Online Health Chat with Jorge Gonzalez-Martinez, MD, PhD, Silvia Neme-Mercante, MD and Chetan Malpe, MD
November 12, 2013
Epilepsy is one of the most common neurological disorders in our country, affecting approximately 2.5 million Americans of all ages and backgrounds. This medical disorder is thought to be caused by abnormal nerve connections, genetic causes, other medical conditions, trauma, poisoning or abnormal nerve signaling chemicals called neurotransmitters.
Seizures from epilepsy can be alarming, but can be treated successfully in many cases. These seizures may take various forms – including the type that appear to have an absence of recognizable symptoms except for stiffening of the body (tonic) and the other form of seizure involving jerks and shaking (clonic). Seizures may range in severity from mild to grand mal seizures. Seizures can also be classified as partial, or focal seizures—both simple and complex, and the generalized seizures.
Fortunately, many seizures can be controlled through medication. When drug therapy has been tried and is not effective, epilepsy surgery is an option. Other therapies for epilepsy treatment include the ketogenic diet and vagus nerve stimulation.
Remarkable advances in the diagnosis and treatment of epilepsy have been made in recent years.
About the Speakers
Jorge Alvaro Gonzalez-Martinez, MD, PhD is a board-certified neurosurgeon. Dr. Gonzalez-Martinez completed his fellowship in functional and epilepsy surgery and residency in neurosurgery at Cleveland Clinic. He also completed a fellowship in stereotaxis, neuro-oncology at Wayne State University-Detroit Medical Center, in Detroit. He completed a residency in neurosurgery and received his medical degree from University of Sao Paulo Faculty of Medicine, Sao Paulo, Brazil. His specialty interests include epilepsy surgery and medical treatment of epilepsy in children and adolescents, general neurosurgery, brain malformations causing epilepsy, brain tumors, mechanism of epileptogenesis and vagus nerve stimulation.
Silvia Neme-Mercante, MD is a board-certified neurologist in our Epilepsy Center as well as our Sleep Disorders Center in Cleveland. Dr. Neme-Mercante completed her sleep medicine fellowship and epilepsy research fellowship along with her neurology residency at Cleveland Clinic. She received her medical degree from Universidad Nacional de Cordoba-Argentina, in Argentina. Her specialty interests include medical and surgical treatment of adults with epilepsy as well as adult sleep disorders.
Chetan Malpe, MD is an epileptologist in our Weston, FL office. He completed his fellowship in clinical neurophysiology, EEG and epilepsy at Cleveland Clinic after completing his residency at State University of New York Health Science Center, in Brooklyn, and an internship in internal medicine at Staten Island University Hospital, in Staten Island, NY. He received his medical degree from George Washington University School of Medicine, in Washington, DC. His specialty interests include epilepsy and electroencephalogram (EEG).
Ahsan Moosa Naduvil Valappil, MD is a board-certified pediatric neurologist in Cleveland Clinic’s Epilepsy Center. He is board certified in clinical neurophysiology and epilepsy monitoring. Dr. Naduvil completed his fellowships in child neurophysiology, EEG and epilepsy, and pediatric neurology at Cleveland Clinic. He also completed a research fellowship, neurology and other training at Trivandrum Medical College, University of Kerala Trivandrum, in Kerala, India. Dr. Naduvil completed his pediatric residencies at Cleveland Clinic and Post Graduate Institute of Medical Education and Research, in Chandigarh, India, as well as other training at Amrita Institute of Medical Sciences and Research Institute, in Cochin, Kerala, India. He completed medical school at Thanjavur Medical College, Thanjavur, in Tamilnadu, India. His specialty interests include medical and surgical treatment of epilepsy, hemispheric epilepsy syndrome and hemispherectomy/ hemispherotomy, ketogenic diet therapy, genetic and metabolic causes of epilepsy, Rasmussen encephalitis, autoimmune epilepsy, video EEG monitoring, and invasive EEG monitoring.
Ajay Gupta, MD is section head of pediatric epilepsy in Cleveland Clinic’s Epilepsy Center. He is board certified in neurology with special qualifications in child neurology and in clinical neurophysiology. Dr. Gupta completed his fellowship in neurophysiology at Cleveland Clinic, and his fellowship in clinical genetics at Saint George's Hospital Medical School, University of London, in London, England. He completed his residencies in child neurology and pediatrics at Cleveland Clinic. Dr. Gupta completed medical school at Post Graduate Institute of Medical Education and Research, in Chandigarh, India, Punjab University Faculty of Medicine, in Punjab, India, and Guru Nanak Dev University Faculty of Medicine, in Punjab, India. His specialty interests include surgical and medical treatment of children with epilepsy, epilepsy treatment in neurocutaneous disorders, intraoperative monitoring and brain mapping for epilepsy surgery.
Let’s Chat About Epilepsy Innovations: New Advances in Epilepsy Treatment Options
Diagnosis: Signs and Symptoms
AlwaysNU: During diagnosis, do all video EEGs (electroencephalograms) provide the same information?
Silvia_Neme-Mercante,_MD_: Video EEG is an excellent tool to confirm the diagnosis of epilepsy. During the study electrodes will be placed on your head to record your brain waves. Some patients may need a more prolonged recording over three to five days.
MissScarlett: Does epilepsy cause different symptoms depending on the individual, or are there certain effects common to all sufferers?
Silvia_Neme-Mercante,_MD_: Yes, patients with epilepsy can present different symptoms! Patients with partial epilepsy may have only auras (a warning sensation). Others may have partial or focal seizures (patients may become unresponsive, experience shaking of only one side of the body, etc). Some patients may experience grand mal seizures also called convulsions. Patients with generalized epilepsy may experience staring spells, arms jerks and convulsions. Please see your doctor if you experience any seizure-like symptom.
Long-term Effects of Epilepsy
JPRew: Due to an aneurysm that caused scar tissue, I have had seizures. I experience four grand mal seizures four days after surgery. I continue to have petit mal (absence) seizures occasionally. Will my brain ever be able to heal itself to the point where I can go off the anti-seizure medications that I am taking?
Jorge_Gonzalez-Martinez,_MD_: Seizures may get better and completely stop, but it is difficult to predict how long this will take.
Chetan_Malpe,_MD_: Most patients with epilepsy caused by a lesion in the brain (which means a structural abnormality, such as scar tissue) will have a long-term potential of having a seizure in the future, and would benefit from the protection obtained by taking an antiseizure medication for a long term. There is no way to know with absolute certainty whether at some point in the future you would be able to discontinue taking antiseizure medications, and be free of the risk of ever having a seizure off medication. Certainly, an abnormal electroencephalogram (EEG) with epileptiform discharges recorded would significantly increase the risk of having a seizure off medication, and would likely prompt your physician to encourage you to continue taking antiseizure medication for a long term.
Sudden Unexpected Death in Epilepsy (SUDEP)
Lossitto: Is SUDEP (sudden unexpected death in epilepsy) a condition that is likely to occur with patients with Dravet Syndrome? If so how can it be prevented?
Ahsan Moosa Naduvil, MD: In general, the risk of SUDEP—though minimal in an individual patient—is real when we consider large number of patients. Subjects with intractable epilepsy are at a relatively higher risk. As patients with Dravet syndrome have intractable epilepsy, this puts them at higher risk than other patients with less frequent seizures.
Some general recommendations to reduce the risk are:
- Decrease the number of seizures with optimal treatment, including medical treatment, diet and surgery when feasible.
- Keep your sleep environment safe with a firm mattress, firm pillow, and no loose clothes or redundant blankets. This is to prevent suffocation if one has a seizure in his or her sleep when lying face down.
- Have a monitor, such as a baby monitor, to monitor noise related to a grand mal seizure.
- Encourage sleeping on your back.
loveitaly: My daughter, who is 32 years old, has had developmental disabilities from birth (seizure disorder and cerebral palsy) and also has medical issues. She is non-ambulatory and nonverbal. She is extremely sensitive to seizure medications and has experienced major side effects from them. Since she is petite in size and weight, no normal dosage for adults suits her. Her rescue medication is Ativan® (lorazepam), and she takes it as needed. It makes her sedated on and off for 24 hours, but she is able to swallow. Now she has insomnia, we are working with her physician about this. She turns hyperactive, becomes red and laughs without control. That is not her normal behavior. I have heard that melatonin can cause her menstrual period to become irregular, and she is very regular currently—thanks to natural progesterone cream. She does take sedatives on a daily basis, but I have heard that they can increase seizures. She takes Klonopin® (clonazepam), phenobarbital, Trileptal® (oxcarbazepine), and Synthroid® (levothyroxine). She also takes Prevacid® (lansoprazole), Maalox® and Tylenol® (acetaminophen) as needed. She can't be sedated because she won't eat, and being hyperactive triggers seizures. Could this be some behavior instead? She always has been an angel.
Chetan_Malpe,_MD_: It sounds like your daughter is taking multiple antiseizure medications, and is having some behavioral symptoms that might either be related to the adverse effects of medication, or might potentially be related to seizure activity. This can be a challenging situation. One way to try and address this is with video EEG (electroencephalogram) monitoring, which might allow us to record her brain activity when she is demonstrating these behaviors to determine whether they are seizure-related, or medication-related. This may make it easier to adjust her medications appropriately.
