Diagnosis and Treatment of Epilepsy

1. Diagnosis and Treatment of Epilepsy Marcelo E. Lancman, M.D. Director, Epilepsy Program NEREG

2. Comprehensive Epilepsy Center Referrals Evaluation: ●History/Exam ●EEG ●Imaging Controlled Not Controlled Video-EEG Epilepsy Non-epileptic Events Refer Medical Management Surgical Management

3. Epilepsy and Seizures • What is epilepsy? • What is a seizure?

4. Epilepsy 0.5-1% Seizures 5-10% Incidence

5. Partial Simple Complex Generalized Absence Atonic Clonic Tonic Tonic-clonic Myoclonic Classification

6. Evaluation…A Team Approach • Initial intake by epileptologist • Patient/family history • Physical exam • Review of records

7. Plan to include… • Testing • EEG, labs • Imaging • MRI, CT

9. Diagnosis and Control • Diagnosis is clear • Patient placed on anti-epileptic drug appropriate for type of epilepsy

10. The Poorly Controlled, Intractable Seizure Patient • Despite medical management, patient continues to have frequent, debilitating seizures • Commonly on polytherapy (more than one medication)

11. Video-EEG Monitoring • Continuous EEG monitoring along with continuous audio-video taping • Requires inpatient admission

12. Goals of Video-EEG Monitoring • Epilepsy vs. non-epileptic events • Characterize epilepsy type • Pre-surgical evaluation

13. Non-Epileptic Events • 20 to 30% of patients referred with diagnosis of intractable epilepsy • Events that do not have electrical source in brain • May have physical or psychological causes that are not epilepsy • But CAN also occur in patients who have epilepsy

14. Non-epileptic events • Physiologic (other medical conditions) • Referred to other medical specialist • Psychological or pseudoseizures • Referred to psychiatry and neuropsychologist who work with this type of stress-seizure • Psychiatric medication, psychotherapy, education

15. Brief history of epilepsy treatment • 1912: phenobarbital • 1924: EEG began to be used • All of the treatments we will discuss today have only come about in the last 80 years

16. Medications • Choices based on epilepsy type, patient profile, side effect profile, cost • Best to have patient on single antiepileptic drug (AED) • May need polytherapy (combination of medications) • Adding meds requires going up slowly with the new agent before discontinuing previous drug • Polytherapy requires deep knowledge of interactions

17. Carbamazepine (Tegretol) Phenobarbital Ethosuximide (Zarontin) Phenytoin (Dilantin/Cerebyx) Valproic acid (Depakote) Primidone (Mysoline) “Old Reliables”

18. Gabapentin (Neurontin) Lamotrigine (Lamictal) Topiramate (Topamax) Felbamate (Felbatol) Diastat (Diazepam) Tiagabine (Gabitril) Pregabalin (Lyrica) Zonisamide (Zonegran) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Rufinamide (Banzel) Newer AED’s

19. Medication choices based on epilepsy type…

20. Tegretol Dilantin Depakote Neurontin Lamictal Phenobarbital Pregabalin Keppra Topamax Gabitril Zonegran Trileptal Mysoline AED’s for Partial Epilepsy

21. Best AED’s for Generalized Epilepsy • Depakote • Lamictal • Topamax • Zonegran • Keppra • Rufinamide

22. How to use polytherapy rationally • Pharmacodynamics(what the medication does to the body) • Pharmacokinetics • (what the body does to the medications) • Absorption • Distribution • Elimination • Half life • Liver • Kidneys

23. How to use polytherapy rationally • Side effects • Dose-related • Idiosyncratic (each person is different)

24. For patients that do not respond to medication • Ketogenic diet • Vagus nerve stimulator • Epilepsy surgery

25. Ketogenic Diet (@1920) • High fat, low carbohydrate/protein diet • Requires hospitalization to start it • NPO until patient in ketosis • Parent education • Meds to be taken into account • Recommended mainly for young children due to compliance and efficacy

26. Epilepsy Surgery • The goals are: • To determine where the seizures are coming from • To make sure is safe

27. Epilepsy Surgery • To determine where the seizures are coming from Video-EEG monitoring MRI MRS: PET: SPECT:

28. EEG Slide 99-10-31/ROUTINE

33. Epilepsy Surgery • To make sure that it is safe Wada test: to study speech and memory Neuropsychological testing: mental functions (IQ, memory, attention) and personality assessment Psychological evaluation Ophthalmologic evaluation

35. Epilepsy Surgery • Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES • Depth electrodes • Subdural electrodes

38. Types of Epilepsy Surgery • Temporal Lobectomy • Extratemporal Resections • Hemispherectomy • Corpus Callosotomy

40. Outcome after epilepsy surgery • Anterior temporal lobectomy • 70-80% seizure free • Neocortical resection • With lesion: 50-80% seizure free • Without lesion: 30-50% seizure free • Hemispherectomy • Significant improvement • Corpus Callosotomy • Significant improvement for drop attacks

41. Complications of surgery • Low rate of complications • Infections • Bleeding • Anesthesia • Function

42. Vagus Nerve Stimulator (1997) • Intractable epilepsy patient without focus or desires interim step before epilepsy surgery • Goal is to reduce amount/severity of seizures vs. cure • Device surgically implanted in left chest/axilla area • Coils around left vagus nerve • Stimulation is automatic; patient can additionally stimulate device if aura

44. Summary • Ways to treat epilepsy • Medications • Ketogenic Diet • Surgery • Vagus nerve stimulator

45. Diagnostic Advances • Magnetoencefalography

46. Functional MRI

47. Advances in Treatment • Newermedications • Brivaracetam • Carisbamate • Clobazam • Eslicarbazepine • Ganaxalone • Losigamone • Nitrfazepam • Perampanel • Piracetam • Progabide • Remacemide • Retigabine • Seletracetam • Stiripentol

48. Deep Brain Stimulation (DBS)

49. Neuropace

50. Alternative Treatments • Diets • Supplements • Herbs • Oxygen therapy • Relaxation techniques • Neurofeedback • Art therapy • Massage/yoga