Online Health Chat with Dileep Nair, MD, and Camilo Garcia, MD

Wednesday, November 18, 2015

Description

Epilepsy is one of the most common neurological disorders in our country, affecting approximately 2.5 million Americans of all ages and backgrounds. Remarkable advances in the diagnosis and treatment of epilepsy have been made in recent years. The success of epilepsy surgery is measured in terms of the operation’s impact on seizure control and improvement in quality of life. Successful surgery eliminates seizures in many patients. For others, seizure frequency is markedly reduced.

Twelve years after epilepsy surgery, 44 percent of Cleveland Clinic patients who have undergone temporal lobe resection (removal of tissue)—the most common type of epilepsy surgery—continue to be seizure free. Significant improvement in lifestyle and social interactions also may occur.

New and increasingly effective surgical strategies are continually being developed, which could open up surgical treatment options for more epilepsy patients. For both children and adults, Cleveland Clinic provides state-of-the-art diagnosis and treatment in a caring environment.

The process to determine whether you are a candidate for surgery involves a thorough medical history and physical examination, including brain wave monitoring and other tests. The goal is to identify a specific source of seizures in your brain that can be safely removed without affecting important brain-controlled functions.

About the Speakers

Dileep Nair, MD is board certified in neurology, clinical neurophysiology and epilepsy with many specialty interests including: medical and surgical management of adult and geriatric epilepsy, intraoperative monitoring of the brain and other parts of the nervous system mapping connections in the human brain. He received his medical degree from Northeastern Ohio Medical University, formally known as NEOUCOM. Currently, Dr. Nair is the section head of adult epilepsy and director of intraoperative neurophysiologic monitoring at Cleveland Clinic.

Camilo Garcia, MD is board certified in neurology with many specialty interests including: epilepsy, intractable epilepsy, seizures and epilepsy surgery evaluation. He received his medical degree from Universidad Nacional de Colombia in Bogota, Colombia. Dr. Garcia currently practices at Cleveland Clinic Florida’s Epilepsy Center.


Let’s Chat About Epilepsy


Epilepsy in General

afterTIA: Is it true that there are "triggers" for all seizures like sounds and smells? Or do some seizures happen randomly?

Dileep_Nair,_MD: Some seizures can be triggered by a variety of things. Some common triggers include sleep deprivation, missed medications, alcohol use, stress, menstrual cycle, hyperventilation and flashing lights. There are some very rare seizures that can be triggered by vary specific things like sound, eating, music or touch. The majority of times seizures occur without any clear triggers.

kasiap367: Can I get pregnant if I have epilepsy? What precautions should I take?

Camilo_Garcia,_MD: Yes, you can get pregnant. However, you need to always plan this with your doctor. Medications for epilepsy can cause problems with the baby. The doctor should optimize your treatment ideally with only one anti-seizure medication to minimize the risk. All women who are planning to get pregnant should take Folic acid daily. As I said, the pregnancy should always be planned and discussed with the gynecologist and the epileptologist.

ncom: Can you talk about how to help a person when they are having a seizure, like whether or not to hold their head or arms, or put something under their head? Sometimes I see different advice.

Camilo_Garcia,_MD: The most important part that the family or friends need to understand is that a seizure generally lasts less than two minutes. If this is the first time that it happens, the patient needs to go to the hospital. As a general rule, if someone has a seizure, you have to put him on his side. DO NOT introduce anything in his mouth, even when he is bleeding or he bites his tongue. The airway must be opened at all times. The seizure will probably last less than 3 minutes. After that, the person will slowly recover.

sopha: Is epilepsy genetic?

Camilo_Garcia,_MD: Some types of epilepsy are strictly genetic. However, some other types of epilepsies have some other causes. In general, we think that there is probably a genetic component in all types of epilepsy. It all depends on the cause.


Types of Epilepsy

pgiuliana: I am a 49-year-old male who has had epilepsy for 35 years. I have been taking medications of varying types and combinations with marginal success. I have been considering surgery. I have participated in long-term monitoring, but never had a seizure. I'm interested in surgery, but am having difficulty pinpointing a focal point. I did have an MRI, which faintly suggested a focal point. Of course, I need more information. Is there any way to tell if I'm a good candidate? My seizures are every six weeks (on meds) mostly during sleep, but some not. They last 30 seconds and include slight tremors on the left side it seems (left hand, left leg movements). I am left handed. Thanks in advance.

