Online Health Chat with Ajay Gupta, MD and Deepak Lachhwani, MBBS, MD
March 4, 2013
Epilepsy is a chronic medical condition marked by recurrent seizures (an event of altered brain function caused by abnormal or excessive electrical discharges from brain cells). Epilepsy is a term used for a group of disorders characterized by a tendency for recurring seizures, which are caused by a sudden increase in electrical activity in the brain that may alter behavior, motor function or consciousness.
Epilepsy is one of the most common neurological disorders, affecting up to one percent of the population in the United States. More than 45,000 children are diagnosed with epilepsy every year. Risk factors for seizures include family history of seizures (specifically maternal first cousin) and developmental delay (in language).
Epilepsy is a treatable disorder, with two-thirds of patients becoming seizure free on medication. For those who may not respond to medication, epilepsy surgery may be an effective alternative. Children who fail to respond to trials of two appropriate seizure medications should be evaluated to see if epilepsy surgery is an option.
The process to decide whether your child is a candidate for surgery involves a thorough medical history and physical examination, including brain wave monitoring and other tests. Along with video electroencephalogram (video EEG), testing for surgery requires a brain MRI. Brain PET (positron emission tomography), Ictal SPECT (single-photon emission computed tomography), and MEG (magnetoencephalography) scans may also be necessary in certain patients. The goal is to identify a specific source of seizures in your child’s brain that can be safely removed without affecting important brain controlled functions.
Advancements in our understanding of the causes of epilepsy and new treatments continue to offer hope to even more patients.
About the Speakers
Ajay Gupta, MD is the head of the section of Pediatric Epilepsy in the Epilepsy Center within the Neurological Institute at Cleveland Clinic. Dr. Gupta is an expert in the field of childhood and adolescent epilepsy with emphasis on epilepsy surgery evaluation, difficult to treat epilepsy, and management of epilepsy in the setting of cortical dysplasias and neurocutaneous disorders such as tuberous sclerosis complex and Sturge-Weber syndrome. Dr. Gupta is also a skilled specialist in intraoperative neurophysiologic techniques used during brain surgery to map regions of brain for critical function (including motor and speech control) as well as malfunction (such as seizure origin and brain tumors).
Dr. Gupta completed his fellowship in neurophysiology and residency in child neurology and pediatrics at Cleveland Clinic. He has additional training in clinical genetics during his fellowship at Saint George's Hospital Medical School at the University of London Medical School - Post Graduate Institute of Medical Education and Research. Dr. Gupta was on the Faculty of Medicine at Punjab University and Guru Nanak Dev University in Punjab, India. He is board certified in Neurology with Special Qualifications in Child Neurology and Neurology- Clinical Neurophysiology.
Deepak K. Lachhwani, MBBS, MD, is a staff pediatric epileptologist at the Epilepsy Center within the Neurological Institute at Cleveland Clinic. Dr. Lachhwani’s particular interests lie in treating children with medically refractory epilepsy, functional neuroimaging, pediatric epilepsy surgery and ICU monitoring of neonates and children. His research interests revolve around these fields, with specific reference to clinical outcomes after epilepsy surgery in children with tuberous sclerosis, stroke, Rasmussen encephalitis and medically refractory status epilepticus. He also directs the activities of the Pediatric Epilepsy Support Group, which offers a unique platform for educating and supporting families of these children.
Dr. Lachwani was a clinical scholar in epilepsy during his fellowship at Cleveland Clinic. He completed his residency in neurology and internship in pediatrics at Mayo Clinic, in Rochester, MN. Dr. Lachwani completed his residency in pediatrics and internship after graduating from medical school at Gandhi Medical College, Bhopal University Faculty of Medicine, in Bhopal, India.
Let’s Chat About Pediatric Epilepsy: Are My Child’s Seizures Epileptic and When Should Epilepsy Surgery Be Considered?
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Gupta and Dr. Lachwani. We are thrilled to have them here today to discuss pediatric epilepsy. Let's begin with some of the questions that have come in so far.
