At the USC Comprehensive Epilepsy Center, patients with the neurological disorder receive the highest level of care, backed by innovative research.
On an ordinary February day, 18-year-old Khashayar Pirouzmand was breezing through the physics questions on an important exam at his high school in Iran, excited because doing well could help him get into a top university.
Two hours in, without warning, his life changed dramatically. Very suddenly, he felt a strange pressure in his brain. He raised his hand and tried to say he wanted to go outside, but couldn’t put the words together. He took a deep breath and glanced at his paper. He could no longer solve the problems he had done only minutes before.
Khashayar left the classroom with the test unfinished. By the time he reached home a half hour later, he could speak again. He told his family something had happened to him, but he didn’t think it was serious. He chalked up the incident to the stressful exam.
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The second time, about two months later, he was talking to his aunt when he heard a high tone in his ear, felt pain in his jaw and passed out. He woke up in an ambulance. After tests at a local hospital, doctors gave Khashayar the news: He had epilepsy, most likely caused by a small tumor on the left side of his brain.
50 million people worldwide are diagnosed with epilepsy. One of the most common neurological disorders, it is characterized by unpredictable electrical activity in the brain and recurrent seizures.
Doctors believed Khashayar’s tumor was too close to the language areas of his brain to operate, so he began taking two anti-seizure medications. They didn’t stop his seizures, which started escalating. Each time, he lost the ability to put words together or make sense of them. He tried finishing his university entrance exam, but couldn’t.
The next year, his seizures again kept him from completing the exam. Khashayar’s dream of traveling to America to study engineering seemed nearly impossible.
Center of Excellence
Little did he know that in a few years, Khashayar would find himself at the USC Comprehensive Epilepsy Center, designated a level 4 center by the National Association of Epilepsy Centers. The highest accreditation possible, this distinction indicates the center’s capability to treat the most complex cases.
When he finally arrived in Los Angeles two years ago, he saw a community physician for his epilepsy prescriptions who recommended he go to Keck Medicine of USC for help.
Within the USC Comprehensive Epilepsy Center, a multidisciplinary medical team provides the most advanced care for patients with complex issues, including those who experience uncontrolled seizures, severe side effects from medication or who want to get pregnant while having epilepsy.
The team includes board-certified epileptologists, neurosurgeons, neuroradiologists and psychologists, along with epilepsy nurses, occupational therapists and nutritionists.
“Patients come to us because they need a higher level of care,” notes Christi Heck, MD, medical director of the center and professor of clinical neurology at the Keck School of Medicine of USC.
That level of specialty is necessary because epilepsy can be extremely challenging to diagnose and treat, in part because it has a wide range of potential causes, including genetics, prenatal injury, meningitis, strokes, tumors and traumatic brain injury.
More people die of epilepsy (50,000) each year than from breast cancer (40,000). This includes people who develop SUDEP or “sudden unexpected death in epilepsy,” as well as those who die from seizure-related drownings or burns. Khashayar initially met with George Nune, MD, assistant professor of clinical neurology at the Keck School. Dr. Nune changed Khashayar’s medications to see if that would halt the seizures.
“Approximately one-third of patients have medically refractory epilepsy, which can’t be controlled with medication,” Dr. Nune says.
Dr. Nune asked Khashayar if he was interested in surgery, which held the potential to remove the source of his epileptic seizures. “I was very excited,” Khashayar says. “It seemed like an adventure for me. I wanted to try it.”
Listening to the Brain
The first step: capturing the electrical impulses in Khashayar’s brain. The center is equipped with the most advanced imaging and diagnostic technologies, including video electroencephalographic monitoring (EEG), an invaluable tool to diagnose epilepsy symptoms, using non-invasive electrodes attached to the head.
Khashayar spent a week in Keck Hospital of USC, as his medical team gradually withdrew him from all medication to trigger and track his seizures. This would enable them to characterize what type of seizures he was having and where they originated within the brain.
Jonathan Russin, MD, assistant professor of clinical neurological surgery at the Keck School, likens the on-the-scalp video EEG to “trying to listen to a conversation through a wall.”
Dr. Nune and Dr. Russin escalated the testing to the next level: phase II intracranial EEG monitoring to more accurately locate the area where seizures began and those areas which are essential for speech production. This higher-level brain mapping is like “being inside the room listening to the conversation,” Dr. Russin says.
Dr. Russin implanted a very thin mesh of electrodes over the surface of the brain in the relevant region. His typical seizures were then recorded over the course of several days as Khashayar dutifully did physics homework and watched documentaries in the intensive care unit (ICU). Dr. Nune then electrically stimulated the various brain areas under this mesh to determine which disrupted the ability to speak in his native Farsi. These would have to be preserved during surgery.
Pinpointing the area responsible for language as accurately as possible for each individual is essential “because once patients have been having seizures for so long, their brain often has reorganized itself,” Dr. Russin notes.
Armed with the results, Dr. Russin could proceed. His goal was to remove as much of Khashayar’s tumor as possible, while avoiding delicate tissue.
“You’re talking about potentially curing somebody of their seizures and changing the trajectory of their life,” he says. “If our patients have the courage to undergo these procedures, it’s our responsibility to do the job right with the least amount of risk.”
Khashayar was more than ready. “I said, ‘Let’s go.’ This was my chance to get better.”
Science at its Best
For Khashayar, surgery gave him his life back. He occasionally hears a high tone in his ear (an “aura” or warning of a potential seizure), but the seizures no longer come. He is on two medications for now, a precaution for the first few years after surgery.
Khashayar has started driving again and he is hard at work studying for his university degree. During his treatment at Keck Hospital, he realized the specific field he wants to pursue — electrical engineering. Being in the hospital, with electrodes implanted in his brain, he felt like a living-breathing embodiment of science at its best.
“In one moment, engineering and neuroscience and medical school were all combining to cure the patient — me — of epilepsy,” Khashayar says. “It’s kind of amazing.”
Improving Access to Advanced Care
The center serves as the academic anchor to the USC Epilepsy Care Consortium.
“This unique partnership is composed of nearly a third of all the certified epilepsy centers in our state,” says Charles Liu, MD, PhD, professor of clinical neurological surgery and neurology at the Keck School and secretary of the consortium. “This maximizes patient access to the resources of an academic medical center while minimizing travel.”
The patient’s local neurologist remains the main point of contact, while Keck Medicine specialists assist with care management through teleconferencing. “If a patient needs more advanced care than is available in their community,” Christi Heck, MD, says, “they can come here and we can co-manage that care with their local doctor.”
The center also addresses the transition that teen and young adult patients must make from children’s services to adult care. “There’s a very big gap between being a child with epilepsy and being an adult with epilepsy,” Heck says. The transition clinic includes a navigator who reviews each case and directs the patient to the services they need.
Looking for Another Option?
What if a patient isn’t a candidate for tumor resection? The USC Comprehensive Epilepsy Center calls on a variety of leading-edge techniques such as responsive stimulation devices and other neuromodulators — essentially pacemakers for the brain — that work to prevent seizures at their source. The center was involved in early clinical trials that led to approval of the devices.
by Candace Pearson
Photo by Kremer-Johnson Photography