Online Health Chat with Camilo Garcia, MD, Cleveland Clinic Florida and Jorge Gonzalez-Martinez MD, PhD, Cleveland Clinic Ohio
November 3, 2016
Remarkable advances in diagnosing and treating epilepsy have been made in recent years. Surgery has become a treatment option for many adults and children with medically intractable epilepsy — the 30 percent of epilepsy patients for whom drug therapy is either ineffective or produces intolerable side effects.
At Cleveland Clinic’s Epilepsy Center, we are committed to our epilepsy patients — providing excellent clinical management and applying advanced diagnostic and therapeutic techniques and approaches. Our team of dedicated physicians, health care professionals and support staff participate in the evaluation and treatment of our epilepsy patients who come here from across the country and around the world.
If anticonvulsant medications have failed to control your epilepsy, or you are experiencing intolerable side effects from anticonvulsants, you may be a candidate for epilepsy surgery. The process to decide whether you’re a candidate involves a thorough medical history review and a physical examination, including brain wave monitoring and other tests. In some cases, surgery is not possible. Seizures may come from multiple brain areas, or the risk on brain function may be too high. In these situations, other options are available.
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 the majority of cases. In a minority of cases, seizure frequency is markedly reduced.
Using modern statistical methods of analysis, the Epilepsy Center group was able to determine that in the group of patients evaluated, 78 percent were completely seizure-free two years following temporal lobectomy, 66 percent were seizure-free five years following surgery, and more than 50 percent remained seizure-free more than a decade later.
About the Speaker
Dr. Camilo Garcia attended medical school at Universidad Nacional de Colombia and completed his training at Cleveland Clinic. He has certifications in neurology and neurology-clinical neurophysiology. Dr. Garcia is also a member of American Epilepsy Society, American Academy of Neurology and International League Against Epilepsy.
Dr. Jorge Gonzalez-Martinez attended medical school at University of Sao Paulo Faculty of Medicine in Brazil. He later received his doctorate at Universidade de Sao Paulo. After that, he came to Cleveland Clinic and finished his training. He treats adults, children and adolescents. Dr. Gonzalez-Martinez is certified in neurological surgery.
Let’s Chat About Epilepsy Surgery
Onset and Diagnosis
JPM: What’s the best way to diagnose seizures?
Camilo_Garcia,_MD: The diagnosis of seizures is based on the description of the seizure events and an evaluation in the epilepsy monitoring unit. Most of the time, the description of the seizures by the patient and the relatives helps the epileptologist/neurologist diagnose if the events are seizures or not. The evaluation in the hospital, in the "epilepsy monitoring unit," helps confirm the diagnosis. In the hospital, we try to capture the seizures on video and correlate those findings with a continuous recording of electrical activity of the brain (continuous electroencephalogram).
Curious09: Is it true that people can get epilepsy as they get older? I thought it was something you got as a kid.
Camilo_Garcia,_MD: Patients can develop seizures at any age including newborns or the elderly. In fact, in developed countries, the most common age of onset is after 60 years old. The most common cause of epilepsy or seizures in the elderly is stroke, but there are other causes such as tumors, brain malformations, vascular problems, etc.
Marta84: Can someone in their mid-30s start having seizures?
Camilo_Garcia,_MD: Epilepsy can start at any time in life. Epilepsy or unprovoked seizures are more common in children and the elderly, but they can start in the mid-30s as well. The cause needs to be evaluated by the neurologist/epileptologist.
Tim007: My cousin’s seizures aren’t being controlled and she’s looking into VNS or a pacemaker-like device. Could you please tell me what is the difference?
Camilo_Garcia,_MD: I’m sad to hear your cousin's seizures are not controlled. These two devices have been approved for the treatment of refractory epilepsy. The difference is the area of stimulation. The main idea of the devices is that they can "modulate" the response of the cells in the brain. VNS or vagal nerve stimulator, stimulates the vagus nerve that is located in the neck. That stimulation goes to the brain, whereas the "pacemaker" or "NeuroPace" stimulates the area of the brain that is responsible for the seizures. Those treatments help with the seizures, but most of the times are not curative treatments. In other words, they may improve the frequency of the seizures. In order to assess if your cousin is a candidate for those treatments, she needs a full evaluation in the hospital.
blessedx3: My son is currently on Vimpat, Neurontin, Trileptal and Onfi, all with varying degrees of side effects. Do you see good success of the VNS in patients that currently take several medications to control tonic-clonic seizures? He would still need to take medications in addition to the VNS, correct?
