Neurosurgical Interventions for Epilepsy

April 15, 2022

Transcript

Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information, as we partner with you in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge, and perhaps change how you care for kids. Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd.

As a little kid on the playground, in addition to rocket scientist being code for super smart, brain surgeon was also sometimes thrown into the mix. Today, I’m talking pediatrics. We have one of our very own super smart brain surgeons. Dr. Meysam Kebriaei, who is one of our kid expert neurosurgeons here at Children’s Minnesota. Dr. Kebriaei has been with Children’s since 2013 and has been named a top doctor and rising star by Minneapolis St. Paul magazine every year since 2015. Some of his special interests include epilepsy surgery, brain and spinal cord tumors, vascular malformations of the brain and spine, minimally invasive pediatric spine surgery, and congenital anomalies of the brain and spine. We’re going to talk about all of that and more today, and it’s a pleasure to have you with us.

Dr. Meysam Kebriaei: Thanks so much. I’m glad to be here.

Dr. Angela Kade Goepferd: So Meysam, let’s start with how you decided on pediatric neurosurgery. Did you grow up thinking I’m going to be a brain surgeon someday?

Dr. Meysam Kebriaei: I did not actually, but once I got to medical school, like we all do, we did the rotations and I really enjoyed every rotation we did. I thought, boy, maybe I’m going to be a geriatrician or maybe I’m going to be an internist. Then I did general surgery. I’m going to make some of my general surgery colleagues mad, but I thought, boy, these guys are really serious, that’s not for me. Then I did orthopedics and really enjoyed it.

Then I spent some time with neurosurgery team and just fell in love. The time would fly by. I would work 14, 15 hours a day and look at the clock and be like, oh, I wish I could do more. I spent a lot of time… If I had any free weekends, I’d go around with the neurosurgery team and really enjoyed it quite a bit. Then once we did the grueling residency. Our third year we got an opportunity to spend time with our pediatric neurosurgeons who were phenomenal. Still really good friends with them today. They were great mentors and just really love working with kids as we all do. Kids are so inspirational. Being able to do what I love and treat kids has just been amazing,

Dr. Angela Kade Goepferd: Obviously, as a pediatrician, I agree with you wholeheartedly that treating kids is amazing. I think I’m too scared to have my hands on kids’ brains. I certainly tip my hat to you being able to do that. As a primary care pediatrician myself I think often we wonder, when is it appropriate to send patients to neurosurgery versus maybe other specialties like neurology or orthopedics if it’s something with a spine? Can you kind of help us understand what are some of the more common reasons that we might refer to neurosurgery? How might we differentiate referring to you versus some other specialties, say for a spinal related thing?

Dr. Meysam Kebriaei: For really a lot of the spine related issues, one, we’d always be happy to see any kid. If you think, should we refer them to children’s neurosurgery or should we not? I mean, please refer. We’re happy to see them. We’ll refer them to the right person if we’re not the experts in that area. But anything spine related, obviously, we treat whether it’s congenital, neoplastic, and issues like that. As far as the obvious, obviously there the rare, I think brain tumors. Kids with epilepsy typically, with seizures, should be seen by neurology first. Spinal cords that are tethered spinal cord, any sort of congenital abnormalities that may need surgery, would be the first line of defense.

Dr. Angela Kade Goepferd: What about cranial malformations? Kids who have different plagiocephaly and things like that.

Dr. Meysam Kebriaei: We would certainly be the right people to send to. But at Children’s here, we’ve got a really great multidisciplinary team made up of myself that and that entire neurosurgery team, as well as the craniofacial team. We actually have craniofacial clinic. We get a lot of referrals directly to us as neurosurgeons, but we forward those to our craniofacial team. Then it’s a more of a comprehensive team approach that includes physiatrists, and orthotists, and physical therapists, as well as our ENT colleagues. If they need surgery, of course, we’d be involved in that.

Dr. Angela Kade Goepferd: Sure. You mentioned epilepsy and I know one of your special interests is an epilepsy surgery. We were chatting a little bit before we started recording. I’d love to hear updates around what is new in treating epilepsy. When I trained, there weren’t a lot of options from a neurosurgical perspective. I’d love to hear what’s new and what you’re doing primarily.

Dr. Meysam Kebriaei: With epilepsy, as we all know, it’s an incredibly tough disease. Not just for the patient, but for the family as well. As a society, it’s a devastating disease that affects every of a patient’s life. I’m really excited to be part of the team that treats epilepsy because there’s so many new advances. I feel like almost daily, there’s a new advance. Number one, just the drugs that are out there to treat epilepsy. Back when we were medical school, I remember just trying to memorize all the side effects of these anti-epileptic… I thought that was one of the toughest parts of med school. You’re like, wow, I’m so sorry that we are in a state where our patients have to take these medications with so many side effects. But medications have come a long way to treating epilepsy and are tolerated so much better.

