Blog #121: IF YOUR SEIZURES AREN’T CONTROLLED EPILEPSY SURGERY IS SAFE AND REALLY CAN HELP

I have addressed epilepsy surgery before in several of my 120 monthly epilepsy blogs published at LanceFogan.com since 2011. Evidence is overwhelming that epilepsy surgery, if you are a candidate, is safe and can be tremendously beneficial in reducing, or even, curing your epilepsy.

 

The chief research officer and epilepsy specialist at Cleveland Clinic, Lara Jehi, MD, detailed the patient-centered pros and cons associated with epilepsy surgery, as well as the stigmas related to it. “Even before you put a patient through the surgical testing, neurologists have to identify if they’re a surgical candidate. The most cost-effective option is to send them to get that evaluation.” Jehi hopes that her study can help demystify some of the preconceived notions that surround epilepsy surgery. NeurologyLive /www.neurologylive.com/videos/lara-jehi-md-pros-and-cons-of-epilepsy-surgery.

 

A recently published study that evaluated costs found epilepsy surgery was cost effective ($328,000) compared to medical management ($423,000) in surgically eligible patients and more effective (measuring Quality Adjusted Life Year of 16.6 vs. 13.6 QALY) than medical management in the long run. The quality-adjusted life year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived.¹

 

The data has potential to raise eyebrows within the epilepsy community, and ultimately sway more patients to not only get the surgery, but to at least have their own surgery-eligibility evaluated. Dr. Lara Jehi feels that patients don’t fully understand the benefits that come with epilepsy surgery. She encourages those eligible to at least consider surgery knowing their less-than-effective anti-seizure medication will probably not improve their quality of life.

 

“There are a lot of fears out there. Some justified, but some due to misperception and misinformation that may stop someone from getting to the point of looking at brain surgery.” Jehi provides insight on the truth behind the stigmas related to epilepsy surgery and whether patient fears are legitimate. In the above video Jehi discusses moms worried about weeks long hospitalizations for testing, other family responsibilities during that time; time off work; relatives with past complications due to other types of surgeries.

 

Her study results confirm the positives of surgery. Epilepsy surgery is underutilized and not recommended to a large number of patients by their neurologists despite multiple studies proving its effectiveness and long-term benefit with drug-resistant temporal lobe epilepsy. Jehi hopes that her study can help demystify some of the preconceived notions that surround epilepsy surgery.

 

1. Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Cost effectiveness of surgery for drug resistant temporal lobe epilepsy in the US. Neurology. Published online July 8, 2020. doi: 10/1212/WNL.0000000000010185

 

 

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.

 

 

Blog #94: DISAPPOINTING NEWS: NO IMPROVED SEIZURE CONTROL WITH NEW ANTIEPILEPTIC DRUGS OVER PAST 30 YEARS

A recently published study found that one-year seizure-free rates for epilepsy patients have hovered at 64 percent for 30 years. More than one-third of patients experience epilepsy that is uncontrolled.¹ Seizure frequency has not greatly changed. Adding, or substituting, antiepileptic drugs (AED) did not significantly lead to complete seizure control.

For those patients who stayed seizure-free for a year, 87 percent were taking just one AED and 90 percent achieved freedom from seizures with either the first or the second AED. If the initial AED failed, the second and third regimens provided only an additional 12 percent and 4 percent likelihood, respectively, of seizure freedom. Reductions in seizure frequency for treatment-resistant patients on each new AED, however, are not insignificant. But, only 2 percent achieved optimal seizure control with subsequent AEDs.

Current AEDs do not modify the underlying cause, i.e., the pathobiology of epilepsy.

Most patients in the study initially took Carbamazepine (Tegretol), valproate (Depakote) and phenytoin (Dilantin) in the 1980’s and 1990’s. Later, levetiracetam (Keppra) and lamotrigine (Lamictal) were the initial AEDs. Although some newer drugs have novel anti-seizure mechanisms, they did not improve long-term seizure control.

Worse prognosis for control was associated with: a) the number of seizures that occurred prior to treatment; b) a family history of epilepsy in first-degree relatives and; c) a history of recreational drug use in epilepsy patients.

Research into interfering with or reversing the underlying seizure-inducing process, rather than just suppressing seizures, continues.

The secondary benefits of newer AEDs should be kept in mind compared with older AEDs: these include lower risks for birth defects, improved cognitive profiles and minimal drug interactions.

Newer drugs in the pipeline hold promise. Experience will reveal their efficacy.

Genetic manipulations and immune therapies are exciting research areas to improve or cure epilepsy.  

Epilepsy-surgery can be curative in properly selected patients.

1. Chen Z, Brodie MJ, Liew D, et. al. Treatment outcomes in patients with newly diagnosed epilepsy treated with established and new antiepileptic drugs. A 30-year longitudinal cohort study. JAMA Neurology 2018; 75 (3): 279-286.

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.

