…they vary in quality due to differences in their training, experience and services. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.
A surgeon, for example, who performs a complex procedure often, has better success with it than a surgeon who does the same procedure only occasionally. The complication rate and the death rate for the same procedure may be many times higher at one hospital than another.
Clearly, the doctor and hospital that you choose have a direct impact on how well you do — especially when you need treatment for a condition such as epilepsy, a chronic recurrence of seizures due to brain abnormalities. Epilepsy is not rare. It affects nearly one in every 100 Americans, or more than 2 million of us.
Seizures can be controlled with medications in about 75 percent of people. When epilepsy can't be controlled with medications it is called "intractable." This means that disabling seizures continue to occur even though the patient has received the maximum medical treatment. Intractable epilepsy may be helped by surgery. In the past 10 years, major advances have been made in the accuracy of diagnosing epilepsy, in drug and surgical treatment, and in understanding the daily problems people with epilepsy face. As a result of advances in surgery, each year 2,000 to 5,000 new patients could benefit from surgery, whereas only 500 people are helped currently.
But taking advantage of these advances means making some difficult and important decisions such as choosing a doctor and a hospital. No one has more at stake than you; it's one of the most important decisions of your life.
This guide deals with difficult-to-control epilepsy. You may be reading it because you or a family member have just been told you have epilepsy, because your epilepsy is not being controlled by medications, or because you are considering epilepsy surgery. By making the comparisons we talk about, you will be prepared should the need for surgery arise.
Most of us do more research when we buy a car or television set than when we choose a doctor and hospital. That may be because we don't know what questions to ask or what to base our evaluation on. There is no consumer magazine that rates doctors and hospitals the way Consumer Reports rates air conditioners.
There are many different ways to measure quality care, and there is no universal agreement on which should be used. However, at The Cleveland Clinic Foundation, we believe that you can use the following six points, or quality indicators, to compare health care providers:
-Credentials
-Experience
-Range of services
-Participation in research and education
-Patient satisfaction
-Outcome
Choosing a doctor or hospital is often influenced by values. You may want a hospital that is close to home. You may want a hospital with a specific religious affiliation. But when you need specialized medical care for difficult-to-control epilepsy, it is essential that you also include in your decision a doctor's qualifications and a hospital's track record. These quality indicators will help you with that kind of evaluation should you require surgery for epilepsy.
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A Step-by-Step Guide
This guide helps you choose a doctor and hospital by:
-explaining intractable epilepsy and how it's diagnosed
-describing treatment for difficult-to-control epilepsy — seizure-preventing drug therapy, monitoring and epilepsy surgery;
-describing how patients are monitored and evaluated for surgery
-explaining six points that indicate quality; and
-providing questions and answers from The Cleveland Clinic Foundation that you can use to compare doctors and hospitals.
Epilepsy is a neurological disease, a disease of the central nervous system. Seizures occur when discharges of electrical energy from brain cells become uncontrolled. A sudden medical problem can trigger a seizure, but this doesn't mean the diagnosis is epilepsy. Epilepsy involves seizures that continue to occur.
Seizures that involve all of the brain are called generalized. Those that are limited to one part of the brain are called partial, or focal, seizures. This guide deals mainly with the most common form of focal seizure — the anterior temporal lobe seizure.
It's important for people with epilepsy to be treated at the appropriate level of care, according to the National Association of Epilepsy Centers (NAEC). Patients whose epilepsy is hard to control should be referred to specialized centers, according to the NAEC, while those whose epilepsy can be more easily controlled ordinarily need not be referred to such centers.
If you have a seizure, your family doctor may start treatment. If seizures can't be controlled within three months, "a referral to a general neurologist is indicated," according to the NAEC. If the seizures can't be controlled within nine months after that, a referral to a specialty epilepsy center is the next step. And if a person is likely to need epilepsy surgery, the NAEC recommends referral to a fourth-level surgical epilepsy center. See the box for more information.
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This is the highest level of specialty epilepsy center described by the NAEC.
