Online Healthchat with Prakash Kotagal, MD
Thursday, August 18, 2016
At Cleveland Clinic’s Epilepsy Center, we are integrating various measures of overall health with every patient encounter. For those who may not respond to medication, epilepsy surgery and electrical brain stimulation may be options. Advancements in our understanding of the causes of epilepsy and new treatments continue to offer hope to ever more patients.
Depending upon the degree of seizure control, patients who have epilepsy can participate in many of the same activities that other people do. We recommend that patients engage in an active and healthy lifestyle, including outdoor and indoor sports. Reasonable seizure precautions are advisable, however, to prevent injury due to falls, drowning or motor vehicle accidents. The treating physician can advise you as to which activities are safe.
Some patients with epilepsy have learning or memory difficulties and alterations in mood or behavior, which should be brought to the attention of the treating neurologist for appropriate diagnostic testing and treatment. Cleveland Clinic Epilepsy Center offers a comprehensive and multidisciplinary treatment approach for managing such issues. Specialists in pediatric neuropsychology and child and adolescent psychiatry are an integral part of the treatment team.
Some of the most important outcomes that the epilepsy team focuses on include improvement in quality of life in adult and pediatric epilepsy patients treated with medications or following surgery, seizure severity in adult and pediatric patients treated with medications, or, following surgery, long-term seizure freedom after the procedure.
About the Speaker
Cleveland Clinic’s well-reputed pediatric epileptologist Dr. Prakash Kotagal treats patients with epilepsy at Cleveland Clinic’s Epilepsy Center. He received his training in pediatrics at St. Louis University and in pediatric neurology at Cleveland Clinic.
Dr. Kotagal is on the editorial board of several epilepsy journals and has contributed numerous papers in those journals. He has authored many epilepsy-related book chapters and is currently on the advisory board of the Epilepsy Association in Cleveland. Dr. Kotagal’s clinical and research interests include: pediatric epilepsy and epilepsy surgery, seizure semiology, neurostimulation, new antiepileptic drugs and the relationship between sleep and epilepsy.
Let’s Chat About Epilepsy in Children
Basics About Epilepsy
GrannyG: What causes seizures?
Prakash_Kotagal,_MD: Seizures may be caused by many factors. Some are metabolic (low glucose or low calcium levels in the blood); others are seen immediately following head trauma or at the onset of a stroke. Most children have seizures due to abnormal electrical brain activity. This may be due to genetic or inherited reasons, birth defects in the brain, scarring from an old stroke, a brain tumor or hemorrhage. In about 40 percent of cases, no obvious cause is identified.
GrannyG: How do you diagnose epilepsy?
Prakash_Kotagal,_MD: A good description of history and potential risk factors, along with a neurological examination are important first steps. These are followed by an EEG (brain wave test) in an effort to determine if a child's seizures are focal or partial (arising from a localized part of the brain) or generalized (from both sides of the brain). EEG waveforms may also help us identify specific subtypes of epilepsy, which is very helpful to making an accurate diagnosis and to planning treatment. Many patients will also need a brain scan (MRI preferably), which shows us the structure of the brain and helps us to detect potential causes (scarring, birth defects, stroke, tumor, etc.). Depending on what the neurologist feels could be causing the seizures, additional tests may be needed including metabolic or genetic testing, consultation with an ophthalmologist, etc.
tooshort4you: How often do you see children misdiagnosed?
Prakash_Kotagal,_MD: At a tertiary epilepsy center like ours, we do see some patients who have not been diagnosed correctly, but it is not a large number (single digits).There are several reasons for misdiagnosis, and it doesn't mean the neurologist did anything wrong. For example, an outpatient EEG may not have shown any spikes or sharp waves, so the doctor had to make an educated guess as to seizure type and which drug to use. Others may show multifocal or generalized EEG discharges when the problem is caused by a focal lesion. Some others may have non-epileptic/psychogenic seizures. My suggestion would be to utilize inpatient video-EEG monitoring to capture the seizures whenever the child's seizures are not controlled by the initial drug or when a new seizure type emerges.
MichaRo: Can epilepsy go away on its own? Do kids "grow out of it"?
Prakash_Kotagal,_MD: Children whose seizures come under complete control and do not have any breakthrough seizures for at least two years and their EEG does not show any epileptic discharges may be able to come off seizure medication. This should be decided by the child's neurologist. In certain epilepsies (benign rolandic epilepsy), remission is expected by the time the child reaches adolescence. About two-thirds of children with childhood absence epilepsy also go into remission after the age of 10. This occurs as a result of brain maturation. Remission is less likely if the EEG is continuing to show spikes and when there is a structural brain abnormality.
MichaRo: My 8-year-old son has epilepsy. Can he participate in gym class at school? What kind of exercise or physical activity is safe for him?
Prakash_Kotagal,_MD: Most patients with epilepsy can participate in gym and sports activities unless, of course, frequent seizures are an immediate safety concern. Swimming is generally permitted as long as there are proper supervision and a lifeguard present. Patients should avoid climbing to heights, as a seizure could result in a fall and injury. It is best to ask your child's doctor for advice. We do want children to be active and not excluded from most activities that their peers are doing. As an aside, it is important to ensure adequate sleep, as lack of sleep often leads to more seizures.
kyats: I worry about my son in hot temperatures because he seems to seize during illness (spike in fever).
