Cincinnati Children’s Performs Less-Invasive Epilepsy Surgery

Cincinnati Children’s can now perform less invasive epilepsy surgery, thanks in part to a new MRI-guided laser system that targets and destroys small areas of seizure-causing tissue.

Nine-year-old Nick Tuley of Hamilton, Ohio, became the first patient to have this procedure performed on April 21. Although it will be a year before the treatment team can say with certainty whether he is seizure free, he has not had a seizure since the operation.

The operation was Nick’s third brain surgery. Like many patients with difficult-to-treat epilepsy, Nick underwent two brain surgeries within one week in 2013. The first procedure was a craniotomy, an invasive surgical procedure in which a bone flap is temporarily removed from the skull to access the brain and record seizures from electrodes surgically placed on the brain surface. The second procedure, performed a week later, was a second craniotomy to remove the brain electrodes and remove the area of brain found to be causing his seizures.

While the surgery reduced the number of seizures Nick had, one or more “rescue” medications were often required to stop them. A review of another brain MRI revealed residual abnormal brain tissue that could have caused the seizures.

“In the past we would have had to re-open the craniotomy to remove this tissue, even though the area to be resected (removed) is relatively small,” says Francesco Mangano, DO, chief of Pediatric Neurosurgery at Cincinnati Children’s.

With new technology, however, neurosurgeons at Cincinnati Children’s were able to ablate, or destroy, tissue using a small, flexible laser applicator which is guided to the target area in the brain through a small incision – while the patient is in a magnetic resonance scanner. The MR images allow the surgeon to precisely monitor treatment in real time. Laser light heats and destroys the target area, with minimal risk of potential damage to surrounding, healthy tissue.

“Our goal is to decrease the invasiveness of surgery and decrease complications while getting excellent, seizure-free outcomes,” says Hansel Greiner, MD, a neurologist and co-director of the epilepsy surgery program at Cincinnati Children’s. “This requires a major investment in equipment and highly-trained staff to give Dr. Mangano the best information about where the seizure-causing tissue is. The better our information the more likely it will be that he can perform less invasive surgery.”

The Visualase® MRI-guided laser ablation system first received FDA clearance in 2007. Cincinnati Children’s is the first institution in the Cincinnati area to obtain this technology. In Nick Tuley’s case, Dr. Mangano and neurosurgeon Ellen Air, MD, used the technology to reach Nick’s hippocampus, an area deep in his brain where a small amount of tissue needed to be ablated. Because Nick was in the MR unit inside the operating room suite, Dr. Mangano could see the zone of tissue as it was being destroyed.

“With previous technologies, such as radiation therapy, the tissue would not die right away,” he says. “You wouldn’t know whether you were successful, and you wouldn’t know for several months. With this system, the tip of the laser destroys tissue in the hippocampus, and you can see that in real time. You take out the catheter, close the incision, and you’re essentially done.”

Visualase is the latest imaging technology used to extend the capabilities of neurosurgeons at Cincinnati Children’s. In recent years, the division of Pediatric Neurosurgery updated its BrainLAB technology. This technology allows neurosurgeons to see exactly where lesions are in the brain and to navigate around them on a computer screen, almost like a global positioning system (GPS) of the brain. This clinical application of technology follows years of research at Cincinnati Children’s to allow surgeons to use advanced brain mapping in different types of cases, such as vascular malformations, brain tumors and in patients with epilepsy.

“BrainLAB, fuses different kinds of magnetic scans to analyze blood flow changes and abnormalities and draw a detailed picture of what fibers look like deep inside the brain,” says Dr. Mangano. “This can help identify areas of motor and language function, highlight regions of seizure activity in epilepsy patients, and visualize tumors that were impossible to see before. It also allows surgeons to plan for and perform surgeries they might never have attempted with such confidence.”

Cincinnati Children’s also purchased technology called ClearPoint®, which provides real-time stereotactic guidance for the placement and operation of instruments or devices during the planning and operation of minimally invasive procedures in the brain in conjunction with MR imaging, such as laser-guided ablation in Nick’s case. Stereotactic surgery is a form of surgical intervention which makes use of a three-dimensional coordinate system to locate small targets inside the body and to perform some action on them.

The overlapping use of functional MRI, stereotactic navigation and intraoperative neuromonitoring allows brain tumor surgeons and neuroradiologists to see the impact of each surgical decision in real time. The three cornerstones of surgical imaging are layered: MRI, functional MRI and tractography (3D visualization) are the map; stereotactic imaging reveals the safest routes to a tumor; and neuromonitoring gives immediate results of every movement.

But the major highlight of neurosurgical improvement at Cincinnati Children’s, according to Dr. Mangano, was building the right team.

“We now have a team of pediatric specialists in epilepsy, neuropsychology, neuroradiology, neurosurgery and pathology,” he says. “This has resulted in little surgical morbidity, no mortality and excellent outcomes from seizures. We do about 100 epilepsy surgery cases a year, and as many as 60 percent of patients can be seizure free within a year. This is a terrific outcome, considering those patients were deemed intractable by their neurologists and may have had epilepsy for many years prior.”

The epilepsy surgery program is part of the Comprehensive Epilepsy Center at Cincinnati Children’s, which has cared for more than 5,000 children. The center, one of only a few in the country with a magnetoencephalography scanner dedicated to studying children and teens, has been designated a National Association of Epilepsy Centers (NAEC) Level 4 epilepsy treatment center, a distinction given only to those centers qualified to diagnose and treat the most complex seizure disorders.

The Comprehensive Epilepsy Center is directed by Tracy Glauser, MD, a physician in the division of Neurology.

As for Nick Tuley, his mother, Sonya, says it would be wonderful if he no longer had to worry about where he might be when he has his next seizure, because they can be life-threatening if they can’t be stopped. Although he won’t be allowed to wrestle any longer, his plans include swimming, riding bikes, playing baseball and basketball, and Tae Kwan Do.
About Cincinnati Children’s

Cincinnati Children’s Hospital Medical Center ranks third in the nation among all Honor Roll hospitals in U.S. News & World Report’s 2014 Best Children’s Hospitals. It is also ranked in the top 10 for all 10 pediatric specialties. Cincinnati Children’s, a non-profit organization, is one of the top three recipients of pediatric research grants from the National Institutes of Health, and a research and teaching affiliate of the University of Cincinnati College of Medicine. The medical center is internationally recognized for improving child health and transforming delivery of care through fully integrated, globally recognized research, education and innovation. Additional information can be found at www.cincinnatichildrens.org.