Dileep_Nair,_MD: It sounds like you're in a category of patients with what we call "medically intractable epilepsy." This is a condition in which epileptic seizures are not being controlled in spite of two appropriate anticonvulsant medication trials that have been appropriately taken by the patient. Patients with this condition are candidates for epilepsy surgery. Investigations for this condition include a high resolution MRI scan of the brain and video-EEG monitoring. It is true that in the vast majority of cases, we require seizures to be recorded during the video-EEG monitoring stay. I would encourage to you to seek out an epilepsy center for another video-EEG monitoring evaluation to see if they can record your seizures. This is the first step in determining if you are a good candidate for epilepsy surgery.

kat39: I want to have the surgery to remove the part of my brain causing my epilepsy, but have been told that I was born with it: juvenile myoclonic epilepsy. Is surgery an option?

Dileep_Nair,_MD: Juvenile myoclonic epilepsy is a genetic form of epilepsy. Previously, this form had been referred to as a generalized epilepsy. There is usually no brain abnormality that is associated with this form of epilepsy that is amenable to surgery. Therefore, there is no resective surgery (removing a part of the brain) that has been shown to be beneficial for this type of epilepsy.

slimjim: What is uncontrolled epilepsy?

Dileep_Nair,_MD: In the medical field, this condition is called "medically intractable epilepsy." This has been defined by the experts as failure of two or more appropriately selected anticonvulsant medications, which have been tried at appropriate doses and taken consistently by the patient. There are many other factors to consider regarding whether a medication has failed to control seizures including how long the medication has been taken and what was the seizure frequency prior to starting the medication. For instance, if a patient had been having seizures once every six months, it would take longer than six months of being seizure free on a medication to see if the medication is working. Whereas if a patient was having a seizure once a week, it would take a far less amount of time to see if a medication is working.


Diagnosis and Treatment

ncom: Will you discuss how seizures occur and how epilepsy is initially diagnosed?

Camilo_Garcia,_MD: Seizures are caused by sudden, abnormal electrical discharges in the brain. The diagnosis of epilepsy is based on the clinical history (the description of the events/seizures and the information provided to the physician) and ancillary tests, the electroencephalogram (EEG) being the most important. The electroencephalogram is a brain wave test that helps to record the electrical brain activity.

ncom: How then is treatment initially determined, and does it vary depending on the type of seizure?

Camilo_Garcia,_MD: The treatment is initially determined by the information provided by the patient and the electroencephalogram. Epilepsy can be divided into two types: Generalized or focal/partial epilepsy. The initial medical treatment is based on this distinction. There are specific medications for these type of seizures.

afterTIA: Is the diagnosis of epilepsy based on how many seizures, how often they happen or what causes them? My father had two seizures over a two-week period, but hasn't had any before or since.

Camilo_Garcia,_MD: Seizure is only one occurrence, which means only one event. Epilepsy is defined as two or more unprovoked seizures. Unprovoked means that there was not a secondary cause that triggered the seizures; for example, "low blood sugar, electrolyte imbalance." If your father had two seizures, he needs to be treated with anti-seizure medications. Further investigation with other tests are needed, including EEG and MRI. These tests will help us to determine the possible etiology or cause. The frequency of the seizures is undetermined and varies from patient to patient. There are multiple causes including trauma, infections, tumors, malformations of the development of the brain and stroke.

amelia: What is a Wada test?

Dileep_Nair,_MD: The Wada test is a test performed by a radiologist during which a catheter is placed in one of the groin arteries and threaded to one of the two carotid arteries in the neck. The carotid arteries are two of the main arteries that supply the brain. The radiologist injects an anesthetic agent that temporarily "numbs" one half of the brain. The effect lasts only a short period of time during which the neurologist or neuropsychologist assess the patient's language and memory abilities. This test is used to determine which side of the brain controls the ability to speak. It can also assess the memory reserve of the left and right sides of the brain. This test assesses the functional capacity of each side of the brain as it relates to language and memory function prior to planning epilepsy surgery. It is used to assess and potentially reduce the risks for any language or memory problems following various neurological surgeries including those for epilepsy.


More on Medications

babyoh: What is the best seizure medication on the market?

Camilo_Garcia,_MD: There is no single "best" medication on the market. The best medication is the medication that can control the seizures causing minimal or no side effects to the patient. The medication treatment is based on the type of epilepsy and the history of the patient. The physician and the patient together discuss different options according to the diagnosis and then decide what is the best treatment for the patient. There are at least 25 different medications that can be used for different types of epilepsy. We always make the decision based on the history and the type of epilepsy.

lenny: What seizure medications are recommended for the elderly?

