For nine years, Laura Koellsted tried as hard as she could to lead a
normal life. It was not easy. Every day, from deep within her brain, a
cluster of cells would fire all at once, out of sequence, as out of
control as a fast-moving storm.
Koellsted's brain was behaving far outside its normal routine, one
where nerve cells communicate in a stable stream of electricity. Those
cellular misfires Koellsted experienced are seizures. Hers were so
frequent, unpredictable, and debilitating—her right leg would kick out
uncontrollably and she would crash to the floor— she wasn't safe doing
anything. She couldn't care for her two young children. She couldn't
work. She couldn't drive. Finally, to limit her falls, she stayed in
bed and when she had to move around her home, she crawled instead of walking.
Uncontrollable seizures lead to intractable epilepsy diagnosis
Sometimes medications would work, but not permanently. Koellsted had
become one of those people whose seizures become intractable to
medication—and she turned to Stanford's
Intractable Epilepsy Program for help. An impressive set of epilepsy
specialists from several medical and scientific disciplines became
the team that combined the most advanced forms of seizure and functional
brain mapping to find the source of Koellsted's seizures with a
millimeter precision. Those maps enabled the surgery that returned
Koellsted to a normal life.
"Treating intractable epilepsy is like a hunt with many twists
and turns," said neurologist Josef Parvizi,
MD, PhD, director of the Intractable Epilepsy Program.
"Each person's seizures are unique, with a unique origin and a
unique seizure network that the abnormal brain waves traverse, causing
each person's unique seizure behavior."
Capturing a seizure's winding track through the brain means
penetrating the bone that protects the brain. Once, neurologists
observed changes in blood flow through the brain that indicate seizure
activity. Now, with state-of-the-art technology, they can apply the
highest power of MRI, called a 7-Tesla,
to look for clues, too. They can also use a video-based EEG to gauge
electrical activity. The most detailed method of seizure hunting is a
combination of intracranial recording of seizure activity and
functional brain mapping.
Implanting electrodes for direct brain mapping of seizures
"Implanting electrodes over the surface of the brain allows us
to go beyond the skull," Parvizi said, "so we can listen to
what's happening from inside the brain instead of what we can hear
from the outside. From the outside you can hear the explosions, but
you can't hear who is whispering and who is saying what to whom."
Using this functional brain mapping technique provided information
crucial for identifying the source of Koellsted's seizures.
What Parvizi and the intractable epilepsy team found in Koellsted's
brain made treatment an even more delicate task than usual. Her
seizures came from the part of the brain that controls sensation and
movement in her legs, a part of the brain difficult to see or listen
to because it's where the two halves of the brain overlap.
Intracranial brain mapping would have been the only way to find that
spot and it was not available when Koellsted was first diagnosed.
"With thick bone and such a deep source, we would have been blind
to the seizure's abnormal brain waves by just listening through the
skull," Parvizi said.
With the electrodes placed directly on Koellsted's brain, Parvizi
could stimulate them to connect function with location. He was
watching those cells near the seizure source to determine what might
happen if they were inadvertently damaged. After her fourth day of
testing and mapping in the hospital, Parvizi came into Koellsted's
room and said, "We found it. We're going to get it."
Functional brain mapping leads to successful epilepsy treatment
Before the intractable epilepsy team proceeded, they warned
Koellsted of the risk: If something went wrong with the surgery, she
might lose feeling in her legs. "I didn't care," Koellsted
said. "I was in agony. Even without feeling, I could learn to
function again as a human being. I could be a mother to my children
and a wife to my husband. And I could go back to work."
The surgery took eight hours. The degree of precision was so
demanding that the neurosurgeon did not use a scalpel. Instead, she
suctioned the cells, removing just those in the main hub of the
seizure source. Koellsted recalled her first moment in the recovery
room. "I remember waking up and someone saying, 'Can you move
your foot?' I said, 'Yes,' and they said, 'Okay, you're not
paralyzed.' I remember being very happy and going back to sleep."
Finding the right team to treat intractable epilepsy
"When patients with intractable epilepsy come to Stanford for
treatment," Parvizi said, "what they will find is a unique
team that fuses clinical care and science. We collaborate with our
colleagues in multiple departments throughout Stanford Hospital &
Clinics and Stanford University, including computer science,
engineering, psychology, and radiology. We get together to improve our
current methods or inventing entirely new ways of mapping the brain,
which will at the end lead to better treatment options for our
patients. On the clinical side, we also get together to discuss each
and every single epilepsy surgery case. We meet on a weekly basis, and
a group of 10 to 20 clinicians who aren't afraid of opposing each
other, brainstorm about the best treatment options for individual patients."
Koellsted still takes a couple of medications to control her
seizures, which have now stopped completely. Their absence helped her
convince the California Department of Motor Vehicles to let her take a
driver's test to regain her license. She passed. That particular
restoration of independence was a big part of her recovery, she said.
"I wanted surgery years ago, but I realized that when the time
was right, I was given the right surgeon and the right doctors. I'm
grateful every day for the people who made me whole again."