Wednesday, May 24, 2017

Blog #82: THE NEW CLASSIFICATION OF SEIZURE TYPES IN SIMPLER TERMS. KNOW THE TYPE OF EPILEPSY YOU HAVE.




A new and revised classification of seizures and epilepsies was released in March, 2017 by the International League against Epilepsy (ILAE). It offers clearer terms so that patients can communicate better with their physicians and so that doctors can better communicate with each other. 

The guidelines incorporate opinions from experts and the public and received final approval by the ILAE executive committee before being submitting to the peer-reviewed journal, Epilepsia 1. Complex partial seizures, grand mal and petit mal are some of the seizure types with new updated names. Can you find your type of seizure with its new, revised name in the updated classification below?

* Seizures are separated based on where they begin in the brain. Focal seizures have onset in one hemisphere of the brain, while generalized seizures engage both hemispheres at onset.
* For focal seizures, the next classifier is level of awareness.
* “Focal aware” replaces the term “simple partial.” A seizure is “focal aware” if the person's awareness is intact, even if they are unable to talk or respond during the seizure.
* “Focal impaired awareness” replaces the term “complex partial.” A seizure is “focal impaired awareness” if the person's awareness is impaired at any time.
* Next, focal seizures are described in terms of motor symptoms.
* In a “focal motor onset seizure,” some type of movement – whether twitching, jerking, or stiffening – occurs during the seizure. Focal motor onset seizures include automatisms, atonic, clonic, epileptic spasm, hyperkinetic, myoclonic, and tonic seizures.
* In a “focal non-motor onset seizure,” only non-motor symptoms – including changes in emotions, sensations, or thinking – occur. Focal non-motor onset seizures include autonomic, behavior arrest, cognitive, emotional, and sensory seizures.
* “Generalized tonic-clonic seizure” is still used to describe seizures with stiffening (tonic) and jerking (clonic), replacing the old term “grand mal.”
* “Generalized absence seizure” involves brief changes in awareness and may involve repeated or automatic movements, such as lip smacking. This term replaces the old term “petit mal.”
* New seizure types, such as myoclonic-tonic-clonic or myoclonic-atonic, are included.
* Unknown seizures are those that physicians cannot designate as having focal or generalized onset with about 80 percent certainty. Physicians can now describe a seizure with an unknown onset as tonic-clonic, behavior arrest or epileptic spasms.


      1) Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper. Epilepsia 2017 Epub 2017 Mar 8.



Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Tuesday, April 25, 2017

Blog #81: Elderly Adults with New-Onset Epilepsy Are Often Prescribed Older, Less Effective Anti-Epilepsy Drugs


            Approximately one percent of the population, or three million people, have epilepsy. Several decades ago the most prevalent age-group that developed epilepsy was children. Times have changed. Today, it’s the elderly who develop epilepsy just as often, if not more so. See my Blog # 15, December 14, 2011 on this website.
 
            Health-care has vastly improved over the past half-century resulting in people living longer. However, longer longevity results in potentially more brain scarsa very common cause of epilepsy. Scars result from strokes and “hardening” of the arteries, brain injuries, tumors, infections, Alzheimer’s disease and other brain degenerations. 

            Older adults diagnosed with new-onset epilepsy may not receive optimal treatment because they are too often prescribed the older anti-epilepsy drugs (AEDs). Prime examples of these are Dilantin (phenytoin), developed in the late 1930’s, and barbiturates (phenobarbital), in use for over a century. Non-neurologist physicians (e.g., emergency department doctors, and geriatricians), are often more familiar with these older drugs than with newer ones; these are the physicians who usually evaluate and initiate treatment of patients after their first seizure.

            Older drugs’ common side-effects include “brain fogginess” and drowsiness which can worsen unsteadiness that may already afflict the elderly. Dilantin promotes bone density loss more than newer AEDs. The newer AEDs developed over the past twenty years, such as Keppra (levetiracetam), Lamictal (lamotrigine), and many others are reasonably well-tolerated and can be more effective. Dilantin has many drug interactions, too, including lowering the effectiveness of some cholesterol-controlling medications. One key reason for using the older AEDs, however, can be that they cost less than the newer ones.