Prakash_Kotagal,_MD: Some children have more seizures when they are running a fever. These children may have a mutation in the SCN1A (sodium channel) gene that predisposes them to have seizures with fever or even low-grade fever. Besides treating fever promptly and any underlying source of fever (ear infection, etc.), you should also discuss your concerns with your pediatric neurologist. If a person is diagnosed with this condition, we try to avoid using medications that act on the sodium channel gene in those with SCN1A mutation. These medications include Trileptal, Lamictal and Tegretol. Supervision, when playing outdoors in the hot sun, and getting adequate fluids are also a good idea.
lacey: How prevalent are non-epileptic events in children? We are currently working with the family of an 11-year-old experiencing non-epileptic events.
Prakash_Kotagal,_MD: We don't have accurate numbers for children, but 8 percent to 10 percent of adults with epilepsy also have non-epileptic events. Usually, they have both epileptic and non-epileptic events, but there are certainly others with only non-epileptic events. Sometimes, the non-epileptic events are caused by a physiological condition such as syncope or fainting, whereas others have a psychological basis (psychogenic). Video-EEG is helpful in sorting out what exactly is happening followed by an evaluation by child psychiatry and/or child psychology. Proper counseling is essential to successful treatment.
missL34: I am a teacher. What basic first aid tips should I know to help a child in case of a seizure?
Prakash_Kotagal,_MD: Every child with seizures should have a Seizure Action Plan form completed and on file with the school nurse. This would detail what should be done when the child has prolonged or frequent seizures. Some seizures may consist of only staring, blinking, and brief confusion. Sometimes this is followed by tiredness. Allowing the child to leave the classroom and rest in the nurse's office for a few minutes would suffice. In the case of a grand mal (generalized tonic clonic) seizure:
- Do not panic, call for assistance if needed.
- Lower the patient to the ground and loosen any tight clothing.
- Place the patient in a semi-prone position so any saliva or vomitus will easily drain out of the mouth. Do not force any object or your fingers into the mouth. You may suffer an injury or break teeth.
- Do not panic; time the seizure so you know how long it lasted (most grand mal seizures are no more than one or two minutes long). If the seizure is continuing longer than five minutes, call the ambulance for transportation to the nearest emergency room.
- After a grand mal seizure, patients are very sleepy and tired for several minutes or even a couple of hours. They may also complain of headache and nausea, and may vomit.
- The Seizure Action Plan should detail what rescue medication (if any) should be given. Generally, rectal diazepam (Diastat) is given when the grand mal seizure is longer than three minutes.
tooshort4you: Is Cleveland Clinic doing any clinical trials with medical cannabis?
Prakash_Kotagal,_MD: We have been in contact with one manufacturer to do a clinical trial, but the protocol has not been finalized yet. I expect it may take several more months before the trial is ready to enroll patients.
GBrown: What are some of the latest innovation for help managing children’s seizures? Do you have any thoughts on medical marijuana?
Prakash_Kotagal,_MD: When conventional seizure medications are not working, other treatments like the ketogenic diet and epilepsy surgery should be considered. Anecdotal reports have suggested a benefit to using medical marijuana, but I have also seen many who have not responded to it. We expect results from clinical trials with marijuana to be available in a year or two, which would be helpful in deciding where this therapy fits in. Neurostimulation, namely vagus nerve stimulation (VNS) and responsive neurostimulation (RNS), is also a helpful option in selected cases.
CandaBmom: When should surgery be considered for treating a child with epilepsy? How often is it necessary and what are the possible side effects?
Prakash_Kotagal,_MD: The first seizure medication has a 50 percent likelihood of stopping all seizures. If that does not happen, then the second medication has about a 10 percent chance of controlling seizures. However, after failure of two medications, subsequent medications will only have a 5 percent chance of completely controlling seizures. Thus, around 70 percent can be fully controlled with medications, leaving 25 percent to 30 percent with inadequately controlled seizures. This group of patients should be investigated to assess if they are candidates for epilepsy surgery. In those who are candidates for epilepsy surgery, between 50 percent and 75 percent of patients will become seizure-free (but will still need to take at least one medication for the long term). Since the course of epilepsy becomes known as early as one to two years after diagnosis, one should not wait years to consider epilepsy surgery. Surgery at an earlier age is shown to improve long-term developmental outcome. Also, ongoing seizures interfere with schooling, behavior, employment, and social adjustment, so earlier surgery is better.
Jerry: How effective are epilepsy medications? What are the side effects?
Prakash_Kotagal,_MD: We just mentioned the effectiveness of seizure medication in the preceding question. Side effects vary according to the particular drug. The package insert will contain a long list of side effects, and some may not be relevant to your child. Your neurologist is the best person to discuss the side effects as they pertain to your child. It is not uncommon for patients to experience tiredness, moodiness/irritability when first starting a new medication. These generally subside in a couple of weeks. If they are persistent and bothersome, you should bring that to the attention of the neurologist to see if the dose or timing of medication should be adjusted. For most seizure medications, taking after meals is helpful in slowing the absorption and thereby lessening some side effects. A rash due to drug allergy should be promptly reported to your doctor, as it may continue to worsen unless the medication is stopped. Patients should be regularly seen by their doctors. Often, we check blood levels of the drug, blood counts, liver functions, etc.
That is all the time we have for questions today. Thank you, Dr. Kotagal, for taking time to educate us about epilepsy in children.
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 http://my.clevelandclinic.org.
To make an appointment for an evaluation with Dr. Kotagal or any of our Cleveland Clinic epileptologists in Cleveland, please call 866.588.2264 or email email@example.com. To learn more about Cleveland Clinic’s Epilepsy Center in Cleveland, visit us online at clevelandclinic.org/epilepsy.
For More Information
Each year, our team sees more than 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, please visit clevelandclinic.org/epilepsycenter.
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