for epilepsy.  Cornell had been a very active research center for this technique, and Arnold decided this new treatment would be right for him.

VNS starts with the surgical implantation of a small, pacemaker-like device under the skin of the chest, with a wire leading to the vagus nerve in the left neck.  The treating physician then programs the device to deliver electrical stimulation every few minutes.  Side effects may be transient deepening of the voice, but there are no medication-type side effects, such as drowsiness or dizziness.

This brand new treatment worked very well for Arnold.  Side effects wore off in a few weeks.  He became seizure free and no longer needed to take gabapentin, stopping that one year later.  He attended and graduated college, got a driver’s license, and recently got married.  His epilepsy condition has improved dramatically and the future looks bright for an excellent quality of life, despite having needed to overcome multiple obstacles in the past to have come this far.

Responsive Neurostimulator

What You Need To Know

In summer 2014, Drs. Steven Karceski - Neurologist, Theodore Schwartz - Neurosurgeon and the Epilepsy Team at NewYork-Presbyterian/Weill Cornell Medical Center successfully placed the first cranial implant for epilepsy since the device received premarket approval from the FDA in fall 2013.  The implant is designed to detect abnormal brain activity that occurs before a seizure and respond with stimulation to interrupt the activity and avert a seizure. The Weill Cornell Epilepsy Team was part of the clinical trial that tested the device over the past eight years to demonstrate its safety and effectiveness.

The device, the RNS® System from NeuroPace, consists of a neurostimulator and two to four intracranial leads. The implanted neurostimulator works in two stages: in the first stage it records brain activity in the area of a patient’s brain where his or her seizures are known to originate; in the second stage the device is programmed to detect abnormal electrical activity in that area and deliver mild stimulation to interrupt it and prevent the seizure.

The implant is intended for patients with epilepsy that is not well controlled with medication and who suffer from disabling seizures (approximately 400,000 people in the United States alone). Clinical trials showed a significant improvement in seizure frequency for patients treated with the cranial implant, with no serious device-related adverse events reported in any of the three trials.

Drs. Karceski and Schwartz are optimistic about the prognosis after these implant surgeries. “For patients like ours, who have seizures that medication can’t control, this is a very promising new option,” Dr. Schwartz said. “Since I’d been involved in the clinical trial I was confident that this would become a good option. It feels great to have a procedure like this become available, and then see how it can give someone their life back.”

Patient Story

Watch Tracey's story

Tracey Drake, 41, had been experiencing near-daily seizures for 15 years – the debilitating seizures had significantly affected her life and left her unable to work.  “I had tried every epilepsy medication out there,” she says, “you name it, I’d tried it. Nothing worked.”   Her long list of unsuccessful medications included carbamazepine, lacosamide, lamotrigine, acetazolamide, clobazam, valproate, eslicarbazepine, perampanel, and topirimate.  Many drugs did not work and produced drowsiness and tiredness. 

In the past she underwent brain surgery to remove abnormal blood vessels and also to remove brain scar tissue.  She tried a surgically implanted vagus nerve stimulator.  None of these significantly reduced her seizures.

When her neurologist, Dr. Karceski, suggested she consult a neurosurgeon, Dr. Schwartz, to see if she would be a good candidate for a new implant, Tracey jumped at the chance.  The new implant was a responsive neurostimulator (RNS).

“I was maybe a little nervous about it, since the procedure was so new,” she says. “But mostly I was excited that finally there was a possibility of getting back to a normal life.”

The device was implanted on June, 2014, and 10 days later Tracey reported that she felt great. “I’m in the programming stage right now, with the implant recording signals, and in August I’ll come back to have the device turned to stage two, when it will begin sending the signals that should prevent seizures.” 

Since then, she has been uploading the recorded electrical signals from her brain, via the internet, to a server for storage.  Dr. Karceski has reviewed the brain waves, and this allowed him to improve programming of the RNS device stimulation.  Tracey’s seizures occur significantly less often and are less severe.  The vagus nerve stimulator was turned off, and medication dose reductions have been started.  The prognosis for continuing improvement is excellent.

