Beta Klinik private international hospital, Bonn

Beta Klinik, an international private hospital in Bonn that first opened its doors to patients in 2008, is set in a picturesque location on the banks of the Rhine. Today the hospital has 60 specialist doctors and 180 staff and covers an area of more than 13,000 square metres.

The clinic's diagnostic and therapeutic range currently covers more than 30 medical specialties. The newest addition to the clinic's therapeutic spectrum is an expert centre for the treatment of epilepsy. Under the leadership of the renowned Professor Christian Elger, Beta Klinik became the first hospital in Germany to perform successful laser ablation surgery of an epileptic focus, in collaboration with the neurosurgeon Prof. Thomas Gasser.

Since 2015 Beta Klinik has been a cooperation partner of the University Hospitals of Bonn and Cologne in the field of cancer treatment (CIO Köln – Bonn), and following the creation of the expert Centre for the Treatment of Cancer Aachen, Bonn, Düsseldorf, Cologne

Specialists rate the clinic as a medical facility of university standard. The hospital comprises 27 clinical departments and medical centres, among them:

• department of adult and paediatric radiology;
• department of nuclear medicine;
• department of ophthalmology;
• department of oncology;
• department of urology;
• department of general internal medicine;
• department of cardiology;
• department of gynaecology and breast medicine;
• department of neurosurgery;
• department of neurology and epilepsy treatment;
• department of adult and paediatric neuroradiology;
• department of orthopaedics, joint surgery, joint replacement surgery and sports traumatology;
• department of vascular surgery;
• department of phlebology and angiology;
• department of plastic and aesthetic surgery;
• department of psychosomatic medicine, psychiatry and psychotherapy;
• department of sleep medicine;
• department of physiotherapy and sports rehabilitation;
• department of sports medicine;
• department of surgery and proctology;
• department of dermatology and allergology;
• department of preventive medicine;
• central laboratory;
• department of anaesthesiology.

«Beta Neurology» — a specialised expert centre for the diagnosis and treatment of epilepsy and neurological disorders

Neurological diseases are extremely diverse and require thorough diagnosis. This is the only way to select the ideal therapy for each patient's individual pattern of symptoms. The experts at the «Beta Neurology» centre offer the entire range of diagnostics and therapy for neurological diseases available today. Under the leadership of Professor Dr. med. Christian Elger, a highly experienced neurologist and epileptologist, every individual case is investigated to establish the cause of the epilepsy.

Outstanding diagnostic quality is ensured by high-quality imaging, including 3.0 Tesla MRI scanners. In-depth diagnostics make use of electroencephalography (EEG), long-term EEG monitoring and long-term video-EEG monitoring (VEM) on an inpatient basis.

Targeted treatment of epilepsy and movement disorders

Thanks to many years of experience in university hospitals, the staff of «Beta Neurology» — Professor Christian Elger, Dr. med. Monika Jeub, PD Dr. med. Pawel Tacik and Dr. med. Stefan Kuczaty — guarantee professionalism and targeted treatment of epilepsy and other seizure disorders. Working closely with the neuropaediatrician Dr. med. Stefan Kuczaty, Professor Christian Elger and his colleagues carefully analyse the results of the differential diagnosis of seizure disorders and develop individual therapy for patients of all ages.

The treatment of movement disorders covers the whole spectrum of neurological disorders and clinical pictures — from Parkinson's disease to cerebrovascular and neurodegenerative diseases such as dementia and amyotrophic lateral sclerosis (ALS). The approach to these disorders is just as comprehensive as the care of patients with spastic diplegia and musculoskeletal impairment following a stroke. In PD Dr. med. Pawel Tacik, the «Beta Neurology» centre has a specialist in the use of botulinum toxin for the treatment of movement disorders.

In close cooperation with the neurosurgery department of Beta Klinik, new gentle and modern methods of treating epilepsy and movement disorders are being introduced into clinical practice. All diagnostic procedures in preparation for epilepsy surgery, including the implantation of stereotactic electrodes to localise the epileptic focus, are carried out in close interdisciplinary cooperation with the neurosurgeons. Interventional minimally invasive MRI-guided laser ablation surgery has been added to the range of gentle epilepsy surgery offered by the «Beta Neurology» centre.

