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As opposed to the generalized seizures, the focal seizures or partial onset seizures are much more common in adults. This is what most of what I see. With partial onset seizures again the symptoms are interesting and difficult too, because it completely depends where they’re coming from in the brain. And so in adults, the seizures have three main types. They’re called simple-partial, complex-partial, and then secondarily generalized. And it all has to do with how much of the brain is involved. And so you can imagine there’s a scar in the brain, the size of your pinky tip and that scar can be anywhere, let’s say it’s in the temporal lobe where the majority of seizures originate. In that area, that part of the brain is firing off in a disorganized way. It’s a tiny area and because it’s so small, there’s no alteration of consciousness, there’s no confusion, but the area right around it gets activated. That electrical activity sort of is conducted to the brain cells right around there. And so you get a feeling for whatever that is. And I point out if that was in your vision area, you could have a visual hallucination. If it was in a motor area, you might get jerking on the opposite side in the temporal lobe. There are some very consistent symptoms people get. Often either butterflies in the stomach or this rising feeling in the stomach, like you’re on a roller coaster. But people can get Deja Vu. A funny taste. Almost always unpleasant, a funny smell. A panic feeling, unprovoked anxiety. And again, there’s no alteration of consciousness. So people will often say, that’s not a seizure. That was an aura. Well, that is, that’s a small seizure. That’s a simple partial seizure. Then as a seizure, gets a little bit bigger, a little bit more of the brain is involved. Then you start to have some alteration of consciousness. And I would point out that this is often very gray, right? There’s the there, you know, there is the black and the white. No the totally aware of what’s going on in the, totally not aware of what’s going on. But there’s all of these shades of gray in between and we call these sort of dyscognitive symptoms where you’re just not quite right. You’re not functioning at full capacity. And again, it has to do with just how much of the brain is involved with the seizure activity.
And then there are some other types of what we call neuromodulation. These are surgeries to help control seizures bu, aren’t necessarily going to completely stop them, but help control them. And the one that’s been around the longest is something called the vagal nerve stimulator. This is a pacemaker device that’s implanted under the skin and the pacemaker is, or there’s a wire then this run underneath the skin to the neck to a nerve in the neck called the vagus nerve and it sends an impulse to that nerve and then through a black box mechanism, nobody knows exactly how it works. It sends a signal up into the brain that helps control seizures. And on average maybe a 50% reduction in seizure frequency. Some patients more, some patients less. The advantage of the vagal nerve stimulators, it’s not another pill, they don’t have to remember to take it, and it has an on demand feature, meaning you can take a magnet and actually if you can tell a seizure is coming on, you can swipe the magnet on the device. And what that’ll do is that’ll cause the device to turn on, which can abbreviate or prevent a seizure. There’s another device that’s actually an implanted in the skull and an electrode is actually put into the seizure focus itself, and that device will detect a seizure and actually zap the brain and prevent the seizure from occurring. The challenge with that device, it’s called the neuropace device, is that you have to be really sure where or fairly certain where the seizures coming from before you can implant it.
So then we think, well, Gee, what do we do after medications and so after medications we have a few different options. The first and sort of best option as far as controlling seizures would be epilepsy surgery. That always scares everybody when it comes up. And when I talk about epilepsy surgery, I’m actually talking about removal of part of the brain. And the key there is that we are able to identify where the seizures are coming from and take that part out. Now not all people with epilepsy have focal seizures. So the people who have generalized seizure disorders, we can’t do surgery to take out part of their brand because it comes from everywhere. And then in people with focal seizure disorders, a large percentage of those patients, we can’t actually nail down exactly the spot. And so how do we nail down the spot where the seizures are coming from? We do a couple of things. One: we do an MRI of the brain and again we’re paying very careful attention for any subtle little scar that we can associate with where the seizures coming from. We also do the video EEG monitoring. That’s an integral part of nailing down where the focus is. Where’s the seizure coming from? Again, the video EEG monitoring is, it’s a significant chunk of time where someone is admitted to the hospital, an EEG is put on their head and we want you for a week, sometimes more, sometimes less and we’re actually looking to capture seizures. In that situation, we’ll often remove medications to provoke seizures a little bit. Recognizing that this is a very supervised situation where if someone were to have a prolonged seizure or too many seizures, we have ways to treat those as well. Surgery is attractive because we know that in someone who’s failed three different medications and continues to have seizures, the likelihood of making them seizure free is very low and it can be in the right scenario much, much better with surgery, like 80% in the right kind of cases. And even in the cases where it’s not 80% still significantly better than more medication adjustments. A large percentage of patients won’t be able to have epilepsy surgery because we won’t be able to be certain where the seizure focus is.