At this level, the center should be capable of conducting complete preoperative evaluation and monitoring. Its staff should have the expertise to perform a broad range of surgical procedures for epilepsy.
Evaluation. A thorough evaluation to find the cause of seizures or localize their source includes a detailed medical history as well as a complete physical and neurological examination. In addition, most patients require further testing such as blood chemistry and urine tests; electroencephalograms (EEGs); and skull x-rays and brain scans such as computerized tomography (CT scans), magnetic resonance imaging (MRI) and positron emission tomography (PET) scans.
Medication. Most seizures can be controlled by medication. But anti-convulsive drug therapy is individualized. The drug selected depends upon the type of seizure being treated. Even in patients with the same seizure type, the effective dose will vary with age, weight, sex and other factors. The majority of people may be treated with a single drug. However, if that fails, various drug combinations may be tried. The process of finding the most effective drug, drug dose, or drug combination can take weeks or months. It also involves taking systematic measurements to monitor the amount of drugs present in the blood.
When seizures can't be controlled by drugs, surgery is considered. In the past, it could take more than 10 years to determine that drugs couldn't control seizures. That now can be determined within two years.
Monitoring for Surgery. Patients must be tested and monitored to determine if surgery is the right choice. This involves making sure that the seizures really are caused by epilepsy and that the seizures can't be controlled — even by drugs given in the highest possible doses. Finally, intensive monitoring is essential in determining the location of the seizures, which dictates the type of surgery necessary.
This process generally begins with prolonged video-EEG and monitoring. With electrodes attached to the scalp, EEG equipment and video cameras are used to record seizures and monitor the brain's activity. If doctors can find the seizure source using this technique, surgery is considered. If more information is needed, the brain itself is monitored. This involves placing electrodes or grids inside the skull over a specific region of the brain.
Testing also includes the intracarotid amobarbital test (Wada Test), which is used prior to surgery to delineate areas of the brain that control speech and memory function.
Surgery. Different types of seizures require different surgeries.
-Anterior temporal lobe resections: Patients who have focal seizures originating in the anterior temporal lobe can benefit the most from surgery. That is because their seizures are restricted to an area of the brain that can be removed without damaging vital functions such as speech, memory and movement. The operation that is performed is called resection, or removal, of a specific area, or section, of the brain. If seizures originate in the anterior temporal lobe, the appropriate operation is called anterior temporal lobe resection. Other areas of brain tissue can be removed depending upon the seizure source.
-Corpus callosotomy is done to reduce the frequency of disabling seizures for patients who have intractable generalized seizures which result in frequent falls and injuries to the body.
-Hemispherectomy, which involves removing one of the brain's hemispheres, is done to stop seizures for patients who have hemiplegia (paralysis of one side of the body).
After surgery, some patients may be completely free of seizures; others may find their seizures reduced by varying degrees. Some patients may have to continue to take medication, but their seizures are better controlled. Surgery may not be successful for some people, and a second operation may be needed.
Controlling seizures is only the first step in treating the whole person. Educational, social and psychological counseling are all part of the total treatment plan.
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The NAEC recommends that these facilities include the following:
-An inpatient recording suite with access to full resuscitative capabilities.
-A dedicated unit with a nursing staff whose sole function is to care for individuals with epilepsy. The unit's design and furnishings should minimize risk of injury to patients subject to seizures and falls.
-On-site, 24-hour medical coverage.
-Availability of the full spectrum of imaging services on-site.
-Fourth-level surgical programs that perform monitoring of patients with indwelling electrodes must ensure electrical safety and must meet the American EEG Society's recommendations for intensive neuro-diagnostic monitoring.
Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, if may not be possible to get complete information for each of these quality indicators. But when providers are willing to give you as much information as possible, it's a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capability.
If you are told that you have epilepsy, if your seizures cannot currently be controlled, or if you may need epilepsy surgery, talk to your family doctor or the neurologist who is treating you. Ask about having an epilepsy specialist review your diagnosis and treatment plan. Epilepsy specialists have training and experience in epilepsy treatment and devote a major portion of their practice and research to epilepsy. Get the names of several doctors and hospitals with the most experience. Ask the questions we suggest. Make comparisons. Then make your decision. Be an informed consumer for yourself and your family.
How can you use these indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to a report "The Quality of Medical Care: Information for Consumers" produced by the U.S. Congress, Office of Technology Assessment.
The report states that patients about to have surgery can be confident if the hospital performs a high number of relevant procedures, if it has a low mortality (death) rate, and if the surgeon has extensive training and experience in the procedure.
On the other hand, the report states: "...if a hospital had a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals required longer travel."
Do the doctor and hospital measure up?
Credentials have been set by nationally recognized medical professional organizations to verify that doctors and hospitals meet certain standards in the delivery of health care.
Doctors:
Board certification, or an international equivalent, is a sign that doctors are highly trained in their field. Doctors who specialize should be board certified in the specialty in which they are practicing. Each specialty has a national board which is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialty have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty, and have passed a difficult examination in their specialty area. Some excellent doctors are not board certified. Board certification, however, is generally a good indication of competence and experience.
Doctors who specialize in epilepsy are board certified in the specialty of neurology or neurosurgery.
Has the doctor been board certified in neurology?
All 8 Cleveland Clinic epilepsy specialists are board certified in neurology by the American Board of Psychiatry and Neurology. All have completed epilepsy and/or neurophysiology fellowships.
Our 6 child neurologists are board certified in neurology with special qualification in child neurology by the American Board of Psychiatry and Neurology. All are board certified in pediatrics by the American Board of Pediatrics.
Does the doctor who monitors and interprets the EEG tracings have board certification and special expertise in monitoring?
Seven of 8 Cleveland Clinic epilepsy specialists who monitor and interpret EEG data are board certified in clinical neurophysiology by the American Board of Clinical Neurophysiology.
Is the epilepsy surgeon board certified in neurological surgery?
All 4 epilepsy surgeons in the epilepsy program are board certified in neurological surgery by the American Board of Neurological Surgery.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps, or loses accreditation based on its meeting certain criteria for staffing, equipment and facility safety requirements. Although accreditation is voluntary, most hospitals go through the process. If the hospital that you are considering is not accredited, it is important to know why.
Although no organization exists to accredit epilepsy centers, the National Association of Epilepsy Centers has recommended some guidelines for services offered as well as staffing.
Hospitals that do measure up are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital's reputation is available through the mass media, books such as The Best Hospitals in America, the government, and consumer groups.
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For information about a hospital's status, call the Joint Commission on Accreditation of Healthcare Organizations at 708/916-5800.
Is the hospital accredited by the JCAHO?
Yes.
Does the facility meet guidelines for services and staff for fourth-level specialized epilepsy centers as recommended by the National Association of Epilepsy Centers?
Yes. The Cleveland Clinic's Epilepsy Center meets and exceeds the guidelines for both fourth-level medical and fourth-level surgical epilepsy centers. These include the categories of personnel (doctors, nurses, technologists) that staff the program; their credentials; tests that should be performed; and equipment that should be available for accurate evaluation and monitoring.
Has the hospital been positively and consistently recognized for medical excellence and leadership by the news media, consumer advocates and government agencies?
Yes. Most recently, the Cleveland Clinic was recognized as one of the six best neurology centers in America, based on the responses of 400 medical specialists, in the August 5, 1991 issue of U.S. News & World Report. A previous physician survey in the April 30, 1990 issue of the magazine also recognized the Cleveland Clinic as a leader in neurology.
For two years in a row, those same issues of U.S. News have named the Clinic one of "America's Best Hospitals." The Cleveland Clinic has also been singled out for excellence in "The Best in Medicine: Where to Get the Finest Health Care For You and Your Family" (Crown, 1990).
Does practice make perfect?
In the case of complex, specialized medical and surgical care for epilepsy, the more experience the doctor and hospital have with the necessary procedures, the better the results usually will be.