Alongside these, the clinic performs deep brain stimulation for movement disorders and vagus nerve stimulation for epilepsy.
Areas of diagnostic and therapeutic expertise of the neurological centre in the treatment of epilepsy and movement disorders:

• comprehensive drug treatment;
• ketogenic diet;
• resective epilepsy surgery;
• vagus nerve stimulation;
• MRI-guided laser ablation of the epileptic focus;
• transcranial ultrasound imaging of the substantia nigra in Parkinson's disease;
• deep brain stimulation in Parkinson's disease.

Areas of specialisation of the «Beta Neurology» centre

The areas of specialisation of «Beta Neurology» cover the entire spectrum of diagnosis and treatment of neurological diseases, including physiotherapy. Interdisciplinary work and close cooperation between specialists from different medical fields at Beta Klinik make it possible to offer a personalised approach to the examination and treatment of neurological conditions such as:

• epilepsy;
• musculoskeletal disorders;
• disorders of consciousness;
• headache and migraine;
• dizziness and vertigo;
• muscle spasms, muscle pain and muscle weakness;
• polyneuropathies;
• cranial nerve injuries, nerve damage or compression syndromes such as carpal tunnel syndrome, and lesions of the nerve roots and plexuses (radicular syndrome),
• herniated intervertebral disc;
• diseases of the spinal cord (myelopathies);
• amyotrophic lateral sclerosis (ALS);
• movement disorders of various aetiologies, such as Parkinson's disease, dystonia and stroke;
• chronic inflammatory diseases of the central nervous system;
  dementia.

Epilepsy and seizure disorders: the importance of an accurate diagnosis and consistent treatment

Epilepsy is a very common neurological condition made up of a heterogeneous group of disorders with widely differing origins. Their main symptom is epileptic seizures, which vary in presentation depending on the severity of the disease and have a considerable impact on patients' everyday lives. In the worst case, severe epileptic seizures can be fatal; they become a heavy burden on health and on social participation. But even more pronounced seizures can seriously interfere with patients' schooling, work and personal lives.

Epilepsy is not a uniform group of diseases but rather a large group of disorders of the central nervous system accompanied by epileptic seizures. Genetic predisposition plays a certain role in their development. Depending on the type of predisposition, patients with a susceptibility to epilepsy will sooner or later experience their first epileptic seizure. Once the genetic nature of the disease has been established, personalised therapy is developed; patients who wish to have children require special counselling. In addition to epileptic seizures proper, there are conditions with seizure-like disturbances that are not caused by epilepsy. These include certain motor disturbances, fainting and psychiatric illnesses. Establishing the differential diagnosis is often very difficult.

In Germany alone more than 600,000 people suffer from epilepsy, and every year the condition is diagnosed in around 40,000 people of all ages. Around 200,000 cases are considered difficult to treat. As a rule, these patients have drug-resistant forms of epilepsy and therefore require specialised diagnostics and therapy.

At the «Beta Neurology» expert epilepsy centre the causes of this chronic disorder of the central nervous system are studied in detail, differential diagnosis is carried out and an individual form of therapy is developed for patients of all age groups.

The «Beta Neurology» expert epilepsy centre is headed by Professor Dr. med. Christian Elger, a highly experienced epileptologist with an outstanding reputation, who has many years of experience in the study and treatment of epilepsy as head of one of the best-known research and treatment institutions — the Department and Outpatient Clinic of Epileptology at the University Hospital Bonn. In 2018, together with Dr. med. Thomas Gasser and Dr. med. Axel Jung, he founded the «Beta Neurology» expert epilepsy centre, where Professor Elger took over the medical directorship.

In Germany alone more than 600,000 people suffer from epilepsy, and every year the condition is diagnosed in around 40,000 people of all ages. Around 200,000 cases are considered difficult to treat. As a rule, these patients have drug-resistant forms of epilepsy and therefore require specialised diagnostics and therapy.

At the «Beta Neurology» expert epilepsy centre the causes of this chronic disorder of the central nervous system are studied in detail, differential diagnosis is carried out and an individual form of therapy is developed for patients of all age groups.

The range of therapeutic services of the «Beta Neurology» centre:

• treatment of drug addiction;
• ketogenic diet;
• MRI-guided laser ablation technology using VisualaseTM;
• epilepsy surgery (in cooperation with the neurosurgery department of the University Hospital Bonn);
• vagus nerve stimulation;
• treatment of autoimmune diseases associated with epilepsy;
• treatment of epilepsy in patients with tuberous sclerosis;
• treatment of epilepsy in patients with other neurological disorders, for example migraine.

