Froedtert Today

June 2006 Issue

No More Lost Moments

Of the estimated 2.7 million people in this country who have epilepsy, more than 100,000 live in Wisconsin. Epilepsy — a disorder of the brain that makes people susceptible to seizures — affects all races, ages and ethnicities.

Living with epilepsy is a different challenge for each person. The Comprehensive Epilepsy Program at Froedtert & the Medical College of Wisconsin is one of the few programs in the country offering a multidisciplinary approach to care, helping people with epilepsy live as normally as possible.

Following a comprehensive evaluation that led to successful surgery, seizures are now a thing of the past for 39-year-old Jennifer Seel from Bonduel,Wisconsin. Although Jennifer lived with seizures from the time she was born, they didn’t really interfere with her life — until the last few years. Jennifer and her husband, James, operate a 225-cow dairy farm in Bonduel, near Shawano.

“I’ve had seizures about every other day for as long as I can remember,” she said. “They were mostly simple partial seizures that lasted up to 30 seconds. When I was older, sometimes I would have three or four seizures a day when it was closer to my monthly period.”

“About 60 percent of women with epilepsy experience increased seizure frequency around menstruation and ovulation,” Romila Mushtaq, MD, Medical College of Wisconsin epileptologist said. “That’s because there’s a dynamic relationship between hormones and seizures for women. The balance of estrogen and progesterone in a woman’s body greatly affects the frequency of seizures. These hormonal changes cause greater health challenges for women with seizures during puberty, the onset of menstruation, pregnancy and menopause.”

There are two main types of epilepsy:

In primary generalized epilepsy, electrical changes in the brain that accompany seizures start all across the brain simultaneously. No single area of the brain is responsible for producing these seizures and they typically occur without warning. A person may stare, lose consciousness, fall to the floor, have jerking movements or become stiff.
In partial epilepsy, electrical changes start in one part of the brain and may spread to other areas over the course of seconds. There may be a warning the seizure is coming. The person has a blank stare and is not aware of his or her surroundings during the seizure. The seizures are called simple partial seizures if consciousness is retained, and complex partial seizures if consciousness is impaired. Seizure activity during a simple partial seizure can spread to other parts of the brain, leading to a complex partial seizure, or a new secondary generalized seizure.

Jennifer had simple and complex partial seizures, some of which would progress to generalized convulsions. She usually knew when a seizure was about to begin. “I had a tightening in my stomach and tingling up and down my spine,” she said, “I had a stroke before I was born, which is thought to be the cause of my seizures.” Since childhood, Jennifer had been taking Dilantin, an anti-epileptic medication.

Seizures Changed

Jennifer used to experience a secondary generalized seizure about once every two years, but in recent years, they began to occur more often. “In 2004, I had three generalized seizures and each time, my husband had to call an ambulance. I would become unconscious and keep seizing. Afterwards, I had a headache.” These were lost moments in Jennifer’s life. In early 2004, she had to give up driving and relied on her husband to get around.

Gizell Larson, MD, Jennifer’s neurologist in Neenah,Wisconsin, conducted an MRI scan that showed a smaller temporal lobe and scar tissue on the left side of her brain. Dr. Larson placed Jennifer on a slow release form of Dilantin to see if her seizures would respond to maximizing the medication she was already on. As time passed, however, it was apparent to Dr. Larson that Jennifer’s seizures were unlikely to respond fully to medications alone

Surgery Considered

Surgery may be an option for people with epilepsy whose seizures are disabling and/or are not controlled by medication. In October 2004, Dr. Larson referred Jennifer to the Comprehensive Epilepsy Program at Froedtert & the Medical College of Wisconsin to be evaluated.

The Comprehensive Epilepsy Program was one of the first in Wisconsin to offer surgery as an option for patients with drug-resistant epilepsy. The program offers state-of-the-art diagnostic technologies for patients with seizures that can’t be controlled with anti-epileptic medications alone.

“More than 60 percent of people with new onset of epilepsy respond well to medication,” Manoj Raghavan, MD, PhD, Medical College of Wisconsin epileptologist and director of the Comprehensive Epilepsy Program said. “However, about 35 percent of patients remain resistant to medication management. These patients may benefit from surgery or vagus nerve stimulation. Successful epilepsy surgery depends on selection of patients and our ability to identify the region of the brain that produces seizures. Before we can remove that area, we need to know if there are important brain functions located in the same area.”

Linda Allen, BSN, RN, Epilepsy Program coordinator, managed all of Jennifer’s testing. “Our goal is to improve patients’ overall quality of life. Ideally, we’d like to make them free of seizures without side effects,” Allen said.

