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Epilepsy in Children and Adolescents

Introduction

Cleveland_Clinic_Host: There are more than 2.7 million Americans of all ages living with epilepsy and every year, there are more than 45,000 children ages 18 and younger diagnosed with epilepsy. Epilepsy occurs almost as often in children as other conditions like asthma and diabetes.

Approximately, 25% of all patients that have been diagnosed with epilepsy have seizures that may persist despite treatment with medication. There have been great advances in surgical treatment options, and epilepsy surgery may be an option for those with difficult to control epilepsy. However, less than 20% of these patients actually reach an epilepsy center to benefit from surgery.

Today’s guest, Ajay Gupta, MD, is part of the professional Staff at the Epilepsy Center and Neurological Institute at Cleveland Clinic. He is Assistant Professor at the Cleveland Clinic Lerner College of Medicine, Case Western Reserve University. Dr. Gupta also directs the multidisciplinary Tuberous Sclerosis Program at Cleveland Clinic.

Dr. Gupta is an expert in the field of childhood and adolescent epilepsy, with emphasis on epilepsy surgery evaluations and management of epilepsy in the setting of brain malformations and neurocutaneous disorders such as tuberous sclerosis complex, Sturge-Weber syndrome and epidermal nevus syndrome. Dr. Gupta is also a skilled specialist in intra-operative neurophysiological techniques used during brain surgery to map regions of brain for critical function (motor, speech control) as well as malfunction (seizure origin, brain tumors).

Dr. Gupta has made innovative research contributions in the areas of epilepsy surgery and treatment in children. He has authored more than 50 original articles and review papers in peer-reviewed international journals and textbooks. He has served as a Principal Investigator for seminal multicenter clinical trials for epilepsy drugs and devices for treatment of epilepsy in children and adults.

Cleveland_Clinic_Host: For additional information about Cleveland Clinic Epilepsy Center, please visit us on our website clevelandclinic.org/epilepsyeducation or call us locally 216.444.5559 or toll free 800.223.2273 ext 4-5559.


Pediatric Epilepsy Overview

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Ajay Gupta, MD. We are thrilled to have Dr. Gupta here today for this chat. He is considered an expert in the field of childhood and adolescent epilepsy. Let’s begin with some general questions about pediatric epilepsy.

tjswts: Our 5 year old daughter was diagnosed with Dravet Syndrome in October 2008. We added clorazepate to her existing Keppra medicine as her tonic clonics increased from one per week to twice per week. We found that the clorazepate caused confusion and her seizures began to be prolonged requiring much more frequent use of Diastat. So we decided to wean her of the clorazepate, but have found that frequent myoclonics are now present when they were not present prior to the addition of clorazepate. Is it possible that these new myoclonics are a result of the introduction of this drug or the withdrawal of it?

Speaker_-_Dr__Ajay_Gupta: It is possible that withdrawal of the clorazepate did precipitate the myoclonic seizure activity. Therefore alternative options could be considered such as: Valporate, or other benzodiazepines.

madandcrazy: What is the difference between controlled and uncontrolled seizures?

Speaker_-_Dr__Ajay_Gupta: Uncontrolled seizures are ones that occur frequent enough to disable personal and family life - at home, work, at school or in social settings.

The line between controlled and uncontrolled seizures is individual - meaning what may be disruptive to one person may acceptable to another depending on their lifestyle.

mitchl: My son was diagnosed as being autistic at 2 years old. He now has seizures. He had an MRI done. It showed lack of brain development. Could this cause his seizures? They started at age 3. He is now 4 1/2. Would he be a candidate for surgery? We are on our third medication and his seizures are still not under control. He does not talk.

Speaker_-_Dr__Ajay_Gupta: Yes, brain malformations (lack of brain development in your question) could cause seizures. Your child could undergo evaluation to determine if he is a surgical candidate. Usually, if the an epilepsy patient fails 2-3 trials of single appropriate medication, surgical evaluation should be considered.

Not every child with brain malformation is a candidate for surgery, however many children are.

pitpatput: If a child has a normal EEG and MRI, will other tests be able to pinpoint the problem? Seizures are only controlled by the Ketogenic diet.

Speaker_-_Dr__Ajay_Gupta: Yes, seizures are symptoms of a variety of genetic and environmental brain conditions. Hence, appropriate testing should be considered to make a diagnosis of etiology (cause.)

tjswts: Have you found an effective treatment for children with Dravet Syndrome?

Speaker_-_Dr__Ajay_Gupta: The best drug intervention is the one that controls seizures for that child and must be individualized from various broad spectrum drugs such as Valporate, Benzodiazepines and other broad spectrum seizure medications.

grammyjudy: Would you explain what you consider environmental brain conditions?

Speaker_-_Dr__Ajay_Gupta: Head trauma, previous brain surgery, brain hemorrhage, infection etc.

ksp: My daughter was diagnosed with epilepsy, but has her seizures at night, about a half hour after going to sleep. She keeps staring and will not respond. After 15 minutes or so, she comes back around. Can you please comment on this?

