Laser Ablation For Epilepsy - Zapping Those Seizure Cells! Michael Sperling, Jefferson Health, USA
Michael Sperling, epilepsy specialist neurologist director of the Jefferson Comprehensive Epilepsy Center, educates us on laser ablation therapy for epilepsy! He and Torie discuss the minimally invasive nature of the procedure, its advantages over traditional open surgery, and its efficacy in reducing seizures. They also touch on the suitability of the therapy for different age groups and types of epilepsy. The conversation highlights the precision and safety of laser ablation therapy and its potential to improve outcomes for patients.
Reported by Torie Robinson | Edited and produced by Carrot Cruncher Media.
Podcast
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00:00 Michael Sperling
"I remember once seeing a woman who had surgery, she was actually in her early 70s - we wouldn't have considered open surgery for her, but this was easy. I asked her how it went. She said, well, on the way home from the hospital, she stopped at the shopping mall for a couple of hours to pick up a few things! It's at that level of discovery!"00:16 Torie Robinson
Fellow homo sapiens! My name is Torie Robinson, and welcome to, or welcome back to: Epilepsy Sparks Insights.
Now, neurosurgery to treat epilepsy is becoming more and more common, but I’d say one of the fancier, more precise and minimally-invasive types of surgery could be: laser ablation therapy. In today’s episode we hear all about it, for which type of epilepsies it can be used, crazy-short recovery times, and more - from global lead, epilepsy specialist neurologist, Michael Sperling!
Please don’t forget to share your thoughts on this episode with us in the comments below - ‘cause I enjoy reading your thoughts on the topics and responding to them! Also, do subscribe so that we can educate the masses and empower way more people affected by the epilepsies around the world, and, indeed, actually, more clinicians with patients who have an epilepsy - to provide the best care possible.01:09 Michael Sperling
I'm a professor of neurology at Thomas Jefferson University in Philadelphia in the United States, and I'm the Director of the Jefferson Comprehensive Epilepsy Center at the university. And what I do is a mixture of the usual things that people do in academics! I treat a lot of patients, I conduct research, and I am heavily involved in teaching as well as the 3 main areas that we speak about in academics. Independently, I'm involved in international organisations in the International League Against Epilepsy, in the American Epilepsy Society, and the American Academy of Neurology. I'm also the editor-in-chief of the journal Epilepsia, which is the journal of the International League Against Epilepsy; I’m a fairly busy fellow because of all that.01:52 Torie Robinson
We're going to talk together today a bit about laser ablation therapy. It's something I hear about a lot from people around the world, whether it be parents, whether it actually be clinicians or people with an epilepsy. And it's not something that's available everywhere yet, but I know that you have done heaps and heaps of work on this topic. Could you tell us a bit about that, please?02:10 Michael Sperling
Laser Ablation Therapy, which is called Laser Interstitial Thermal Ablation, L -I -T -T “LiTT” (is the technical name for it), is a method of treating epilepsy surgically using what we can euphemistically call “minimally invasive”. So, rather than doing an open craniotomy - where there's a large incision in the scalp and a piece of the bone is taken off, a piece of brain is taken out, and then everything's closed up again - this is a procedure in which a small probe is inserted into the brain, or 2 probes are inserted into the brain, through a tiny hole that's only 3 millimetres in size. And there's a laser light at the tip of that probe, and when the light is turned on, it heats the brain around it, and actually, by heating it a lot, it destroys that little tissue around it. And so, instead of removing it, it destroys the tissue around it and a probe goes in and you can ablate the tissue around it. You can plan it very precisely. You can plan exactly the dimensions of what you want to do. You can do 1 probe or 2 probes, or more than that if you wish. And in that way, it's really a much better tolerated procedure. You know, for example, there's no craniotomy, as I said, there's no big incision - taking a piece of bone off and putting it back - so you avoid a lot of the issue related to a large incision with the risks of infection of a large incision. There's still some risk of infection, but it's much less.03:33 Torie Robinson
This is rare, but you just made me remember I had CSF fluid leak during, after my resection. That's something I guess that wouldn't…04:40 Michael Sperling
Exactly, it wouldn't happen. And to anybody who's been through brain surgery, you know you're in the hospital for several days at least. It is quite painful. The average person takes 4-6 weeks off from work and other activities after surgery and it hurts quite a lot. This is a procedure where you come into the hospital on one day, you go home the next morning. The pain is minimal. The medication we give for pain is either paracetamol - as you say in England, or acetaminophen in the United States - a few doses), people can go back to work the next day or the day after that.04:14 Torie Robinson
The next day?!04:15 Michael Sperling
Yeah, with no limitations. I remember once, seeing a woman who had surgery; she was actually in her early 70s - we wouldn't have considered open surgery for her, but this was easy! I asked her how it went. She said, well, on the way home from the hospital, she stopped at the shopping mall for a couple of hours to pick up a few things!04:37 Torie Robinson
No!04:39 Michael Sperling
It's at that level of discomfort!04:41 Torie Robinson
That’s crazy!04:42 Michael Sperling