In those patients, we have other types of of treatments. One treatment is diet. In children we often use something called the ketogenic diet where there’s a very, very, limited diet with very little carbs. And that has an antiseizure effect. The problem is that in adults, that’s a very difficult diet to stick to. Such a limited amount of carbs one, mishap, you know, one muffin or candy bar and the diet is ruined. So, there are other diets though in adults that may be effective. One’s called the modified Atkins Diet where it’s a limited carb diet, but not as limited as the ketogenic diet. Now the question is, what are the long term ramifications of the modified Atkins died? And we don’t know exactly. We know that it causes weight loss and it causes elevation in cholesterol. Kind of the big questions are, does it affect heart disease and stroke risk down the line? The answers, nobody knows that yet.
Alternative treatments for epilepsy haven’t been particularly effective from my experience. One of the things that comes up most frequently, and I would tell you every day, is the question about marijuana and epilepsy. And there have been some anecdotal reports, particularly stuff you’ve seen on CNN where there’ve been some pretty amazing responses that have occurred when kids have had marijuana or some marijuana extract that has helped control their seizures. And I would point out from my end, it’s very difficult to sort of give any good advice. And the reason is we don’t have any trials really conducted in the fashion or with the rigor that we’ve expected from every other anticonvulsant medication. And so I can tell you, you know, numbers as far as, side effects and interactions with any anticonvulsant, I have no idea with marijuana as to, you know, how much to give, what drug interactions, what other side effects that happen. And I think that one of the traps that people fall into is they don’t think of it as a chemical. They think of pills as chemicals, but marijuana somehow is a leaf. It’s a green leafy vegetable. It’s not a chemical. And that’s not right. It is. It’s a chemical that has potentially some good effects, but the equally potentially bad effects. And I couldn’t tell you anything about, you know, what epilepsy it works for, which ones it doesn’t work for. Could it make some worse? Make some better? And the answer is yes to everything and I just don’t know. So it’s an exciting thing for the future. Is there some really exciting possibilities there? The answer is yes. Would I, you know, can I recommend it to my patients? I can’t, cause I don’t have any data on it at all.
Epilepsy can have a big effect on a patient’s life and lifestyle and a couple of things to sort of think about one, epilepsy and, and sort of life in general is specifically things like driving, getting around. Epilepsy and driving is a state-specific issue. Each state has its own laws and own ways of sort of approaching it. In Arizona, the law says that one you’re supposed to report to the department of motor vehicles if you have epilepsy. And then if you have a seizure that causes alteration of consciousness, you can’t drive for three months. After three months, there’s a form to fill out by the physician that allows you to drive again. Other things that, you know, people don’t always think about if they’re having seizures that can be dangerous. Swimming alone, very dangerous. Working at heights, working with heavy machinery, and problems can occur with respect to job and professions such as, anything that involves driving a motor vehicle, truck driver or operating heavy machinery such as at a mine. Things like that can be difficult jobs for someone with epilepsy to have, mostly because they’re dangerous.
Epilepsy has other effects on lifestyle, often because transportation is so difficult and job restrictions in general because of the seizures can make it difficult to get to job interviews, maintain a job, and it’s such a challenge for my epilepsy patients. We know that the rate of unemployment can be as high as 50% in epilepsy patients, and this is such a huge issue because health insurance is critical for these patients to be able to get their medications and get the care that they need. So it’s a big problem.
So there are some major triggers for seizures that everybody should be aware of. There are specifically, three big ones, actually. One: stress. Stress is the universal trigger for actually everything neurological frankly, but especially epilepsy. And it’s tough because stress is such an individual sort of problem, you know, what’s stressful to you might not be what’s exactly stressful to me. But stress as a general rule is an absolute trigger for seizures. So I recommend my patients find ways to sort of manage their stress, find techniques that work well for them. If it’s seeing a counselor to help work on relaxation techniques, do it, it’s important. Sleep deprivation, a big one. You know, my recommendation is that people try to get what is whatever is regular for them. If they don’t know, then shoot for about eight hours a night. Now, you know, I’ve got some lucky folks who, you know, lived on six hours of sleep a night and that’s what they need. Fine. Whatever works well for you, just get it on a regular basis and you want to have a relatively regular sleep cycle. You know, what is really hard on my epilepsy patients on someone who switches, you know, from night shifts, two days of the week, and then daytime, you know, the other days those switches for epilepsy patients is a really hard, and it can be a big trigger for seizures. And then last is alcohol use alcohol itself is it lowers your seizure threshold and then can provoke seizures. And so I recommend my epilepsy patients abstain from alcohol as much as possible.