Speaker_-_Dr__Ajay_Gupta: The diagnosis of epilepsy should be first confirmed. The best option is to record an event with video EEG. The appropriate treatment, long -term as well as acute rescue treatment, from seizure should then be determined.

mvef111: When a diagnosis of epilepsy in a child is made and proper treatment is started right away; what percentage out grow the disorder?

Speaker_-_Dr__Ajay_Gupta: It depends on the accurate diagnosis. Broadly speaking, if the child is neurologically and intellectually normal, one third of these children could outgrow the epilepsy.

mvef111: Are there any statistics the reveal the re-occurrence of seizures after it was thought the child grew out of the disorder?

Speaker_-_Dr__Ajay_Gupta: About 30-50%, again depending on the actual diagnosis of epilepsy syndrome.

mvef111: If one child is diagnosed with epilepsy in my family, will other children be likely to have a tendency to have epilepsy or other neurological concerns?

Speaker_-_Dr__Ajay_Gupta: Except for true genetic conditions causing epilepsy, family member of children with epilepsy are not at high risk for seizures.

carolyn: My 7yr old was recently diagnosed with BRE (Benign Rolandic Epilepsy.) Two abnormal EEG's, normal MRI and sleep study. Why do some doctors treat this and others don't? She is on 300mg of Keppra 2x a day. How soon should she have another EEG to see if this is working or not, since seizures occur when she is sleeping? Thank You!

Speaker_-_Dr__Ajay_Gupta: To treat or not to treat children with medications is a decision that parents and the physician make together and revisit this decision often depending on the clinical course.

Generally speaking treatment is titrated to seizures and not EEG because BRE finding in EEG may persist even though the child does not have any more seizures. Hence, the value of repeating the EEG depends on the question that you are trying to answer.

grammyjudy: At what age does a child become too old for MEG (magnetoencephalography.)

Speaker_-_Dr__Ajay_Gupta: Never, MEG can be done and repeated at any age.

grammyjudy: Do you know of any case(s) where a child with Intractable Complex Partial Seizures grows out of the seizures?

Speaker_-_Dr__Ajay_Gupta: It really depends on the cause of the seizures and is difficult to generalize.


Pediatric Epilepsy Medications

tjswts: Can a new seizure style develop as a result of removing a medication that was ineffective?

Speaker_-_Dr__Ajay_Gupta: Yes- seizure appearance may change with change in medications in many, but not all children. Sometimes, medications may subdue seizures but not eliminate them.

reedyblues: How often should blood levels be taken in order to know if a toxic level is reached? We have a 9 year old who developed Pancreatitis from being on Depakene. He is now only on Tegretol, but rarely has blood levels taken, usually only when increased seizure activity is noted.

Speaker_-_Dr__Ajay_Gupta: Frequency of taking blood levels depend on new toxic symptoms as reported by the child or parents. Child’s symptom and functioning is more important than any number on the blood level report. Blood levels could help in determining toxicity in children who are too young or too impaired to report how they feel.

Pancreatitis from Depakene is an idiosyncratic reaction and may not have relationship to dose related toxicity.

Check with your physician regarding blood level frequency for Tegretol. In my practice, unless otherwise indicated, I tend to check the blood levels twice per year in most children.

mvef111: How risky is it to try all kinds of medicine for control of seizures with no satisfactory effects and then treat symptomatically with a lesser amount of medication? What is the risk to the development of the brain?

Speaker_-_Dr__Ajay_Gupta: Generally speaking, we replace one medication with another one in patients who are on combination therapies. The success of combination therapies is determined by efficacy as well as side effects.

Too many medications in too high of doses may make a child tired, drowsy and not able to learn. Each child may have their own best medication combination hence the treatment should be individualized.

plindsay: How is a Diazepam infusion used for refractory seizures? What dosage?

Speaker_-_Dr__Ajay_Gupta: Diazepam infusion should only be used in an ICU by an expert. Doses are determined and titrated depending on response.

vilkinofsky: What's your opinion on fish oil helping absence seizures or other types of seizures?

Speaker_-_Dr__Ajay_Gupta: I have no opinion on fish oil related to seizures.


Pediatric Epilepsy Surgical Treatment Options

tallytn: Is DBS (Deep Brain Stimulation) done on children?

Speaker_-_Dr__Ajay_Gupta: It is not an FDA approved or an accepted treatment for epilepsy in children. It is currently under clinical trials for treatment of epilepsy in adults.

mvef111: Can a child be implanted? If the Vagus Nerve Stimulator is used as a treatment for a child, how effective is it?

Speaker_-_Dr__Ajay_Gupta: VNS has been used in treatment of epilepsy in children. Data in long-term outcome of VNS in children is scant. Efficacy can be summarized to 50% seizure reduction in 30% of patients.

rustyk: What is the problem with doing VNS (Vagus Nerve Stimulation) in a young child (3 years old)?