Camilo_Garcia,_MD: There are multiple medications that can be used in the elderly population. Treatment of older patients with anti-seizure medications is complex due to multiple comorbidities (other conditions) and the possible interaction with other medications. The possible treatment should always be discussed with the physician, taking into account all of those issues. Some of the medications that can be used in the elderly are lamotrigine, oxcarbazepine, gabapentin and pregabalin. However, there are other medications that can be considered in this population as well.

JHCIGNA: My 14-year-old daughter was just prescribed levetiracetam (Keppra), initially taken a half tablet a day, which is 250mg. It appears this is taking care of her problem. The physician had instructed us to increase the dosage eventually to two tablets as day, which 1,000mg. Is it possible that the 250mg per day could be enough for her without going up to 1,000 mg? Also, would this prescription have fewer side effects or more than some of the other medications? I'm particularly concerned about the possibility of depression and increased thoughts of suicide that this medication has. Do all of the anti-seizure meds have the possible side effects of depression and increased thoughts of suicide? Thanks.

Camilo_Garcia,_MD: The dose of the medication depends on the type of epilepsy and the frequency of the seizures. Sometimes, we have to increase the dose if the seizures are not controlled. As a general rule, some patients can be controlled with doses ranging from 500mg twice daily to 1500mg twice daily. However, if the doctor instructed you to increase the dose to 1000mg twice daily, you should ask the doctor why? Most likely, he wants to protect you daughter better. The main side effect of this medication is mood swings or mood problems. Generally, the family or the patients complain about irritability. This side effect can appear and the physician must be aware. If this happens, the medication can be changed for another one. There is a black box warning from the FDA about suicide ideation with anti-seizure medications. However, in general practice, this side effect is very rare.


Surgery Specifics

LouMcN: What criteria are required for considering surgery? What does a pre-surgical evaluation involve?

Dileep_Nair,_MD: There are several criteria required to determine whether a patient is a good candidate for epilepsy surgery. Some of the important ones include first determining if they have failed medical therapy. This is sometimes referred to as "medical intractability." This was discussed in one of the earlier questions. Second is to determine if the patient suffers from a focal epilepsy, meaning the epilepsy is beginning in one focus in the brain. Various things are used to determine this, including understanding how the seizures manifest as well as various test results such as EEG and MRI findings. One of the functions of an epilepsy center is to determine if a patient is meeting criteria for epilepsy surgery and to determine where the epilepsy is arising. If surgery is to be performed, an assessment of possible risks associated with removing the particular location where the epilepsy is arising is also discussed. There are also risks of continued seizures, which also has to be discussed when considering the alternatives to epilepsy surgery.

LouMcN: What are the side effects of surgery? Are they different depending on the type of surgery performed?

Dileep_Nair,_MD: You are correct in wondering if the side effects of surgery vary from one patient to another. The location of surgery to be performed will dictate what the potential side effects could be. For example, surgery in the left temporal lobe may result in problems with verbal memory in some patients; surgery in the parietal or occipital lobes could result in visual field deficits, and so on. What is important is that the physicians involved in your care asses these risks for you, taking into account where your seizures are arising and what is your baseline neurological state. The risks have to be balanced against the potential for benefit with the particular surgery planned. This will help guide you in making the right decision, as there are risks of continued seizures if medications are failing.


Tools for Treatment

Paleo: What does the future of epilepsy surgery, or even treatment for epilepsy, look like? Are there any new innovations, clinical trials or research?

Camilo_Garcia,_MD: Epilepsy treatment has changed over the years. Currently in the United States, epilepsy surgery is the next step when a patient fails medical treatment. New surgical techniques for the evaluation of patients with intractable epilepsy (patients who failed medical treatment) and for possible curative or palliative surgery are available in this country. Cleveland Clinic is a pioneer in SEEG (stereo-EEG) in this country and is involved in continuous research for the development of new tools to evaluate and treat patients with intractable epilepsy.

LucyintheSkies: Does Cleveland Clinic perform any types of epilepsy surgery that others centers do not?

