Diagnosis and Treatment of Epilepsy Marcelo E. Lancman, M.D. Director, Epilepsy Program NEREG

Referrals Comprehensive Epilepsy Center Evaluation: ●History/Exam ●EEG ●Imaging Controlled Not Controlled Video-EEG Non-epileptic Events Epilepsy Medical Management Surgical Management Refer

Epilepsy and Seizures What is epilepsy? What is epilepsy? What is a seizure? What is a seizure?

Incidence Epilepsy Epilepsy0.5-1% Seizures Seizures 5-10%

Classification Partial PartialSimpleComplex Generalized Generalized Absence Atonic Clonic Tonic Tonic-clonic Myoclonic

Evaluation…A Team Approach Initial intake by epileptologist Initial intake by epileptologist –Patient/family history –Physical exam –Review of records

Plan to include… Testing Testing –EEG, labs Imaging Imaging –MRI, CT

Diagnosis and Control Diagnosis is clear Diagnosis is clear Patient placed on anti-epileptic drug appropriate for type of epilepsy Patient placed on anti-epileptic drug appropriate for type of epilepsy

The Poorly Controlled, Intractable Seizure Patient Despite medical management, patient continues to have frequent, debilitating seizures Despite medical management, patient continues to have frequent, debilitating seizures Commonly on polytherapy (more than one medication) Commonly on polytherapy (more than one medication)

Video-EEG Monitoring Continuous EEG monitoring along with continuous audio-video taping Continuous EEG monitoring along with continuous audio-video taping Requires inpatient admission Requires inpatient admission

Goals of Video-EEG Monitoring Epilepsy vs. non- epileptic events Epilepsy vs. non- epileptic events Characterize epilepsy type Characterize epilepsy type Pre-surgical evaluation Pre-surgical evaluation

Non-Epileptic Events 20 to 30% of patients referred with diagnosis of intractable epilepsy 20 to 30% of patients referred with diagnosis of intractable epilepsy Events that do not have electrical source in brain Events that do not have electrical source in brain May have physical or psychological causes that are not epilepsy May have physical or psychological causes that are not epilepsy But CAN also occur in patients who have epilepsy But CAN also occur in patients who have epilepsy

Non-epileptic events Physiologic (other medical conditions) Physiologic (other medical conditions) –Referred to other medical specialist Psychological or pseudoseizures Psychological or pseudoseizures –Referred to psychiatry and neuropsychologist who work with this type of stress-seizure –Psychiatric medication, psychotherapy, education

Brief history of epilepsy treatment 1912: phenobarbital 1912: phenobarbital 1924: EEG began to be used 1924: EEG began to be used All of the treatments we will discuss today have only come about in the last 80 years All of the treatments we will discuss today have only come about in the last 80 years

Medications Choices based on epilepsy type, patient profile, side effect profile, cost Choices based on epilepsy type, patient profile, side effect profile, cost Best to have patient on single antiepileptic drug (AED) Best to have patient on single antiepileptic drug (AED) May need polytherapy (combination of medications) May need polytherapy (combination of medications) Adding meds requires going up slowly with the new agent before discontinuing previous drug Adding meds requires going up slowly with the new agent before discontinuing previous drug Polytherapy requires deep knowledge of interactions Polytherapy requires deep knowledge of interactions

“Old Reliables” Carbamazepine (Tegretol) Carbamazepine (Tegretol) Phenobarbital Phenobarbital Ethosuximide (Zarontin) Ethosuximide (Zarontin) Phenytoin (Dilantin/Cerebyx) Phenytoin (Dilantin/Cerebyx) Valproic acid (Depakote) Valproic acid (Depakote) Primidone (Mysoline) Primidone (Mysoline)

Newer AED’s Gabapentin (Neurontin) Gabapentin (Neurontin) Lamotrigine (Lamictal) Lamotrigine (Lamictal) Topiramate (Topamax) Topiramate (Topamax) Felbamate (Felbatol) Felbamate (Felbatol) Diastat (Diazepam) Diastat (Diazepam) Tiagabine (Gabitril) Tiagabine (Gabitril) Pregabalin (Lyrica) Pregabalin (Lyrica) Zonisamide (Zonegran) Zonisamide (Zonegran) Levetiracetam (Keppra) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Oxcarbazepine (Trileptal) Rufinamide (Banzel) Rufinamide (Banzel)

Medication choices based on epilepsy type…

AED’s for Partial Epilepsy Tegretol Tegretol Dilantin Dilantin Depakote Depakote Neurontin Neurontin Lamictal Lamictal Phenobarbital Phenobarbital Pregabalin Pregabalin Keppra Keppra Topamax Topamax Gabitril Gabitril Zonegran Zonegran Trileptal Trileptal Mysoline Mysoline

Best AED’s for Generalized Epilepsy Depakote Depakote Lamictal Lamictal Topamax Topamax Zonegran Zonegran Keppra Keppra Rufinamide Rufinamide

How to use polytherapy rationally Pharmacodynamics (what the medication does to the body) Pharmacodynamics (what the medication does to the body) Pharmacokinetics Pharmacokinetics (what the body does to the medications) (what the body does to the medications) –Absorption –Distribution –Elimination Half life Half life Liver Liver Kidneys Kidneys

How to use polytherapy rationally Side effects Side effects –Dose-related –Idiosyncratic (each person is different)

For patients that do not respond to medication Ketogenic diet Ketogenic diet Vagus nerve stimulator Vagus nerve stimulator Epilepsy surgery Epilepsy surgery

Ketogenic Diet High fat, low carbohydrate/protein diet High fat, low carbohydrate/protein diet Requires hospitalization to start it Requires hospitalization to start it –NPO until patient in ketosis –Parent education –Meds to be taken into account Recommended mainly for young children due to compliance and efficacy Recommended mainly for young children due to compliance and efficacy

Epilepsy Surgery The goals are: The goals are: –To determine where the seizures are coming from –To make sure is safe

Epilepsy Surgery To determine where the seizures are coming from To determine where the seizures are coming from Video-EEG monitoring MRI MRS: PET: SPECT:

EEG Slide /ROUTINE

Epilepsy Surgery To make sure that it is safe To make sure that it is safe Wada test: to study speech and memory Neuropsychological testing: mental functions (IQ, memory, attention) and personality assessment Psychological evaluation Ophthalmologic evaluation

Epilepsy Surgery Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES –Depth electrodes –Subdural electrodes

Types of Epilepsy Surgery Temporal Lobectomy Temporal Lobectomy Extratemporal Resections Extratemporal Resections Hemispherectomy Hemispherectomy Corpus Callosotomy Corpus Callosotomy

Outcome after epilepsy surgery Anterior temporal lobectomy Anterior temporal lobectomy –70-80% seizure free Neocortical resection Neocortical resection –With lesion: 50-80% seizure free –Without lesion: 30-50% seizure free Hemispherectomy Hemispherectomy –Significant improvement Corpus Callosotomy Corpus Callosotomy –Significant improvement for drop attacks

Complications of surgery Low rate of complications Low rate of complications –Infections –Bleeding –Anesthesia –Function

Vagus Nerve Stimulator (1997) Intractable epilepsy patient without focus or desires interim step before epilepsy surgery Intractable epilepsy patient without focus or desires interim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. cure Goal is to reduce amount/severity of seizures vs. cure Device surgically implanted in left chest/axilla area Device surgically implanted in left chest/axilla area Coils around left vagus nerve Coils around left vagus nerve Stimulation is automatic; patient can additionally stimulate device if aura Stimulation is automatic; patient can additionally stimulate device if aura

Summary Ways to treat epilepsy Ways to treat epilepsy –Medications –Ketogenic Diet –Surgery –Vagus nerve stimulator