University Hospitals Case Medical Center Neurosurgeon First in United States to Use Brain-sparing TPO Surgery for Epilepsy

CLEVELAND -- Jonathan Miller, MD, Director of Functional and Restorative Neurosurgery at University Hospitals (UH) Case Medical Center, is using a surgical technique new to the United States that spares most of the brain in patients with intractable epilepsy (untreatable with medications). Whereas traditional surgery for many of these patients is a hemispherectomy, which means removal of half the brain, the new technique, called temporoparietooccipital (TPO) disconnection, spares much of the brain by removing just enough to disconnect the portion affected by the electrical misfirings that are the hallmarks of epilepsy.

“This is a significant alternative to massive resectioning, or removal of large parts of the brain,” said Dr. Miller. “We are able to keep most of the brain intact, which prevents many of the complications associated with more extensive surgery. We want to remove as little brain as possible to get the job done. From our results, the children seem to recover more quickly, and seizure control is no worse than with the more extensive surgery.”

With TPO, relatively small amounts of brain are resected to isolate the areas of brain tissue affected by the electrical misfirings, which are left in place but separated from the rest of the brain. In the more traditional operations like hemispherectomy, a much larger amount of brain tissue would be removed, sometimes up to half of the brain.

According to Dr. Miller, “The advantage of this ‘less is more’ approach is intuitively obvious. Because we’re removing less, the procedure is less traumatic for the patient and recovery time is usually faster.”

According to Dr. Miller, it is important to be aggressive in the diagnosis and treatment of intractable epilepsy in children given the adverse effect of recurrent seizures on early brain development, learning, and memory. Also, young children with this disorder may be better candidates for aggressive surgical treatment because of the increased ability of the developing brain to adapt to the surgical removal of brain tissue, (known as neuroplasticity.)

Two medical groups from Switzerland and Australia have published on TPO. Dr. Miller has introduced the technique to the U.S.

He has performed the surgery on three patients. One of these patients is Finnegan Born-Crow, currently 1 year old, who was diagnosed with intractable epilepsy at two weeks of age.

Finnegan experienced three to five seizures a day. According to his parents, he would become suddenly unresponsive and look to the right for up to several minutes at a time.

His mother Nicole said, “Before the surgery, he was cranky and sleeping all of the time. He wasn’t developing.”

Finnegan had surgery in early 2012, and Nicole said there is a distinct difference since then.

“Now he’s crawling and babbling. He’s cruising along. He’s a completely different baby. Finn is happier and more full of life than we could have hoped for.”

Nicole Born-Crow also credits the guidance and care provided by Ingrid Tuxhorn, M.D., Chief of the Division of Pediatric Epilepsy at UH Rainbow Babies & Children’s Hospital, and her colleague in the division, Asim Shahid, M.D., who worked closely with Dr. Miller.

Dr. Miller points out that disconnection operations are appropriate for only a small minority of all patients with epilepsy. “The ideal candidate has seizures coming from a relatively large area of brain tissue that the patient can live without, since the areas that are disconnected will no longer be functional. Younger patients do well because the rest of the brain can reprogram itself to compensate for the area that is disconnected, but in some cases older children or adults can benefit from these operations.”

Epilepsy is a brain disorder in which a person has repeated seizures (convulsions) over time. Seizures are episodes of disturbed brain activity that cause changes in attention or behavior.

Recurrent, spontaneous, unprovoked seizures associated with epilepsy affect 3 to 5 percent of the population worldwide. The incidence of epilepsy in childhood varies among different age groups and geographic locations. Data from a variety of studies have indicated that recurrent unprovoked seizures occur in 1 to 2 percent of children, with the highest incidence in the first year of life. Epilepsy is usually controlled, but not cured, with medication. However, more than 30 percent of people with epilepsy do not have seizure control even with the best available medications.