            I want this information to prompt patients to discuss their AED choice with their primary physician. Consider a neurologist consulting in their epilepsy care.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Monday, March 27, 2017

Blog #80: How Epilepsy Patients Use Herbal and Botanical Therapies

            In NEUROLOGY NOW, February, 2017, page 12, Dr. Dana Ekstein, senior neurologist at Hadassah Medical Center in Jerusalem, reviewed the use of non-prescribed chemicals and herbs that epilepsy patients use to help control seizures, to treat medication side effects, and to treat their anxiety, depression and memory problems.

            A 2012 American Health Interview Survey revealed about eighteen percent of the American population use complementary herbal and botanical medicines other than vitamins, and nonmineral natural products. Among people with epilepsy half of adults and a third of children use complementary therapies without their physicians’ knowledge. Some of these botanicals interfere with their prescribed antiseizure medications.

 

            Another study, a Canadian study 1, found that fifty-nine percent of patients with epilepsy and thirty-three percent of patients with psychogenic non-epileptic seizures (see my Blog #10: September 23, 2011 Is It A True Epileptic Seizure or a Faked, Psychogenic Seizure With a Psychological Cause?) who participated in the study and who used cannabis, i.e., marijuana, hashish, “pot,” etc., daily perceived improvements in seizure control, stress, sleep quality, and drug side effects. Although their perceived stress reduction may have contributed to the perceived positive impact of marijuana on seizures and nonepileptic events in adults, the researchers reported that they could not reliably conclude that Cannabis was objectively efficacious.


            A Cochrane Review (Cochrane works collaboratively with contributors around the world to produce authoritative, relevant, and reliable evidence in the form of Cochrane Reviews) of cannabinoids for epilepsy found no reliable conclusions could be drawn regarding the efficacy of the studied doses of 200-300 mg daily of cannabidiol component of the marijuana plant (the non-psychoactive component of marijuana plants in contrast to the psychoactive tetrahydrocannabinol [THC] component) 2. Further trials are needed in this area.     

            Another trial led by Devinsky et al 3 concluded that of 137 patients with onset of drug-resistant epilepsy beginning in childhood and currently experiencing at least four seizures per month, thirty-nine percent enjoyed a fifty percent, or greater, reduction in seizure frequency.

            Regarding the treatment of depression in epilepsy with botanicals a Chinese mushroom called Xylaria nigripes was studied in a random, double-blind, placebo-controlled trial of one hundred four patients. The mushroom-treated patients reported significantly improved depression and quality of life scores compared with placebo 4.

           One must use caution in assuming that natural products are safe. Ephedra, St. John’s wort and ginkgo biloba can cause seizures. Tetrahydrocannabinol [THC] may impair memory and executive function and induce psychiatric symptoms. Other unwanted side-effects in cannabis trials include worsening seizures, drowsiness, fatigue, and gastrointestinal complaints. 

            Interactions s between antiseizure drugs and botanicals can include altered blood levels of the antiseizure drugs (cannabidiol increases concentrations of clobazam).

            Dr. Eckstein emphasizes that neurologists need to be well-educated and up-to-date regarding botanical therapies.

1)    Massot-Tamis A, McLachlan RS. Marijuana use in adults admitted to a Canadian epilepsy monitoring unit. Epilepsy Behav. 2016; 63: 73-78.
2)    Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009270. DOI: 10.1002/14651858.CD009270.pub 2.
3)    Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016; 15(3): 270-278.
4)    Peng WF, Wang X, Hong Z et al. The anti-depression effect of Xylaria nigripes in patients with epilepsy. A multicenter randomized double-blind study. Seizure. 2015; 29: 26-33.
 



Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Sunday, February 26, 2017

Blog #79: Telling Your Children You Have Epilepsy


             This topic is critically important for all people living with epilepsy.
            My friend, Tom McGranahan, Jr., is author of Under Siege, a book in which he writes of his own life experience with epilepsy. Tom’s personal history includes poorly controlled grand mal and complex partial seizures from childhood until his current, excellent control following four partial temporal lobe surgical resections.
          Tom wrote the essay below on his website: http://www.epilepsyintheopen.com. Its advice communicating his personal and practical wisdom will be very helpful to readers.



    Telling Your Children You Have Epilepsy
                        February 21, 2017 Tom McGranahan Jr Epilepsy, Neurodiversity
                                                By Tom McGranahan Jr.


Which of us parents want to tell our children we have epilepsy? If medicine is controlling our condition and we’re not having seizures plus they haven’t seen one, why should they be told? And what can we say if they do witness us have a seizure?