It's still possible to have a… there's still a little risk of skin infection for the wound, but it's really much better tolerated. The efficacy of this; how well does it work? It's probably not quite as good as open resection because you don't take out as much tissue, and in general, the more tissue you take out, the results are a little bit better, but the results are reasonably close. So, what's been published thus far is: about 60% of patients who have this, for example, for temporal lobe epilepsy, stop having seizures, and most of the remaining people are significantly improved. If you look at published studies for open surgery. It's not terribly different! Maybe it's a few percentage points lower. There's an upcoming study that will be presenting results in December at the American Epilepsy Society meeting - so, I can't say those yet and they're still under analysis, but I think that will come in reasonably close to that. That would be my guess - based on what I've seen so far. And again, the advantage of this, again: minimal discomfort, the time out of work is basically the time in the hospital and the day you go home. And then, if it doesn't work, you can always go back and do more ablation if you need to, or you can always go back and do an open resection. So, if it turns out that that operation wasn't ideal for you, you can go back and have something else. And unfortunately, epilepsy surgery, you know, is not 100% guaranteed either. So, many people still have seizures after surgery. It's a minority, but a significant minority do, and sometimes we have to think about going back as well. So, that's the big advantage: minimal discomfort, minimal hospital time, minimal disability. And it works quite well.06:20 Torie Robinson
Is it good for… if people have, like, several different places their seizures originate [from]? Multifocal. Could it be useful for that?06:28 Michael Sperling
I mean, probably not. Generally, when people are multifocal, no surgery is going to work terribly well. I suppose, if you have a specific condition like Tuberous Sclerosis, where you've got several discrete lesions, little tubers in the brain, you can identify seizures come from those three; yes, this technique would be good for that. But, most people who are multifocal have much wider areas of abnormality in the brain, so it might not be suitable. It's certainly 1 lesion or 2 lesions, and nothing terribly large also, since the area that you can ablate is not very large. So, we look for people who have relatively small, discrete abnormalities in the brain and you want to target that, and you can do a good job. There's another way of ablating using heat basically from an electrode; it’s called Radiofrequency Ablation. So, the same electrodes that are inserted in the brain recording EEG, you can put [electrical] current through those and heat the brain there. It's much less accurate though - in terms of not being able to calculate the precise area that you're going to ablate. The zone of “normal” versus “abnormal” with thermal ablation using the laser is very precise, it's very crisp, it's a 1 millimetre area from normal brain to abnormal. When you use Radiofrequency, it can be up to… between 5 and 10 millimetres of brain that's kind of scarred and messy along the way…so potentially causing a greater risk for seizures afterwards as well.07:44 Torie Robinson
Well, yeah, so perhaps not ideal…!07:48 Michael Sperling
The other thing I would add is that the results that we've seen thus far represent their results since it started - and it's still a relatively new technique. We've been doing it for a little over a dozen years in the States, much less elsewhere in the world - a year or two at most in other parts of the world. And when you see published results, these are people where we started and we didn't really have the best idea of how to optimise target areas. So, there have been a number of papers that have been published - and I've been involved with some of them - looking at the difference between people who stopped having seizures and those who didn't and we now know better how to target ablation. So, I think the results will be better moving forward than they were in the past.08:30 Torie Robinson
Okay, cool.08:31 Michael Sperling
You have to be careful when you read about things. Whenever a technique is new, you know, doctors don't quite know how to use it the best way, safety tends to improve with experience, and especially something like this - where you have to target specific spots - we learned better how to target, how to design the approach to optimise results. And I think you'll see, you know, better results today than we would 10 years ago when we were using it.08:56 Torie
And is this type of therapy used in adults and children and like neonates - like, babies?09:02 Michael Sperling
Yes, it can be used in people of any age, the key is to have abnormalities that are not terribly large so that you can ablate them safely. In fact, in children, there's one entity called hypothalamic hamartoma - these are very deep, small hamartomas in the hypothalamus…09:14 Torie Robinson
Oh yes!09:15 Michael Sperling
…right above the pituitary gland, and ordinary surgery for that is quite challenging and has a very high complication risk. The thermal ablation is a wonderful way of doing it with much greater safety.09:29 Torie Robinson
Cool!09:29 Michael Sperling
Patients who have, again, small abnormalities of development, something called a Periventricular Nodular Heterotopia (so a small abnormal collection of cells deep in the brain next to the ventricles, the fluid filled spaces). You can target those very nicely with these if they're small. Ablate them, and again, it's in and out, the procedure doesn't take very long, I mean, you're in the operating room for 4 hours, but the actual light is turned on for 2 or 2 and a half minutes!09:55 Torie Robinson
Wow!09:56 Michael Sperling
And sometimes you may pull it back and then turn around for another 2 minutes but the actual procedure doesn't take terribly long…10:03 Torie Robinson
I’d love to watch it, it sounds fascinating!10:04 Michael Sperling
You can do operations that you couldn't do before.10:07 Torie Robinson