All the preoperative diagnostics required when epilepsy surgery is indicated are carried out in close cooperation with the neurosurgeons at Beta Klinik; the implantation of stereotactic electrodes, for example, calls for the precise localisation of the epileptic focus.

Thanks to close cooperation with the BetaGenese rehabilitation unit, which is also located on the Beta Klinik campus, patients with psychogenic non-epileptic seizures in particular can receive excellent psychosomatic and epileptological treatment at the same time.
Interdisciplinary work and close cooperation between the various medical units at Beta Klinik make it possible to diagnose and treat epilepsy in a multimodal and personalised way.

Diagnosis of epilepsy

Today epilepsy is one of the most treatable neurological diseases. In most cases — approximately two thirds — complete freedom from seizures is achieved with drug therapy, which can usually be found at the first or second attempt.

In one third of cases the condition persists despite several attempts to find a suitable drug therapy. In about 20% of the patients in this group, epilepsy surgery is effective. If surgical treatment of epilepsy is not possible, or if the patient declines it, vagus nerve stimulation is indicated — a procedure that became available several years ago.

Apart from the ketogenic diet, other treatment strategies such as naturopathy, acupuncture, homeopathy and psychotherapy lack the necessary evidence of effectiveness.

Preoperative diagnostics in epilepsy

Functional diagnostics to determine the location of the epileptic focus are performed using the following methods:

• routine and long-term video-EEG monitoring (a method of recording the electrical activity of the cerebral cortex), including video recording, in order to measure focal spike-and-wave complexes or asymmetrical slow waves that indicate the presence of an epileptic focus and its location;
• MRI of the brain to visualise the structure of the brain and possible epileptogenic lesions;
• SISCOM: an established imaging procedure that shows the regional increase in metabolism associated with the onset of an epileptic seizure (the SISCOM method / Subtraction Ictal SPECT Co-Registered to MRI is used as an adjunct in cases where MRI fails to reveal an obvious cause of the pathological activity. Another important purpose of the SISCOM protocol is the precise preoperative mapping of the area of the brain that is to be operated on. The high accuracy with which the pathological focus is identified makes it possible to find the site into which the invasive electrodes that suppress epileptic seizures will subsequently be inserted, and to determine their direction.);
• FDG-PET positron emission tomography: a rarely used method of imaging reduced metabolic activity in the seizure focus (FDG-PET is able to show reduced metabolism in areas close to epileptogenic zones and has high sensitivity and specificity for epileptogenic foci in patients with inconclusive findings);
• electrocorticography: a method of functional investigation of the cerebral cortex that involves recording its biopotentials using implanted electrodes placed directly on its surface.

Investigations to delineate the adjacent functional areas of the brain are carried out using:

• functional MRI of language to localise the speech area of the cerebral cortex, which can sometimes replace the Wada test, also known as BOLD functional magnetic resonance imaging (BOLD — blood oxygenation level dependent contrast, i.e. contrast that depends on the degree of oxygen saturation of the blood; BOLD fMRI is one of the most widely used and best-known ways of measuring brain activity; activation leads to an increase in local blood flow with a change in the relative concentration of oxygenated (oxygen-rich) and deoxygenated (oxygen-poor) haemoglobin in the local blood flow);
• the Wada test or Wada procedure: the lateralising intracarotid Wada test with amobarbital (the intracarotid amobarbital test), which involves briefly inactivating (switching off) each cerebral hemisphere in turn, making it possible to determine the dominant location of the patient's speech and memory areas and to predict the functional losses and reserves of the patient's cerebral hemispheres; although modern non-invasive methods of determining the lateralisation of speech and memory, such as functional MRI of the brain and bilateral simultaneous carotid Doppler ultrasound, are increasingly being introduced into clinical practice, they are not yet the «gold standard» for predicting functional impairment in neurosurgical procedures;
• cortical electrical stimulation: direct electrical stimulation of the cerebral cortex to identify the functions located close to the epileptic focus.

Standardised neuropsychological tests are used to document the patient's baseline neuropsychological status, so that it can be monitored and regularly tracked during the postoperative follow-up. Monitoring the patient's neuropsychological profile (a set of standard parameters) provides important information about impairment of brain function.
A comprehensive preoperative work-up helps to plan the further surgical strategy carefully and to avoid postoperative complications.

Therapy

Surgical treatment of epilepsy

Removing the brain tissue responsible for the development of seizures and disconnecting the nerve fibres along which seizure discharges spread are safe techniques with proven effectiveness.

