E P I L E P S Y C A R E AT U N I V E R S I T Y O F C O L O R A D O H O S P I TA L

EPILEPSY CAN AFFECT ANYONE, AT ANY AGE AND FROM ANY BACKGROUND. At the University

of Colorado Hospital (UCH), one of our core missions is to

effectively treat patients who have epilepsy while simultaneously

striving to research and develop the best possible treatments

and procedures in the battle against the disease. That is why

our Comprehensive Epilepsy Center has been rated a Level 4

center by the National Association of Epilepsy Centers (NAEC),

the highest designation level. The UCH Epilepsy Center can

help you and your family to make informed decisions about

the best therapies available, including surgical options. We

have a team of physicians, researchers, nurse practitioners,

physician assistants and other providers who are specifically

trained in treating epilepsy and who provide comprehensive

clinical care and diagnostic testing for our patients.

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TABLE OF CONTENTS

EPILEPSY CENTER OVERVIEW.........................................................................3

EPILEPTIC SEIZURES .......................................................................................5

E PILEPSY SURGERY.........................................................................................7

THE BRAIN .......................................................................................................9

ELECTRODIAGNOSTIC MONITORING UNIT (EMU) ........................................11

NEUROIMAGING – MAGNETIC RESONANCE IMAGING (MRI)......................13

SUPPORT GROUP............................................................................................15

CLINICAL TRIALS............................................................................................17

NEUROFEEDBACK ..........................................................................................19

NOTES ........................................................................................................ .... 21

SEIZURE SYMPTOMSSeizures may take on a variety of forms ranging from a feeling of fear, a flutter in the stomach, a brief stare, a lapse of memory, or body stiffening that may last a few seconds to a few minutes. Seizure activity may sometimes go unrecognized for months or even years, and in some cases patients and their families may not even be aware of the seizures. Meanwhile, in other cases, the symptoms may be much more obvious. In any case, seeking medical assistance to develop a customized treatment plan is the best course of action.

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EPILEPSY CENTER O

VERVIEW

UNIVERSITY OF COLORADO HOSPITAL EPILEPSY CENTEREvery patient who visits the UCH Epilepsy Center receives a comprehensive evaluation, diagnostic testing and treatment to make it possible for patients to live active lives. As Colorado’s only academic medical center, we take a multidisciplinary approach to patient care. This means every one of our epilepsy patients is seen, evaluated and treated by a comprehensive team of epileptologists, neurosurgeons, neuropsychologists, psychiatrists, neuroradiologists, neurodiagnostic technologists and neuroscience nurses.

Available Services

» Outpatient Clinical Care

» Advanced Epilepsy Therapy Clinic

» Seizure and Epilepsy Surgery Support Group

» Outpatient Electroencephalogram (EEG)

» Quantitative EEG

» Long-term Video-EEG Monitoring in the Electrodiagnostic Monitoring Unit (EMU)

» Testing with MRI/ PET/ SPECT/ MEG/ Wada

» Neuropsychological testing

» Epilepsy Brain Surgery

» Implantation and Management of Vagus Nerve Stimulator (VNS) or Responsive Neurostimulation (RNS or “Neuropace®”)

» Clinical Trials

» Neurofeedback

» Functional Neurology Clinic

WHAT IS AN EPILEPTIC SEIZURE?Epileptic seizures are spells that are caused by abnormal excessive electrical activity of nerve cells. These nerve cells are located in the outer layer of the brain that is called “cortex” or gray matter (see picture).

Anybody can have seizures. They can be the result of sudden changes within the brain due to triggers, such as alcohol, drugs, injury, stroke, or abnormal blood sugar or electrolytes, among others. We call these “provoked” seizures, and often no medical treatment is necessary because it is sufficient to remove the trigger.

However, if seizures occur repeatedly, without provocation, we say a person has a seizure disorder. Another word for seizure disorder is epilepsy. For a person who has had at least two “unprovoked” seizures, or one “unprovoked” seizure and a lesion or scar in the brain, medication is recommended.

EEG and MRI results are normal in the majority of people who have had more than one seizure. This is because EEGs are in many cases only abnormal while a person is having a seizure. MRIs can show a lot of detail, but in many patients the area that triggers seizures is too small to be detected.

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Grey matter White matter

EPILEPTIC SEIZURES

TYPES OF EPILEPSY

There are 2 main types of epilepsy:

» Focal epilepsy

» Generalized epilepsy

Focal Epilepsy

In focal epilepsy there is one specific area, a focus, where epileptic seizures start. Sometimes, the focus can be seen on imaging, but more often imaging is normal. If there is a visible abnormality on the MRI, we call it a “lesion”, for example, a scar. In general, if there is a lesion, and seizures are difficult to control with medication alone, surgery should be considered. Focal epilepsy may be cured with surgery by removing the part of the brain that causes seizures.