Board-certified neurologists and neurosurgeons gain experience by devoting a major portion of their practice and research to epilepsy and often receive further training when available. Neurologists may complete one- or two-year fellowships in epilepsy. Expertise in epilepsy surgery comes from the number, variety and complexity of cases neurosurgeons and epilepsy centers perform over a period of years.
The small number of epilepsy centers that perform 75 or more resections a year have developed expert, specialized teams that handle epilepsy surgery on a routine basis, according to The National Association of Epilepsy Centers (NAEC). Centers that perform 25 to 50 resections a year can be quite expert as well.
"One procedure every other week appears to be the minimum number necessary for a team to maintain its skills and do complex procedures on a routine basis," according to NAEC guidelines.
However, many U.S. hospitals do only five to 10 of these surgeries a year. And, while this low volume is to be expected in new programs, it is not enough to maintain skills necessary for the proper surgical treatment of patients with epilepsy.
It may be important to ask whether the doctor performs all procedures at one hospital or several. If the doctor performs procedures at more than one hospital, this increases the volume but means the doctor is working with different teams. The teams, therefore, don't have as much experience working together as they would if the doctor were working with the same team at the same hospital all the time.
How many patients are treated at the hospital each year?
We provide follow-up care to more than 1,000 patients with epilepsy, approximately half of whom are infants, children or adolescents.
How many patients undergo epilepsy monitoring at the facility yearly?
The Cleveland Clinic monitors approximately 300 patients per year.
How long has the hospital been performing epilepsy surgery?
Our program began in 1978. Since that time, we have performed more than 400 epilepsy surgeries.
How many epilepsy surgeries are performed each year?
The Cleveland Clinic currently performs more than 100 epilepsy surgeries yearly. Approximately one-third of these surgeries are done to help infants, children or adolescents who have intractable epilepsy.
How many of these surgeries are resections?
The Cleveland Clinic performs approximately 75 resections each year.
Were all procedures performed by the doctor at one hospital or several?
Our physicians perform all procedures exclusively at the Cleveland Clinic.
Have the doctors established a special expertise in epilepsy and epilepsy surgery?
Our neurologists and neurosurgeons have developed special expertise in epilepsy by devoting a major portion of their training, practice and research to this field.
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Volume Guidelines:
Some organizations have suggested volume guidelines for the number of times a procedure should be performed in order for it to be done competently.
-Surgical procedures for epilepsy should only be performed in centers doing at least 25 resective procedures for epilepsy a year, according to the National Association of Epilepsy Centers.
What services are available?
Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur. If complications arise, you want the best care available, and you want it immediately.
Range of specialty departments:
Medical conditions don't always exist in isolation. Related conditions could endanger the health of other organs. Therefore, immediate access to a full range of specialty departments within a facility is critical.
Range of diagnostic and treatment options:
Surgery for epilepsy is not the only treatment option. Even when surgery is required, it usually follows a long period of medical treatment. It's important, therefore, to go to a facility that can treat epilepsy in a variety of ways. That way you will get the most effective, appropriate and cost-effective treatment available.
Fourth-level epilepsy centers, as defined by the NAEC, are facilities that provide comprehensive diagnostic and treatment services designed for patients with intractable seizures. These centers may have separate medical and surgical programs or one combined medical and surgical program.
A fourth-level surgical epilepsy center, according to the NAEC, should be able to do complete surgical evaluations and should have staff with the expertise to perform a broad range of epilepsy surgeries.
The range of electrodiagnostic, surgical and imaging services that should be provided, according to the NAEC, are presented in the box* to the right.
Is help available from a full range of specialty departments should complications arise due to related conditions?
The Cleveland Clinic's 500 physicians — who are all on staff full-time — provide care in 100 specialties and subspecialties. Because all of these specialties, including pediatrics, are represented at one facility, prompt consultation, diagnosis and treatment are available.
Does the hospital offer a wide variety of options for diagnosing and treating epilepsy?
