By: Rosabel R. Young, M.D., M.S. Pharm, F.A.A.N., Q.M.E.
Certified, American Board of Psychiatry and Neurology with Added Qualifications in Neurophysiology
Board Certified in Brain Injury Medicine (American Board of PM&R)
Certified, American Board of Electrodiagnostic Medicine
Certified, American Board of Clinical Neurophysiology
If recurrent seizures always begin in one well-defined area, the neurologist will further explore possible pathology in that area with brain imaging (MRI) and Electroencephalography (EEG). These studies may reveal abnormal blood vessels, old infections (Cysticercosis), scar tissue from prior brain injury, or a brain tumor. While focal onset seizures are considered the most difficult to treat and least likely to be “cured” permanently, they can be controlled or even eliminated if the identified cause is a “benign” single lesion not likely to spread or recur.
Treatment options include surgery or laser ablation of the lesion, neuromodulation devices, deep brain stimulation, and more recently, targeted ultrasound. Surgery to remove a known lesion is the most promising if the lesion is confirmed to be causing the seizures. However, if the scar tissue area is large, other functions may be lost, not just the seizures. Another consideration is that if the lesion is not itself separate from normal brain tissue, surgical removal will cause new scarring in the surrounding normal brain areas, and the new scars can later cause new focal seizures.
Neuromodulation / Neurostimulation devices like Responsive Neurostimulation (RNS), Deep Brain Stimulation (DBS), or Vagus Nerve Stimulation (VNS) are safer options if the focal area cannot be removed safely. DBS requires precise localization of the seizure onset focus and a small hole in the skull for insertion of the thin electrical wire at the focus to deliver targeted electrical pulses, which modulate neural circuitry to help control seizures and lessen their severity.
Laser Interstitial Thermal Therapy is a minimally invasive procedure that destroys the seizure focus using a flexible laser fiber placed directly into the targeted area of the brain through a small hole in the skull. The laser fiber is then heated to destroy the epileptogenic (seizure-causing) tissue. It relies on continuous real-time MRI to monitor temperature and ensure healthy brain tissue is protected.
Stereotactic Radiosurgery, also called the “Gamma Knife,” is a treatment option for focal epilepsy that does not require cutting or making holes in the skull. It uses precisely targeted ionizing radiation beams of high-dose ionizing radiation to effectively burn the targeted area. It is most effective for brain tumors where it has been shown to permanently damage the DNA of targeted cells and also reduces the associated focal, drug-resistant epilepsy.
High Frequency/Focused Ultrasound uses focused beams of high-frequency sound waves directed from outside the head without having to drill through the skull. The beams pass safely through the skull, converging on a precise spot deep in the brain to generate enough frictional heat to destroy the targeted tissue. It is also guided by MRI to ensure precise targeting, but does not require incisions, burr holes, or insertions of any probes or fibers.
The procedure to be performed has to be selected based on information gathered through Four Phases of evaluation by the neurology team. In Phase 1, non-invasive diagnostic testing is performed, including Video-EEG Monitoring, High-Resolution MRI, and Neuropsychological Testing. Sometimes PET and SPECT Scanning, and MEG (Magnetoencephalography) are also performed if further localization is required before proceeding to Phase 2.
Functional Brain Mapping (Phase 2) is then performed to ensure the surrounding working brain areas are safe and will not be damaged by having surgery nearby. This involves Functional MRI (fMRI) to map brain activity while the patient performs tasks, like reading or memorizing words and pictures to map out areas controlling language, visual spatial functions, and movement.
In the 1990s, Dr. Rivares Young was the “ringside doctor” for the Juvenile Justice Correctional programs for the California Athletic Commission. In that capacity, her job was to examine Juvenile delinquents as young as 12 years old that were participating in boxing, Mixed Martial Arts, and football as part of the Corrections Department rehabilitation activities.
Dr. Young observed that some of these juveniles exhibited more severe behavioral derangements after these activities, including poor school performance, loss of socialization, more violent behavior, and epilepsy. Joined by her colleagues in Neurology, Psychiatry, Psychology, and Behavioral Medicine, Dr. Young advised the State of California to discontinue sports activities that might cause head injuries. Eventually other activities did replace the violent sports, with more focus on rehabilitation and skills development training programs.