Comprehensive and Innovative Care for Epilepsy
Manoj Raghavan, MD, PhDMedical College of Wisconsin Neurologist;
Director, Comprehensive Epilepsy Program
Epilepsy is a serious neurological disorder that affects more than 2.5 million Americans. The disease is characterized by abnormal electrical activity in the brain, which causes seizures. But with appropriate treatment, these seizures can be greatly reduced and even eliminated in many patients. Manoj Raghavan, MD, PhD, describes the Comprehensive Epilepsy Program at Froedtert & Medical College of Wisconsin and the treatment options the program offers.
Q. What is the Comprehensive Epilepsy Program's approach to treating this condition?Our program is one of the few in the country providing comprehensive, individualized care for people with epilepsy. We take a multi-disciplinary, team approach in evaluating and treating patients and address not only patients’ seizures, but also aspects of their lives that might be affected by epilepsy, such as social and workplace challenges. Our treatment options follow evidence-based guidelines, so patients know they’re getting the best care available. Our team includes neurologists, neurosurgeons, neuropsychologists, brain imaging specialists, nurses, social workers and EEG technicians.
Each patient's symptoms, seizure history and prior medical care are carefully evaluated at the time of the initial visit to our clinic. An epileptologist — a neurologist who specializes in epilepsy — reviews this information with each patient and discusses all possible diagnostic and treatment options available. Additional diagnostic studies recommended may include Video-EEG monitoring to characterize the patient’s seizures, magnetic resonance imaging (MRI), other brain imaging tests such as SPECT (Single Photon Emission Tomography) or PET (Positron Emission Tomography), and blood tests to check medical levels. The purpose of these tests may differ from patient to patient. Sometimes these tests may be required to confirm the diagnosis of epilepsy or establish the type of epilepsy a patient has in order to allow the epileptologists to determine the appropriate treatment option for each person. In some patients, these tests may help determine where their seizures arise from in the brain, and whether they would benefit from surgical treatment. The currently approved treatment options include optimal use of anti-epileptic medications, epilepsy surgery to remove the part of the brain causing seizures, and implanting a Vagus Nerve Stimulator — a tiny device that sends electrical pulses to the brain in order to prevent seizures.
Q. Can epilepsy be successfully treated with medication?Medications remain the first line of treatment for epilepsy. In the last decade alone, several new medications have become available for treating epilepsy. We strive to find the drugs or drug-combinations that yield the best seizure control with the least amount of side effects. Over 60 percent of all epilepsy patients may achieve full control of their seizures on one or two epilepsy medications. However, medications may fail to fully control seizures in up to 35 percent of patients with epilepsy. These are patients with what is often referred to as “drug-resistant epilepsy”. If patients continue to experience seizures despite adequate trials of three or more different anti-epileptic medications, they should consult an epilepsy specialist to determine whether alternative treatments such as the epilepsy surgery or implantation of a Vagus Nerve Stimulator should be considered.
Q. What is epilepsy surgery and how does it help patients?The Comprehensive Epilepsy Program at the medical College of Wisconsin was one of the first facilities in Wisconsin to offer surgery as a treatment option for patients with drug-resistant epilepsy. We now perform more than 30 such procedures each year at Froedtert. Surgery is an option only for patients who suffer from “partial” epilepsy. In these patients, the seizures always start from one region of the brain. Although there may often be some structural abnormality in this region of the brain which can be visualized on MRI, this is not always the case. However, if this electrically abnormal region can be located with certainty, one could remove it surgically. Locating the region of the brain causing the seizures is accomplished using tests such as Video-EEG monitoring, brain scans such as SPECT or PET, or in some instances by recording brainwaves directly from the surface of the brain. Before surgery, it is also important to know where important brain functions such as language and memory are located. This can be determined using a test called the Wada test. This test is usually able to determine which half of the brain contains language areas and how well each half of the brain deals with memory related functions.
The nature of the surgery itself depends on how precisely the epileptic region of the brain has been located beforehand, and how close it is to areas that handle important brain functions. If recording of EEG from the surface of the brain is required to pinpoint the epileptic region, the surgery is performed in two sessions or “stages” separated by a few days: In the first surgery the patient undergoes implantation of recording electrodes on the surface of the brain. Seizures are then recorded using these electrodes to determine the precise area from where they start. The same electrodes are then used to apply small electrical currents to different locations of the brain to electrically “map” out the location of critical brain functions. In the second stage of surgery, the location where seizures start from is removed keeping in mind the results of the electrical mapping procedure.
Sometimes, the surgery can be done in a single stage and electrically mapping of brain functions may not be necessary. If mapping of critical areas is required, “awake” surgery is often performed: While in surgery, the patient is woken up from anesthesia and responds to questions during the procedure. The required electrical mapping and removal of the epileptic areas of the brain is completed in one surgical session.
Surgery is the only treatment that can potentially cure a patient of partial epilepsy — its feasibility should be explored in all patients with drug resistant partial epilepsy. The majority of patients who undergo epilepsy surgery experience complete freedom from seizures, while others may experience a significant enough reduction in seizures that they can reduce their medications.
Q. What is Vagus nerve stimulation and when is it an appropriate treatment option?
This treatment involves the surgical implantation of an electrical device under the skin on the left side of the chest — somewhat like a cardiac pacemaker. The device produces an intermittent electrical signal to the Vagus nerve in the left side of the neck which carries these pulses to the brain. For reasons that aren’t fully understood yet, this device can provide very significant seizure reduction in many patients. Additionally, when patients or witnesses realize a seizure is about to occur, they can use a magnet to activate the stimulator and “block” the seizure. One benefit of Vagus nerve stimulation is that it does not produce many of the side effects that medications sometimes cause. Vagus nerve stimulation may be appropriate when medications are ineffective, when surgery is not an option or is not preferred by the patient, or when surgery has failed to fully control seizures.
Q. Are additional methods for treating epilepsy currently being researched?There are a variety of ongoing research initiatives examining epilepsy to help us better understand what causes this disease and how it can be better treated. Froedtert & Medical College of Wisconsin is involved in many of these initiatives including clinical trials of new drugs to treat seizures. At Froedtert & Medical College we have an ongoing interest in advanced brain imaging techniques that not only help locate where partial seizures begin, but also identify functional areas of the brain. These techniques could potentially become standard tools to evaluate patients for epilepsy surgery in the future. We are also currently developing a research protocol for a novel type of experimental treatment involving a pacemaker like device that stimulates deep locations in the brain to control seizures.
Author: Manoj Raghavan, MD, PhD
Source: Every Day
Date: May-August 2005