Lossitto: My 18-year-old son has Dravet syndrome (severe myoclonic epilepsy of infancy [SMEI]). He takes Epilim® (sodium valproate) and occasionally Frisium® (clobazam). He only has nocturnal seizures which last about 30 seconds or less. He is given Versed® (midazolam) when he has had two or more seizures within a 48-hour period. He does not have an intellectual disability, and is currently attending school full time in eleventh grade. He does have poor motor coordination, and drools a lot when he has takes both medications. His seizures occur every five days, and have a predictable pattern and cycle to them. Is there anything else that would be better medications for him?
Ahsan Moosa Naduvil, MD: I am sorry to hear about your son’s condition. He is currently taking two medications that seems to work best for Dravet syndrome.
AlwaysNU: What amount of medication is too much? At what point should another option be considered when medication doses continue to go up, or the number of medications taken go up?
Chetan_Malpe,_MD_: The ideal treatment of epilepsy with medication is monotherapy, meaning "one medication", resulting in "no seizures and no side effects". Typically, an appropriate antiseizure medication should be chosen based on the seizure type you are treating. The dose of the medication is increased to a level at which the seizures are controlled—without causing any adverse effects or toxicities. The lowest dose that reaches this goal should be continued. If the dose is being escalated and adverse effects or toxicity develops, the dose should be reduced, and/or an alternative medication should be tried.
mollie73: I am currently on Keppra® (levetiracetam) 1750 mg and Vimpat® (lacosamide) 150 mg both twice daily. My insurance company wanted me to switch to the generic version of Keppra®. Does it work as well as the 'real' drug?
Silvia_Neme-Mercante,_MD_: It is very important for patients with epilepsy to receive treatment. Keppra® generic is used by some patients and can work very well. Always watch for side effects.
Wee: How does Afinitor® (everolimus) improve seizure activity, cognitive abilities, and autistic characteristics in someone with epilepsy caused by tuberous sclerosis complex (TSC)? What is the affect on the white matter in the brain?
Ajay_Gupta, MD_: At this time there is no clear evidence that Afinitor® effectively controls seizures and helps cognition in TSC. It is not FDA approved for seizures.
Medication Side Effects
MissScarlett: Are there long-term side effects to taking anti seizure medications?
Silvia_Neme-Mercante,_MD_: Yes, any drug has long-term effects. The newer anti-seizure medications carry fewer side effects when they are used long term. Common side effects include fatigue, sedation, and sleepiness. Liver function, blood count and electrolytes have to be checked when using some of the drugs.
twb213: What is Cleveland Clinic's position on the use of medicinal marijuana for the treatment of intractable epilepsy, particularly for children?
Chetan_Malpe,_MD_: Regarding medical marijuana, most physicians would agree that more studies need to be done to demonstrate and prove the efficacy and safety of the use of cannabinoids in the treatment of epilepsy, before we can routinely offer this form of treatment.
CMB: I've heard about something called SEEG (stereo-electroencephalography.) Can you please tell me what it is and who does this procedure?
Jorge_Gonzalez-Martinez,_MD_: SEEG is a minimally invasive procedure designed to localize the areas in the brain responsible for the generation and propagation of seizures. It is minimally invasive because requires a little tiny pinhole in the skull (measuring two mm in diameter), and the passage of little tiny probes (the electrodes). In comparison, large craniotomies are frequently associated with higher complications. SEEG helps patients with difficult to localize seizures where other methods failed on. SEEG is performed at Cleveland Clinic Epilepsy Center and in Europe (France and Italy, mainly).
Hugo: I have had epilepsy for a number of years and have failed with many medications. What are the criteria necessary for considering surgery? What are the different options?
Silvia_Neme-Mercante,_MD_: Patients with persistent seizures who have failed more than two anti-seizure medications are considered refractory to treatment. These patients have to be referred to a surgical epilepsy center to be evaluated for possible epilepsy surgery. After undergoing an extensive evaluation with a multidisciplinary team, including an epileptologist, neuropsychologist, radiologist and more, will determine if you qualify for surgery or not. Some patients will need a more extensive evaluation that includes electrodes implanted in the brain to record seizures and better determine the area from where the seizures are originating.
Wee: What medication—or other treatment option—might be a good option for someone who is taking multiple medications, has intractable epilepsy, is slow and drowsy, has repetitive/autistic behaviors, and is in the pre-puberty stages? Also, how do you know when Tranxene® (clorazepate dipotassium) has "run its course" after taking it for eight years along with multiple medications?