Dileep_Nair,_MD: At our center, we pride ourselves in treating patients of all ages and providing a comprehensive level of care including medications, surgery, diet and device therapy. The strength of our program comes from the number of epilepsy surgeries we do each year. In the last year, we performed approximately 400 epilepsy surgeries. We have two epilepsy neurosurgeons, 10 adult epileptologists and five pediatric epileptologists. As Dr. Garcia mentioned, we are one of the few centers in the county that provides a specialized type of invasive evaluation for epilepsy surgery called SEEG. This is a technique that uses depth electrodes that penetrate into some deep structures of the brain to determine regions of epilepsy onset that may have been "blind" to other techniques used, such as subdural electrodes. We also are one of the few centers in the country that offers MEG. This technique, again, can help evaluate epileptic activity that may have not been visible by scalp electrodes. We also have techniques available to investigate epilepsy including: ictal SPECT, PET scan, 3T MRI scan, Wada tests and functional MRI. What is important is not the type of surgery that is being offered, but rather how we can access the region where epilepsy may be arising. We have all the above tools at our disposal to help determine this for each patient. Not all patients need every test. We determine what is right for each individual in a team conference. This is the challenge to all epilepsy centers: accurate localization of the epileptic focus. The team approach by our physicians to each patient's epilepsy is what drives our success.

Waddle: Is the term "epileptologist" new? Does this require additional schooling or certification? I have never heard of an epilepsy physician with that title before. Thank you for answering.

Camilo_Garcia,_MD: The term "epileptologist" is not new. Most of the people that work with epilepsy patients have at least the minimal training in neurology. However, nowadays some neurologists go for more training for one or two years in neurophysiology and epilepsy. Once the physician finishes the training, he/she is board-eligible for the neurophysiology boards or the epilepsy boards. In summary, an epileptologist is a neurologist with a higher expertise in treating patients with epilepsy. Most of them have been working with epilepsy patients for years or have received a certification after completing a formal training in epilepsy or neurophysiology.

Blade: Is Cleveland Clinic Florida in Weston considered a full epilepsy center or would I need to travel to Cleveland for surgery?

Camilo_Garcia,_MD: Our program is fully integrated with the epilepsy program at Cleveland Clinic in Cleveland, Ohio, which is considered one of the foremost epilepsy treatment centers in the world. Our Weston, Florida, epileptologists work with the Cleveland team of physicians to diagnose and tailor specialized treatment programs for adult patients with epilepsy. Jointly, we offer the world’s largest and most comprehensive centers for epilepsy patient care, manage more than 4,000 adult and 2,000 pediatric visits and perform more than 375 epilepsy surgeries in children and adults each year.

Cleveland Clinic Florida is a Level 3 epilepsy center. In Cleveland Clinic Florida, we can complete all the pre-surgical testing including Video EEG, MRI, PET and SPECT. At this point, we are doing only lesional causes (MRI positive) in Florida. If the patient needs an invasive evaluation with SEEG (stereo-EEG) or subdural grids, the patient goes to Cleveland Clinic in Ohio. However, our goal for the next year is to start invasive evaluations and become a level 4 Epilepsy Center.


Closing

That is all the time we have for questions today. Thank you, Dr. Nair and Dr. Garcia, for taking time to educate us about epilepsy.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.


For Appointments

To make an appointment for an evaluation with Dr. Nair or any of our Cleveland Clinic epileptologists in Cleveland, please call 866.588.2264. To learn more about Cleveland Clinic’s Epilepsy Center in Cleveland, visit us online at clevelandclinic.org/epilepsy.

To make an appointment for an evaluation with Dr. Garcia or any of our Cleveland Clinic Florida epileptologists, please call 877.463.2010.To learn more about Cleveland Clinic Florida’s Epilepsy Center, visit us online at clevelandclinic.org/floridaepilepsy.


For More Information

On Cleveland Clinic

The multidisciplinary Neurological Institute at Cleveland Clinic is a leader in treating and researching the most complex neurological disorders, advancing innovations such as epilepsy surgery, stereotactic spine radiosurgery, interstitial thermal therapy for brain tumors and deep brain stimulation. Annually, our staff of more than 300 specialists oversees nearly 175,000 outpatient visits and performs more than 9,500 surgical/interventional procedures.

Cleveland Clinic has one of the largest, most comprehensive programs in the world for the evaluation and medical and surgical treatment of epilepsy in children and adults. The Cleveland Clinic Epilepsy Center is committed to delivering world-class care for patients with epilepsy by providing excellent clinical management and the use of state of-the-art diagnostic and therapeutic techniques and approaches. We perform clinical and translational research to improve the knowledge and treatment of epilepsy, and strive to train world-class academic epileptologists and clinical neurophysiologists.

Patients and families from across the country and around the world come to Cleveland Clinic’s Epilepsy Center to access our experience and expertise, which has yielded some of the best seizure-free outcomes worldwide.


Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for epilepsy:

Clinical Trials


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