Camilo_Garcia,_MD: Your son seems to have intractable epilepsy. In our opinion, your son should be evaluated for epilepsy surgery before going for VNS. If he was already evaluated for surgery and the final recommendation was VNS, this device may decrease the frequency of the seizures, but the improvement may be seen only after two years of treatment. Initially, he should continue with the same medications, but they may need to be adjusted along with the VNS. In general, around 30 percent of patients have 50 percent reduction of seizures with VNS treatment.
YankeesFan: I’ve read about epilepsy surgery, and it seems VERY invasive. Are there other options?
Camilo_Garcia,_MD: The treatments for epilepsy include medications, diets (Ketogenic diet), surgery and devices. Of the devices, those that do vagal nerve stimulation (VNS), responsive neurostimulation (RNS)(NeuroPace) and deep brain stimulation are the other options. In the US, only VNS and NeuroPace are approved by the FDA as possible treatments for epilepsy. However, the success with those devices is lower when compared with surgery.
TLE: I've had both a video EEG and a stereotactic EEG. Some of the seizures were shown to have definitely come from my temporal lobe. They are not sure if others are coming from another focus or are pseudoseizures. From my research, if the non-epileptic seizure activity is psychogenic, then psych meds and therapy are the suggested treatment, both of which I'm currently doing. My doctor says it's possible that removing the definite focus could help with both. The problem is I can't afford to be out of work for the time it would take for the surgery and recovery, let alone possible complications. Also, I’m wondering about medical marijuana as a possible alternative. Do you have any thoughts on this?
Camilo_Garcia,_MD: My advice would be to seek a second opinion since the diagnosis is not clear. However, up to 30 percent of patients can have "non-epileptic psychogenic seizures" (previously called pseudoseizures) and epileptic seizures. If the questionable non-epileptic seizures are epileptic seizures or not should be clarified before you go for surgery. You could ask your doctors how they can clarify if those are epileptic or non-epileptic. As you were told, psychotherapy is the main treatment for non-epileptic psychogenic seizures.
Lmg93: My son suffered a traumatic brain injury in 1990. He has been on seizure medicine since then. However, he sometimes has what the doctor calls auras. They last about a minute. Would he be a candidate for surgery that is being done KU Medical Center in Kansas City, Kansas or the NeuroBlate laser procedure?Moderator: We are going to have Dr. Gonzalez-Martinez answer this specific question and I will email you his response. He had intended on being at the chat, but got tied up in surgery. As soon as he responds, I will forward his reply and include it in the transcript
More on Medications
LNR: Does surgery eliminate or reduce the need for medications?
Camilo_Garcia,_MD: In most of the epilepsy centers in the US and in our experience, the recommendation is to continue with the medications at least for two years and then decrease the medications slowly, trying to fully discontinue the medications. The final recommendation about discontinuing the medication depends on the type of epilepsy and the cause. Remember that all depends on what the goal is prior to surgery. In some cases, the surgery is to completely eliminate the seizures, but other times, it is done to make the epilepsy easier to control with medications. All these questions need to be answered prior to surgery in order to clarify the expectations of the patient and the family.
Roybaby: What are the side effects of the drugs to control seizures?
Camilo_Garcia,_MD: There are multiple medications for epilepsy on the market, and the side effects are different according to the medication. The most common side effects are drowsiness, fatigue, irritability and lack of energy. There are no right or wrong medications for patients. The best medication is the medication that gives the least side effects to the patient and controls the seizures. Before starting the medication, you have to discuss the potential side effects with your doctor.
blessedx3: What percentage of patients requires medicine after surgery and for how long?
