Pacemakers implanted under the skin near the collarbone to regulate heartbeats are well known. The small electronic device uses electrical signals to trigger a normal heartbeat, ensuring an efficient pumping of blood through the body. One or more wires called leads are threaded into the heart chambers to deliver the impulses when the heart’s natural rhythm is too slow or irregular.
Three million people worldwide – most over the age of 60 (including Prime Minister Benjamin Netanyahu in 2023) – have such cardiac devices implanted in their bodies.
Now, a brain pacemaker to prevent or ease seizures from epilepsy has been implanted in the brain of Z., a 35-year-old mother of four who has been suffering from severe epileptic seizures for many years; despite trying every accepted anti-seizure medication, her condition deteriorated and made life unbearable.
The staff of the Epilepsy Center at Hadassah-University Medical Center in Jerusalem’s Ein Kerem enabled her to undergo a unique surgery that was performed for the first time outside of North America. After locating the exact epilepsy focus in her brain, a pacemaker was implanted that detects abnormal electrical activity, neutralizing it before it becomes an epileptic seizure.
“If it weren’t for the pacemaker implantation, we would have had to remove the area in the brain responsible for the seizures, with all the medical consequences that accompany such a case,” said Prof. Dana Ekstein, director of the hospital’s Department of Neurology and the Epilepsy Center who has been accompanying Z. for more than 15 years of treatment.
A beacon of hope
The surgery which was performed at the Ein Kerem medical center, is a beacon of hope for Z., who lives in the center of the country and has been suffering from severe epileptic attacks for many years.
Until now, Israeli patients who were suitable to undergo the complex procedure had to fly to the other side of the world and undergo the surgery there – but now, for the first time, it took place outside of the US and Canada.
The surgery was made possible after the team identified the location of the exact epileptic focal point in the patient’s brain –the specific area that led to the onset of seizures – in a long and complex process carried out by a multidisciplinary team in the Epilepsy Center.
Dr. Sami Heyman, an epilepsy surgery specialist from the Department of Neurosurgery, together with Prof. Zvi Israel, director of the Department of Neurosurgery and the Functional Neurosurgery Unit at Hadassah, implanted an RNS (Responsive neurostimulation) pacemaker in the Z’s brain. This device continuously monitors the electrical activity in the epileptic area of the brain, identifying the patient’s characteristic personal seizures. If it detects a pattern of abnormal activity, which could lead to the development of an epileptic seizure, it will send short electrical pulses to the epileptic brain region and prevent the seizures.
The pacemaker was developed by NeuroPace in California, represented in Israel by Tzamal Medical. “This is 100% personalized medicine; the pacemaker will be carefully programmed to meet Z’s individual medical needs,” explained Ekstein. She stressed that for Z., customary treatment has not been able to prevent recurrent seizures that cause severe impairment in her functioning. Following the surgery to implant the RNS pacemaker in her brain and healing of the area, the team of the epilepsy unit at Hadassah will activate the pacemaker and program its activity to achieve the best results.
The hadassah department is the only one in Israel that offers RNS pacemaker programming and operates an RNS pacemaker programming clinic for patients who have undergone the surgery abroad and have returned to Israel.
The clinic’s staff, which consists of Hadassah neurologists, also included Prof. Dawn Eliashiv, a renowned epilepsy expert from the University of California, Los Angeles, with extensive experience in the complexities of RNS pacemaker programming. Z. will be followed up and will receive professional guidance at this clinic.
“This revolutionary type of pacemaker has led to an 82% reduction in the number of seizures in the patients I treat in the US, helps prevent sudden death from epilepsy, and enables accurate monitoring of epilepsy foci over long periods of time following its implantation in the brain,” Elyashiv explained.
“I have accompanied Z. throughout her adult life,” Ekstein said, “and together with our staff, we have provided her with various treatments and protocols according to her condition.”
They gave her treatments including medication to control her epileptic seizures and later inserted a VNS (vagus nerve stimulation) pacemaker – a device placed by a surgeon under the skin of the chest wall near the left collarbone that is similar to a heart pacemaker but delivers electrical impulses to the brain via the vagus nerve
Unfortunately however, the disease in her brain progressed and her condition deteriorated. Initially, during her seizures, she experienced episodes of dissociation, which involves disconnects from thoughts, feelings, memories, or sense of identity.
“Over time, her condition deteriorated, and she began to fall during these episodes, which became increasingly dangerous and significantly disrupted her daily life,” Ekstein recalled. “As a married woman with four children, Z. had to be watched carefully throughout her pregnancies, which were difficult and during which we took care not only of her, but also the fetus due to her falls. She began to use a wheelchair more and more, and was constantly fearful.”
Despite all the team’s efforts to adjust her medications and the implanting of the VNS pacemaker, the seizures returned with intensity, and over time, she stopped working.
But the team did not give up. “We embarked on a very complex journey to find the focus that causes epileptic seizures in the brain, which we know how to conduct in epilepsy patients. It included many tests – various MRI tests, video EEG, and PET-CT scan.
Based on these tests, a large multidisciplinary team performed an evaluation and decided which area of the brain might be the focus where Z’s epileptic activity originates from. “We conducted a test in which electrodes were implanted in the suspected area and the area’s activity was monitored, until we understood; we found the epileptic focus responsible for Z.’s epileptic seizures,” Ekstein said.
“We realized that if we cut off the epileptic area in her brain, we would almost certainly cause damage to her vision. It was decided to opt for RNS pacemaker surgery – allowing it to be implanted for the first time in Israel - directly at the origin of the epileptic activity,” she said.
“It is important to emphasize that the innovative pacemaker will respond with an electrical pulse only when an imminent attack is detected in the brain. This is in contrast to other pacemakers on the market, which are implanted in predefined areas of the brain and give pulses throughout the day and night in the patient’s brain,” the professor said.
“The surgery went as planned and was successful,” concludes the Hadassah neurology chief.” “We knew this was the right option for Z. We look forward to activating the pacemaker and to the expected improvement in Z’s condition.”