Ironically, on the night our first daughter was born; I drove my wife, while she was in labor, to the hospital (my license had been revoked and she earlier asked me to promise not to drive) and arrived there just in time. I left her in nurse’s hands and while returning to the car – had a complex partial seizure in the elevator.

I could not & would not hold our first daughter while she was an infant—my seizures weren’t yet completely controlled. I could hold our second daughter when she was an infant while others were around. But I could not and did not baby-sit them… Anyway, there are many hurdles to overcome. I guess it all comes down to the type of family they are part of.

It is simply impossible to shelter our young children from reality. Hopefully they don’t actually see us have a seizure. But how can they not notice sooner or later the daily takings of medicine, pharmacy store visits or parent being asked, “Have you taken your medicine”?

What advice is there for children who are coping with their parent’s epilepsy and have questions about the medical conditions and treatments?

First it’s quite important for us to understand the type of personality that our child has along with the information they’ve been receiving, especially, the different age kids. So we can expect children under the age of 5 to know very little but the little bit that they do know might be very confusing. They can think of these as different events and on top of that watch and feel their parent’s temperament about it. And the older children will feel alienated if not told about it.

So, it is all right to admit that, in some days, you’re not handling it well. Staying positive during our troubles shows (our children) how to keep up their self-esteem during trying times. That’s an important point because it helps them accept the days they are not handling things well.

It’s necessary for parents to tell their kids what’s going on in a way that they can understand. That would comfort the children and offer them a sense of security.

 Describe the overall facts:
  • It is a treatable disorder.
  • It is important to realize that most seizures are very short and stop by themselves.
  • There is no known cause in 50% of cases.
  • Any person can have or get epilepsy from a head injury.
 Tell them what a/your seizure is like:
  • Can be staring away and not responding.
  • It is a: partial (or complex partial, or generalized) seizure.
  • Do not always have control of actions.
  • Eyes may roll up briefly, and the lips turn blue.
  • Can fall down or collapse.
  • Parts of body can start shaking.
  • Mouth can be foaming.
 Inform them how to best respond:
  • Nothing is to be put in the mouth; you can chip teeth or terribly injure your fingers. (It is not really possible to swallow the tongue, though tongue biting could occur).
  • Stay out of reach from the patient for they cannot always keep control of their body.
  • Relax and not start crying or screaming because it goes away fast (Though at times during seizures there will be other people out of control, crying and being hysterical which can be very distressful for the kids).
  • Inform other people or parent or neighbor about the seizure.
  • After seizure has ended ask someone or try yourself if need to – to roll them on their side.
  • Call for ambulance only if:
    • The seizure lasts more than 5 minutes.
    • Parent is having difficulty breathing.
    • Parent is having repeated seizures.
    • Parent takes a bad fall, starts bleeding
Tell them because of seizures you may require some restriction of activities; diving head first off diving board, heading soccer ball, stay up late to watch a movie…

A common school day can put stress on any child. So tell them not to talk to any classmates about their parent having epilepsy. It, unfortunately, can still be a real source of embarrassment or stigma.

Ensure your child the majority of people with epilepsy can have their seizures controlled with medications and can lead normal or nearly normal lives. If a parent can believe in their child and convey that to their child, there is likely a crucial bond occurring. Say to them your epilepsy care/conditions is not the most important thing that’s happening.

We’re teaching and modeling for our kid’s ways to handle things when mistakes are made. So it is all right to admit that, in some days, you’re not handling it well. Staying positive during our troubles shows them how to keep up their self-esteem during trying times. That’s an important point because it helps them accept the days they are not handling things well. Tell them to be a good person, to work hard and to have good values – to do the best they can do, even if that means they fail a test in math or…



Image courtesy of Tom McGranahan Jr.
Tom McGranahan Jr. was born in Richmond Va., the second oldest in a family of eight. Lives with wife Angela and 2 daughters, Mariah and Arielle. He has a Bachelor of Science in Business Administration. He was a member of Virginia State Board for People with Disabilities 6/95-6/99, and speaker at Department of Education’s 3rd National Employment Conference 9/11/00. Exercises every other day at a gym and operates a residential painting business. He steadily perseveres to life’s challenges – like writing this article – even after 50% of the language section of his brain was removed in his 4th brain operation.
Visit his website:
http://www.epilepsyintheopen.com/ 




Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.
.