The Cleveland Clinic' s combined medical and surgical epilepsy program meets and exceeds the requirements of a fourth-level epilepsy surgery center suggested by NAEC in the box* to the left. The Cleveland Clinic's comprehensive range of services includes:
-A testing site for experimental anti-convulsants; comprehensive programs for monitoring blood-drug levels
-On-site radiology and nuclear medicine facilities with the full range of imaging services for epilepsy, including PET, SPECT, computerized tomography (CT), magnetic resonance imaging (MRI) and angiography of the brain
-Two, four-bed epilepsy and seizure monitoring units
-The full range of electrodiagnostic services, including 24-hour video EEG monitoring with surface and sphenoidal electrodes
-Invasive 24-hour recording with three different types of invasive electrodes
-Intracarotid amobarbital test (Wada Test)
-A wide range of epilepsy surgeries: anterior temporal lobe resection; cortical resections of extra-temporal areas of brain tissue; corpus callosotomy; hemispherectomy; and the use of stereotactic and microsurgical techniques
-Awake surgery
-A nursing staff whose sole function is to care for people with epilepsy
-Psychological, rehabilitation and social services
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Electrodiagnostic
-24-hour video/EEG with surface and sphenoidal electrodes
-Invasive 24-hour recording with subdural electrodes, depth electrodes
-Intracarotid amobarbital (Wada) testing
-Functional cortical mapping utilizing subdural electrodes or intraoperative stimulation
-Evoked potential recording, capable of being used safely with implanted electrodes
-Electrocorticography
-Emergency neurosurgery
-Complication management
-Open biopsy
-Stereotactic biopsy
-Lesional excision
-Intracranial electrodes and cortical resection
-Corpus callosotomy
-Cortical resection, including hemispherectomy
-Magnetic resonance imaging
-Computerized axial tomography
-Cerebral angiography
-Quality-assured anti-epileptic drug levels
-24-hour anti-epileptic drug level service
-Pharmacokinetic consultative services
What type of hospital is it?
There are many advantages to selecting a hospital that combines patient care with research and education.
Ideally, the individuals engaged in patient care, research and teaching are organized around a given disease or class of patients, facilitating the sharing of knowledge, research and clinical findings. This approach results in the most rapid transfer of basic scientific knowledge from the laboratory to care delivered at the patient's bedside.
Those individuals on the staff of such a hospital are exposed to an important interchange of ideas. They are also exposed to the newest treatments and forms of technology. At teaching hospitals, physicians are available 24 hours a day.
There may be other advantages to choosing a teaching hospital. Private, not-for-profit, teaching hospitals had lower mortality rates than other types of hospitals, a study in the December 1989 issue of the New England Journal of Medicine suggested.
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Private, not-for-profit, teaching hospitals had lower mortality rates than other types of hospitals…
Is the hospital associated with a teaching program?
Yes. Incorporated in 1935, The Cleveland Clinic Educational Foundation sponsors one of the nation's largest physician postgraduate training programs.
Does the hospital conduct research or clinical trials related to epilepsy?
Basic research in the laboratory is being conducted into the causes of epilepsy.
Epilepsy Monitoring Unit staff are researching the fundamental anatomy and mechanisms that cause epilepsy, using data from long-term implantation of subdural electrodes in epilepsy patients.
Clinical research is being conducted into improving and individualizing intensive presurgical monitoring, modifying surgical techniques, memory function in patients before and after surgery, brain tumors and epilepsy, and epilepsy seizure classification.
Research into the natural history of how and why seizures recur following epilepsy surgery is ongoing.
The effectiveness of experimental anti-convulsants along with various drug combinations is being studied. This gives patients, whose seizures the new drugs are meant to control, access to drugs that will not be available to the public for many years.
Cleveland Clinic neurologists are studying ways to streamline and accelerate epilepsy therapy to allow patients – adults and children – to change drug regimens in only five days instead of the usual weeks to months.
Does the hospital have residency training programs in neurology and neurosurgery?
