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Epilepsy
Epilepsy is a disorder of the nervous system characterized by seizures that often end with a loss of consciousness. Patients with Epilepsy may have frequent or infrequent seizures, and they may be severe or mild, but Epilepsy is a condition that must be medically assessed and controlled.
Symptoms
The nature and degree of symptoms vary depending upon the type of seizure. Some seizures end with a loss of consciousness, others do not. Generally speaking, there are two major categories of seizures: partial seizures an generalized seizures. There are two versions of partial seizures, and four types of generalized seizures.
 Partial Seizures
Simple partial seizures begin in one area of the brain. The movement associated with this type of seizure depends on what area of the brain is affected. When this type of seizure occurs, you will be aware that it is happening and may even be able to talk, but you will not be able to control your movements.
Complex partial seizures usually give some forewarning: you may experience a strange taste in your mouth, hear a strange sound, feel nauseous or have a sense of deja vu. This type of seizure spreads to a larger area of the brain. As the seizure spreads, you may appear to do purposeless repetitive movements such as lip-smacking, picking at clothes, wringing hands or swallowing. You will appear awake, but will be unaware of your surroundings and will have no control over your actions. If the seizure continues to spread throughout the brain, the result is grand mal seizures.
Generalized Seizures
Generalized seizures occur simultaneously throughout the brain. Absence seizures occur most commonly in childhood and are often mistaken for daydreaming or staring spells. Myoclonic seizures are short in duration and result in jerking movements. Atonic seizures are sometimes referred to as "drop attacks," as they cause you to simply drop to the ground. Tonic clonic seizures are also known as grand mal seizures, or generalized seizures.
Treatment
Medical Management
About 80 percent of all patients with Epilepsy become seizure-free on Anti-Epilepsy Drugs (AED's). The type of Epilepsy you have helps determine which medications will work best. It is important to take these medications according to the dosage and schedule your doctor prescribes. It is also important that you develop a "seizure calendar" to keep track of the numbe of seizures that you are experiencing, and when they occur. Bring this with you to your appointments.
All AEDs can cause side effects, possibly related to your dosage. Your doctor will discuss these with you. It is important that you call your doctor regarding any symptoms you experience, though you should not change th way or the amount of medicine you are taking without talking with your docto first. Most important, you should never stop taking your medicine as this can cause status epilepticus which can be a life-threatening emergency.
Periodically, your doctor will ask you to have blood tests done to find out how much medicine is in your blood. Your doctor will inform you of the bes time of day to have these tests done, and will call you with the results to allow you to make any needed adjustments.
Surgical Treatment
Although 80 percent of those diagnosed with Epilepsy respond to drug treatments and become seizure-free, those who do not may be candidates for Epilepsy surgery. The type of surgery you will need depends upon severa factors, including:
 The type of seizures you have
Where in the brain these seizures begin
What functions the affected area of the brain controls
These questions are answered during evaluation and testing at the Sentara Comprehensive Epilepsy Center by a team of staff and doctors who revie each patient's case. Recommendations resulting from that conference including the risks, benefits and successful outcomes of surgery, can then b presented to the patient and family members.
Evaluation
Evaluation is a critical role of Sentara's Comprehensive Epilepsy Program. Evaluations are done to clarify the type and frequency of seizures, in order to maximize the effectiveness of medical treatment and/or to determine i surgical treatment is possible. In some cases, evaluations are necessary to rule out other possible causes for spells which may resemble Epilepsy. Some or all of the following tests may be necessary:
Epilepsy program professionals will conduct a physical exam, and compile an extensive medical history. Patients should provide as many specifics about the nature of their seizures as possible. (It helps to bring a family member who has witnessed your seizures to the initial intake interview to describe your seizures to the neurologist.)
EEG (electroencephalogram)
This is a safe and painless test that gives important information about the health and functioning of the brain. It detects the brain's electrical impulses, creating patterns that can then be viewed on a computer screen and printed. These patterns help the physician determine the nature of your problem and how best to treat it. In preparing for the EEG, you may need to:
Adjust your sleeping schedule (your doctor or nurse will give you particulars on how best to do this).