And then looking at an alternative treatments for epilepsy. And so, there are a few things that have sort of been been developing. So one was this neuropace device, which is relatively recently approved and we’re looking at new ways to use this. But the neuropace device is a device where if we know where the seizures coming from and we can’t remove that part of the brain or don’t want to remove that part of the brain, we can put this electrode on where that seizure is coming from, and it detects a seizure whether you’re aware of it or not and can stop the seizure in its tracks. And that has a potential utility in treating types of epilepsy that we couldn’t treat in any good way. And so an example would be someone who has seizures coming from both temporal lobes. We can’t remove both temporal lobes because that would give you lots of problems specifically with memory. But with the neuropace device, we can actually put those electrodes on the temporal lobes on both sides and it could be detecting where the seizures are coming from and stop them. Another device that sort of out there is a deep brain stimulator and which is something we use very frequently for Parkinson’s disease. This is a device where there’s actually an electrode that’s implanted into the brain, into a part of the brain called the Thalamus, which is a relay area of the brain. And there this, this device can actually electrically stimulate the brain itself causing reduction in seizure frequency. There’ve been some trials on this that have been promising, although hasn’t been approved yet and probably need some more studies down the line. You know, with respect to treatment, there are always new things sort of being evaluated and examined. And even beyond that sort of devices that we have being tweaked, like the vagal nerve stimulator, there are potential changes to the vagal nerve stimulator that might make it more effective down the line. Like an ability for the device itself to detect seizures on its own and Zap that vagus nerve on its own to help abbreviate a seizure so that a person doesn’t have to swipe it themselves. It just automatically goes. So there’s some exciting new things coming along the pikes and always new things kind of coming out there. We’re very excited about any and all new therapies to treat this disease.
There is a lot of research going on in epilepsy, constantly looking for better treatments. It’s kind of interesting and one of the frustrating sort of realities that we’ve dealt with, which is that over the last 20 to 30 years, we’ve had an explosion on number of medications. And I point out that, you know, a drug we use today, was Dilantin, was a drug that we really discovered in the 1930s and was the most commonly prescribed drug until relatively recently. And because, you know, of the boom in medications, we’ve had you know, again, over 20 different anticonvulsants on the market. But one of the frustrating things that we’ve seen is that with all of these new medications, we haven’t seen a reduction in how frequently we control someone’s epilepsy. And so the number of about roughly give or take 60, 65% of patients respond to medications and 30 to 35% continue to have seizures. That hasn’t changed in the last 30 years. So all of these things that we’ve done haven’t had quite the effect on controlling epilepsy that we want. So with respect to research, there are a few things going on. First and foremost, new medications in the pipelines, medications using novel or new mechanisms of action, ideally maybe with more effectiveness, less side effects, and so there are definitely new medications being developed from that end.
So the future of epilepsy treatment is unclear. What I hope to see in the not so distant future is what we call a pharmacogenomic approach to sort of treatment of epilepsy. And so this does get to a little bit to the genetics in some ways. And that is, you know, one of the things I feel most powerless to sort of prevent or, or handle is, you know, I don’t know how you’re going to respond to any medication. And this is true for any disease entity, not just epilepsy, but it’s so important in epilepsy because there’s so many medications that we have to choose from. And so the notion from my end would be, it would be great to be able to take your blood and sample it and be able to sort of see, oh wow, here’s the medication that you’re going to respond to. You know, we should use levatarazatam and not carbamazepine or, you know, and so give me something to help guide me on what medications work well for you.
You know, there are technologies that are being further developed with respect to being able to localize or nail down that seizure focus. And I’ll point out again, surgery can be such a useful treatment for patients. And so the idea would be what other ways can we be certain about where with the seizure focus is? And there’s a device called a MEG, magneto encephalogram which can basically help nail down where the seizure focus is and it can see electrical fields coming out of your brain and be able to sort of nail down where exactly the seizure focus is based on those fields and those electrical fields. The other thing would be that, you know, I envision that, you know, being more effective and more aggressive with surgery. I think that there’s such good data that says that surgery is effective in controlling seizures, especially in people who are refractory and continue to have seizures despite two or three medication trials. And I think we need to get that message out to that to the public and get more aggressive in general about treating patients, because the effects of epilepsy long term are significant. Not only does it affect your ability to enjoy life because you’re always worried about, you know, when’s the next seizure going to happen? What’s the next sort of disaster? You can’t drive. You can’t go swimming alone. You can’t work at heights. Working in general is a challenge. And so, attacking those are, you know, getting seizures controlled, is so incredibly crucial.
Insurance and epilepsy can be a little bit of a challenge. And I speak from my perspective, which is one: insurance is often we’ll have very specific medications that they would prefer covering, medications you have to try first before trying the next medication. Often, Medicaid for instance, will ask for something called a prior authorization. And so the physician can say, look, I think this is the right drug for you. And the insurance company says, look, you can’t use that drug first. You’ve got to try a few other drugs before you get there. And we just have to navigate that individually with the patient themselves and their insurance with respect to getting insurance. Having epilepsy as a prior diagnosis shouldn’t be an impediment to getting insurance. But that’s not something I can really sort of comment on too much. I haven’t had much experience with that.