Progressive Myoclonic Epilepsy Diagnosis
StormyWeather: We just learned that our 6-year-old daughter has progressive myoclonic epilepsy (PME). (Genetic testing was done). She currently does not have an epilepsy doctor following her. Going forward, I was wondering if there is anything we can do to slow the progression. She has dysautonomia as well, so most medicines do not work or cause very bad side effects. I have been trying to research PME, but I am finding that there is not a lot of information out there. I should say that she is currently pretty well controlled.
Ajay_Gupta,_MD: Progressive myoclonic epilepsy is not one disease. This name is applied to a number of different genetic diseases and each one has a different clinical course and outlook. We suggest that you find out the exact disease (diagnosis) with your doctor. This will help in treatment decisions, future plan of care and possible outlooks in the long term. Since these conditions are rare, it may be prudent to see a pediatric epilepsy specialist in conjunction with genetics and neurology specialists to decide the best plan of care for your daughter.
Complex Partial Seizure Diagnosis
Salem: My granddaughter has these episodes, with freezing and staring spells. Her cheeks get red, but her nose and forehead (the T-zone) goes pale. She then starts making a 'clicking' sound like she is gulping or trying to gulp her saliva. She is nonresponsive at these times. They lasted for about a minute and when she’s done she goes right to sleep. She had these frequently for about three days and then stopped. Her parents are taking her to the doctor, but do these spells sound like some kind of seizure?
Ajay_Gupta,_MD: Your granddaughter’s history does raise questions about the possibility of complex partial seizures and an evaluation is recommended.
Absence Seizure Diagnosis
KarenMc: My niece has been diagnosed with absence seizures. What exactly are these and what can we expect with them?
Ajay_Gupta,_MD: Absence seizures are episodes of partial or complete loss of responsiveness to surroundings. These seizures are usually short (lasting 10 to 30 seconds) and occur multiple times in a day. Typically, absence epilepsy is considered a treatable condition. Up to 50 to 60 percent of patients might outgrow it without a need for lifelong medications.
Epilepsy Diagnosis in Late Adolescence
medinamom: Our youngest daughter is 19 years old, and was diagnosed with generalized epilepsy with tonic clonic seizures at 18 years old. We have found this a strange age to develop it because it may be treated by either pediatric or adult epileptologists. To make matters more complicated, our 22-year-old daughter also just developed epilepsy, but she has been diagnosed as having complex partial seizures. What is the age cut-off for treatment by a pediatric specialist? Do you consider it unusual for both daughters to have developed this at these ages and within the same year?
Deepak_Lachhwani,_MD: It is likely that there is an underlying genetic predisposition for developing epilepsy in the family. However, this conclusion needs a careful evaluation and confirmation about the specific type of epilepsy by an epilepsy specialist as well as consultation with a genetic specialist. Typically, pediatric epilepsy doctors would accept new patients until 18 years of age. This may not be a strict rule depending up on a specific practice.
Psychiatric Evaluation in Epilepsy
navash2012: My four-year-old daughter has been undergoing epilepsy treatment for the past nine months. She was taking valproic acid until December, and then started taking Keppra XR®. We have found out that she is mostly in an excited state, and is not sitting and writing well. Her eye and hand coordination is not in sync. When we had a preschool assessment they suggested that we should have our daughter checked by a psychologist. Is something related to epilepsy causing all these issues?
Deepak_Lachhwani,_MD: The symptoms you describe are unlikely to be due to epilepsy. We agree that an evaluation by a child psychiatrist is the most appropriate next step. Drug side effects should be considered in the differential as well.
Language Impairment in Epilepsy
milikiroga: My son is diagnosed with Landau-Kleffner syndrome (LKS). He started having seizures at the age of 4 ½ years old, and he turns 6 years old in April. His seizures are absence, with blinking and his head dropping back. He has been on medication for a year. For the past three months he has been taking Keppra XR® (levetiracetam), valproic acid and frisium. During this time he hasn’t experienced a seizure, but he hasn’t shown any improvement in his language or hearing skills. He had an EEG (electroencephalogram) last week and it showed some improvement. An MRI he had about eight months ago didn’t show any brain damage or lesion. Should we consider surgery and what are the expectations? Will he speak again?