Jorge_Gonzalez-Martinez,_MD_: It is the current standard of care for any patient who has intractable epilepsy (drug-resistant epilepsy)—pediatric or adult—to undergo an epilepsy surgery evaluation at a comprehensive epilepsy center. When medications fail, a carefully selected patient who is a good surgical candidate can benefit from epilepsy surgery. If surgery is not an option, vagus nerve stimulation might be beneficial or possibly dietary modifications (for example, the ketogenic diet in appropriate patients). Tranxene® may work well for many patients. However, like most antiepileptic drugs that are used in patients with intractable epilepsy, the medication may lose its efficacy over time—leading to breakthrough seizures (which is the nature of intractable epilepsy).
lucygusmao: My daughter is 16 years old. She is taking Keppra® (levetiracetam) and Trileptal® (oxcarbazepine) now, but she already changed her medication four times. It has been very hard for her. She was always a grade A student, beautiful and with lots of friends, but now she feels alone, with no friends and her grades are a mess. She cannot concentrate in class, and has had many seizures—sometimes in class. She is very depressed. We would like to consider surgery. I want my happy and beautiful daughter back.
Silvia_Neme-Mercante,_MD_: One of the side effects of Keppra® is depression. Please discuss her symptoms with her epilepsy doctor. To determine whether a patient is a candidate for epilepsy surgery, patients will have to be referred to a surgical epilepsy center for an evaluation.
Jorge_Gonzalez-Martinez,_MD_: It will also depend on what type of surgery she needs. In general complications are low (two to seven percent). Our Epilepsy Center can be contacted in Cleveland by calling 216.636.5860 or 866.588.2264. To make an appointment with any of our epilepsy specialists in Weston, Fla., please call 954.659.5671 or 877.463.2010. You can also visit us online at www.clevelandclinic.org/epilepsycenter.
taylor1400: My grandson has had epilepsy since the age of 4 years old. He is 18 years old now. He has had two split brain surgeries and he has a vagus nerve stimulator (VNS). He is also on a lot of medications, and nothing has made him seizure free. Is there anything new that might help him? Could he be seen at Cleveland Clinic for evaluation? The only health insurance he has is Medicaid.
Jorge_Gonzalez-Martinez,_MD_: The most important question is to know if he has focal or generalized epilepsy. We will be happy to see him evaluate his condition, so we can propose the correct treatment.
Moderator: To make an appointment with Dr. Gonzalez-Martinez, Dr. Neme-Mercante, or any of our epilepsy specialists in Cleveland, please call 216.636.5860 or 866.588.2264. To make an appointment with Dr. Malpe or any of our epilepsy specialists in Weston, Fla., please call 954.659.5671 or 877.463.2010. You can also visit us online at www.clevelandclinic.org/epilepsycenter.
mollie73: I am 58 years old, and I started having seizures at 50 years old. I had a right temporal lobectomy in July 2011. I have had two seizures since the surgery. One was in January 2012 and the other in January 2013. I feel they are both triggered by emotional stress, since they occur within a day of what would have been my wedding anniversary. My neurologist in charge of the surgery said I should meditate. Do you have any suggestions?
Silvia_Neme-Mercante,_MD_: Patients who underwent epilepsy surgery have to continue their anti-seizure medication for a period of time which will be determined by your epilepsy doctor. Stress can trigger seizures.
mollie73: Since I have had two seizures since my right temporal lobectomy in 2011, my neurologist mentioned a second surgery. Is this a common approach?
Jorge_Gonzalez-Martinez,_MD_: Yes. For some patients, additional surgery will result in seizure freedom. Our seizure freedom rate in reoperation is approximately 50 percent.
Mark92630: What process do you use to determine if it is safe for an epilepsy patient to drive an automobile? Is it possible for a patient to be given driving privileges with restrictions appropriate to the nature of his or her seizures? This is a huge quality-of-life issue for our family.
Silvia_Neme-Mercante,_MD_: Patient's seizures should be well controlled before they can drive again. For some states is a six month wait, and in other states the patient has to have a 12-month seizure-free period. Your Bureau of Motor Vehicles forms will have to be completed by your epilepsy doctor before you start driving again. Requirements may depend on the state.
MissScarlett: What things can family members do to help epilepsy sufferers manage their condition?