There are a lot of great organizations to help with epilepsy. The best one that’s been around the longest in Arizona is The Epilepsy Foundation of Arizona. They’re based out of Phoenix. They have an outreach though to every city in Arizona and they’re a fantastic organization to get involved with. So The Epilepsy Foundation is a national organization. They have a headquarters and then each state though has their own sort of area that they run it themselves. And so, you know, it’s a national organization. They fund, you know, studies. They do all kinds of fantastic work in treatment prevention of epilepsy and getting the word out on epilepsy. But it’s run statewide here and the, you know, the president currently is Suzanne Metso Mauri, who is fantastic and eager to help anybody who has any questions, concerns, can feed them information, and can be involved as an advocate in any way they like.
So with respect to causes or risk factors for epilepsy. Again, that is something that sort of changes a little bit with age. But in general, what we’re looking for is major head trauma associated with skull fracture, loss of consciousness, any history of brain infection, meningitis, encephalitis. In older adults, we are certainly looking for a prior history of stroke. It’s interesting, about 20% of all strokes can lead to seizures later on. The seizures that occur with strokes, they don’t occur at the time of the stroke. That’s actually unusual. This is months or years later as the scar tissue forms. So it’s not one of these things that happens immediately and it depends on the type of stroke itself.
So with respect to cause of epilepsy or cause of the seizure, absolutely thinking about it a little bit differently in young adults versus older adults. Although the workup is always pretty similar, but you know, the things that we’re looking at in younger adults, would be of course, you know, medications, illicit, drug use, and specifically anything that’s activating to the brain. So things like cocaine and methamphetamine especially that can provoke alcohol use, unfortunately. And then also, I mean, we’re thinking much more along the lines of, you know, genetic and generalized epilepsy in those types of patients as opposed to the patients over 50 and 60. We’re thinking along the lines of, you know, post stroke epilepsy, is there any stroke? A brain tumor? Actually, you know, amongst the top three causes of epilepsy is neurodegenerative diseases. So things like Alzheimer’s, as it progresses, and usually not in the early stages, but in the later stages, can actually cause enough injury in the brain that it can provoke seizures.
With respect to who gets epilepsy, It’s interesting because there’s a bit of a, a misconception and that is that everybody with epilepsy has it from childhood. I think there are a lot of people have this vision of a child with cerebral palsy in a wheelchair and that’s what epilepsy is. And in the 1990s through some epidemiologic studies we realized that actually isn’t exactly true. Yes, there’s a spike in the occurrence of epilepsy in childhood and in young age, maybe around 10 it does start to peter off and through your 20s and 30s and 40s it’s relatively infrequent and stays relatively stable. And then you hit about age 55 and we realized there was an increase in the incidence of epilepsy. And after about age 65, the incidence of epilepsy appears to be higher than in any other age group. So as people get older, new cases of epilepsy are much more common than we thought. Now the question is, well why, where are these coming from? It’s probably mostly related to post-stroke, epilepsy, but in general thing, people are living longer, living through things that in the past they didn’t, they didn’t live through, whether that’s brain trauma, cancer, or strokes, and that’s where they’re coming from.
The symptoms of epilepsy are recurrent unprovoked seizures. It’s important to recognize that, you know, the generalized tonic clonic seizure, then big convulsive event, a grand mal seizure, which is a term that frankly we try not to use, but we do, that is actually not the most common type of seizure. And it’s those partial onset seizures, those staring and confusion spells, which are much more common. And you know, I see this very frequently, which is people just don’t always recognize recognize that that was a seizure. They see it happen and they blame it on, you know, something else, whether it’s a TIA often, is what they’ll sort of label it as. And they’re actually seizures. So this is one of those, one of those types of diagnoses that the patients, the families and the physicians have to sort of be specifically thinking about. And again, it’s recognition that it’s not a disease of childhood only. It’s a disease that we’re seeing and people over the age of 50 and 60 and especially as our population gets older, we’re going to have to be more and more vigilant about picking it up.
The next question I often get asked is sort of well when should I call 911 if someone has a seizure. And so I would point out that if it’s a first time seizure or anything that you’re uncomfortable with calling 911. Get them in the hospital. That being said, if someone has epilepsy, we have a known seizure disorder, well it’s probably not particularly helpful to go into the hospital every time someone has a seizure. So when do you go in a couple of circumstances. One if the seizure is particularly prolonged, how long is a prolonged seizure? About five minutes if the seizures. Longer than five minutes call nine one one. And so one of the things that I recommend when someone’s having a seizure, it’s just try to look at the clock, try to get some idea of what the time is. It’s hard to do when you’re panicking when a loved one is having seizure, do your best. The next thing that I would sort of pay attention to is back to back seizures. So when someone has a seizure, doesn’t come back to their baseline and has another seizure and bolt those circumstances back to back seizures and prolonged seizures, they probably need intravenous medication to help control their seizures. Calling 911 the paramedics in Tucson are fantastic. They’re trained to recognize seizures and treat them in the field if they need it, and they’ll get them to a hospital where they can get the treatment that they need. Lastly, if anyone gets hurt, if there is any injury that you think is something you can’t handle, you’re not sure about, get them into the hospital. Outside of that, patients don’t always need to come into the hospital for seizure. Often a call to the neurologist alerting them that they had the seizure and asking for what to do next is enough.
So if someone’s coming to the office with seizures, be prepared to have an MRI of the brain, and EEG and a thorough history taken from the physician, or care provider that’s treating you. I often talk to my patients about the fact that it’s difficult, and I liken the perfect test or I think about the perfect test. And to me the perfect test is a pregnancy test. It’s negative or it’s positive end of story. You got your answer. In epilepsy and seizures, often that isn’t the case. And so we’re stuck as physicians trying to make our best diagnosis with the information that’s available, recognizing that the information is far from perfect. And so how do I try to make that determination? What do I need to make a diagnosis of epilepsy in a patient? So first and foremost, the history from the patient and it’s really, really useful to have the patient, the person coming in and someone else, a friend, family member, preferably who knows them, who can help kind of augment the story. And the idea here is that someone comes, someone’s referred to me for a first time seizure, for instance. I want to know, I’m going to be very careful about trying to go back and ask about anything in the past that sounds like a seizure. About 50% of people with a first time seizure who come in for a first time seizure have actually had a seizure in the past. And it’s sort of, sometimes because people don’t recognize these complex partial seizures, they don’t recognize some of the seizures cause they’re subtle. They’re not obvious. It takes a little bit of fishing this sort of determine that.
And it helps to have the patient who may not even recognize what’s going on. And one of the difficult things that we have in epilepsy is that the organ, your brain involved in recognizing what’s going on and in the environment and recognizing something isn’t right. It’s the organ that’s not working right. And so inherently there’s a problem, they’re often in recognition by the patient themselves as to what’s going on. So, that being said, the history is probably the most important part of what I need. But I’ll augment that with other studies. The next thing that I’ll want is an MRI of the brain. A CT scan can work, but an MRI is much more sensitive and much better. I’ll point out a CT scan is as an x-ray where they take slices through your head and we can image the skull really well, but the brain is a little bit harder to see with x rays. Where an is a giant magnet. And it doesn’t show the bone very well, but the brain itself, we see with exquisite detail. And what I’m looking for. I can’t see seizures with an MRI. But what I can see is structural abnormalities in the brain that I know would be associated with seizures, certain types of stroke. Again, I’ll point out not all strokes can cause seizures, but some can. Brain tumors, scar tissue, and sometimes very subtle scar tissue, but we can pick it up. So an MRI would be really useful. I will point out that for a new seizure patient, we usually want to do these studies with contrast. Contrast is really important. This is where they give you an IV and they inject contrast into your veins. And the idea is that can be much more sensitive for picking up things like brain tumors that we wouldn’t necessarily pick up with a normal scan.
The other thing that we’ll want, and equally important as the MRI, if not more important, is the electroencephalogram or EEG. An EEG is a test where what we’ll do is we’ll hook up electrodes to your head and usually it’s 21 electrodes through the head. They’re on the skin, nothing inserted into the skin, and they glue them on. So it’ll make your hair sort of messy for a couple of days or a day. And what you do is ideally you come in a little bit, sleep deprived. We tend to ask people to have a half nights sleep prior to the study. And the idea is we want you to come in, go into this nice dark room and take a nap. 20-30 minutes. And what we’re doing is we’re looking at all the brainwaves. And your brainwaves are incredibly small. You know, it’s interesting the eyeball has a charge that’s a hundred times more than the brainwaves that we see. So when you blink, we can actually see a huge change in the charge and the EEG. But what I’m looking for is what we call epileptiform discharges. What are epileptiform discharges? They are certain wave forms. They look like big spikes. And when I see those in someone who’s had a seizure, I know that there’s a high degree of likelihood they’re going to have another seizure. And that’s often something that we’ll use to treat someone for epilepsy. I will point out that one of the issues we have is the EEG is so useful, but it’s an insensitive test. It’s about 50% sensitivity. What does that mean? So if I take someone I know who has epilepsy and I do an EEG on them, half the time the EEG is normal. And so an abnormal test is really valuable because it’s so insensitive. When I see something abnormal, that’s something I can really use and sort of help understand what’s going on with you. But when it’s normal, you have to take it with a grain of salt because you can still have epilepsy and have a normal EEG. You can also have a normal MRI and have epilepsy. So this is sort of where we get into this difficult position where if someone comes in with a seizure, they have a normal MRI and EEG, we have a sometimes a difficult decision to make or we just, we can’t know for sure. And so we have to make our best judgment and sort of go from there.
You know, as far as causes, it’s tough because it’s not uncommon that we can’t find the cause. There is a large percentage of patients who we just don’t have a perfect answer for why exactly they have seizures. And that’s something that we always have to sort of recognize and be vigilant about reevaluating every so often because sometimes things change over time.
The other population that’s uniquely affected by epilepsy are women. And the interesting thing is that women have a couple of things that affect them differently. One, your, your hormones have a specific effect on epilepsy. And the sort of, the way that I think about it is that estrogen is proconvulsant and progesterone is anticonvulsant. And so anytime you either have a spike in estrogen, which is sort of observation or a relative increase in estrogen and decrease in progesterone, which is right around the menses, your period, that seizures can be more frequent. And the majority of women, 60%, some may say more, but in that range notice a variation in their seizure frequency with their cycle. And, you know, it used to be a fallacy in the past that women with epilepsy shouldn’t have children, which is absolutely silly, but women with epilepsy do have to sort of face the fact that they do have a higher rate of having children with birth defects. This is, we think more related to medication than anything else. And I often sort of preface my description to women saying, and this is, I give a statistic that sounds really scary, and then try to explain why it shouldn’t sound quite so scary.
So with respect to anatomic or specific types of epilepsy and seizures, there’s actually several different types of, which is one of the ways, one of the reasons it’s so interesting for me and I think difficult for patients to understand. I would back up and say that in general, seizures come in two different types. One type is from a very specific area of the brain. We call those focal or partial seizures. And then there are seizures that come from everywhere in the brain at once we call those generalized seizures. And then that also then applies to the epilepsy. And that there are generalized epilepsies and focal epilepsies or localization-related epilepsies. And those, those differences actually have a huge impact on what the symptoms are and what the patient feels. And the big difference is in the generalized seizures, they start everywhere in the brain at once. And the way that I tend to think about them is that often these are genetic epilepsies. So the gene is in every cell of the brain. So when someone has a seizure, everything goes off at once. There’s no warning, they can’t tell it’s happened and just boom, it happens. And they can have several different types of seizures.
Commonly they’ll have absence seizures or what we used to call petit mal seizures and with those is people just sort of stare off. No warning. That my flutter their eyes and my last for 10, 15 seconds, no aura or warning and no after effects. They’re just not there. These are hard to detect for patients. They don’t always notice and, you know, these is are the types of seizures that astute parents or teachers will recognize in kids, but in adults there are really difficult to nail down. People can have generalized tonic-clonic seizures where they stiffen up and shake all over. Those are very scary for families. Appears as patient stops breathing, often people can bite their tongue, have urinary incontinence. But there are other types as well, something called a myoclonic seizure where people just have a jerk and that’s it. A jerk is, they’re seizure. Often happens after a poor night’s sleep. People can have also atonic seizures where they lose all tone and fall. Those often happen in people who often have cognitive impairment, developmental delay, and had these seizures since childhood, often very difficult to control.
I often get asked questions about epilepsy first aid or what do you do when someone has a seizure? Someone you care about has a seizure. How do you approach it? And there are some important things to sort of be aware of. First when someone has a seizure, and in general the type of seizures that we’re talking about for this type of issue is a convulsive seizure whereas clear cut, someone’s having a big old convulsion and it’s scary. They like they’re dying, they stopped breathing, their lips turn purple, they have fun with the mouth, there might be blood. What do you do? So the first thing I would tell people to do is check out the environment and make sure that person’s in a safe place. If they’re not in a safe place, try to safely move them. If you can. Next, let them have their seizure. Don’t hold them down and by, absolutely, there should be no reason that you stick anything in their mouth. And there’s this common fallacy that someone having a seizure will choke on their tongue. That won’t happen. But if you try to stick your finger in their mouth, they’ll bite your finger off, and then they’ll choke on that. So keep everything away from the mouth, let them have the seizure, time the seizure if you can. And then once the seizure is over, you want to turn them on their side. After the seizures over, they often will have a hard time protecting their airway. And sometimes people will get nauseated and vomit and they can actually choke on their own vomit. And so having them on their side protects their airway so that they can clear it.
Often during these periods, people sort of look spacey. They’ll stare off and they might have what are called automatisms are automatic behaviors. And so the common sort of automatisms people have will be lip smacking, swallowing repeatedly, or people can have actually hand automatisms where they’ll rub their fingers together, they might pick at things absentmindedly. A typical duration for a seizure like this can be 30 seconds to about three minutes and they can be subtle. So often people don’t notice or don’t recognize these seizures. As someone sitting by themselves, by themselves watching TV, if you’re not watching them like a hawk, you’d never know that they were necessarily having a seizure. After the seizure is over the brain is exhausted, and the person is often I’m exhausted too. And that is that they’re often confused afterwards and sleepy. And that’s often a big distinguishing kind of character between the absence seizures and a complex partial seizure. Because both of those seizures, you’re sort of staring off, you’re not responsive. But with a complex partial seizure, there’s an aura often about 50% of the time. And then afterwards there’s a postictal period or this sort of after a seizure period where you’re just not right, confused, or sleepy often. If the seizure were to get even bigger, well then the motor cortex gets involved and it can cross over the connection between the two hemispheres, which is called the Corpus callosum and involve the other side of the brain. And then you’ll get what are called secondarily generalized seizure where the body stiffens up and shakes. Again, we call it secondarily generalized cause it started in one focal area and then spread out. Again, you know, these are typically a few minutes at most in duration. Four minutes would be a long seizure. And then afterwards people are exhausted, wiped out, not their normal selves for minutes to hours afterwards.
Seizures have a big impact on someone’s life. And this is one of these underrecognized undertreated sort of areas in epilepsy. And it’s important to sort of recognize two specific things. One is the occurrence, the co-occurrence, of psychiatric disease with epilepsy. So and it sort of makes sense if you think about it. I mean epilepsy does is a disease of neurochemicals and electrical discharges that change the neurotransmitters in the brain and those same neurotransmitters which are involved in seizures and thinking clearly are involved in your emotions. And so, with epilepsy we see a high rate double the incidents of depression and anxiety and triple the rate of suicide. And so it is an important thing to recognize that depression is something that is very common in people with epilepsy, that we don’t ignore it and that we treat it aggressively and often it requires an antidepressant. I will point out that a lot of people sort of don’t want to go on antidepressants or they fear them because if you look at the side effect of any antidepressant, it’ll say seizures as a potential side effect. And they sort of say, “Wait a minute, doc, I’ve got seizures. Why did you put me on a drug they can cause seizures?” And the answer is that by and large, most, but not all, most antidepressants are perfectly safe in people with epilepsy. It’s something that you should talk to your doctor about If you’re experiencing depression and very seriously consider being on an antidepressant.
There are a lot of studies that we do to help localize or understand someone’s seizures. And often we use those though when we’re more trying to specifically design a treatment plan for somebody who’s not responding like we want. So for instance, a pet scan we use quite a bit, but it’s when we’re trying to decide if someone’s a candidate for epilepsy surgery, we’ll do a pet scan. And what we see with a pet scan is we see the metabolism of the brain and how actively the brain is metabolizing glucose usually. And in areas of the brain where the seizures occur or originate from, that area can be hypometabolic. And so again, what would I’m thinking about often in those cases is can I detect exactly where the seizures coming from and define an area that we could potentially remove to stop seizures.
There are lots of options for epilepsy treatment. The mainstay of epilepsy treatment is the large number of anticonvulsant medications, again I point out over 20 with more coming up. But if epilepsy medications or anticonvulsants don’t work, we have other options including brain surgery, dietary changes, or what we call neuromodulation devices.
What types of problems in the brain can cause seizures? And the answer is there’s a lot. First of all in adults, especially people over the age of 55 who develop seizures, the most common cause is a stroke. But really it’s not the stroke that causes the seizure. It’s the scar tissue that’s formed around there and the way that I tend to think of this is that any scar in the brain, the brain itself, every cell in the brain has a function. You know, the neurons function to make the brain work. But every other supporting cell has an important function to keep sort of the environment there just right so that your brain works well. When there is scar tissue that forms either from a stroke, from trauma, from a brain tumor, and that scar tissue changes that environment and the brain cells aren’t happier and can’t work as well. And that often, although not always, but that often can cause the cells to become prone to firing. And that misfiring is what ends up causing a seizure.
Women with epilepsy have double the rate of major fetal malformations than the general public. And again, I would point out that this is thought to be probably more related to medication than anything else, although there may be other factors that we don’t understand. But I point out that if you know, if you double a small number, it’s still a small number. So if the general population, about two to 3% of all women have children with made her major fetal malformations, cleft palate, heart malformations or Spina Bifida. So 2 to 3% of all women in women with epilepsy, it’s 4 to 6%. So 94 to 96% of all women have perfectly healthy, normal babies. Things that we need to pay attention to though are the medications that they’re on and the doses and how many medications they’re on. And we know that there are a couple of medications that are specifically more problematic in women who are going to get pregnant. The first and foremost the drug that is the most problematic is depakote. Highest rate of fetal malformation, specifically Spina Bifida. And so women of childbearing age, generally, we want them off of Depakote, if at all possible. Sometimes it’s not possible, but we certainly try our hardest. And there’s another one called topiramate. Topiramate is a drug that’s been associated with cleft palate. And so that’s another one that we try to avoid if we can. Often women of childbearing age are on folic acid. The folic acid is given specifically for prevention of birth defects. Nobody knows how much folic acid is the right amount. Often we’ll prescribe two milligrams, but if someone’s actually actively trying to get pregnant up it to four milligrams. It’s a water soluble vitamin, and whatever you don’t need you’ll pee right out. And so, specifically hormonal changes, changes with menstrual cycle and pregnancy are two specific issues that have to be addressed with women, and are incredibly important not to forget. And we often do, it just gets brushed over. No one asks, but worth talking about.