In the context of preoperative epilepsy diagnostics, doctors need to answer the following questions:

• is the diagnosis of "epilepsy" correct?
• is the diagnosis of "drug-resistant epilepsy" correct?
• can freedom from seizures be achieved surgically?
• is it possible to determine the epileptic focus precisely?
• will the operation harm other brain functions?
• how do the chances of success of surgical treatment and its risks compare with non-surgical therapy?

Once the examination programme has been completed, its results are discussed in detail with the patient and their family, so that a well-founded and balanced decision can be made about whether surgery is possible or contraindicated.

All diagnostic procedures in preparation for surgery, including the implantation of a stereotactic electrode to localise the epileptic focus, are performed in close cooperation with the neurosurgery department of Beta Klinik. The gentlest operation available today is the unique MRI-guided laser ablation of the pathological focus.

Since February 2015 the European project "e-pilepsy.eu" has offered detailed information on epilepsy surgery for specialists and patients.Surgical treatment of epilepsy

Surgical treatment of drug-resistant epilepsies. Possible strategies:

1. anterotemporal lobectomy / anterior temporal lobectomy (surgical removal of the anterior temporal lobe for therapeutic purposes);

2. hippocampectomy / limited temporal resection — selective resection of the hippocampus and of the amygdala located in the medial part of the temporal lobe.

Both procedures are used in drug-resistant temporal lobe epilepsy with the focus in the anterior part of the temporal lobe. When the epileptic focus lies in the mesial structures, which is the case in 80% of temporal lobe epilepsies, a selective amygdalohippocampectomy is performed, or a combination of it with temporal lobectomy. Complications of temporal resection may include moderate short-term memory impairment, loss of 1/4 of the visual field and others. Up to 70% of operated patients become completely free of seizures, and 10% report a significant reduction in seizure frequency.

3. palliative callosotomy, which involves dividing the corpus callosum (the structure responsible for «connecting» the right and left cerebral hemispheres) and is indicated for patients with generalised seizures and bilateral independent epileptic foci in the frontal lobes, as well as for patients with frequent epileptic seizures such as «drop attacks» — brief seizures in which the patient loses muscle tone and falls to the floor; callosotomy prevents the rapid spread of seizure activity from one half of the brain to the other;

4. combined resection and disconnection procedures;

5. extratemporal neocortical resection;

6. vagus nerve stimulation with implantable devices

7. multiple subpial transections / multiple subpial incisions. Multiple subpial incisions involve making vertical cuts around the focus of epileptic activity. They are used when the focus itself cannot be removed, for example when it is located in the speech area or in the motor cortex. Under certain conditions they can be an alternative to resection. Cutting the nerve fibres vertically makes the horizontal spread of pathological impulses impossible. At the same time the vertical cortical connections are preserved and no pronounced neurological disorders occur. After the procedure a temporary neurological deficit is observed, which resolves within a few weeks. The effectiveness of multiple subpial incisions reaches 70%.

8. hemispherectomy is used to treat epilepsy 20 times less often than temporal resection and proves effective in 2/3 of cases. ;

9. focal resection involves removing the source of the pathological impulses together with a thin layer of the adjacent cerebral cortex. As a rule, the source is a focal lesion of the cortex — an area of atrophy or dysplasia, a tumour, a cyst or a cavernous angioma. If the source of the epileptic activity is the area around the pathological region of the cortex, an extended resection is required. Focal resection is used when the location of the focus is clearly defined and it can be removed without significant damage to a functionally important cortical area.
After focal resection, 55-65% of patients with epilepsy show a reduction in seizure frequency or the complete disappearance of seizures.
Focal forms of epilepsy are amenable to classic block resection and occur in 1/20 of patients with epilepsy and in 1/3 of patients with a drug-resistant form of the disease.

In major surgical procedures the indicated approach is not the resection of tissue together with the blood vessels supplying it, but the disconnection of nerve pathways: lobotomy, hemispherotomy or functional hemispherectomy, namely:

• disconnection (damage to the long nerve fibres connecting different brain structures;
• callosotomy;
• multiple subpial incisions (vertical cuts in the cerebral cortex without the removal of tissue).