Wash and dry your hair thoroughly. Do not use conditioners, hairsprays or other styling products.
Most patients will be asked to eat a meal or a snack two hours before the test, but because some tests require that you do not eat, check with your doctor.
Take your normally prescribed medications.
To conduct the EEG, electrodes will be applied to your scalp with a gel. During the test, you will be asked to breathe deeply and quickly. This may cause mild dizziness or tingling, which is normal. You will open and shut your eyes, as a light flashes on and off (this can cause you to see various colors and patterns). It is important that you follow all instructions, relax and remain quiet during the course of the test. You will be able to resume all normal activities following the test. (You may want to shampoo as soon as possible following the test so the gel will be easier to remove from your hair.) Results of the test will be reported to your physician; he or she will discuss them with you.
MRI (Magnetic Resonance Imaging)
An MRI allows your doctor to view your brain by specific sections, facilitating a highly detailed picture that gives more information on the location of an abnor-mality. It works using a magneti field, so there is no radiation involved. Magnetic signals are fed into a computer which assembles a picture. Because the MRI ignores bone which can obstruct CT images, this device provides a clearer picture of tumor located near the bone, and can provide a wider variety of image angles. It can detect edema (swelling), but has difficulty distinguishing edema from a tumor. Patients with cardiac monitors, pacemakers or surgical clips cannot take an MRI because of conflicts with the magnetic fields. MRI scanning also detects evidence of all types and degrees of brain injury.
The day of your test you may eat and do all other activities that you would normally do. When you arrive you will be asked to remove all jewelry, bank cards, and any other metal you may have on you. You will be asked to lie on the table and remain very still. The technologist will give you earplugs to lessen the noise, or you may bring a cassette tape to listen to while the test is being conducted. You will periodically be able to speak to the technologist through microphones. It is completely painless and takes about one hour to complete. You will be moved inside a relatively small and noisy round tube for this test; if you have difficulty being in a confined area, speak with your doctor.
Once the test is completed, it will be reviewed by a radiologist who will discuss the results with your doctor. Your doctor will explain the results to you at your next appointment.
Video/EEG monitoring
As many as 25 percent of adults who have seizures may have completely normal EEG's. This is because the brain's seizure activity pattern can come and go and is not always apparent during routine EEG tests. The video EEG allows for long-term monitoring of brain wave activity * it enables your doctor to see what actually happens to yo before, during and after a seizure. The test's purpose is to determine where in the brain your seizures begin. It can be conducted in a few hours, but in some cases may take five to seven days, depending on how frequently your seizures occur and how many seizures need to be recorded. In general, yo can expect to spend five days in the hospital.
We ask that a family member or close friend stay with you as much as possible during your hospital stay. They can alert the nurses when you are having a seizure, and can describe the seizures you're experiencing and compare them with the ones you have had in the past. The hospital will do all we can to make your friend or family member comfortable during your stay. At the beginning of the test, the equipment and process will be fully explained to you. The side rails of the bed will be padded for your safety, and there will be a capped area of intravenous access, should you need medication to stop a seizure. Electrodes will be placed on your head, attached with glue.
Some conditions may also require sphenoidal electrodes. These are thread-like wires that are placed just in front of your ear with a small needle. (The area will be numbed before the electrodes are attached, and a small bandage will be placed over the wires.) These special electrodes provide additional information about the temporal lobes of the brain.
They will remain in place until recording has been completed. If you experience soreness where the wires are attached, talk to your nurse. The electrodes will remain in place until you are discharged, though you will be able to get to the bathroom and walk around the room. You will need to bring clothes that zip or button down the front or back, as you will not be able to pull anything over your head. You will not be able to take a shower or wash your hair until the electrodes are removed. The nurse will give you additional instructions during your stay, and a member of the Epilepsy staff, in addition to a neurologist, will update you on your progress. You will be given some information about the results of your monitoring before you are discharged, but the final results will be presented to you at an appointment with your doctor two to three weeks later. Your family is encouraged to join you for this appointment.