The key with medications is that one, they all have potential side effects. For any medication out there I can line up people on either side to tell you how great it is and how bad it is. And so until you try it, it’s hard to tell for sure. And the other key that I point out to all my patients is that generally speaking, the key to starting something new is to go slow. Start with the lowest dose possible and inch up a little bit, get you to a therapeutic dose, and again, I would point out a low therapeutic dose and then we sort of see what happens. If another seizure happens often and we sort of say, okay, if another seizure happens, you are taking the medications you’ve been on it a reasonable amount of time, well shoot, we need to bump it up a little bit. The data tells us that about 50% of patients respond becoming totally seizure-free after one med. After two meds, we’re looking at probably about 60% or close to 60%. After three meds, the likelihood of making someone’s seizure-free is below 4%. it’s very low.
So with respect to confirming the diagnosis, that is sometimes something that we need to try to do. And in the circumstances where that comes in most frequently is we take the information initially that we get and we decide we’re going to do something, treat or not treat and sort of see what happens. And if someone doesn’t do well, seizures continue and we’re trying to figure out, well shoot are they seizures, is there something else going on? What’s happening? There is a more definitive way to diagnose seizures and that’s with something called the video EEG often done in an epilepsy monitoring unit like we have here at TMC. And with that, what happens is someone comes in to the hospital and actually is admitted for a week and we put an EEG on their head and under careful supervision we often will withdraw medications. And the idea is to capture a seizure with the EEG on your head. And the idea is that that really is the gold standard for detecting seizures because if it is indeed a seizure we’ll see that electrical storm or those electrical discharges in the brain change as the seizure progressive.
My name is Dave Teeple. I’m a neurologist at The Center for Neurosciences. A little bit about me. I’m actually born and raised in Tucson, Arizona. Went to high school at South Point High School. Went to the University of Arizona where I was a biochemistry major and born and raised in Tucson. Sort of had to the itch to get out. So left Tucson and went to medical school in New York City at Columbia University where I spent four years. Loved it. New York City is a fantastic city, but I realized how much I missed home. And so I sort of came back around. I did my residency and actually did a preliminary year of medicine at the University of Arizona where, so basically I was an intern and then did a neurology residency at Barrow Neurological Institute where I was chief resident and then did an epilepsy fellowship there as well. And then after epilepsy fellowship moved to Tucson to be the epileptologist for TMC, the adult epileptologist for TMC and also for The Center for Neurosciences. And in practice here for six years. I’m married, I have two wonderful kids, love living in Tucson. Since I’ve been here because this is my home, sort of, I think I’ve been trying to be very active in making Tucson a place where I’d want to get my healthcare. And that’s been as the director of stroke at TMC, I’m the division head of neurology at Tucson Medical Center. I am the president of the American heart and stroke association, really focusing on stroke. Been heavily involved in the epilepsy foundation, chairing the walk here, and also just being involved. And then over the last two years, I’ve actually been the director of the transitional residency program at THMEP, which is a fun way for me to be involved in the academic side of medicine, which I really love as well. I am on faculty at the University of Arizona as well. I do teach the neurology residents from the University of Arizona.
So the definition of epilepsy is any condition which causes or predisposes somebody to recurrent seizures. And so a little bit of a background and you know, anybody can have a seizure. A seizure is an electrical storm in the brain. The brain is misfiring in a way that causes the brain not to function right. And anybody can have one. I mean, if your electrolytes are out of whack, if you’ve had too much alcohol, you can have a provoked seizure. But the difference between someone with epilepsy and a provoked seizure is that people with epilepsy, it’s not provoked. It comes out of the blue. And about 10% of the population will have a seizure at some point in their life, but about 1% of the population has epilepsy.
Epilepsy is any condition that predisposes someone to have recurrent seizures. I would point out there are hundreds of different conditions that can predispose to someone having unprovoked recurrent seizures. Epilepsy can manifest as a variety of different types of seizures, sometimes as subtlest staring, but can be as obvious as a generalized convulsion. The age groups that we see epilepsy in aren’t just kids, but actually even more common in adults over the age of 65. the treatments that are available are many and that we point out that most people actually respond well to treatments and become seizure free. In those that don’t, there are a variety of other options including surgery and dietary changes. With respect to overall prognosis, over 60% of patients become seizure free, and then the ones that don’t, there are a multitude of options to consider.
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