Vagus nerve stimulation

The vagus nerve innervates the organs of the head, neck, chest and abdominal cavity and provides:

• motor innervation of the muscles of the soft palate, the pharynx and the larynx, as well as of the striated muscles of the oesophagus;
• parasympathetic innervation of the smooth muscle of the lungs, oesophagus, stomach and intestines, and of the heart muscle; it also influences the secretion of the gastric and pancreatic glands;
• sensory innervation of the mucous membrane of the lower part of the pharynx and of the larynx, of an area of skin behind the ear and part of the external auditory canal, of the eardrum and of the dura mater of the posterior cranial fossa.

In essence, the nerve provides the connection between the heart, neck, lungs and abdominal cavity and the brain. This signalling pathway is used for vagus nerve stimulation: the vagus nerve can be isolated very well in the neck, where the electrodes can be securely attached. The cable is connected under the skin to a pulse generator implanted in the chest wall and works like a cardiac pacemaker. The stimulator regularly sends signals to the vagus nerve (for example, every 5 minutes for 30 seconds), which has numerous connections throughout the brain.

Worldwide, vagus nerve stimulators have been implanted in approximately 45,000 patients with epilepsy, most of whom live in the USA. In Germany about 700 vagus nerve stimulators have been implanted, 200 of them in Bonn.

In approximately 40-50% of patients there is a stable and lasting reduction in seizure frequency (by at least half).
Vagus nerve stimulation also significantly improves the quality of life and the emotional well-being of many patients. However, complete freedom from seizures is achieved in at most 10% of cases. On the whole, the vagus nerve stimulation procedure itself is well tolerated by patients, apart from some hoarseness of the voice during the stimulation phase.

Treatment with vagus nerve stimulation is suitable only for patients with severe forms of drug-resistant epilepsy for whom surgery is not indicated or whose chances of success are not high enough.

Deep brain stimulation

Since 2010 a new method of therapy has become available for the treatment of epilepsy that is difficult to control — deep brain stimulation (hereinafter DBS / Deep Brain Stimulation).

DBS has long been used with great success in other neurological diseases (Parkinson's disease, essential tremor, dystonia).

Deep brain stimulation is particularly suitable in cases where epilepsy is difficult to treat, i.e. where various drugs have failed to reduce the number of seizures and epilepsy surgery is impossible or has not been successful.

Drug treatment of epilepsy

A correct diagnosis of the epilepsy syndrome – is the most important prerequisite for successful drug therapy. In many cases the very first or second attempt, using one drug as monotherapy or two drugs in combination, proves successful. The dose must be chosen so that, on the one hand, the drug protects effectively against seizures and, on the other hand, side effects are kept to a minimum. It is precisely side effects that are often the reason for discontinuing drug therapy.

Adjustments to drug therapy are almost always made on an outpatient basis; only in individual cases is inpatient treatment recommended. The dose must never be changed without consulting a doctor. In particular, abruptly stopping medication — for example because of side effects — can be very dangerous.

For women of childbearing age, planning a pregnancy inevitably raises many questions related to the medication they take, which need to be discussed with a specialist.

Below is a list of the active substances of the drugs and their trade names:

• Barbexaclone – Maliasin (Phenobarbital + Levopropylhexedrine) – in use until the end of 2004
• Carbamazepine – carba, Carbagamma, Carbium, Carbamazepin, Finlepsin, Fokalepsin, Sirtal, Tegretal, Timonil
• Clobazam – Frisium
• Clonazepam – Antelepsin, Rivotril
• Diazepam – diazep, Diazepam, faustan, Lamra, Stesolid, Tranquase, Valiquid, Valium, Valocordin
• Ethosuximide – Petnidan, Pyknolepsinum, Suxilept, Suxinutin
• Felbamate – Taloxa
• Gabapentin – Neurontin
• Potassium bromide – dibro-Be
• Lamotrigine – Lamictal
• Levetiracetam – Keppra
• Mesuximide – Petinutin
• Oxcarbazepine – Trileptal
• Phenobarbital – Fali-Lepsin, Lepinal, Luminal, (Maliasin – in use until the end of 2004)
• Phenytoin – Zentropil, Phenhydan, Epanutin, Phenytoin AWD
• Pregabalin – Lyrica
• Primidone – Liskantin, Mylepsinum, Resimatil
• Retigabine – Trobalt
• Sultiame – Ospolot
• Tiagabine – Gabitril
• Topiramate – Topamax
• Valproic acid/valproate – Convulex, Convulsifin, Ergenyl, Leptilan, Myproin, Orfiril
• Vigabatrin – Sabril
• Zonisamide – Zonegran

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