The Thinkers: At Pitt, expert advocates brain surgery for epilepsy
May 24, 2010 8:00 AM
Anto Bagic is the head of epilepsy treatment at UPMC and a national leader in using magnetoencephalography, or MEG, a way to determine where the epicenters of seizures are in the brain.
By Mark Roth Pittsburgh Post-Gazette
The prospect of brain surgery can be frightening.
Not only can a doctor remove a part of what makes you you, but the legacy of brain surgery is clouded by such crude procedures as frontal lobotomies.
And yet, when it comes to epilepsy, surgery is being vastly underused, says Anto Bagic, director of the University of Pittsburgh's Comprehensive Epilepsy Center.
Epilepsy affects 2.5 million to 3 million people in the United States, and nearly 1 million of those patients have uncontrolled seizures -- periodic electrical firestorms in their brains that cannot be governed by medications.
Position: Assistant professor of neurology, chief of the epilepsy division, University of Pittsburgh medical school.
Residence: Franklin Park
Education: Master's in science and M.D., University of Zagreb, Croatia; neurology resident, Georgetown University, Washington, D.C.; research fellowships, National Institutes of Health and Uniformed Services University of the Health Sciences.
Professional honors: Founding board member, American Clinical Magnetoencephalography Society.
Publications: More than 70 articles, book chapters and abstracts in professional publications.
Within that group, Dr. Bagic estimates, at least 100,000 would make good candidates for surgery, meaning they have failed two medications and their seizures are generated from a single part of their brain that could be removed without damaging a vital function like movement or speech.
Yet only about 3,000 people in America get epilepsy surgery each year. "In other words," he said, "for every person who gets surgery, there are 33 people out there walking around who could benefit from it."
There are a few reasons for that, he said.
First is a reluctance among patients themselves. "People are still inclined to go through 10 medications hoping something will work before they are willing to commit themselves to surgery. In general, people just aren't comfortable with the idea that somebody opens up your head and takes a piece of your brain out."
Doctors are also less assertive than they could be.
"As a profession, we fail to communicate the options appropriately to the patients and take the initiative. Even today, those who are more inclined toward surgery are sometimes considered too aggressive or pushy."
And yet for those 100,000 to 150,000 patients who have failed all their medications and still have devastating seizures, an operation is "the only potential cure. The rest is just treatment. I think we are allowing our patients to suffer way too long. If you are waiting 15 to 25 years for surgery, and we can see your seizures are very likely to be uncontrolled, the epilepsy just becomes more resistant to treatment."
Sharp-eyed and dapper, the Croatian neurologist came to Pitt five years ago, and still speaks in a distinctive Eastern European accent.
Part of the reason he is confident about recommending surgery for some of the most intractable epilepsy patients is because he has access to a $3 million device known as a MEG machine, for magnetoencephalography.
The MEG machine uses extremely sensitive detectors to map the magnetic fields created by the brain's electrical activity, and because epilepsy involves "a critical mass of brain cells firing together in a violent way," Dr. Bagic said, it can help pinpoint the source of seizures in the brain.
The device located at UPMC is one of only about 20 in the nation being used for both medical care and basic research, and while it does not create an image of the brain directly, its map of the brain's shifting signals, measured over milliseconds, can be plotted onto an image of the patient's brain.
The MEG device sometimes yields important surprises. Four years ago, he said, a woman brought in her daughter, who was suffering 20 seizures a day. A standard electroencephalogram, or EEG, showed the seizures were coming from either the right or left temporal lobes -- parts of the brain that sit above the ears.
But using the MEG machine, "after many hours of work, we determined that the seizures were coming from the right parietal lobe [on the upper side of the head] and being falsely represented by the EEG in the temporal lobes."
In another case, he was able to use the MEG device to identify and surgically remove the source of seizures in a woman with tuberous sclerosis, which causes tumors to grow throughout the body, including the brain. Today, the young woman is free of seizures and able to drive a car, which is one of the goals most intensely sought by people with epilepsy.
Other brain imaging methods, such as functional magnetic resonance imaging (fMRI) or positron emission tomography (PET), measure brain activity indirectly, but the lag time is too great for the quicksilver changes of epilepsy. "It's like trying to reconstruct a car accident by studying the wreckage rather than by watching the accident," Dr. Bagic said.
Sometimes, doctors need to be even more precise about the epicenter of a seizure. In those cases, they bring patients into the hospital, remove a part of their skull, place an electrode grid directly on the surface of the brain and then wait for them to have a seizure. The electrode array can pinpoint where the disturbance erupts.
Even if every epilepsy patient eligible for surgery could get it, there would still hundreds of thousands more with uncontrolled seizures, Dr. Bagic said.
Some of them can be helped by a procedure known as vagal nerve stimulation, in which electrodes fire signals up the vagus nerve that runs from the torso to the brain.
But others aren't so fortunate.
"People with epilepsy who are uncontrolled may have very miserable lives," he said. "They have a much lower opportunity to get an education, and fewer employment opportunities. Marital stability is shaky, and overall they make less money."
Dr. Bagic's MEG device would be of great value if it were only used for his epilepsy diagnoses, but because it sits in a major research institution, it is also being employed for several scientific studies.
The MEG machine is currently being used for studies of dementia, depression and amyotrophic lateral sclerosis, or Lou Gehrig's disease. Dr. Bagic is also using it to chart the progress being made by UPMC's first hand transplant recipient, Josh Maloney, who lost his right hand in a Marine training exercise explosion.
Over the course of the first year since his 2009 hand transplant, the MEG readings have shown him going from virtually no sensory signals in the brain for his transplanted hand to a pattern that is almost the same as in his other hand, findings that may help future hand transplant patients.
As a founding board member of the American Clinical MEG Society, Dr. Bagic has lobbied for regular insurance coverage for MEG scans used in epilepsy diagnosis and mapping tumors and other brain lesions.
"I think this is a great technology and I think it can help many people. I truly believe that with it, we will turn people who were not surgical candidates and who were destined to suffer into people who can be cured."