But then surgery, which a lot of people are afraid of, and it’s really, really underutilized. It’s very effective for epilepsy. The guidance is if a patient has been on two or more seizure medications, on the right dose for the right amount of time, they really should get a referral to a Level Four epilepsy center to be considered for surgery. Level Four epilepsy center, which we’re lucky to be part of at Children’s, is made up of neuro epileptologists and neurologists, neuropsychologists, neuroradiologists, neurosurgeons. We really do a very thorough workup and then we discuss surgical options for that patient.

Even within just the surgical realm, I’ve been in practice for nine years now. In the last nine years, there have been so many advancements. Just in monitoring, invasive monitoring. There’s noninvasive monitoring, which we’re all familiar with, which is a scalp EEG leads. Well, now there’s stereotactic EEG placement. Whereas before I would have to make a big incision, big craniotomy. We lay these big grids on top of the surface of the brain, which were fraught with complications like bleeding postoperatively. Obviously kids were adults wouldn’t tolerate them. They would take the wires, pull them out. That’s not good, of course. Cerebral spinal fluid leaks, infections. Then also the brain has peaks and valleys. When you put a grid on, you’re just setting the electrical activity of the peaks. You map the seizure focus. Sometimes you go in there, you remove the seizure focus. Then the patient still doesn’t have as good of success rate as we would’ve hoped. Only to find out later that, well, the seizure was coming more from the depth that we weren’t able to record.

Where now, we’re actually one of the few centers, the region that does this. Where we have a robot and we place minimally invasive, without making a single decision. We place usually around 15 or so wires into the brain where we think the seizures are coming from. We’re able to map out the seizures within a millimeter or two. If there’s an area that we think is an area that’s causing the seizures, that increases our successful outcome to about 80, 90% with surgery. Where we go in there and we remove that portion that’s causing the seizures.

The other problem we ran into is there are a lot of parts of the brain that you can’t just go in there and remove it because you can, but you’d lose function that’s very vital to active of a daily living. Now, I’m proud to say that we’ve implanted two responsive neurostimulator systems, RNS. Which is where you go in, you remove portion of the skull, and you put in a generator. Then you can put in either a depth electrode, or a lead on the surface of the part of the brain that’s causing seizures, as an eloquent part of the brain so we can’t remove it. It acts as a live EEG, picks up electrical activity. Wen there’s a seizure, it sends a little shock, resets the brain. It’s very effective and we’ve implanted the second one at Children’s. I think that’s one of the state, if I’m not mistaken, with very good success. So it’s-

Dr. Angela Kade Goepferd: That’s really incredible.

Dr. Meysam Kebriaei: It’s really exciting. Part of that, you see some of our patients back. A lot of our patients, you see them back and follow up, and it’s been years and they haven’t had a seizure. The patients are so much happier, so much brighter. The ones with developmental delay have gained so much, because as you know, when your brain is seizing, it’s either seizing or recovering from seizures. There’s no opportunity to learn, develop, grow. It really makes a big impact on everyone.

Dr. Angela Kade Goepferd: What a huge difference and outcome for kids who can get out of having constant seizures. It sounds like the surgery, as I knew it in my training, we were scared of it because it was a big invasive surgery. Often not very precise, so kids would lose function or maybe have big surgeries. It sounds like now we’ve gotten much more sophisticated, much less invasive, and really been able to produce far better outcomes for kids which is really great.

Speaking of surgery, one other area that as a primary care pediatrician I’m often running up against, is hydrocephalus related procedures. So VP shunts, or other types of shunts, to deal with hydrocephalus. Whether that’s from prematurity, or cranial malformation, or other things. Can you help us understand what might be evolving in that area? What’s new, what’s different, what we should know about.

Dr. Meysam Kebriaei: Shunts are still the mainstay of treatment for hydrocephalus. That’s where you put a tube into the ventricular system and hooked up to a pressurized underneath the scalp. That’s hooked up then to another tube that goes from that valve into, usually the belly or the heart, and sometimes the lungs and drains in there. The shunts, when they work they’re great, but the downside of them is shunts always malfunction. We know that they do malfunction. It’s just a matter of when. If we see a kid that’s had a shunt for a decade or so without a malfunction, they’ve at some point, luckily have become independent of that shunt. It’s not that the shunts worked so well, or the shunt surgeon was awesome. Although, we’d love to take the credit. But the reality is they were one of the lucky few percentage where the hydrocephalus had resolved on its own.

Now endoscopy has become a lot bigger factor in treating hydrocephalus. Endoscopic third ventriculostomy’s. Where we go in there with a small endoscope, about a few millimeters in diameter. We enter the lateral ventricle. Then we advance it into the third ventricle and make a small opening into the floor of the third ventricle, and create a bypass without having to put any permanent devices or foreign objects like shunt in. The only downside to that is the patient has to have the right anatomy. You have to have a blockage between the third and fourth ventricle. Be of a certain age, have a certain etiology, the blockage.

