Epilepsy: Medical and Surgical Treatment

By Patrick Reed | 4/01/19 8:30 AM

Epilepsy is a neurological disorder that most often begins during childhood and can have many causes. It manifests in uncontrollable brain seizures that occur at random, with potentially life-threatening effects. Fortunately, many cases of epilepsy can be controlled through medication and even surgery.

In this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes a pediatric neurologist and a pediatric neurosurgeon to discuss diagnosing epilepsy, medical treatment for the condition, and surgical options.

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Dr. Samir Karia is a pediatric neurologist and Director of Epilepsy at Norton Children’s Hospital in Louisville, and Dr. Ian Mutchnick is a pediatric neurosurgeon and Surgical Director of the Pediatric Epilepsy Functional Spasticity Program at Norton’s.

“When we have a seizure, it can be because of various reasons,” Karia says. One example, he explains, would be due to low glucose (blood sugar) in the brain. “But when we have a seizure that happens repeatedly, then we consider it epilepsy.”

Diagnosing Epilepsy
As noted above, epilepsy can be caused by various underlying conditions that affect the central nervous system. These can include genetic diseases such as Dravet syndrome or Aicardi syndrome, both of which begin in infancy and are lifelong conditions. Aicardi syndrome, caused by a defect in the X chromosome, predominantly affects infant girls.

Epilepsy can also be caused by a structural abnormality in the brain or a developmental abnormality, Karia says. Brain tumors can also cause epilepsy, and so can traumatic injuries to the brain.

“I guess the way I see it is that a seizure is something you can have, and you can have it in conjunction with something else,” Mutchnick says. “It certainly represents something wrong. Sometimes we can see it – we get a scan, and it shows a tumor, and voila! Sometimes you can’t see it. But either way, it arises from some abnormality. If you have epilepsy, that means you have regular seizures, multiple times.”

Karia says that about 5 out of 100 children will have febrile seizures – seizures as a result of fever. This age group ranges from six months to five years of age. Having febrile seizures does not increase the chances of having epilepsy in the future, however.

Febrile seizures have a genetic component, and so do epileptic seizures, Karia says. “If a single patient presents with seizures, there’s a one in five likelihood that they occurred due to inherited reasons. The remaining four out of five patients do not have any positive family history. So it depends on the specific type of the gene and the specific type of the epilepsy.”

Incidence rates for epilepsy have increased in recent years, but Karia says that is due to advances in diagnosing the condition. Neurologists have more precise tools to examine brain wave activity nowadays, with the EEG (electroencephalogram) being the primary diagnostic tool.

The EEG is “a common test we do in which we put electrodes over the brain similar to when we put them over the heart to monitor heart rhythm,” Karia says. “Here, we monitor brain wave activity. If there are disturbances in the electrical charges, those can be a tell-tale sign for seizures.”

As for warning signs of epilepsy, Mutchnick says, “I would say that, if you see your kid doing something weird, bring him in for an evaluation – especially if it involves any compromise in their level of consciousness.”

A child waking up in the morning with oral bleeding, or unexplained vomiting during the night, can be evidence of seizures, Karia says. A certain type of epilepsy called photosensitive epilepsy can be triggered by blinking lights or other visual stimulation, he adds. “It’s very important that if there are unusual symptoms that happen over and over again, those may be indicative of a seizure,” he cautions, “and it needs to be evaluated right away.”

Medical Options and Surgical Procedures
There are two treatment goals for epilepsy, Karia says. The first priority is to stop a seizure if it is happening and if it won’t stop spontaneously. “That’s what we call rescue therapy,” he says. “The other part is, we try to avoid the recurrence of seizures, and we call that prophylaxis, seizure prophylactic treatment.”

Certain medications are used to treat seizures, and the criteria is determined by various factors, according to Karia: these include the patient’s age, genetic inheritance, and any abnormalities that are found through imaging tests.

Also, Karia says that it’s very important for the neurologist and his/her team to ascertain how frequent the seizures are, and how severe. Seizures that require a trip to the emergency room each time they occur will require different treatment than those that can be managed by intervention at the site.

Initial EEG tests will provide enough information for Karia and his staff to explore treatment protocols. “If we do find a structural abnormality, then we know that we may need surgical intervention and we need evaluation and admitting the patient into the hospital, what we call epilepsy monitoring units,” he says.

At this point, Mutchnick and his team collaborate with Karia in order to find a surgical procedure that can either make the seizures stop completely or become less severe. But there is more to consider.

“In parallel with trying to locate where the seizure is coming from, we’re also trying to start to understand where different functions are in this patient,” he says, “because we also want to get a sense of what the cost is of potentially taking out this epileptogenic focus in the brain.”

For example, Mutchnick says that if he finds that a right frontal lesion is causing debilitating epilepsy, and he can pinpoint the correct area on the right frontal lobe, it is possible that the lesion could be removed without any major loss of function in the patient. On the other hand, if the affected area is in the left temporal lobe and extends back several centimeters, then it may exist in the area where the patient’s primary language and memory abilities are.

“You have to go to the parents and say, ‘Well, we could take this out, but it is likely to leave the patient with a deficit,” Mutchnick says. “And in almost all cases, what emerges is not some conclusive crystal ball kind of decision, what emerges is a choice between the morbidity of having something resected or fiddled with in your brain and how likely it is that you are going to see a benefit of some defined level. And really, it’s up to us and the parents to collaborate well enough to achieve decision quality then, on what happens next.”

Mutchnick says that the imaging software he uses today allows him and his team to integrate multiple visual data streams into a composite that provides a view of the brain from multiple vantage points. He presents a series of slides showing traditional MRI, CT, and X-ray scans, each of which display different visual information, and then presents an image from the software package he currently uses that produces a more lifelike and detailed rendering.

“When we look at this picture, there’s no escaping knowledge that’s relevant to making good decisions for this patient,” he says. “That’s why I think that this kind of software is going to be increasingly a part of any epilepsy service.”