“Linda did a good job informing me about what the procedures would be like and what to expect,” Jennifer said. Jennifer’s care began in October 2004 with a full evaluation and history. In November, she spent three days in the Epilepsy Monitoring Unit at Froedtert & the Medical College of Wisconsin. She underwent video-EEG monitoring to record her brain’s electrical activity and her behavior during seizures. The monitoring allows diagnosis of the type and location of a patient’s seizures. The test confirmed the suspicion that her seizures came from the left temporal region of the brain. After monitoring, Jennifer was started on Trileptal, one of the newer anti-seizure medications.

“When a patient has only been on an older drug such as Dilantin for a long period of time,we usually try one or two of the newer drugs at the maximum tolerated dosage before we determine the seizures are drug resistant,” Dr. Raghavan said.

In February 2005, Jennifer’s dose of Trileptal was increased. By May, she reported having almost daily simple partial seizures, but only one generalized seizure, which was a small improvement. It seemed unlikely medications alone would control her seizures fully. Dr. Raghavan gradually increased Trileptal doses, while reducing the Dilantin.The Dilantin was finally discontinued. He also requested a neuropsychological evaluation for Jennifer. This testing of different mental functions is done to determine what kind of deficits the patient has, and is required before surgery can be performed. Tests were performed by Sara Swanson, PhD, neuropsychologist in the Comprehensive Epilepsy Program.

Test results all indicated Jennifer’s seizures originated from her left temporal lobe. However, structures outside the temporal lobe were also abnormal as a result of the stroke she had before birth.

“Jennifer had significant weakness in her right arm since childhood, indicating old injuries in the frontal lobe as well,” Dr. Raghavan said. “She was having simple partial seizures about every other day, and more often around the time of her period. The frequency of her seizures was our main concern.”

From June to November, Jennifer continued to take Trileptal, but still experienced frequent simple and complex partial seizures. Another of the newer antiepileptic medications called Keppra was added. At this time, her team considered further evaluation for surgery appropriate.

“Regardless of whether we proceed to surgery or not, we optimize a patient’s medications, because there’s no guarantee surgery will fully eliminate seizures,” Dr. Raghavan said. “Even after successful epilepsy surgery, patients continue to take medication for at least a couple years before we consider reducing doses.”

Because consequences of uncontrolled seizures can be serious — even life-threatening — this intensive testing and monitoring process is especially critical to ensure treatment will be appropriate and as effective for each individual as possible. “If we can’t control the seizures,we need to be concerned about seizure-related injuries, progressive cognitive decline, increasing drug resistance — and the possibility of developing new areas in the brain that generate seizures,” said Dr. Raghavan. Uncontrolled epilepsy may also lead to status epilepticus, a life-threatening condition in which the brain is in a state of persistent seizure. Quality of life can be significantly impaired, with psychological and social effects that include anxiety, depression and restrictions on activities and employment.

In mid-October, Jennifer had a Wada test. During this test, a medication called Amytal is injected into blood vessels supplying the brain to put one side of the brain to sleep. By putting to sleep each half of the brain in turn, epilepsy specialists can find out which half is important for language and memory functions. “About 95 percent of people have language on the left side, but Jennifer’s pre-birth stroke caused language to develop on the other side. Her memory functions were also on the right side.This was a good thing,” Dr. Raghavan said.“We could do surgery on the left side without causing impairment of Jennifer’s language or memory.”

Two-Stage Surgery

In late October, the Comprehensive Epilepsy Program team concluded Jennifer was a candidate for a two-stage surgical procedure. In the first stage, special electrical contacts or “electrodes”would be placed over the region of the brain suspected to be causing her seizures, allowing her brain activity and one or two seizures to be recorded. This would allow the precise areas causing the seizures to be identified.The region of the brain being targeted for surgery could then be mapped by applying small currents to the electrodes and testing Jennifer’s functions at the same time. This would indicate important brain areas to avoid during surgery. The final step would be to remove the areas producing the seizures.

In November, Jennifer saw Medical College of Wisconsin Neurosurgeon Wade Mueller, MD, to discuss the surgery in detail, and Linda Allen for pre-surgical education. And in January 2006, Jennifer’s medical team began her complex surgical process.Over a period of days in the ICU, Jennifer was closely monitored to determine the part of her brain generating her seizures. Dr. Raghavan “mapped” the area for removal after making sure there was no functioning brain tissue there. Dr. Mueller then removed the targeted area.The last step was to place electrodes behind the area he had removed, where he discovered additional abnormal tissue. Once that was gone, Jennifer was on her way to a post-surgery life she calls “wonderful.”

Smooth Recovery

After eight days in the hospital, Jennifer returned home. “Life has been wonderful since my surgery, especially during the ‘female’ time of the month,” Jennifer said. “My pain has disappeared and I’m not as grouchy, because I’m not having seizures. My thought processes are clearer now.”

Jennifer’s last seizure was on December 28, 2005. On March 28, 2006, she began driving again. (Wisconsin law requires a person be seizure-free for three months to be eligible for a driver’s license.) For now, she continues to take Trileptal and Keppra — and she has no more lost moments.

Source: Froedtert Today

Date: June 2006