Friday, December 15, 2017

Laser ablation surgery for temporal lobe epilepsy

Cara Pressman, a 15-year-old-girl from New York, had two simple words to say to the insurance company that denied coverage for brain surgery that would save her from a life of seizures.

Pressman has been suffering from seizures for several years, so you could imagine how the teenager felt when her chance to recover from the condition was taken away from her.

"Screw you."

That was Pressman's response to Aetna, her family's insurance provider, after the company denied coverage for brain surgery that would end her seizures.

Pressman has been having seizures since she was 9 years old, usually several times per week. Every time it hits, the teenager's body grows cold and starts shaking. She then zones out from between 20 seconds to two minutes, while she remains aware of what goes on around her. The seizures can be triggered by almost anything, including exerting herself, feeling stressed, and being happy, and Pressman described the experience as "having a nightmare but while you're awake."

The teenager thought that her seizures were coming to an end though. Doctors recommended Pressman to undergo a laser ablation surgery that will remove damaged tissues in her brain that they believe are causing the seizures. The doctors even scheduled the minimally invasive brain surgery on Oct. 23.

However, it was not meant to be. Three days before the surgery, Aetna told Pressman's parents that they were denying their family coverage for the teenager's laser ablation surgery. The insurance company said that the procedure was still experimental, and its effectiveness in treating seizures has not been established.

"Considering they're denying me getting surgery and stopping this thing that's wrong with my brain, I would probably just say, 'Screw you.'"

In the laser ablation procedure, surgeons will drill a small hole into Pressman's head and then use a laser to target and remove the damaged tissue. The alternative method, named temporal lobectomy and the one that Aetna covers, will involve the removal of a bigger portion of the teenager's skull to expose the brain matter that needed to be cut.

Studies, however, show mixed but promising results for laser abration surgery as a way to stop seizures. Some claim that the procedure is 75 percent effective in treating seizures that medication could not address.

The Food and Drug Administration has approved laser abration surgery, and the epilepsy community widely views the procedure as an effective option for treatment.

"I would not call it experimental at all," said Mayo Clinic neurosurgeon Dr. Jamie Van Gompel regarding laser abration surgery, adding that temporal lobectomy is more dangerous.

1 comment:

  1. Petito GT, Wharen RE, Feyissa AM, Grewal SS, Lucas JA, Tatum WO. The impact of stereotactic laser ablation at a typical epilepsy center. Epilepsy Behav. 2017 Nov 21;78:37-44.


    Stereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes.

    A retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan-Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset.

    One hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55-60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p=0.79). Stereotactic laser ablation patients were older than those with resections (47.0years vs. 35.4years, p=0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18days) compared with open resection (3.43days; SD: 3.16 days) (p=0.0002).

    We now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA.