Diagnosis and Treatment of Epilepsy

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Diagnosis and Treatment of Epilepsy

• Marcelo E. Lancman, M.D.
• Director, Epilepsy Program
• NEREG

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

• What is epilepsy?
• What is a seizure?

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Incidence

• Epilepsy
• 0.5-1

• Seizures
• 5-10

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Classification

• Partial
• Simple
• Complex

• Generalized
• Absence
• Atonic
• Clonic
• Tonic
• Tonic-clonic
• Myoclonic

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EvaluationA Team Approach

• Initial intake by epileptologist
• Patient/family history
• Physical exam
• Review of records

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Plan to include

• Testing
• EEG, labs
• Imaging
• MRI, CT

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Diagnosis and Control

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

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The Poorly Controlled, Intractable Seizure Patient

• Despite medical management, patient continues to
  have frequent, debilitating seizures
• Commonly on polytherapy (more than one medication)

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Video-EEG Monitoring

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

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Goals of Video-EEG Monitoring

• Epilepsy vs. non-epileptic events
• Characterize epilepsy type
• Pre-surgical evaluation

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Non-Epileptic Events

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

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Non-epileptic events

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

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Brief history of epilepsy treatment

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

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Medications

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

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Old Reliables

• Carbamazepine (Tegretol)
• Phenobarbital
• Ethosuximide (Zarontin)

• Phenytoin (Dilantin/Cerebyx)
• Valproic acid (Depakote)
• Primidone (Mysoline)

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Newer AEDs

• Gabapentin (Neurontin)
• Lamotrigine (Lamictal)
• Topiramate (Topamax)
• Felbamate (Felbatol)
• Diastat (Diazepam)

• Tiagabine (Gabitril)
• Pregabalin (Lyrica)
• Zonisamide (Zonegran)
• Levetiracetam (Keppra)
• Oxcarbazepine (Trileptal)
• Rufinamide (Banzel)

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Medication choices based on epilepsy type
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AEDs for Partial Epilepsy

• Tegretol
• Dilantin
• Depakote
• Neurontin
• Lamictal
• Phenobarbital
• Pregabalin

• Keppra
• Topamax
• Gabitril
• Zonegran
• Trileptal
• Mysoline

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Best AEDs for Generalized Epilepsy

• Depakote
• Lamictal
• Topamax
• Zonegran
• Keppra
• Rufinamide

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How to use polytherapy rationally

• Pharmacodynamics (what the medication does to the
  body)
• Pharmacokinetics
• (what the body does to the medications)
• Absorption
• Distribution
• Elimination
• Half life
• Liver
• Kidneys

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How to use polytherapy rationally

• Side effects
• Dose-related
• Idiosyncratic (each person is different)

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For patients that do not respond to medication

• Ketogenic diet
• Vagus nerve stimulator
• Epilepsy surgery

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Ketogenic Diet (_at_1920)

• High fat, low carbohydrate/protein diet
• 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

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Epilepsy Surgery

• The goals are
• To determine where the seizures are coming from
• To make sure is safe

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Epilepsy Surgery

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

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EEG Slide
99-10-31/ROUTINE
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Epilepsy Surgery

• 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

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Epilepsy Surgery

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

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Types of Epilepsy Surgery

• Temporal Lobectomy
• Extratemporal Resections
• Hemispherectomy
• Corpus Callosotomy

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Outcome after epilepsy surgery

• Anterior temporal lobectomy
• 70-80 seizure free
• Neocortical resection
• With lesion 50-80 seizure free
• Without lesion 30-50 seizure free
• Hemispherectomy
• Significant improvement
• Corpus Callosotomy
• Significant improvement for drop attacks

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Complications of surgery

• Low rate of complications
• Infections
• Bleeding
• Anesthesia
• Function

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Vagus Nerve Stimulator (1997)

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

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Summary

• Ways to treat epilepsy
• Medications
• Ketogenic Diet
• Surgery
• Vagus nerve stimulator