Laser Brain Surgery

What You Need To Know

The Laser Surgery Program at the Weill Cornell Brain and Spine Center uses state-of-the-art laser interstitial thermal therapy (LITT) to treat patients using tiny beams of light. These beams heat the area, destroying the abnormality without damaging surrounding healthy brain tissue.  Because no radiation is involved, people who have LITT do not have to worry about the possible side effects that can happen due to radiation. Laser ablation represents the latest generation of minimally invasive neurosurgery, and is an advanced new option for people who have certain kinds of epilepsy.

Surgical treatments are often considered when a person has seizures that are not well-controlled with medication.  Laser surgery, the newest type of neurosurgery, can be an effective option.  In some people, “traditional” open surgery can have a high risk: this could be due to the location of the lesion or due to a patient’s other medical problems. Laser therapy in epilepsy has opened the door for less invasive surgical treatment in cases that were previously considered non-surgical, or that would have required a larger surgical procedure to achieve seizure reduction. In some cases, the surgical target of an epileptogenic network is deep, multiple, or carries significant morbidity based on surgical approach. Recent studies have shown the effective use of laser therapy in treating epileptogenic lesions such as cortical dysplasia, tuberous sclerosis, hypothalamic hamartomas, mesial temporal sclerosis, and periventricular nodular hyperplasia. Laser ablation therefore creates an opportunity to provide appropriate patients with the possibility of a less invasive way to reduce or cure their seizures.

During a laser procedure, the neurosurgeon creates a small opening in the skull – no craniotomy is required – and inserts a laser probe. Using MRI guidance to ensure the most precise placement possible, the surgeon delivers the laser through the applicator to reach the target. Real-time temperature maps allow the surgeon to monitor the area being heated during the procedure to destroy the lesion without damaging healthy brain tissue around it. Outcomes for patients undergoing this new advanced procedure have been excellent, although long-term results will need to be studied. 

The Laser Surgery Program is staffed by specially trained neurosurgeons from the Epilepsy Surgery service at the Weill Cornell Brain and Spine Center. Our Epilepsy Surgery service is part of the widely acclaimed Comprehensive Epilepsy Center at NewYork-Presbyterian/Weill Cornell Medical Center. Nationally recognized for its pioneering achievements in research and clinical innovations, the Comprehensive Epilepsy Center provides a multidisciplinary approach to the complex medical and social needs of patients with seizure disorders. 

Patient Story

This is a work of fiction serving an educational purpose. Names, characters, places, events and incidents are used in a fictitious manner, based on past patient cases. Any direct resemblance to actual persons, living or dead or actual events is coincidental. 

Andrew has had severe (refractory) epilepsy since he was 1 year old. Even though he tried taking multiple medications over the years, his seizures continued. Overcoming the challenges of schooling and working as a person with epilepsy, he was able to become a physician assistant.  But persistent seizure attacks, and unrelenting medication side effects, were unacceptable to him.

After detailed state of the art evaluations with Clinical Neurophysiology and Neuroradiology testing at the Weill Cornell New York Presbyterian Epilepsy Center, it was determined his seizures came from the right temporal lobe.  In the past, a very effective treatment for this would have been open neurosurgery through the skull, and surgical removal of the brain tissue causing seizures.  This has risks and does not appeal to some patients.

Now, the Center is able to offer a new alternative to patients like Andrew.  That is laser interstitial thermal therapy (LITT).  A small fiber optic laser probe is placed into the epilepsy source (focus) under computer assisted magnetic resonance imaging (MRI) guidance.  No skull opening and removal is needed.  Heat is applied through the laser to destroy the offending epileptic tissue that causes the seizures.

Always striving to improve himself, Andrew underwent laser surgery in 2015 for his epilepsy.  There were no adverse events and he has been free of seizures ever since then.  He currently takes care of his family and works in his church.  Because he has been seizure free for a year now, he has applied to get his driving license.  Andrew looks forward to and anticipates continuing improvement in many aspects of his daily life, due to the new innovative therapy he decided to pursue at NewYork-Presbyterian/Weill Cornell.

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