The departments of Neurology and Neurological Surgery train five to 10 fellows each year in one- and two-year fellowship programs and five residents each year who are interested in advanced work in epilepsy and clinical neurophysiology. The Cleveland Clinic offers an EEG training program.
Is everybody happy?
If you ask one person about his or her experience with a doctor or hospital, you get one person's point of view. Patient satisfaction surveys allow you to judge quality based on the experience of many previous patients. This provides you with a more objective measure to use.
Most hospitals routinely use surveys to learn if patients are satisfied with their medical experience. They can use these results to improve their services.
Patient satisfaction often reflects the personal side of care. Surveys ask questions such as, How willing are the doctors and nurses to listen? Do they answer questions and explain treatments? How much time does the doctor spend with the patient? Is the hospital clean? Is the food good?
Patient satisfaction information can predict what your experience in a particular hospital is likely to be.
How satisfied are hospitalized patients with their experience at this facility?
87% of patients who are hospitalized at the Cleveland Clinic for a neurological condition such as epilepsy are satisfied with their hospital care.
94% say they would return.
How satisfied are outpatients with their experience at this facility?
91% of patients with a neurological problem such as epilepsy who come to the Cleveland Clinic for outpatient services are satisfied with their experience.
90% say they would return.
Is there a program to help patients and their families with the difficulties that may arise during a hospital stay?
Cleveland Clinic Foundation patients may call an ombudsman – another name for a patient-relations representative – if they have concerns about their care.
Patients in the Cleveland Clinic hospital may dial a 24-hour Helpline from their hospital room if they have any problems, questions, suggestions or concerns related to service.
How did the patient do?
Many outcome indicators can be used to measure the success of treatment. The importance of each varies with the treatment. For procedures used to treat life-threatening conditions, death rates and complication rates are important.
For epilepsy surgery, however, death and complications are uncommon. The way outcome is measured for epilepsy surgery – including anterior temporal lobe surgery which this guide emphasizes – is in terms of the operation's impact on seizure control.
Successful epilepsy surgery will result in eliminating or significantly reducing the number of seizures. Seizure-free patients may still experience auras – warning feelings that may occur before a seizure – and take medication. However, while seizures couldn't be controlled with drugs before surgery, they can be controlled after surgery.
Although success can't be guaranteed, especially for people who are seriously ill, chances for a good outcome are increased by choosing a hospital with good outcomes for the treatment that you are undergoing. If you can't get information about outcome from a doctor or hospital, look at alternatives. Try to compare results for patients like yourself to learn what your risks or chances of success really are.
However, comparing epilepsy centers on the basis of outcomes is not easy. Centers define improvement differently (see the box on the next page). You're comparing apples and oranges when one hospital defines success as reducing seizures by 90 percent or more and another defines success as reducing seizures by 75 percent or more.
Seizure patterns change over time. Some people are seizure-free right after surgery and then have a seizure. Others have seizures after surgery that decrease in frequency and eventually stop. This means success rates change depending on whether they are reported at six months or two years.
Success also depends on the type of patient you are. The more localized, or confined, the source of your seizure, the better the chances that surgery can make you seizure-free. In general, following anterior temporal lobectomy, 60 percent of people are seizure-free and 80 percent show worthwhile improvement. This is according to outcomes reported by our center and other large centers. Specific outcome information is presented on the opposite page.
What is the hospital's success rate for anterior temporal lobe resection?
Overall, 70 percent of patients continued to be seizure- free or to have the frequency of their seizures reduced by 90 percent or more one year after surgery. These results are from our most recently published study in the Journal of Epilepsy.
Within what range can you generally expect success rates for anterior temporal resection to be?
Anterior temporal resection has resulted in success rates of 55 to 70 percent, according to a National Institutes of Health Consensus Development Conference on Surgery for Epilepsy held in 1990. Success by this panel was defined as no seizures for five years after surgery, although some auras may still be present and some patients may still be taking medication.
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How Are Outcomes Reported?
Outcomes are reported by the degree to which seizures are reduced following surgery.