Speaker_-_Dr__Ajay_Gupta: The problems of VNS include surgery, anesthesia, risk associated with a pacemaker in your body, difficulty in prediction if it will be helpful or not and low risk of infection.

Hence the decision to implant VNS has to be individualized to every child after discussion of benefits, risks and other alternative options.

rustyk: With VNS, do the seizures have to be focal in order for it to work?

Speaker_-_Dr__Ajay_Gupta: VNS has been implanted in children with focal as well as generalized seizures.

rustyk: What experience has the Clinic had with VNS with children? Is the outcome of results similar to that in adults? Do the children experience discomfort with the device that is implanted?

Speaker_-_Dr__Ajay_Gupta: Cleveland Clinic has implanted VNS in children when it appears to be the best option for that child after weighing benefits, risks and alternatives.

Data on long term success with VNS in children is scant. However, the results appear similar to that of adults.

The degree of discomfort is the same except in very small children where their body size must be considered in relationship to the size of the pacemaker.

grammyjudy: You just mentioned that "if the 3rd medication fails, surgical evaluation should be considered" is that an overall guideline or only in certain diagnoses?

Speaker_-_Dr__Ajay_Gupta: Failure of second or third medications is a generally accepted timeline to explore surgical options.


Pediatric Epilepsy Research

margp: Any new research on the effect of stress on pediatric seizures?

Speaker_-_Dr__Ajay_Gupta: It is always a possibility. Parents should watch for reproducibility of seizures after a trigger such as stress. Stress is a normal part of life, but we should do what can be done to avoid a seizure trigger.

pellmell: How much research has been done on the new drugs? Why and what makes you prescribe certain drugs to children?

Speaker_-_Dr__Ajay_Gupta: Most if not all epilepsy drugs are FDA approved for use in children which requires proof of efficacy. Drug selection is individualized for every child depending on their type of seizures, diagnosis of epilepsy syndrome, risk factors & side effects from drugs and ease of drug administration.

hianddry: Are there any investigational drug studies for children taking place at Cleveland Clinic or at any other epilepsy centers at the present time? If so, where and what?

Speaker_-_Dr__Ajay_Gupta: Yes - we ask you to go to clinicaltrials.gov where all the federal and corporate clinical trials are listed. You may also visit the Cleveland Clinic Neurological Pediatric Research Trials site.
 
mvef111: Are there any special study groups for children with difficult to treat epilepsy in the Ohio area?

Speaker_-_Dr__Ajay_Gupta: Cleveland Clinic specializes in treatment of complex and difficult to treat pediatric epilepsy. We also participate in clinical research and clinical trials. For more information, please refer to www.clevelandclinic.org/epilepsy


Pediatric Epilepsy Family Support

lexieg: Childcare is a problem! What resources can you recommend to help find childcare for children with a seizure disorder?

Speaker_-_Dr__Ajay_Gupta: Local epilepsy foundations are a great source. There are also magazines focused on children with special needs. A great place to begin would be your local library or the Internet.

lrsellars: My daughter has Lennox Gastaut Syndrome, dx Nov 07. She's been doing relatively well until Dec 08. We've been referred to an Emory in Atlanta for further testing. We are having more and more night time seizures. I want to call the doctor when we've had a lot of activity during the week but I feel like some of this they expect me to deal. I've not asked our new doctor how often I'm to call him, so what do other families do?

Speaker_-_Dr__Ajay_Gupta: Every family has their own learning curve depending on their child's seizure needs. While you should educate yourself in dealing with your child's medical needs, you must discuss with your physician anytime that you feel uncomfortable.

The Epilepsy Foundation website has several useful educational resources. Other resources are listed at the end of this transcript.


Pediatric Epilepsy Ketogenic Diet

mvef111: Is the ketogenic diet really successful for most children who try it?
Speaker_-_Dr__Ajay_Gupta: Ketogenic diet is successful in approximately 50-60% of patients who try it and do it correctly.

On July 27th, Dr. Ingrid Tuxhorn will be doing a chat specifically about diet and epilepsy. Please refer back to the website clevelandclinic.org/webchat for additional details.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Ajay Gupta is now over. Thank you again Dr. Gupta, for taking the time to answer our questions today.

Speaker_-_Dr__Ajay_Gupta: We admire your courage and continuing dedication to treat your child's difficult and sometimes chronic illness. We pray for their good health and recovery. Thank you for joining us.

If you have more questions, please go to www.clevleandclinic.org/epilepsy or email us at epilepsy@ccf.org. A copy of this transcript will be posted to the website.


More Information

For information about Cleveland Clinic Epilepsy Center or to schedule an appointment with Dr. Ajay Gupta or one of his colleagues, please visit us on our website clevelandclinic.org/epilepsy  or call us at 216.444.5559 or toll free at 1.800.223.2273 ext 45559.

Some interesting articles about this topic from Cleveland Clinic may be found at the following links:

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 4-771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2009, please use our contact link clevelandclinic.org/webcontact.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.


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