Diagnosis and Treatment of Diagnosis and Treatment of EpilepsyEpilepsy

Marcelo E. Lancman, M.D.Marcelo E. Lancman, M.D.Director, Epilepsy ProgramDirector, Epilepsy Program

NEREGNEREG

ReferralsComprehensive

EpilepsyCenter

Evaluation:●History/Exam

●EEG●Imaging

Controlled Not Controlled

Video-EEG

Non-epilepticEvents

Epilepsy

MedicalManagement

SurgicalManagementRefer

Epilepsy and SeizuresEpilepsy and Seizures

What is epilepsy?What is epilepsy?

What is a seizure?What is a seizure?

IncidenceIncidence

EpilepsyEpilepsy

0.5-1% 0.5-1%

SeizuresSeizures

5-10%5-10%

ClassificationClassification

PartialPartialSimpleSimpleComplexComplex

GeneralizedGeneralizedAbsenceAbsenceAtonicAtonicClonicClonicTonicTonicTonic-clonicTonic-clonicMyoclonicMyoclonic

Evaluation…A Team Evaluation…A Team ApproachApproach Initial intake by epileptologist Initial intake by epileptologist

– Patient/family historyPatient/family history– Physical examPhysical exam– Review of recordsReview of records

Plan to include…Plan to include…

Testing Testing – EEG, labsEEG, labs

ImagingImaging– MRI, CTMRI, CT

Diagnosis and ControlDiagnosis and Control

Diagnosis is clearDiagnosis is clear

Patient placed on anti-epileptic drug Patient placed on anti-epileptic drug appropriate for type of epilepsyappropriate for type of epilepsy

The Poorly Controlled, The Poorly Controlled, Intractable Seizure PatientIntractable Seizure Patient

Despite medical management, patient Despite medical management, patient continues to have frequent, debilitating continues to have frequent, debilitating seizuresseizures

Commonly on polytherapy (more than one Commonly on polytherapy (more than one medication)medication)

Video-EEG MonitoringVideo-EEG Monitoring

Continuous EEG monitoring along with Continuous EEG monitoring along with continuous audio-video tapingcontinuous audio-video taping

Requires inpatient admissionRequires inpatient admission

Goals of Video-EEG Goals of Video-EEG MonitoringMonitoring Epilepsy vs. non-Epilepsy vs. non-

epileptic eventsepileptic events

Characterize epilepsy Characterize epilepsy typetype

Pre-surgical Pre-surgical evaluation evaluation

Non-Epileptic Events Non-Epileptic Events

20 to 30% of patients referred with 20 to 30% of patients referred with diagnosis of intractable epilepsydiagnosis of intractable epilepsy

Events that do not have electrical source in Events that do not have electrical source in brainbrain

May have physical or psychological May have physical or psychological causes that are not epilepsycauses that are not epilepsy

But CAN also occur in patients who have But CAN also occur in patients who have epilepsyepilepsy

Non-epileptic eventsNon-epileptic events

Physiologic (other medical conditions)Physiologic (other medical conditions)– Referred to other medical specialistReferred to other medical specialist

Psychological or pseudoseizuresPsychological or pseudoseizures– Referred to psychiatry and neuropsychologist Referred to psychiatry and neuropsychologist

who work with this type of stress-seizurewho work with this type of stress-seizure– Psychiatric medication, psychotherapy, Psychiatric medication, psychotherapy,

educationeducation

Brief history of epilepsy Brief history of epilepsy treatmenttreatment 1912: phenobarbital1912: phenobarbital 1924: EEG began to be used1924: EEG began to be used All of the treatments we will discuss today All of the treatments we will discuss today

have only come about in the last 80 yearshave only come about in the last 80 years

MedicationsMedications Choices based on epilepsy type, patient profile, side Choices based on epilepsy type, patient profile, side

effect profile, costeffect 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 Adding meds requires going up slowly with the new agent before discontinuing previous drugagent before discontinuing previous drug

Polytherapy requires deep knowledge of interactionsPolytherapy requires deep knowledge of interactions

““Old Reliables”Old Reliables”

Carbamazepine Carbamazepine (Tegretol)(Tegretol)

PhenobarbitalPhenobarbital

Ethosuximide (Zarontin)Ethosuximide (Zarontin)

Phenytoin Phenytoin (Dilantin/Cerebyx)(Dilantin/Cerebyx)

Valproic acid (Depakote)Valproic acid (Depakote)

Primidone (Mysoline)Primidone (Mysoline)

Newer AED’sNewer 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 Medication choices based on epilepsy type…epilepsy type…

AED’s for Partial EpilepsyAED’s for Partial Epilepsy

TegretolTegretol DilantinDilantin DepakoteDepakote NeurontinNeurontin LamictalLamictal PhenobarbitalPhenobarbital PregabalinPregabalin

KeppraKeppra TopamaxTopamax GabitrilGabitril ZonegranZonegran TrileptalTrileptal MysolineMysoline

Best AED’s for Generalized Best AED’s for Generalized EpilepsyEpilepsy DepakoteDepakote LamictalLamictal Topamax Topamax ZonegranZonegran KeppraKeppra RufinamideRufinamide