SPECT (Single Photon Emission Computed Tomography)
This type of scanning may also be performed during your hospitalization. This involves injecting a harmless radioactive tracer at the time of the seizure. Later, a picture can be taken (imaging) which will show which part of the brain was most activ during the seizure.
Testing for Surgery Candidates
Neuropsychological testing
As part of your evaluation for Epilepsy surgery you will be scheduled for a series of neuropsychological tests, designed to determine how different parts of your brain work and how your seizures have affected your ability to do certain tasks. You will be asked to do such thing as answer questions, assemble puzzles, draw pictures from memory as well as other tests to determine strength, coordination and language ability. The testing takes approximately four to six hours, in addition to a one-hour interview with your neuropsychologist. This testing will be scheduled through the Comprehensive Epilepsy Program, and the results will be explained to you at your next appointment.
Wada testing
Epilepsy surgery involves removing the part of the brain where the seizures begin. The Wada test is conducted to be certain that the area to be removed does not control important functions such as language and memory; in other words, it is a way of insuring that you retain these abilities.
A catheter is inserted into the groin area and fed to the carotid artery. A short-acting drug is injected into the catheter, shutting down one side of the brain. The drug will cause one side of your body to become paralyzed for about five minutes. You may also lose your ability to speak. During this time, you will be shown pictures or objects to pronounce and remember. After the drug's effect has worn off and you have regained your ability to move, your memory will be tested by presenting you with four options and asking you to pick out the items you were previously shown. The test is not painful, although you may experience mild discomfort when the catheter is first inserted. You may feel strange and have a difficult time staying awake. After the test is over, you will need to lie flat with your leg perfectly straight. You will remain at the hospital at least six hours after the test to make sure that the site where the catheter was inserted is healing. You will be able to resume your normal activities the following day.
Invasive monitoring
If your doctor is unable, using surface monitoring, to determine where the seizures begin, it may be necessary to record your seizures by placing electrodes directly on the brain, requiring a surgical procedure. (The specific type of electrodes used and the nature of your surgery will depend on the area of your brain that needs evaluation. Your situation will be fully explained to you by your doctor.)
The night before surgery you may not eat or drink anything after midnight, with the exception of the medication you will be required to take in the morning with a sip of water. When you get to the hospital, an IV will be inserted and an anesthesiologist will come and talk with you. You will then be transported to the operating room. Your surgery will last from two to five hours. After surgery, you will be transported to the Neurosurgical Intensive Care Unit (NICU) to be closely monitored for 24 hours.
The next day you will go to the Epilepsy Monitoring Unit and will remain there until a sufficient number of seizures have been recorded. You can expect to remain in the hospital for roughly the same amount of time you would for surface monitoring (about five days). Also similar to surface monitoring, we ask that, if possible, a family member or friend remain in the room with you to watch for seizures. Hospital staff will make arrangements to make your guest as comfortable as possible.
Because these electrodes are placed next to the linings of the brain, you can expect to have a moderately severe headache; let your nurse know when yo are in pain and medication will be given to you. After your seizures have been recorded, you will be returned to the operating room where the electrodes wil be removed. Depending upon the type of monitoring you received, you wil either have surgery right away to remove the damaged area of your brain, or you will go home for a few weeks before having the final surgery.
Surgery
The night before surgery you may not eat or drink anything after midnight, with the exception of the medication you will be given in the morning along with a sip of water. When you arrive at the hospital, an IV will be inserted and the anesthesiologist will speak with you. You will then be transported to the operating room. Your surgery will last four to six hours, and your family will be given updates on the progress of the surgery.
You will awaken in the Neurosurgical Intensive Care Unit (NICU) where you will remain for 24 to 48 hours, during which time you will be closely monitored. You will be connected to at least two IV lines, a catheter and a special arterial line in your wrist. Your head will be bandaged and you can expect some degree of headache. You may experience nausea. Let your nurse know when you are in pain so that you can receive medication for it.
