MAPPING THE BRAIN
Marvin Girard is sturdy-looking, with big hands and sizable shoulders. His rugged, weathered face speaks of years of working outdoors. He looks fit for a man of 70. A lifetime of hard work and clean living will do that for you.
Fifteen years ago, he and his wife, Carol, moved to Sarasota from Farbor, Mo., where they had farmed their own land for 25 years. The parents of four children, they brought their “Show Me State” values with them. Retirement? Not for him. Girard put his carpentry skills to work in the construction industry. He refused to slow down. Then an unseen enemy forced him to.
Girard first noticed something wrong in June 2007. His unstoppable energy was draining away. At night, his legs and arms sometimes twitched uncontrollably. He felt tired, weak, and, at times, confused and dizzy. But Girard didn’t tell Carol. Griping about aches and pains just isn’t his style. So he kept his problem to himself and tried to ignore it—until, one afternoon, he passed out at his desk and badly bruised his face. That got Carol’s attention, and they made an appointment for a check-up. But the unnamed problem beat him to the punch.
A few days after he passed out, Girard’s leg and arm movements woke Carol up around 2 a.m. His left leg and left arm were twitching violently. He seemed unconscious—gone. Carol couldn’t get him to respond to her voice. Terrified, she called 911, and the couple made their first trip to the emergency room, where they were met by their family doctor.
After conducting an electroencephalography (EEG) and an MRI, the doctor determined that Marvin had experienced a seizure. He prescribed Dilantin, a drug used to control convulsions. Then he sent him home with instructions to rest and to report any new seizures.
Girard returned home and obeyed doctor’s orders. But the problem wasn’t under control. He found himself forgetting simple things. He had a hard time signing his own name. His legs and arms went into sudden tremors up to eight times a day. He felt weak, exhausted and just plain lousy.
Three days later, Girard had a very bad night. A seizure shook his whole body. “I thought he was dying,” Carol said. “He was unconscious and making noises.” Another call to 911; another visit to the emergency room. This time, Dr. Gregory Hanes, an area neurologist, was called in. After a preliminary examination, Hanes admitted Girard into Sarasota Memorial Hospital’s small but high-tech epilepsy unit for further monitoring.
Thankfully for Girard, the year was 2007, not 1967. Twenty-first-century diagnostic technology has transformed the treatment of seizure disorders and epilepsy. Accurate surgery depends on accurate information. Epilepsy, a disease of the brain, is particularly tricky. The human eye—even a highly trained surgeon’s eye—can’t always see the problem, let alone see to fix it. Today’s diagnostic tools often can, and they’re getting better.
Good thing. It’s no small problem. Seizure disorders and epilepsy affect 2.5 million Americans. A seizure is any abnormal behavior caused by erratic electrical activity in the brain. A single seizure does not necessarily mean a person has epilepsy. Epilepsy is a condition that happens when the system of the brain that governs electrical activity is altered, causing recurring seizures. The condition usually appears in childhood and adolescence. A number of factors, including head trauma, high fever, infection and unknown genetic elements are thought to cause it. When the disease strikes someone over the age of 60, Alzheimer’s disease, strokes and other degenerative conditions are often the reason.
There are two types of seizures. The first, a generalized seizure, affects both sides of the brain at the same time and produce full grand mal convulsions. The second, known as partial seizures, occur in one region of the brain. The person experiencing this kind of seizure is usually affected in one localized area.
Hanes knew something had triggered Girard’s seizures, but he didn’t know what kind of seizures they were, or where they were occurring in the brain. To find out, he needed to study Girard’s brain activity over a prolonged period of time—and take advantage of those cutting-edge diagnostic tools.
Initially, Hanes prescribed video-electroencephalography (EEG) monitoring, an advanced imaging procedure that continuously monitors brain activity over a period of several days. A traditional EEG lasts about a half hour and gives a snapshot of brain wave activity during that particular recording period. During video-EEG monitoring, the neurologist takes the patient off seizure medication and connects electrodes to the patient’s scalp. The electrodes record brain activity and then transmit this data to a computer network. By analyzing the data, a neurologist can locate seizure-triggering areas, determine the nature of the seizure and observe the brain’s function between seizures.
In addition to the electrodes, Girard’s hospital room was set up with video cameras to constantly record his movements during the entire stay. If he went into a seizure, the room had an event button Girard or anyone else could press to mark the time.