Results are expressed by first telling what percentage of patients were seizure-free.
Next, there is a group of patients who have a significant reduction in the number of their seizures. This is where centers differ in the way they classify successful outcomes:
-Some define success as reducing seizures by 90 percent or more.
-Others define success as reducing seizures by 75 percent or more.
A center's results will be higher if it defines success as reducing seizures by 75 percent or more. Its results will be lower if it defines success as reducing seizures by 90 percent or more.
At the Cleveland Clinic, we consider surgery successful when it makes a patient seizure-free or reduces that patient's seizures by 90 percent or more.
The Epilepsy Program
The Cleveland Clinic's epilepsy team is a national and international pacesetter in treating epilepsy, both medically and surgically. The Cleveland Clinic is one of only a few U.S. medical centers with the technology and experience necessary to map the brain's electrical activity, localize the seizure source, and then, if advisable, remove it.
-The sections of Epilepsy and Sleep Disorders are staffed by nine physicians, including child neurologists, adult neurologists and a psychiatrist. Approximately 25 technologists and five nurses are involved in patient care activities. Working closely with this group are specialists from neurosurgery, psychiatry, nuclear medicine, radiology and neuropathology.
-The Section of Epilepsy Surgery includes four staff surgeons. These surgeons perform more than 150 epilepsy surgeries of all types each year. These include implantation of stereotactic depth electrodes, and epidural peg and foramen ovale electrodes; microsurgical temporal lobectomy; extratemporal resection; hemispherectomy; and corpus callosotomy.
-Epilepsy specialists utilize three different types of invasive recording devices to monitor patients being considered for surgery, whereas most centers employ only one of the techniques. With all of these options available, the epilepsy team can individualize the screening and mapping of each patient prior to surgery and operate with more precision.
-The Cleveland Clinic has developed a program to train personnel from the Bodelschwinghsche Clinics in Bethel, Germany, in state-of-the-art brain mapping and surgical techniques.
-Since 1988, the Cleveland Clinic has sponsored three international conferences on epilepsy-related topics.
-The Cleveland Clinic is one of only a handful of epilepsy centers currently performing second operations for people whose first operation has not succeeded in controlling seizures. Nearly half of 15 patients in a recently published study have remained seizure-free for periods of up to 82 months, giving selected patients a second chance at seizure control.
Epilepsy surgeons must precisely distinguish between tissue that is causing seizures from that which is not so that they can remove as much of the seizure source as possible without disturbing normal brain tissue. The Cleveland Clinic's team has contributed greatly to this process:
-Development of sophisticated brain mapping techniques in 1980 for patients with intractable epilepsy, allowing surgeons to more precisely delineate the source of seizures and enabling them to remove more tissue without damaging vital functions. This increases the likelihood of eliminating seizures.
-Pioneering of a microsurgical technique, for use in anterior temporal lobe surgery, that allows removal of more of the anterior temporal lobe without unnecessarily removing adjacent tissue.
-Development of a new approach to evaluating the effects of extent of resection on surgical outcome and complications. This approach, using postoperative MRI, may allow comparisons of surgical techniques practiced at different institutions.
-Development of a computerized, paperless EEG system to collect and store data. This permits sorting, manipulation and analysis of data on screen, making the most critical highlights of the data rapidly accessible.
-Development of a program in collaboration with the Cleveland Clinic's Neurological Computing Section that permits on-line calculation of single-dose pharmacokinetic studies.
-Development of the epidural peg electrode, which may be necessary to accurately localize the seizure source during monitoring.
-Development of a technique that uses the epidural peg with the foramen ovale electrode to allow some patients to avoid more invasive procedures.
-Adaptation of electrodes and other surgical techniques to be used in the presence of scarring that exists in difficult second operations for patients whose seizures recur.
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For Information
If you need more information or want to make an appointment with a Cleveland Clinic epilepsy specialist, please call one of the numbers below:
216/444-8919
(in Cleveland)
800/545-7718
(toll-free outside Cleveland)
Reprinted with permission by: Med Help International