Camilo_Garcia,_MD: There is not a specific percentage of patients who require medication after surgery. Those questions need to be clarified before surgery with your neurologist/epileptologist. In general, if the surgery is successful and curative, some physicians may decide to discontinue the medication after a certain period of time. However, it depends on the goal prior to surgery. If the objective was to be curative, you have to discuss with your doctor when to discontinue the medications. But, if the objective of the surgery was to improve quality of life, the patient may need to continue taking the medications.
Dana: Are there any new medications for epilepsy?
Camilo_Garcia,_MD: Yes, there are new medications for epilepsy. Some of the new medications are brivaracetam, eslicarbazepine and ezogabine.
TLE: Do you have any thoughts on medical marijuana?
Camilo_Garcia,_MD: Medical marijuana has been studied in epilepsy, and is only recommended for certain, specific conditions and only in children. Currently, medical marijuana has not been proven to be effective in adults. Medical marijuana is still under research for epilepsy.
Effects of Epilepsy
blessedx3: Do people with epilepsy have a shortened life span, and will their cognitive function suffer if no further action is taken other than daily medication? My son suffers a lot from short term memory loss, which we believe is a result of the medicine. Would that be regained after surgery?
Camilo_Garcia,_MD: The memory problem that your son has could be either a medication side effect or secondary to the epilepsy itself. Recurrent, uncontrolled seizures can cause cognitive problems including memory decline. People with epilepsy have a shortened life span when compared with the general population. This has been proven to improve after epilepsy surgery. The surgery may improve or decrease the frequency of the seizures, and if successful, may stop the cognitive decline. It also depends on the area of the brain removed.
LNR: Is there a higher rate of Alzheimer's disease in those with epilepsy or in those with epilepsy surgery?Camilo_Garcia,_MD: Alzheimer's disease is a degenerative disease with a different etiology. However, there are patients with Alzheimer's disease with epilepsy or seizures associated. There is not a higher incidence of Alzheimer’s disease in epilepsy or in patients undergoing epilepsy surgery. There are patients with memory problems related to frequent seizures, but this is not the same as Alzheimer's disease. Memory problems could be secondary to recurrent, uncontrolled seizures, or if the area of the brain resected in surgery is involved in memory processing. I hope this clarifies your question
That is all the time we have for questions today. Thank you, Dr. Camilo Garcia, for taking time to educate us about epilepsy surgery.
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 with Camilo Garcia, MD, or Jorge Gonzalez-Martinez MD, PhD, or any of the other specialists in Cleveland Clinic’s Epilepsy Center, please call toll-free 866.588.2264 or for Cleveland Clinic Florida please call 877.463.2010. Learn more about the Cleveland Clinic Epilepsy Center online at clevelandclinic.org/epilepsycenter.
For More Information
About Cleveland Clinic Epilepsy Center
Cleveland Clinic has one of the largest, most comprehensive programs in the world for the evaluation, medical and surgical treatment of epilepsy in children and adults. Our goal is to help you or your loved one manage this disease in order to enjoy a fuller, more productive life.
Our team of dedicated physicians, health care professionals and support staff participate in the evaluation and treatment of our epilepsy patients who come here from across the country and around the world.
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.
Advanced Diagnosis, Treatment & Care of Future Patients
Cleveland Clinic's Epilepsy Center team:
- Diagnoses and treats more than 10,000 patients with epilepsy each year
- Delivers highly specialized care for adults and children in state-of-the-art facilities for evaluating patients for and performing epilepsy surgery
- Provides state-of-the-art diagnostic approaches and therapies
- Has established comprehensive research programs for testing anticonvulsant drugs and monitoring blood-drug levels, as well as other research to advance epilepsy treatment for adults and children
- Trains the most promising future academic pediatric and adult neurologists, epileptologists, neurophysiologists, educators and other specialists interested in epileptology
Cleveland Clinic Health Information
Learn more about the treatment options for Epilepsy.
- Epilepsy Overview
- Epilepsy: Who Should Be Evaluated?
- Types of Epilepsies and their Associated Symptoms
Cleveland Clinic Treatment Epilepsy Guide
Download our free Epilepsy Patient and Surgery Guides to learn more about the latest treatment and management information.
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