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The Mind is a Mysterious Place

Diary of a Director General
By Prof. Ehud Kokia
Director General, Hadassah Medical Organization

Dear Family and Friends of Hadassah,

In the last decade, researchers in neurology, neurosurgery and related fields have made major advances in understanding the mind and the impact of diseases and disorders on its many functions. Heightened understanding has led to changes in treatment protocols and advances in treatments themselves. Prof. Tamir Ben-Hur, Head of the Department of Neurology, was the driving force behind the creation of Hadassah's Comprehensive Epilepsy Center, one of the many places where this new approach is especially evident.

"Epilepsy is a key to the brain; our brain is what we are, it tells us about the world," says Dr. Shahar Arzy, one of Center's adult neurologists and epilepsy specialists. "The things that affect the brain affect our very selves." Characterizing the condition as a disorder "not a disease," he and Dr. Dana Ekstein, the other adult neurologist and epilepsy specialist, explained how the Center's super skilled specialists help people with epilepsy, medically and surgically.

Apart from the adult epileptologists, the team includes Dr. Mony Benifla, Head of the Department of Pediatric Neurosurgery, pediatric neurologists and epileptologists Dr. Odeya Bennet and Dr. Israel Matoth, along with a neuroradiologist, a neuropsychiatrist, psychologists and EEG technicians. All of them feel that the addition of a social worker would help complete the group.

Established about two years ago, word has spread quickly about the Center's holistic approach. Today, about 1,000 patients a year visit the adult and pediatric clinics. About one percent of the population suffers from epilepsy in Israel and worldwide. While the actual number may appear small, epilepsy is among the most prevalent serious neurological conditions and its impact on the patient and the family is enormous.

Epilepsy can have a specific cause like a trauma, cancer or a tumor – or a more general one that originates in a disorder of the cerebral network. That could be genetic or metabolic in origin, Dr. Ekstein says, but in many patients we cannot pinpoint a specific cause. There is a huge variation in patients and how their epilepsy is manifested. Contrary to conventional thinking, convulsive seizures as portrayed on the screen and in the literature are not so common.

Most brain disorders are characterized by a lack of function. In epilepsy, the brain over functions – part of the brain is working on its own generating excessive electrical activity. That can demonstrate itself in many ways – as a seizure, a staring episode, an uncontrolled movement or a strange feeling. Dr. Ekstein pointed out that as Dr. Arzy noted, "we epileptologists regard that activity as a window into the function of the brain."

Most patients – about 70 percent of them – respond to medication. Every week when the Epilepsy Center team sits down together to try and figure out how best to treat their patients, it is the 30 percent of people whose conditions are resistant to medications – the 30 percent with intractable epilepsy – that present the greatest challenge.

Each of those patients undergoes a thorough workup and a variety of tests to see if Hadassah's specialists can pinpoint the cause of their seizures and optimize their treatment. They check the MRI to see if there is a developmental malformation in the structure of the brain or a tumor that can be treated surgically. They examine the CT and EEG scans looking for correlations between brain activity and seizures. Using video EEG monitoring, the team tries to capture the seizures, map them and locate their origin in the brain, looking to determine if they are situated in one place or scattered throughout the brain, which is harder to treat.

Equipped with reams of test results and clinical data, they pool their creative input and decide on a course of action. Sometimes it is possible to surgically remove the brain tissue that triggers the seizure, but first, Dr. Benifla says, the tissue must be identified and then it must be determined if the tissue can be removed without causing damage to other parts of the brain.

So the search for additional information and the effort to pinpoint the focal point of the seizures continues. Advanced analyses are conducted using data collected from EEG, MRI and PET examinations, metabolic studies and neuropsychiatric tests.

Sometimes invasive EEG monitoring is necessary. This involves mapping seizures by placing EEG electrodes directly on the brain, Dr. Bennet explained. The surgical procedure is conducted in the operating room.

First, Dr. Benifla removes a section of the skull and places up to 100 electrodes – rather than the 27 used in regular EEG testing—on a specific area of the brain. These electrodes combined with video monitoring measure the variations of brain activity, With the electrodes in place, Dr. Bennet says, the epileptologists stimulate different areas of the brain to map essential functional areas for language and motor functions. This important step could determine whether or not surgery is possible. While still connected to the electrodes and monitoring equipment, the patient is transferred to the Intensive Care Unit where the seizures are recorded so that the epileptologists can determine the precise location of the seizures' onset zone.

After all the information is collected, if surgery is indicated, the patient returns to the operating room where, guided by the data and the epileptologists, Dr. Benifla removes the aberrant area. Not every patient with intractable epilepsy is eligible for surgery, their conditions simply preclude it – but for those who are, 70 percent are cured.

So far, Dr. Bennet, Dr, Matoth and Dr. Benifla – the pediatric epilepsy team – have used the information collected through invasive monitoring to operate on three children – ages six, seven and 15 – three children whose days and lives have moved from fearing the next seizure to dealing with issues that all children their ages confront. The 15-year-old, a girl who is now 16, now has a boyfriend, "but," she says, pointing to her mother, "she doesn't like him."

"Children are harder to operate on than adults," Dr. Benifla says, "and they present a greater challenge because their brains are still developing. Yet," he adds, "their brains can recover faster than adults. About a month ago he had the chance to make the comparison for himself, conducting invasive EEG monitoring on a 47-year-old patient of Dr. Ekstein's who had been completely healthy until five years ago. Then the patient began to have seizures that became progressively worse until he spent his days and nights "waiting for the siezures." During the first round of monitoring, the epilepsy team located the area of the brain responsible and soon Dr. Benifla will follow up on what they have found.

Hadassah's Epilepsy Center is the perfect example of how interdisciplinary medicine works to the patient's benefit; an outstanding demonstration that the sum total of creative specialists is greater than their individual talents. When the Surgical Center on Lower Level Four of the Sarah Wetsman Davidson Hospital Tower opens next year, there will be a special Pediatric Suite with two operating rooms where Dr. Benifla can practice his special skills on children. And when the Neurosciences Center opens on the Ninth Floor, to the delight of Dr. Ekstein and Dr. Arzy, there will be four rooms specifically designated for the Adult Epilepsy Monitoring Unit, with all of the essential monitoring equipment built in – and appropriate space for the necessary labs.

The mind is still a mysterious place but at Hadassah, every day, in ways previously considered impossible, through their actions and the research the Comprehensive Epilepsy Center attracts, the team is shedding light on some of the mind's more elusive behaviors.



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