For infants, we have what’s called choroid plexus coagulation and endoscopic third ventriculostomy. ETV-CPC is what we call it to make it more palatable to say. That’s proven to be successful as well. But again, you have to have the right patient selection. With us, in newborns with interventricular hemorrhage, we go in with endoscope and we coagulate quite a bit of the choroid plexus that’s in the lateral ventricles, and we do an endoscopic third ventriculostomy. The success rate is about that of a shunt, which is really exciting because a shunt’s really… There’s a quote, that a shunt is a life sentence. Again, it works great if that’s what you need, but really when you have a shunt, it is with you for the rest of your life.

You didn’t ask this question, but one area that I always think about and worry about, is at children’s hospitals they’re really equipped to take care of patients with shunts and follow them regularly. But when they transition to an adult practice, a lot of times those mechanisms aren’t there. I always think, well, how can we make that transition better so that pediatric patients that’s been doing great and thriving, despite having a shunt, can continue to do well and thrive in life as an adult? I have not come up with a solution for that yet.

Dr. Angela Kade Goepferd: You mentioned that shunts will always malfunction. If they haven’t “malfunctioned” in 10 years, it means that the hydrocephalus resolved. Can you just help us sort of differentiate when we should be worried about a shunt and when we shouldn’t?

Dr. Meysam Kebriaei: A lot of times it isn’t the shunt. As we know in our practice and our training, you want to keep an open mind that kids with shunts have all the other pathology that kids without shunts have. A lot of times viral infections can present with very shunt malfunction like symptoms, very similar to them. One of the things that I look for is if they have diarrhea, it’s probably not shunt related. Each age group presents differently with shunt malfunctions. Infants, what we tell families, is if they have down setting eyes where they’re looking down, but they have a hard time looking up or past the horizon. That’s a sign of increased pressure in the head where there’s pressure in the back of the brain stem. That’s what we commonly see.

Lethargy is a common sign of shunt malfunction, of course. It’s a sign of respiratory infections and other infections as well too. When in doubt, and especially at Children’s Hospital, and it’s becoming more commonplace across the US in children’s hospital, where we have access to limited MRI’s. Where they can get a quick MRI. It takes six, seven, eight minutes, as opposed to a 45 minute MRI where a young child can’t handle without sedation. When in doubt, I would get a limited MRI. There’s no radiation associated with it like there is with a CT scan. In older kids that can communicate verbally, headache is the most common presentation. Nausea, vomiting, headache would be some of the more common symptoms we see. Lethargy would be another.

Dr. Angela Kade Goepferd: In addition to epilepsy and VP shunts, what else do you think is really important that we talk about relative to pediatric neurosurgery? Things I’m thinking of might be newer areas that you think we should know about. Things that we might mistakenly send a neurosurgery that really shouldn’t go to neurosurgery. Or things that we aren’t sending that we should be sending. Any other kind of advice or updates that you want to give.

Dr. Meysam Kebriaei: Absolutely. I think epilepsy is a big one. If you have a patient that has tried a couple of medications, they’re still having breakthrough seizures, talk to them. Encourage them to talk to their neurologist, or give us a call, or send us a referral. We’ll be happy to see that patient and see if they’d be a candidate for potential epilepsy surgery or further workup. As far as the other things go, I think some referrals that we see may be prematurely. We have a lot of student athletes in Minnesota. When a patient has a fall or motor vehicle accident, they have negative imaging and they some muscle soreness, tenderness at palpation. It’s just been a few days. Typically, when they’re neurologically intact, typically that patient will do well and it’s a muscle sprain. But again, when in doubt, we’re happy to see them. Obviously, we don’t want anybody take the chance and say, well, I’m not comfortable with this, but I don’t want to bother neurosurgery. You’re not bothering us. It’s our privilege to see these patients.

The other things I would say is, this doesn’t maybe affect referrals as much, but I’d say that new things on the horizon. One thing I’ve been really happy about and excited about is what a fast pace we’re improving with our studies of brain cancer and brain tumors. Where we can really modify our chemotherapy treatment to the tumor based on molecular subtyping and genetic studies that now we’re able to do. My dream is that one day my kids, hopefully, and if not, my grandkids will look back and say, “Wait for a brain tumor, you cut into someone’s skull for that and removed it? What is wrong with you, grandpa or dad?” That we can treat it with a medication. I think it’s really exciting to see these treatments. They’re a lot more effective and they’re a lot more custom tailored for each patient with a brain tumor. I think we’re doing a great job with that.

Dr. Angela Kade Goepferd: It’s always great when we feel like medicine is getting more precise. So we can really treat each kid in the way that they need to be treated, as opposed to applying a blanket treatment to them and hoping that it works.

Dr. Meysam Kebriaei: Absolutely.

Dr. Angela Kade Goepferd: Well, thanks so much for talking with me today. I feel like I learned a lot. I really like talking with smart brain surgeons and I really appreciate not being one. Thanks for being a brain surgeon.

Dr. Meysam Kebriaei: Well, I appreciate that. I appreciate that a lot. It was really nice to talk to you as well.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.