How to use polytherapy How to use polytherapy rationallyrationally Pharmacodynamics Pharmacodynamics

(what the medication does to the body)(what the medication does to the body)

Pharmacokinetics Pharmacokinetics (what the body does to the (what the body does to the

medications)medications)– AbsorptionAbsorption– Distribution Distribution – EliminationElimination

Half lifeHalf life LiverLiver KidneysKidneys

How to use polytherapy How to use polytherapy rationallyrationally Side effectsSide effects

– Dose-related Dose-related

– Idiosyncratic (each Idiosyncratic (each person is different)person is different)

For patients that do not For patients that do not respond to medicationrespond to medication Ketogenic dietKetogenic diet Vagus nerve stimulatorVagus nerve stimulator Epilepsy surgeryEpilepsy surgery

Ketogenic Diet (@1920)Ketogenic Diet (@1920)

High fat, low carbohydrate/protein dietHigh fat, low carbohydrate/protein diet Requires hospitalization to start itRequires hospitalization to start it

– NPO until patient in ketosisNPO until patient in ketosis– Parent educationParent education– Meds to be taken into accountMeds to be taken into account

Recommended mainly for young children Recommended mainly for young children due to compliance and efficacy due to compliance and efficacy

Epilepsy SurgeryEpilepsy Surgery

The goals are:The goals are:

– To determine where the seizures are coming To determine where the seizures are coming fromfrom

– To make sure is safeTo make sure is safe

Epilepsy SurgeryEpilepsy Surgery

To determine where the seizures are To determine where the seizures are coming fromcoming fromVideo-EEG monitoringVideo-EEG monitoringMRIMRIMRSMRS: : PETPET: : SPECTSPECT: :

EEG Slide

99-10-31/ROUTINE

Fp1-F7

F7-FT9

FT9-T7

T7-P7

P7-O1

Fp2-F8

F8-FT0

FT0-T8

T8-P8

P8-O2

FT9-FT0

A1-A2

Fp1-F3

F3-C3

C3-P3

P3-O1

Fp2-F4

F4-C4

C4-P4

P4-O2

ECG-RFECG-RF

SaO2(%)

HR(bpm)

Comment

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

spike

Fp1-F7

F7-FT9

FT9-T7

T7-P7

P7-O1

Fp2-F8

F8-FT0

FT0-T8

T8-P8

P8-O2

FT9-FT0

A1-A2

Fp1-F3

F3-C3

C3-P3

P3-O1

Fp2-F4

F4-C4

C4-P4

P4-O2

ECG-RF

SaO2(%)

HR(bpm)

Comment

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Epilepsy SurgeryEpilepsy Surgery

To make sure that it is safeTo make sure that it is safeWada testWada test: to study speech and memory: to study speech and memoryNeuropsychological testingNeuropsychological testing: mental functions : mental functions

(IQ, memory, attention) and personality (IQ, memory, attention) and personality assessment assessment

Psychological evaluationPsychological evaluationOphthalmologic evaluationOphthalmologic evaluation

Epilepsy SurgeryEpilepsy Surgery

Some cases in which the localization is not Some cases in which the localization is not clear or where function could be affected clear or where function could be affected will require INVASIVE ELECTRODESwill require INVASIVE ELECTRODES

– Depth electrodesDepth electrodes– Subdural electrodesSubdural electrodes

Types of Epilepsy SurgeryTypes of Epilepsy Surgery

Temporal LobectomyTemporal Lobectomy Extratemporal Extratemporal

ResectionsResections HemispherectomyHemispherectomy Corpus CallosotomyCorpus Callosotomy

Outcome after epilepsy Outcome after epilepsy surgerysurgery Anterior temporal lobectomyAnterior temporal lobectomy

– 70-80% seizure free70-80% seizure free Neocortical resectionNeocortical resection

– With lesion: 50-80% seizure freeWith lesion: 50-80% seizure free– Without lesion: 30-50% seizure freeWithout lesion: 30-50% seizure free

HemispherectomyHemispherectomy– Significant improvementSignificant improvement

Corpus CallosotomyCorpus Callosotomy– Significant improvement for drop attacksSignificant improvement for drop attacks

Complications of surgeryComplications of surgery

Low rate of Low rate of complicationscomplications– InfectionsInfections– BleedingBleeding– AnesthesiaAnesthesia– Function Function

Vagus Nerve Stimulator Vagus Nerve Stimulator (1997)(1997) Intractable epilepsy patient without focus or Intractable epilepsy patient without focus or

desires interim step before epilepsy surgerydesires interim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. Goal is to reduce amount/severity of seizures vs.

curecure Device surgically implanted in left chest/axilla Device surgically implanted in left chest/axilla

areaarea Coils around left vagus nerveCoils around left vagus nerve Stimulation is automatic; patient can additionally Stimulation is automatic; patient can additionally

stimulate device if aura stimulate device if aura

SummarySummary

Ways to treat epilepsyWays to treat epilepsy– MedicationsMedications– Ketogenic DietKetogenic Diet– SurgerySurgery– Vagus nerve stimulatorVagus nerve stimulator