Generalized Epilepsy

In generalized epilepsy the whole brain is involved at the very onset of a seizure. Imaging is usually normal and there is no particular part of the brain that can be surgically removed to cure generalized epilepsy. Therapies include medication and stimulation devices, like the vagus nerve stimulator.

WHY CONSIDER EPILEPSY SURGERY?The goal of treating seizures is to make you seizure free. In approximately 60% of people who are diagnosed with epilepsy this is achieved with medications. Unfortunately, in about a third of patients drugs will reduce seizure activity, but seizures still happen frequently. We can predict that a person’s seizures are relatively resistant to drugs when he or she has tried at least two medications and seizures haven’t stopped. Studies have shown that the third or any more drugs have a less than 5% chance to make a person seizure free.

So if seizures persist after at least two medications have been tried, we say the seizures are “drug-resistant”. Any person who has seizures despite treatment with at least two anti-seizure drugs should be educated about epilepsy surgery.

Epilepsy surgery options are:

» Removal of a brain area that triggers seizures

» Implantation of a stimulation device that lowers the seizure frequency

» Vagal Nerve Stimulation (VNS)

» Responsive Neurostimulation (RNS)

Generally speaking, if surgical removal of the seizure-onset area is possible, the person has the best chance to become seizure free (around 30% to 80%, depending on the location of the area and other circumstances). As a rule, if a lesion is visible on MRI the chance for cure is higher.

If a stimulation device is used, the person has a much lower chance to become seizure free (5% to 20%) and usually continues on anti-seizure drugs. However, stimulation treatments offer an alternative to taking yet another medication.

36%47%

4%

13%

Seizure-free with 1st drug

Seizure-free with 2nd drug

Seizure-free with 3rd or mulitiple drugs

Pharmacoresistant epilepsy

Success with anti-seizure drugs

Kwan P, Brodie MJ. N Engl J Med. 2000;342(5):314-319

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THE BRAIN AND ITS FUNCTIONSThe brain is protected within a person’s skull. It has two halves, called the left hemisphere and the right hemisphere.

In most people, the left hemisphere contains language function. Sometimes, a left-handed person can have language function in the right side of the brain. The brain half that contains language is labeled the “dominant hemisphere”.

Each half of the brain has four lobes: a frontal lobe, a parietal lobe, an occipital lobe and a temporal lobe. As a general rule, the right side of the brain is responsible for the left side of the body and the left side of the brain for the right side of the body.

The frontal lobes control behavior and motor function on the opposite side of the body, the parietal lobes register all sensation from the opposite side of the body, the occipital lobes register vision, and the temporal lobes process hearing, memory and language.

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THE B

RAIN

PARTS OF THE HUMAN BRAIN

FRONTAL LOBE

TEMPORAL LOBE

BRAINSTEM

CEREBELLUM

PARIETAL LOBE

OCCIPITAL LOBE

ELECTRODIAGNOSTIC MONITORING UNIT (EMU) – PHASE 1 MONITORINGThe Electrodiagnostic Monitoring Unit (EMU) is a part of the University of Colorado hospital that is equipped to capture and analyze seizures. It is staffed by a team of caregivers specialized in epilepsy, including epileptologists, neurodiagnostic technologists, neuroscience nurses, fellows, residents, and medical students. Our goal is to give you the best care as we evaluate, diagnose and treat your seizure disorder.

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The EMU contains advanced computers and software specifically designed to record seizures using EEG and video 24 hours a day. As this is often the first diagnostic step that provides detailed information on seizures, this evaluation in the EMU is called “Phase I” monitoring. The test usually requires several days in the hospital. During the hospitalization we frequently reduce medications and deprive patients of sleep to make the seizures more likely to happen in a reasonable time. The patient’s medications are generally resumed before discharge home.

The valuable information we obtain in the EMU is used to diagnose seizure types and help guide medical treatment. In addition, this information can determine which surgical therapies should be considered in appropriate patients. For example, it can be used to localize any potential seizure focus in patients with drug-resistant epilepsy who may be surgical candidates. If you are a possible surgical candidate, you will be seen in the Advanced Epilepsy Therapy Clinic. At this appointment, you will review your test results and discuss any further testing that may be needed, as well as different surgical options.

WHAT TO EXPECT The Electrodiagnostic Monitoring Unit is in the Anschutz Inpatient Pavilion 1 at the University of Colorado Hospital. Take Elevator D to the 7th floor and check in at the reception desk. You will be escorted to your private room.

After arrival in your room you will be visited by many of our staff, including nurses, medical students, neurodiagnostic technologists and physicians. A registered nurse will help you get settled in your room, fill out admission paperwork and place an intravenous line. A resident will take a complete medical history and do a physical examination. A neurodiagnostic technologist will apply the EEG electrodes and begin the recording of your EEG study.

In order to trigger seizures you may experience:

» Medication changes

» Hyperventilation (deep breathing)

» Photic stimulation (flashing lights)

» Sleep deprivation

Your room will have a private bath, television, DVD player and telephone. There is a Wii video game system available for your use as well as a recumbent exercise bike.

To make your stay more comfortable, you should bring:

» Comfortable clothing such as pajamas or sweat pants

» Shirts that button, snap or zip all the way down the front

» Books, laptop computer or games

» Movies and music

» An adult family member or friend is welcome to stay with you

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THE MRI The University of Colorado Hospital (UCH) utilizes the newest technology for neuroimaging, the 3 Tesla (3T) magnetic resonance imaging (MRI). The 3T MRI has several advantages over older MRI technologies:

» Quality of images. UCH uses the highest level of imaging technology, including the only short-bore 3T MRI machine in the Rocky Mountain region. This technology produces an unprecedented level of image quality allowing physicians to see more than ever before. Small soft tissue abnormalities – often the only finding in patients with seizures – can be seen better with higher magnet strength.

» Accurate interpretation. At UCH, all MRIs are read and interpreted by fellowship trained neuroradiologists with extensive experience.

An MRI takes about 30-40 minutes. It is important that you lie very still to get the best images.

SEIZURE AND EPILEPSY SURGERY SUPPORT GROUPThe Support Group meets the third Wednesday of each month. Time: 7:00 p.m. – 9:00 p.m.Location: 7th floor east conference room in the Anschutz Inpatient Pavilion.

Patients, family and friends are welcome to discuss surgery and to ask any questions. For further information regarding the support group meeting, please, contact the Nurse Navigator at 720-848-2108.

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CLINICAL TRIALS FOR EPILEPSY AT UNIVERSITY OF COLORADO HOSPITAL Clinical trials provide researchers and the medical community with the ability to investigate innovative treatments for epilepsy. Those who participate in the trials receive novel therapies under the care of physicians and research staff members at no charge. Research participation is invaluable as it helps expand the number of approved, reliable treatments. The goal is to increase knowledge about new epilepsy therapies while providing additional treatment options for patients. The link below provides access to the University of Colorado website that lists all ongoing trials. It has information on how to contact our study coordinator and it tells you whether you are eligible for any of the studies.

For more information on clinical trials, visit:www.ucdenver.edu/academics/colleges/medicalschool/departments/neurology/clinicaltrials/Pages/ Epilepsy-Clinical-Trials.aspx

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NEUROFEEDBACK AND SEIZURESWhat is neurofeedback? Neurofeedback is a form of biofeedback that uses EEG sensors to sample, analyze and “feed back” information about the brain’s electrical activity. Your brainwaves are very complex signals. Low frequency, or “slow”, waves and high frequency, or “fast”, waves have different functions in different regions of the brain. During neurofeedback, people learn to change their brainwaves by exercising and strengthening balanced neural pathways. During training sessions, people work toward increasing healthy brain rhythms while suppressing unhealthy rhythms. The more you exercise your brain and produce healthy brainwaves, the stronger those rhythms will become.

The potential for neurofeedback as an anti-seizure therapy was discovered more than 40 years ago. The first scientific paper documenting the experience of doctors with neurofeedback as a therapy for seizures was published in 1972. Since then, multiple medical studies have shown that neurofeedback can reduce seizure frequency, even in patients whose seizures are not controlled by currently available anti-seizure medications. Although individual results may vary, with sufficient training improvements can be long-lasting. A recent review of studies of neurofeedback in patients with drug-resistant epilepsy calculated that 79% of the patients treated in these studies had some reduction in seizure frequency.

We have been offering neurofeedback training with certified providers to patients with epilepsy here at the University of Colorado Epilepsy Center since 2012. For more information about whether neurofeedback is appropriate for you, a family member or friend, ask your provider or start online at the Biofeedback Certification International Alliance website (www.bcia.org). This website has more information about neurofeedback and has a listing of certified neurofeedback providers in your area.

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CLINIC NURSE – 720-848-2080NURSE NAVIGATOR – 720-848-2108

ANSCHUTZ OUTPATIENT PAVILION1635 Aurora CourtAurora, CO 80045

www.uchealth.org

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