The day after surgery, the catheter and arterial line will be removed. You will be able to sit in a chair and eat a soft diet. Each day you will be encouraged to be increasingly active, and you should be discharged in three to five days. You will probably remain on antiepileptic drugs for at least two years following surgery, though your doctor may gradually reduce your dosage.
There are a variety of surgical options for patients with Epilepsy. These include:
Temporal lobectomy
This involves removal of part of the temporal lobe. This is the most common type of Epilepsy procedure and has the best success rate.
Extra temporal lesionectomy
This involves removing that part of the brain outside of the temporal lobe that appears abnormal on the MRI (and therefore is believed to be where the seizures begin).
Corpus callosotomy
In this procedure, brain tissue is not removed, but the connections between the left and right hemispheres are eliminated. This procedure is usually most effective for patients with "drop attacks" (atonic seizures).
Hemispherectomy
This procedure involves removing nearly all of one of the hemispheres of the brain. It is conducted on patients with severe motor seizures involving only one side of the body and who already have a hemiparesis (one-sided paralysis) and non-functioning hand.
Multiple Subpial Transections
This surgery involves making small incisions in the brain which interfere with the spread of sequence impulses.
Electrical Stimulation Treatment
Another option for treatment involves using a Vagus Nerve Stimulator (VNS). This device is implanted in the chest wall and connected to the vagus nerve in the neck. It produces a mild electrical stimulation that travels from the vagus nerve to various areas of the brain. This process disrupts the electrical discharges of the brain and reduces the frequency of seizures in some patients.
Attached to the VNS is a magnet that, when placed over the stimulator, turns it off in case of an emergency. When the magnet is placed over the stimulator and then quickly removed, it generates an extra stimulation which, in some patients, stops or reduces the severity of a seizure.
Implanting the stimulator requires surgery. The night before surgery you may not eat or drink anything after midnight, with the exception of the medication you will b given in the morning along with a sip of water.
When you arrive at the hospital, an IV will be inserted, and the anesthesiologist will speak with you. You will then be transported to the operating room. The stimulator will be implanted in the left chest wall and the electrodes will be connected to the vagus nerve in the neck. The surgery will last about two hours. After surgery you will spend the night in the hospital and will be able to go home the next morning. You can expect some minor discomfort at the two incision sites.
Two weeks after the surgery, your doctor will turn on the stimulator to the lowest setting. You may feel the stimulation and may experience some changes in your voice; these will pass when the stimulator stops. (Expect this doctor visit to last longer than usual, as your doctor will want to make sure you are comfortably tolerating the stimulation.) After the initial visit, you will return to your doctor every two to four weeks to increase the stimulation as necessary until the seizures stop.
Research
Research in the U.S. on every level of Epilepsy treatment is ongoing, and several new drugs are currently in clinical trials that will be available in the near future. Advances in imaging are providing more and better information about the structure of the brain and making it easier for doctors to locate lesions and other abnormalities.
Prevention
Seventy percent of all Epilepsy cases cannot be traced to a specific cause. There are certain behaviors that can trigger a seizure, including alcohol and drug abuse. There is also the possibility of a genetic predisposition toward Epilepsy. Some of the major risk factors for Epilepsy cannot be controlled, such as central nervous system infections, cerebral tumors and cerebral vascular disease.
Because Epilepsy is most strongly linked to head trauma, the best form of prevention is to take reasonable precautions. Do not dive if you are unfamiliar with the depth of an area, always wear your seatbelt; make sure you wear helmets when cycling and roller blading.
Support Groups/Resources
Many patients and families find great comfort and support in talking with other patients, families and caregivers who have had (or are having) similar experiences. Support group meetings are free of charge, and are facilitated by a trained peer or qualified professional.
Sentara's Epilepsy Support Group meets every first Thursday of the month at Kempsville Presbyterian Church. Call Mary Wilson at 499-7155 for more information.
For more information about Epilepsy support and services, contact:
The Sentara Comprehensive Epilepsy Center
Phone: (757) 388-3127
The Epilepsy Foundation of America
Phone: 1-800-332-1000
Centers for Disease Control and Prevention
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