Chetan_Malpe,_MD_: Family support is an invaluable asset to patients with epilepsy. Family members can help in numerous ways, such as with transportation when driving privileges are temporarily suspended, encouraging patients to take their medication consistently, attending doctor's visits to help report any adverse effects of medications or other concerns, helping to keep a seizure diary documenting the frequency and severity of seizures, and providing emotional support. There is an excellent book that I recommend to patients and their families that is easy to read and provides accurate information regarding issues related to epilepsy. It is called "Epilepsy 101: The Ultimate Guide for Patients and Families," by The National Epilepsy Educational Alliance.
mollie73: If a person has seizures, does drinking alcohol increase the chance of having a seizure?
Chetan_Malpe,_MD_: Alcohol can lower your seizure threshold and make it more likely of having a seizure—especially if the alcohol intake is excessive. In addition, most antiseizure medications warn against combining the medication with alcohol. If you are considering drinking alcohol in moderation, you should discuss this with your neurologist.
Lossitto: Has there been any research that links certain foods, such as gluten-related foodstuffs, to an increase in seizure activity in Dravet syndrome?
Ahsan Moosa Naduvil, MD: There are no published studies on the role of gluten-related diet and seizures in Dravet syndrome. Celiac disease (a gluten-sensitive disease) occasionally cause epilepsy that is linked to calcium deposits in the brain. However, this is distinctly different from Dravet syndrome and we do not see a plausible theory to suggest a role for gluten-related foods in Dravet syndrome.
Lossitto: Are there any foods that decrease seizure activity?
Ahsan Moosa Naduvil, MD: The ketogenic diet or one of its less restrictive variations— such as a modified Atkins’ diet or a low glycemic index diet—may be an option. As high as 40 percent of patients on these forms of diet report more than 50 percent reduction in seizures at three – and six-month follow up. All diet therapies should be supervised by a physician and dietician team to ensure safety.
Research and New Therapies
Spartan1985: What new technological innovations are under FDA consideration? I have heard of a "new generation" of vagus nerve stimulators (VNS). Does anyone have any information?
Jorge_Gonzalez-Martinez,_MD_: NeuroPace RNS® will be approved soon. It is a form of neurostimulation for epilepsy.
taylor1400: How would the NeuroPace RNS® differ from the old VNS?
Jorge_Gonzalez-Martinez,_MD_: It is a different method of stimulation, more specific with relative higher chances for seizure control.
Lossitto: Is there any new research or innovative therapy for patients with Dravet syndrome?
Ahsan Moosa Naduvil, MD: You may find information related to this on this NIH webpage: NINDS Dravet Syndrome Information Page.
Moderator: I am sorry to say that we are at the end of our chat. We appreciate your participation and hope you will join us for other chat topics in the future.
Thank you, Dr. Gonzalez-Martinez, Dr. Neme-Mercante, Dr. Malpe, Dr. Naduvil, and Dr. Gupta, for sharing your expertise and answering questions today about new advances in epilepsy treatment options.
Jorge_Gonzalez-Martinez,_MD_: Thank you so much for the great questions. I hope the chat was informative and useful. I am looking forward the next opportunity.
Silvia_Neme-Mercante,_MD_: Thank you for your excellent questions.
Ahsan Moosa Naduvil, MD: Thank you.
Ajay_Gupta, MD_: Thank you.
To make an appointment with Dr. Neme-Mercante, or any of our epilepsy specialists in Cleveland, please call 216.636.5860 or 866.588.2264. To make an appointment with Dr. Malpe or any of our epilepsy specialists in Weston, FL please call 954.659.5671 or 877.463.2010. You can also visit us online at www.clevelandclinic.org/epilepsycenter.
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On Cleveland Clinic
At Cleveland Clinic’s Epilepsy Center, our team is continually searching for basic science breakthroughs and novel clinical applications that can help improve outcomes and quality of life in patients with epilepsy. New, increasingly effective medical and surgical strategies are continually being developed which could open up additional treatment options for more epilepsy patients. At Cleveland Clinic, we have one of the largest, most comprehensive programs in the world for the evaluation, medical and surgical treatment of epilepsy in children and adults.
Pediatric and adult neurologists; neurosurgeons; neuroradiologists; nuclear medicine physicians; nurse specialists; pharmacologists; physical, occupational and speech therapists; dietitians; neuropsychologists and psychiatrists; educational counselors and social workers; and an array of scientists and technologists all work together to offer individualized care to adults and children. Our Epilepsy Center has a long tradition of delivering advanced, innovative care for patients of all ages with epilepsy by providing excellent clinical management and utilizing state-of-the-art diagnostic and therapeutic techniques. We perform clinical and translational research to improve knowledge of epilepsy and to broaden diagnostic and treatment options for our patients. We also strive to train world-class academic epileptologists and clinical neurophysiologists.
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