“Continuous monitoring is invaluable because it captures seizures while they’re happening,” says Hanes. “It helps us more accurately determine the nature of the patient’s seizure. The better we can classify it, the better we can control it. If surgery is indicated, we can also pinpoint where the seizure onset is in the brain.”
During his few days of monitoring, Girard experienced several partial seizures. After analyzing the data, Hanes located a schematic abnormality in the top right part of Girard’s brain. The likely cause of the seizures was an electrical discharge in this area. Such neural misfires are usually related to head injury, infection, stroke or tumor. Usually, the cause remains unknown.
Further MRI and other imaging testing confirmed that Girard had a suspicious mass in the top right portion of his brain. Hanes prescribed surgery to remove it. The tricky part was removing as little of the surrounding healthy brain as possible. New technology was available for that, too.
Again, better surgery depended on better diagnostics. Before the procedure, Hanes called Dr. Julio Cantero, a clinical neurophysiologist and an epiletologist, to consult with Girard. Cantero is well-known for his work with electrocorticography (ECoG). This cutting-edge surgical procedure entails placing electrodes directly on the exposed surface of the brain to record electrical activity in the cerebral cortex.
“Think of it as brain mapping,” says Cantero. “We put electrodes directly on a suspicious area of the brain, and then we stimulate it and try to identify what happens.” Cantero explains that erratic electrical activity indicates the source of the seizures—a troublemaking epileptogenic zone.
ECoG is performed while the patient is awake and the brain exposed. During the procedure, the neurophysiologist stimulates the area of the patient’s brain suspected of causing the seizure. Simultaneously, the patient’s motor, speech and vision abilities are monitored to ensure that the surgeon isn’t removing part of the “eloquent cortex,” the areas of the brain responsible for speech, comprehension, movement, sensation, memory and sight.
Cantero and Hanes confirmed that the suspicious mass in the top right wasn’t part of the eloquent cortex. The neurosurgeon, Dr. Robert Kanago, could safely remove it. But the human brain is complicated, and full of surprises. Further ECoG testing showed that the source of the seizure wasn’t part of the mass that Kanago was going to remove. “The focus of the seizure was about a centimeter away,” says Kanago. “If I had just removed the mass, Mr. Girard’s seizures would have continued. The ECoG helped us exactly pinpoint the problem area.” More good news showed that the mass wasn’t a malignant tumor. It was harmless scar tissue, probably the result of an injury or stroke.
Girard returned home after a few days in the hospital. A few weeks later, he began six weeks of physical therapy. “I had to learn how to walk again,” he says. Although the therapy helped, it took more than a year to regain full motor control in his left leg and left arm. He was forced to retire from the construction business and has only recently begun driving again.
Still shaken from the experience, Girard says he’s just beginning to feel like he’s getting his life back. “I was really ready for him to start driving,” says Carol. “It’s great to have him behind the wheel again.”
Girard knows he’s one of the lucky ones. He hasn’t had a seizure since his surgery and is off the seizure medication he had to take for months afterwards.
Hanes says that he still hasn’t tracked down the cause of Girard’s seizures. He probably never will.
“Our risk of seizures increases with age,” Hanes says. “It’s a wiring problem, really. The wiring ages in an old car or home. It’s the same with the human brain. Epilepsy is more of a risk factor for children and adolescents and then cools off in our 30s and 40s. In our 50s and beyond, there’s a steady increase of acquiring epilepsy because of strokes, arterial sclerosis and injuries. Girard is a success story. We were able to accurately diagnose the source of his seizures and then completely cure him of them.”
The good news for area residents?
Through the auspices of Sarasota Memorial Hospital, Drs. Hanes, Cantero and Kanago are planning a full-fledged epilepsy center where, as Cantero explains, “We’ll be able to identify people with intractable epilepsy [the kind that does not respond well to medicine], do the tests required, and offer pre- and post-surgical procedures.” They predict that the center will be up and running by 2011.
“Mr. Girard is one of our success stories,” says Cantero. “If things work out, we’ll have many more.”
Dr. Julio Cantero: IMG Neurology, 943 S. Beneva Road, Ste.102, Sarasota; (941) 906-7155
Dr. Gregory Hanes, Negroski & Stein Neurology, 1921 Waldemere St., Ste. 701, Sarasota; (941) 487-2160
Dr. Robert Kanago: Neurosurgery and Spine Specialists; 5831 Bee Ridge Road, Ste. 100, Sarasota; (941) 308-5700.
Seizures in up to 30 percent of people with epilepsy do not respond to available medications.