Deepak_Lachhwani,_MD: Your questions are very important. However in order to answer them your pediatric epilepsy doctor would need to look at the tests including EEG tracings, neuropsychological testing, speech and language evaluation and MRI images among others. The language recovery in LKS can lag behind the improvement seen on EEG. Typically, seizures are not very frequent or even may even remain controlled while the language difficulties are most obvious.
mollylonglong: My daughter has severe speech apraxia, but does not have developmental delays. Could surgery help her speech?
Deepak_Lachhwani,_MD: Epilepsy surgery is reserved for treating medically refractory focal epilepsy.
Behavior and Epilepsy
MC: My 5-year-old son has generalized convulsive epilepsy. He also has anger issues. Is it possible that the anger issues could be related to the epilepsy?
Ajay_Gupta,_MD: Behavior issues are quite common in children with epilepsy. Children with epilepsy may require behavior intervention as well as consideration for medications for these issues.
Memory and Epilepsy
rhode island: Why is memory such an issue for epilepsy patients, and what are some suggestions in handling it?
Ajay_Gupta,_MD: Memory issues are common in patients with epilepsy. Memory issues are usually multi-factorial (due to many factors). These factors could be the primary disease that causes epilepsy, burden of seizures, number and doses of epilepsy medications, as well as other medications that the patient might be taking for mood, behavior, sleep, etc. In depth studies of these factors may guide us to develop individualized approaches that may help a particular patient.
Puberty and Epilepsy
robg2: Does puberty have any effect on epilepsy/seizures?
Ajay_Gupta,_MD: This is controversial. The effect of puberty on a child’s seizures cannot be predetermined. It is possible that a few children may have some increase in frequency or severity of their seizures temporarily during puberty. Close observation as well as medical management adjusting epilepsy drugs according to weight gain would be helpful. In female patients, keeping a log of seizure occurrences during a particular phase of the menstrual cycle might also be helpful for the physician adjusting medications.
Medications for Epilepsy
marytheartlady: My son started having seizures in 2005 at the age of 14 years old. He has had a total of 14 seizures to date with the last one occurring in June 2012. He takes 1500 mg Keppra® (levetiracetam) twice daily,1050 mg Trileptal® (Oxcarbazepine) twice daily, and Dilantin® (phenytoin) 200 mg one time daily and 25 mg one time daily. There seems to be no pattern to his seizures, and they are unpredictable. Is this too much medicine? Since he started having seizures around puberty, will they stop when he is in his 20s? His life is full and normal. He is an excellent student and tennis player except he has had no freedom from seizures yet. Is surgery an option? Should he be on different medications? Is there some path we are not thinking of? What is the future of research?
Deepak_Lachhwani,_MD: If your son is not experiencing any adverse effects on this combination of medications, he is not necessarily on too much medication. Having said that, we usually try to use one or two medications in combination for treatment. You may want to discuss with his epilepsy team to see if his medications may be reduced from three to two medications.
Fluffy: Do you ever consider symptoms due to medication side effects as a reason to change treatment?
Deepak_Lachhwani,_MD: Yes, it is important to choose a medication with minimum to no side effects if possible.
mollylonglong: My daughter was diagnosed with infantile spasms in October 2010 when she was five months old. Her spasms stopped with Sabril® (vigabatrin), but seizures began this fall in 2012. She was put on Trileptal® (Oxcarbazepine) and was seizure-free for five weeks. Her medications were increased and she was only seizure-free for one week. Her physician added Topamax® (topiramate) and she was seizure-free for four weeks. The dose was increased, and she was only seizure-free for 10 days. Since her seizures returned, she was started on Onfi® (clobazam) and weaned from Topamax®. She is now up to full strength on Onfi®, and this is the second week. We are hopeful that this medication will work for her, but are cautious because the others have failed.
Deepak_Lachhwani,_MD: You are describing a typical course of a ‘honeymoon period’ with new medications. It is possible that Onfi® may be the answer for her. However, if seizures recur while on Onfi®, it may be reasonable to pursue an epilepsy evaluation to look for underlying cause, which may influence choice of treatment.