Blog #49: Psychogenic "Fake" Non-Epileptic Seizures

(This blog was originally posted on August 27, 2014)

 

 

Experience shows that up to one-third of our patients in epilepsy clinics have involuntary, psychogenic, fake pseudoseizures. They resemble the patient’s true epileptic seizures; distinguishing between them can be very challenging.

Some of our “epilepsy” patients are misdiagnosed: they never had epilepsy to begin with. Close follow up may lead to clues that the seizures are not real, such as: poor seizure control in the face of repeatedly normal electroencephalograms (EEGs); varied physicality of the “seizures;” and they occur conveniently during emotional stress.

 Psychogenic “seizures” show no abnormalities on the EEG indicating that they do not originate in abnormal epileptogenic nerve cells in the brain. Highly sensitive EEG telemetry recordings with video pictures of patients in a hospital setting show this when patients exhibit their “seizure” activity. That pseudoseizures occur complicates care of our patients. Twenty to thirty percent of patients have poorly controlled refractory epilepsy; anti-seizure medications can’t prevent them. Neurologists must consider if the patient’s refractory seizure control could be due to involuntary, psychogenic seizures in addition to the patient’s true epileptic seizures or they do not have epilepsy at all.

So then, what is the problem? In most cases the patient is not consciously “faking” their seizures. Rather, underlying psychological problems and stresses seem to induce the “seizure.” These “seizures” could support the patient’s loss of control and augment his dependency in his life patterns without insight or understanding. This, in turn, relieves responsibility for his failings. He becomes a sick and dependent person satisfying his various psychological needs. This is called a “conversion syndrome.”

LaFrance and associates recently published a study on treatment of “refractory” seizure patients who had never showed EEG abnormalities during their “seizures.” They did not actually have epilepsy. A form of psychotherapy which his group calls “cognitive behavioral therapy,” reduced seizures by 51.4%; it also improved their quality of life, social interactions and reduction in depression and anxiety. This Cognitive Behavior Therapy is unique. It will be found in the researchers’ Taking Control of Your Seizures: A Workbook, to be published later in 2014 by Oxford University Press (1). This therapy emphasizes assertive communication. The patients learned to identify auras for their pseudoseizure so they could then act to avoid it. Some kept thought records so they could review their thoughts and moods from a different perspective. The researchers found that many of these patients had suffered abuse and trauma. This version of psychotherapy addressed their patients’ core beliefs. It helped people who felt victimhood to feel empowered and to take control of their “seizures.”

The longer the pseudoseizure condition exists without effective treatment the more difficult it is to control. Neurologists can improve psychogenic non-epileptic seizure-healing by suspecting it earlier. Ordering EEG video monitoring sooner, and which lasts hours to days after initiating care for a new poorly-controlled epilepsy patient, can reveal the true diagnosis. Then patients can discontinue their ineffective antiseizure medications and get into an effective psychiatric treatment program as identified above.

(1) LaFrance WC Jr, Baird GL, et. al. Consortium Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures: A randomized clinical trial. JAMA Psychiatry, Epub 2014 Jul 2.

 

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.

Blog #23: Epilepsy Treatment: How Effective?

(This blog was originally posted on May 29, 2012)

 

 

        Nearly one percent of the world’s population experiences recurrent seizures, i.e., epilepsy.  That’s approximately seventy million people, including three million in the United States. As patients and their physicians know, treatment often is unsatisfactory.

The May 15, 2012 issue of Neurology reports a study in which Brodie, et al. (1) followed almost 1100 newly-diagnosed epilepsy patients, ages 9-93, between July1, 1982 and March 31, 2008. Their epilepsy was due to various identified structural brain abnormalities (including injuries, strokes and scars, abnormal blood vessels and others), presumptive genetic causes, and unidentified causes.

Treatment consisted of initiation of a single antiepileptic drug considered appropriate for that patient. If the seizures continued then a different antiepileptic drug was substituted or added to the drug regimen. If seizures persisted a third antiepileptic drug was substituted for the other single drug or it was added on.

The researchers concluded that 68% of all of the seizure patients were seizure-free, i.e. had no seizures for at least one year without having to change the treatment. Among these almost 62% were on a single drug.  Forty-nine percent of the study population was seizure-free on the first antiepileptic drug tried. Any individual patient’s treatment success or failure usually became clear soon after initiation of treatment.

Brodie and co-investigators found there was a higher probability of freedom from seizures if only one drug was required for control; there was less confidence of full seizure control if more than one drug was required. Even less seizure control was experienced if more than two drug attempts were necessary. Less than 2% of patients who required multiple trials of medications, however, became seizure free.

This data is helpful for physicians in their discussions with patients with epilepsy. It can reinforce patient compliance with treatment. We can tell our patients that there is significant hope for a good prognosis in treating their newly diagnosed epilepsy.

1.Brodie, MJ, Barry, SJE, Bamagous, GA, et al. Patterns of treatment response in newly diagnosed epilepsy. Neurology. 2012; 78: 1548-1554.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel.