January 19, 2009
Cleveland_Clinic_Host: Today's Live Web Chat is with Imad Michel Najm, MD. He will be answering a variety of questions about Adult Epilepsy: Non-medical treatment of patients living with epilepsy, what happens when all else fails.
Dr. Imad Michel Najm, the Director of Cleveland Clinic Epilepsy Center, has been with Cleveland Clinic since 1992 in the Department of Neurology. Dr. Najm received his medical degree from St. Joseph University Faculty of Medicine in Beirut. His post-doctoral research training was at the University of California-Irvine and the University of Southern California focusing on the molecular mechanisms of epilepsy. He completed a clinical residency in neurology and a fellowship in epilepsy and clinical neurophysiology at Cleveland Clinic.
Dr. Najm leads a multidisciplinary team in the Epilepsy Center with a comprehensive range of skills and knowledge. State-of-the-art diagnostic capabilities, extensive medical and surgical treatment programs and an active research focus that has yielded important basic and clinical science contributions that made the Cleveland Clinic Epilepsy Center a place of national and international prominence as a leading facility for the investigation and management of epilepsy. Each year the Epilepsy Center staff members see more than 4,000 adults and 2,000 pediatric patients and perform more than 300 surgical procedures. The Epilepsy Center also uses the most advanced invasive and noninvasive technologies available to localize the epileptic focus and develop targeted treatment plans.
Cleveland_Clinic_Host: If you would like more information regarding the management and treatment of Adult or Pediatric Epilepsy, please call the Cleveland Clinic Epilepsy Center at 216.445.0601or toll-free 800.223.2273, ext. 50601. You may also visit the web site at clevelandclinic.org/epilepsycenter
Welcome to our Online Health Chat with Dr. Imad Michel Najm. We are thrilled to have Dr. Najm here today for this chat. Dr. Najm, we received a number of questions from the Mahoning Valley Epilepsy (MVEF) group in the Toledo/Warren area that they would like to be addressed. We are happy to have their participation. Let’s begin with some general questions about Adult Epilepsy management and treatment.
Youngstown1: Is there an exact linkage to people in a family having a tendency to develop epilepsy? Has a gene been found to determine that for sure?
Speaker_-_Dr__Imad_Najm: In some cases, there have been some genes identified as potentially playing a role in some rare cases of familial epilepsies. These findings although they are strongly suggestive of a link, they do not prove for sure a direct causative relationship between the majority of cases of epilepsy and gene mutations/changes.
Epilepsy: Diagnosis and Evaluation
Youngstown6: I have a friend who was diagnosed with abdominal epilepsy. What is this condition and how is it treated?
Speaker_-_Dr__Imad_Najm: If I understand your question correctly, your friend may be complaining of an abdominal sensation in isolation or preceding the development a "seizure." If this is the case, your friend may be having what we call in Epilepsy terms an "abdominal aura". The majority of patients with abdominal auras and seizures (so called psychomotor or complex partial seizures) have epilepsy arising from the temporal lobe.
The treatment of temporal lobe epilepsy like any other type of epilepsy is through the use of anti-epileptic medications. If medications fail (2-3 medications fail), a pre-surgical evaluation is needed. This pre-surgical evaluation consists in the majority of cases in an admission to a dedicated epilepsy unit during which seizures are captured both on video and EEG (brain wave recordings in a dedicated epilepsy monitoring unit setting), an MRI of the brain and multiple other tests. These investigations may be needed to further study and characterize the type of epilepsy and decide for future management and treatment plans.
Amongst other things, the initial evaluation would determine if your friend is a potential surgical candidate or not (especially if treatments with antiepileptic medications fail to control the seizures/auras).
My suggestion is that your friend be seen and evaluated by an epileptologist (neurologist with subspecialty fellowship training in epilepsy and clinical neurophysiology) who would then determine the next course of action.
Epilepsy and Seizures
Youngstown8: Are there any activities someone can do to lessen seizure activity, e.g. Yoga, mind concentration, hypnotism or bio-feedback?
Speaker_-_Dr__Imad_Najm: It is known that stress plays a role in triggering (but not necessarily causing) some seizures. Therefore, any activity that would lead to decrease stress or alleviate stress would potentially be helpful in decreasing the number of epileptic seizures.
Youngstown2: It seems that during the time of the month that the moon is full, I am apt to have more seizure activity. Is there any thing that proves this or indicates why this might happen?
Speaker_-_Dr__Imad_Najm: Unfortunately we do not understand for the most part why seizures at times seem to occur at different times or days of the month. We know that seizures tend to occur in situations during which our body is going through some “stressful” conditions (psychological and/or biological).
The best understood cyclical relation between a biological condition/change and epilepsy is in women during or around the menstrual period: Some women with epilepsy report a significant increase in seizure frequency during their menstrual period.
Youngstown3: I have been diagnosed with epilepsy and other medical conditions. I do not like to take medicine especially those prescribed for control of epilepsy. How much damage is this causing to my brain?
Speaker_-_Dr__Imad_Najm: Seizures or the majority of so called focal (partial) epilepsies could be damaging to the brain. We strongly recommend that medical treatment is initiated in most patients with recurrent epileptic seizures. Should a particular medication be associated with side effects, there should be other options that need to be discussed with your doctor. As a matter of fact, the majority of new anti-epileptic medications are associated with less side effects and do not interact with most medications taken for other conditions.
I believe that an adequate medication would be found to be helpful in your condition without the associated side effects.
Medical treatment for the control of seizures is necessary is important to prevent the potentially damaging effects of some seizures on the brain and to avoid the other complications of epilepsy (that include body injury and at times sudden death). My recommendation is to please discuss these concerns and issues/options with your doctor.
grammyjudy: I have 2 questions: Question 1: Has radiology technology advanced much since Oct. 2007? My grandson (age8) has Intractable Complex Partial Seizures and was tested at Cleveland Clinic in 2007 and brain mapping was too risky since his tests couldn't pinpoint exactly where in the frontal lobe his seizures occur. Question 2: He is on medications and the Ketogenic Diet - are there any other non-medical treatments now which might help him? And meds he is on, is there anything else?
Speaker_-_Dr__Imad_Najm: To answer the first question, unfortunately there have been no major advances in the imaging technologies and the post-processing of imaging data since 2007 to suggest another evaluation at this stage.
Since 2007, there has been one experimental treatment that has been tested called Responsive Neuro-Stimulation (RNS®). This treatment (that is not approved for non experimental use) has the potential to be used in the future in patients in whom the seizure onset is known, but surgery to remove that epileptic area is too risky.
The principle of this treatment resides in detecting the early stages of seizure onset through EEG recordings from permanently implanted electrodes in the brain. The data is continuously transmitted to a computer chip that is implanted in the skull. When a seizure pattern is detected, the system responds by sending back a brief electrical stimulus to try abort or to stop the seizure.
At this stage, we do not know if this treatment modality is going to be helpful for a large number of patients. We think that within the next couple of years we will have some good idea about its utility in patients with hard to control epilepsy.
Regarding your second question about medications, since 2007 there has not been a new medication introduced. But recently the FDA approved for clinical use in adult patients with epilepsy a medication that is considered an adjunctive treatment for focal epilepsy. This medication will be available by March 2009 and will be called Vimpat ®.
Youngstown4: Is one age better for surgical intervention than another?
Speaker_-_Dr__Imad_Najm: The sooner the better.
Youngstown5: When is it favorable to seek the option for surgical treatment? Is it better to operate on a child or an adult? How does the brain respond to the different age?
Speaker_-_Dr__Imad_Najm: As I mentioned above, the sooner the surgical intervention is contemplated and done, the better the prognosis is. Having said that, the option for surgical treatment should not be entertained unless appropriate medical treatment options have been exhausted. It is agreed upon in the epilepsy community that at least two or three anti-epileptic medications should be tried in any patient prior to performing surgical evaluation.
Surgery is a safe option in the majority of children and adults. At Cleveland Clinic we do epilepsy surgeries on patients of all ages from infants to older adults.
The brain adapts to surgical resections much better during childhood then it does in older patients. This is a phenomenon known as "plasticity" (the brain works like a sponge). This phenomenon enables other areas of the brain to pick up functions of regions that were resected. For these reasons, we think that surgery should not be delayed if a patient failed 2-3 types of medications whatever the patient's age is.
Epilepsy: When Should You Have Surgery?
jweber: My 15 year old daughter began having seizures 6 mo. ago. Her doctors have not said the word epilepsy. They did find a lesion on her brain which they believe is causing the seizures. When is the diagnoses epilepsy?
Speaker_-_Dr__Imad_Najm: First, let me make it clear that not all seizures are "epileptic." Epilepsy is due to recurrent epileptic (electrical) storms inside the brain. Epilepsy is defined as the occurrence of two or more epileptic seizures. A diagnosis of epilepsy is confirmed in the majority of cases by EEG (brain wave recordings) and/or through the recording of seizures with video and EEG in a dedicated epilepsy monitoring unit (EMU).
Please check with your doctor to find out if your child's seizures are epileptic or not. If her seizures are epileptic, the next step would be to find out if her seizures are really due to the lesion that is already identified in the brain.
Amanda: What are some non drug things other then surgery and omega 3's that have been shown to help on some level with seizures?
Speaker_-_Dr__Imad_Najm: Stress reducing activities, vagus nerve stimulation, ketogenic diet (in some children) and potentially newer treatment modalities such as RNS and deep brain stimulation (DBS).
devined: I'm a parent of a 20 yr adult young man. We have been dealing with this condition every since he was 6 yrs old. I have fears of not doing enough. How can I help?
Speaker_-_Dr__Imad_Najm: My suggestion is that you seek the input from an epileptologist at a comprehensive epilepsy center. Your son may be a surgical candidate and therefore a pre-surgical evaluation at a multi-disciplinary dedicated epilepsy center such as Cleveland Clinic Epilepsy Center may be helpful.
Epilepsy: Medication Control after Surgery
Epilepsy: From MVEF I had brain surgery three years ago. I have been doing fine, no seizure activity. My doctor still has me on medication to control seizure activity, When can I feel sure I would not have more seizure activity if I did not take any meds for controlling seizures?
Speaker_-_Dr__Imad_Najm: Please check with your doctor regarding the number of medications that you need to take and the dosages of these medications.
It is extremely important that you do not stop your medications without your doctor's permission. There are some tests that we rely upon to guide us through this process and your doctor should be able to explain to you.
In general, the longer you are seizure free after surgery the better the prognosis. It is important to remember that the main goal of epilepsy surgery is SEIZURE CONTROL on or off medications.
Epilepsy: Diet and Nutrition
Youngstown7: How much does diet play in controlling seizure activity?
Speaker_-_Dr__Imad_Najm: We think that some diets may help in decreasing the number of seizures or in very rare situations lead to seizure control (with the additional use of antiepileptic medications). This has been shown in the case of the so-called ketogenic diet. The ketogenic diet is a high fat, no carbohydrate form of dieting. This diet has been used in children with catastrophic severe epilepsy where medical treatments failed and the child is not thought to be a surgical candidate.
It is unclear if other forms of diets such as Atkins diet plays any role in seizure control.
jweber: How does the ketogenic diet work. What about taking some sort of fish oil to reduce seizure activity?
Speaker_-_Dr__Imad_Najm: It is unclear how ketogenic diet would work. It is an area of active research in the lab. One potential mechanism would be on a receptor in the brain that would lead to decrease seizures.
It is not clear if fish oil would have an anti-seizure effect or not but it may be protective against seizure induced brain damage.
Epilepsy and Pregnancy
Youngstown10: How soon after surgery for epilepsy can a woman have a baby?
Speaker_-_Dr__Imad_Najm: Good question! There are no set recommendations on when a woman would be able to conceive and have a baby after epilepsy surgery. In general, we would like to make sure that the surgery was able to control seizures (for this reason, we like to wait 6-12 months after surgery), minimize the number of medications that the woman is taking (we prefer that no more than 1 medication is given), and have been no other surgical complications.
Youngstown11: How long after surgery for epilepsy can you say you are cured of epilepsy?
Speaker_-_Dr__Imad_Najm: Long-term outcome studies at Cleveland Clinic and some other large national and international epilepsy centers around the world suggest that most patients who are seizure free 5 years after surgery would remain seizure free when followed at 10 or 15 years after surgery.
Although we do not use the term "cure" in these situations, but for all likelihood, if a patient has been seizure free for more than 5 years after surgery, this patient has a very slim risk of seizure recurrence later on.
At Cleveland Clinic we will be discussing this particular issue during an upcoming international conference that we will be organizing in Cleveland, Ohio in June 2009. For more information, go to clevelandclinic.org/epilepsy. The information is available on the home page.
Epilepsy: New Technologies - MEG
grammyjudy: Is radiology technology reaching the point so a definitive area can be found? My grandson, age 8, was at Cleveland Clinic in 2007 and brain mapping was too iffy.
Speaker_-_Dr__Imad_Najm: As I mentioned before, technology has not changed much over the last two years, but we think that in the next couple of years would have some new technologies.
Although it is not an imaging technology but magnetoencephalography (MEG) is a new technology that we started to use at Cleveland Clinic in 2008 for the evaluation of some of more challenging cases. This technology has the potential in some situations to pinpoint to the area of the brain where seizures may be arising from. Please check with your grandson's doctor to find out if MEG would be helpful.
flukefam: Besides the RNS that was already mentioned, what other therapies are being researched?
Speaker_-_Dr__Imad_Najm: Other therapies include deep brain stimulation (DBS) techniques. These techniques rely on electrical stimulation of specific areas of the brain such as thalamus, subthalamic nucleus, hippocampus, and other targets in the brain to potentially control seizures.
Some of these targets and techniques are currently under experimental clinical investigations and others are currently been tested in the lab.
Youngstown9: Is the Vagus Nerve Stimulator used for any other seizure type than temporal?
Epilepsy: Thank You
herman: Dr. Najm...This is not a question, just a big THANK YOU for all you and your colleagues have done for our granddaughter, Bethany. You're the best! Ken and Kathy.
Speaker_-_Dr__Imad_Najm: Thank you so much. This is the least we can do.
Epilepsy: From MVEF My friend had brain surgery in March of 2007. For a while he did not have any seizure activity, but after a year some seizure activity resumed. Now the seizures seem to happen during the night. Will he need to consider more surgery?
Speaker_-_Dr__Imad_Najm: More surgery may be helpful in some situations. My recommendation is to check with his/her epileptologist. The epileptologist will discuss the potential benefits of another surgical evaluation.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Najm is now over. Thank you again Dr. Najm, for taking the time to answer our questions today.
Speaker_-_Dr__Imad_Najm: Thank you very much. We realize that we may not have been able to answer all your questions today. Please, if you have a question, email us at email@example.com and either I or another specialist will get back to you.
Cleveland_Clinic_Host: There will also be a live pediatric epilepsy chat with Ingrid Tuxhorn, MD on March 26, 2009, between 12:00 p.m. and 1:00 p.m. (EST).
- If you would like more information regarding the management and treatment of epilepsy and the Epilepsy Center at Cleveland Clinic’s Neurological Institute please visit clevelandlcinic.org/epilepsycenter or send an email at firstname.lastname@example.org. You may also call 800.223.2273 ext. 50601.
- A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult
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