Surgery for Epilepsy
Nyselife: The more research I do, the more it appears that surgery may be the preferred method to treat epilepsy. At first our mindset what to exhaust all medication avenues before surgery, but surgery seems to have a high success rate. What is that rate? What are the key variables to a successful surgery?
Ajay_Gupta,_MD: Epilepsy surgery is a very attractive option for certain patients with epilepsy. Evaluation for epilepsy surgery should be considered in any patient who has uncontrolled seizures after a trial of two appropriate medications. The most important variable that improves the likelihood of surgical success in the control of seizures is the presence of a lesion on the brain MRI that overlaps with the seizure recording on video EEG (electroencephalogram). If the lesion can be completely removed without producing any new neurological deficits, surgery is likely to be successful in controlling seizures.
medinamom: Is surgical intervention an option for generalized epilepsy?
Deepak_Lachhwani,_MD: The pre-surgical evaluation at an experienced pediatric epilepsy center (like the Pediatric Epilepsy Monitoring Unit in The Cleveland Clinic Epilepsy Center) is key to determine candidacy for surgical treatment. If the generalized epilepsy is due to an underlying focal brain problem, surgery may be offered.
Fluffy: My four-year-old has parietal cortical dysphasia with a venous angioma in the same area. Is surgery a consideration when the side effects are affecting his future? He was two years old when his seizures started. After the medications were started, he came home a different child. He was hyperactive, had poor eye contact and was moody. Now we are on another medication, Trileptal® (Oxcarbazepine), since Keppra XR® (levetiracetam) became ineffective. After two years of being seizure free my son was starting to wean off medications when his seizures returned with a fury.
Deepak_Lachhwani,_MD: Yes, surgery may be a good option if medications are controlling the seizures at the cost of a very poor quality of life. It is important to make sure that medication dose is not too much. If it is, a simple dose adjustment can minimize side effects. In order for surgery to be offered, it needs to be established that the dysplasia (abnormal growth) causing seizures can be safely and completely removed. This is determined by a presurgical evaluation and the help of an experienced Pediatric Epilepsy Center.
mollylonglong: Describe the recovery process of epilepsy surgery. What limitations or precautions must be taken?
Deepak_Lachhwani,_MD: The recovery is different for each child. It also depends on the type of epilepsy surgery. Typically, your child may need to be in the hospital for seven to 10 days after surgery. If there are no complications, they are discharged home or to a rehabilitation facility. Recovery may take longer if they have any complications (such as bleeding, infection, stroke, etc).
mollylonglong: If my child is considered a favorable candidate for surgery, how long does it take to get scheduled for surgery?
Deepak_Lachhwani,_MD: Usually within a week or two. For emergency cases, of course the surgery is scheduled as soon as possible.
Nutrition and Supplementation for Epilepsy
ChatUser: My 2-year-old son has been diagnosed with generalized myoclonic seizures. He is now on Keppra XR® (levetiracetam). I have read about taking vitamin B6 with Keppra®. Is this worth trying? If so, what form is best and how much? Could the epilepsy or Keppra® cause developmental delays? He has been on track so far. How worried should I be about the side effects of the Keppra®?
Ajay_Gupta,_MD: The best antiepileptic drug for your son depends on the accurate diagnosis of epilepsy syndrome or its cause. Keppra® can cause behavioral and mood side effects. There have been anecdotal (unconfirmed) reports that vitamin B6 supplementation helps these side effects. The decision about whether your son should continue Keppra® should be based on efficacy or effectiveness as well as the degree of side effects. We do not have evidence to recommend vitamin B6 therapy. Children with epilepsy are at risk of developmental delay depending on the cause of epilepsy. Medications, especially in high doses and combined with other medications, may produce some slow learning and processing.
mary5cale: What information can you share about sodium and seizures? My 17-year-old son has had absence seizures since he was young. After medicines were not helping he was tested to see if he was a candidate for epilepsy surgery. He had that in June 2010. Two years almost to the day later he had a grand mal seizure, and then another seizure one month after that, and another two months after that one. On New Year’s Eve he had another seizure. It almost seems that something builds up in his system and tries to get out. I have read articles on sodium— and how too much and too little can play a big part in your system. Another interesting fact is that his acne gets really bad and sometimes he even gets a sore. As I said I believe some toxins or a build up of sodium accumulates until he explodes. Please give me your thoughts on this. We live in Indiana and have our first appointment with Dr. Lachhwani in March.