Excuse my layperson's terms, but you're “zapping” this tissue that has been identified as being the problem. And what actually happens to it? Because if you're like…are you burning this tissue? Do you remove it? Or do you leave it there to, kind of like, wither away? What happens with it?10:26 Michael Sperling
So, this is not like a cutting laser that's used to cut metals or if you think of some of the old James Bond movie where Bond is lying down and there's a light coming from his toes up towards the center of his body, just slice him in half - it's nothing like that! It's a probe that puts heat into the tissue around it and it gets it quite hot, the tissue is damaged, and then the body's own repair mechanisms basically eat that tissue. You're left with a little hole where that was. So, the tissue is just cleaned up.10:50 Torie Robinson
And that just fills up with fluid and...10:52 Michael Sperling
Yeah, it's cleaned up by the body's natural mechanisms and there's a little hole there and it scars around it and that's that. And again, it's quite small - a typical area that's ablated might be 12 to 15 millimetres in diameter, so, you know, half an inch or so, a little over half an inch in diameter.11:11 Torie Robinson
And so you've already told us about how swift this actual laser ablation can be. What about any potential negative effects in terms of things, like, to do with psychiatry? ‘Cause we know that that's really common in resections, for instance.11:26 Michael Sperling
The risks relate in part to the invasiveness of the procedure and how much brain tissue you remove. So, this is much less invasive, it has much less stress than an open craniotomy. And the patients don't have to go to the intensive care unit. As I say, they're out in a day from their hospital stay!11:42 Torie Robinson
It’s crazy!11:44 Michael Sperling
So, the general stress is less - and stress clearly plays a role in psychiatric complications early after surgery. The amount of tissue removed or ablated is much less than an ordinary resection. So, again, the sort of the side effects of surgery are going to be less. And the cognitive side effects: again, it depends upon where you're ablating. So, the most common place to ablate is the temporal lobe and the deep part called the hippocampus. And you can still have effects on memory there, so there may be some decline in memory after the procedure. You'd have that with resection. But not taking out a lot of tissue laterally (on the side), there's less effect on language, for example. If you're ablating in other regions of the brain - it depends what those areas do. And as far as the psychiatric complication; any changes can be followed by a transient psychiatric complication. What we've seen in general with epilepsy surgery is that if there are adverse psychological or psychiatric effects, they tend to occur relatively early and they typically are, you know, are better within 1 - 3 months. And on balance, if you look at how people are 6 months to 1 year later, net scales and psychopathology are much improved on average. It's very easy to make people worse. It's a lot harder to make them better! And it is certainly possible to have a complication with any kind of procedure as this is…it's still surgery - though it's far less invasive than an open craniotomy. But, we just see less in the way of problems with it.13:16 Torie Robinson
Thank you so much to Michael for getting us excited about Laser Interstitial Thermal Ablation therapy - it does sound rather swish, honestly, and quite cool! And, as with so many other treatments, I’m thinking, you know; gosh, there’s an innumerable peopulatino…of people with a refractory epilepsy who could no doubt benefit from it!
Do check out Michael’s papers on the subject - links on the website torierobinson.com (where you can also check out the podcast, the video, and the transcription of this episode), and, if you haven’t already, don’t forget to like, comment, and subscribe to our channel, share this episode with your friends/colleagues/family members(!) and see you next week! -
Michael Sperling, M.D., is Baldwin Keyes Professor of Neurology and Vice-Chair for Research at the Sidney Kimmel Medical College at Thomas Jefferson University. Michael completed medical school at Temple University, Neurology residency at Mount Sinai Hospital in New York City, and trained in epilepsy and clinical neurophysiology at UCLA. He served on the faculty at UCLA and the University of Pennsylvania prior to Thomas Jefferson University. He is an internationally known clinician-scientist in the field of epilepsy, known particularly for his work in the field of epilepsy surgery and electrophysiology.
Michael founded and developed the Jefferson Comprehensive Epilepsy Center, which is devoted to clinical care, research, and education in epilepsy. The centre has treated many thousands of people over the years and is especially well known for its surgical program, experimental therapeutics, and care for people with refractory epilepsy. His approach to epilepsy care integrates clinical practice with research to facilitate advances in therapy, utilizing single institution and multi-institutional clinical research consortia to foster scientific advances. Over the years, his research interests have included epilepsy surgery outcomes, epilepsy electrophysiology, cognitive electrophysiology, genetics in epilepsy, and experimental therapeutics for epilepsy.
Michael lectures widely in the U.S. and overseas, and has organised numerous courses and conferences. Michael has trained many clinical and academic epilepsy specialists in the U.S. and abroad, published over 700 peer-reviewed papers, book chapters, and several books. He has only just stepped down from the position co-Editor-in-Chief of Epilepsia and is a former president of the American Clinical Neurophysiology Society, former president of the Philadelphia Neurological Society. He is active in the American Epilepsy Society, American Academy of Neurology, and International League Against Epilepsy. -
LinkedIn: michael-sperling
Jefferson Health: sperling-michael
Jefferson Academic: sperling
Epilepsia: onlinelibrary.wiley.com/doi/epdf/10.1111/epi.18057
ILAE: michael-sperling
ResearchGate: Michael-Sperling-2