Deepak_Lachhwani,_MD: The sodium intake from a regular diet is very unlikely to result in a sodium imbalance and cause seizures. Only extreme diets, certain medications or inappropriate rehydration with electrolyte solutions can cause significant sodium imbalance. This can be measured with a blood test. Such sodium imbalance can result in severe seizures. We feel that seizures from a sodium imbalance can be easily distinguished from epileptic seizures by your doctor and his team with the help of specific tests.
Transcranial Magnetic Stimulation Research
irishmum: Our 8-year-old son was diagnosed with refractory epilepsy 1 1/2 years ago. (He was completely healthy with no underlying medical conditions prior to onset.) His seizures are multifocal, so he is not a candidate for surgery. He usually has at least one seizure a day, sometimes multiple. He is on three different antiepilepsy drugs, and suffers from side effects of these. His quality of life is poor at this point. We heard about TMS. What is your experience with TMS (transcranial magnetic stimulation) in pediatric patients in terms of seizure control with refractory epilepsy? We would like to wean him off some of his medications since the side effects are almost as bad as the seizures he continues to have despite them.
Deepak_Lachhwani,_MD: We do not have experience with TMS for the treatment of seizures.
Epilepsy Clinic Appointment
Ahmed: My son is five years old and was diagnosed with epilepsy at nine months old. He has many types of seizures. He gets full body drops, head drops, eyes shifting to left with head turning to left shoulder, body jerks, eyes rolling, left eyeball shaking, looking up, left eyeball twitching and eyes not together. He is developmentally delayed. My poor, little boy suffers from seizures everyday. We tried over 10 medications and diet changes, but they did not work—making things worse. We read a lot about how amazing Cleveland Clinic is. We are moving on Wednesday to Cleveland, Ohio from Michigan. What is the process of coming to Cleveland Clinic? Will he be seen right away? Should I bring him to the emergency room?
Ajay_Gupta,_MD: We will be happy to take care of your son. Please call to schedule an appointment at 866.588.2264 or 216.636.5860 and ask for a pediatric epilepsy clinic appointment at the main campus. Your son appears to have difficult-to treat-epilepsy and is likely to require a comprehensive evaluation. Please be sure to bring all the previous reports and CDs of MRIs, if available.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Ajay Gupta, MD and Deepak K. Lachhwani, MBBS, MD is over. Thank you, Dr. Gupta and Dr. Lachhwani for your time today.
Dr_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.
Dr. Lachhwani: Thanks for your questions. This was a great chat. I hope this was helpful.
To make an appointment with Dr. Gupta, Dr. Lachhwani or any of our other pediatric epilepsy specialists, please call 216.636.5860 or 866.588.2264. You can also visit us online at www.clevelandclinic.org/epilepsycenter.
For More Information
On Cleveland Clinic
Each year, our team sees over 2,000 children with pediatric epilepsy in our outpatient clinics, and evaluates more than 300 children in our dedicated state-of-the-art Pediatric Epilepsy Monitoring Unit. More than 100 children with severe conditions undergo epilepsy surgery annually. The broad range of services offered by a unified group of pediatric epilepsy specialists makes ours one of the foremost programs of its kind in the world and among one of the only in the country that provides a well-rounded range of care for every pediatric epilepsy patient.
Surgery is only one aspect of our epilepsy care. The Cleveland Clinic Epilepsy Center is staffed by a number of doctors who specialize in various aspects of epilepsy, as well as experienced pediatric nurses, social workers and child life specialists, allowing us to manage all aspects of pediatric epilepsy care For more information about pediatric epilepsy, please refer to: http://my.clevelandclinic.org/childrens-hospital/health-info/diseases-conditions/neurological-conditions/hic-Your-Child-and-Epilepsy.aspx.
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