Blog #92: Citizens Influence New York State Law: Driving With Epilepsy

      A few weeks ago I saw a TV report: a Brooklyn driver ran a red light and killed two children, ages four years and one year old and injuring others, including a pregnant woman — “It was something you see in a horror movie,” a witness said. The car dragged one kid’s stroller more than 350 feet at Ninth St. and Fifth Ave. in Park Slope, Brooklyn, N.Y.

      According to reports, this auto accident was caused by a driver afflicted with multiple sclerosis, seizures and a heart condition. After the accident she said she didn’t recall the red light or hitting anything. On-sight witnesses reported that she seemed oblivious to what had just happened. That strongly suggests that this person’s epilepsy caused a seizure.

      Neurologists evaluate and treat people who experience altered and loss of consciousness.  In contrast to the epilepsy type that causes falling to the ground with convulsive shaking, I had to include the non-convulsive type epilepsy as a possible cause of a person’s altered behavior. This form of epilepsy can be difficult to recognize. The non-convulsive forms include complex partial seizures and petit mal seizures. People suffering these common forms of blank-outs may walk about, converse in a confused manner, turn on water faucets and eat at a table with other people all the while they are in a mental fog—out of contact with their environment and without memory of their actions.

      Children may suffer these seizures but teachers, families and even medical workers may miss the correct diagnosis. These people may be considered to be “slow learners,” or have hearing problems, attention-deficit disorders (ADD) or autism. The prime diagnostic tool, the electroencephalogram (EEG), commonly is normal because the epileptiform abnormalities may not occur in the brain during the hour or so that the person is connected to the brain-wave-detecting equipment. Brain scans routinely are normal, too. The diagnosis can be made by speaking with observers who note these patients’ “foggy” mind-states. My novel, DINGS, is a medical mystery story of just such a bright third-grader who is failing school because of his unrecognized complex partial seizure-blank outs. He’s just not “keeping up.”

      Upon seeing this report on TV two weeks ago I recognized Brooklyn’s Park Slope as a neighborhood in which my cousins live. I sent them my opinion that the driver must have had a seizure causing the accident of which she had no memory. “It was murder,” they told me.

     Why was this woman with epilepsy driving?

      I related that my state, California, is only one of six states where state law requires physicians to report people with altered consciousness. New York is not one of those six states. The other 44 states hope that people with epilepsy will report themselves to the Department of Motor Vehicles (DMV). That’s a problem. Some of my California epilepsy patients would become understandably belligerent when I would caution them of their driving responsibilities and to stop driving until sanctioned by the DMV; they were endangering their families, passengers, the public and themselves. “No, Doc. Don’t send that report in. Are you going to pay my mortgage?” Personal insight, personal economics and ethics all swarm in their minds as they make decisions of giving up their driving privilege, i.e., their DMV license.

     Upon learning my information my Brooklyn cousin asked if he could share it with a New York State legislator’s office. That same week Brooklyn State legislators unveiled a bill to create a mandatory reporting system and to authorize the DMV to evaluate pe  I shall be following New York’s action.

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 #91: Non-Drug Treatments for Epilepsy

            Many patients whose epilepsy responds poorly to antiseizure medications (20-30% of the three million American epilepsy population) may benefit from non-drug treatments. A study presented at the 71^st American Epilepsy Society Annual Meeting showed evidence that Vagus Nerve Stimulation (VNS), the ketogenic diet and a surgical procedure―corpus callosotomy—may reduce generalized and focal seizures. Among patients who failed three anticonvulsive medications between ages 8 months to 20 years, with a mean age of 10 years, underwent one of these treatments. Most of the patients’ parents were pleased with the results.¹ Sixty-three percent of patients who went on the ketogenic diet reported 50% or greater  reduction of their  generalized seizures. Fifty-four percent of patients who underwent corpus callosotomy and 52% of patients who received vagus nerve stimulation reported 50% or greater reduction in their generalized seizures.

            A very important benefit in withdrawing multiple anticonvulsive medications is that drug side effects are minimized: drowsiness, poor concentration, weight control problems, blood testing, teratogenic risks for women among other effects.

• Vagus Nerve Stimulation is sometimes referred to as a "pacemaker for the brain." A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. A person with a VNS device is usually not aware it's operating.

• The ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy. It is prescribed by a physician and carefully monitored by a dietitian. It is extremely strict, with calorie, fluid, and protein measurements. Ketones are formed when the body uses fat for its source of energy. The body usually uses carbohydrates (such as sugar, bread, pasta) for its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead. Higher ketone levels often lead to improved seizure control but the precise reason is not understood.

• Corpus callosotomy The corpus callosum is the most important connection between the two halves of the brain. Callosal surgical sectioning is quite effective in reducing seizure frequency in patients who have generalized epilepsy with drop attacks. It is generally reserved for this selected population. It is an epilepsy surgery procedure that is considered palliative only. It mediates communication between the two hemispheres of the brain. Seizures may spread rapidly from one hemisphere to the other by way of the corpus callosum; thus seizure spread is reduced and control is increased.  Serious complications are exceedingly rare.

            Dr. Dave Clarke, Clinical Director of Epilepsy at Texas Children’s Hospital at the Baylor College of Medicine in Houston led a study with colleagues at the Dell Children’s Medical Center in Austin between January 2010 and November 2015. They compared seizure control, cognitive and behavioral factors, quality of life and parental satisfaction.

            Parents reported a 50%, or greater, reduction in generalized seizures in 63% of patients who went on the ketogenic diet, 54% of patients improved who underwent corpus callosotomy and 52% of patients improved who received VNS.

            “Many doctors keep trying medications without considering alternatives,” said Dr. Clarke. He suggests doctors introduce treatment alternatives after two anticonvulsive medications fail to control seizures.

1.      www.neurologyreviews.com: Jack Remaly in Neurology Reviews. January 2018, page 1, 45-46.

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 #90: Which Patients with Epilepsy Can Safely Drive?

 

            The perennial question from our patients is, “Can I drive, Doctor?” Only California, Delaware, New Jersey, Nevada, Oregon and Pennsylvania throw this decision to the state’s Department of Motor Vehicles (DMV). These states’ laws make it mandatory for physicians to report persons who are diagnosed with epilepsy to the state DMV; however, it is the DMV that decides if the patient may drive, not the physician. Failure to report an epilepsy diagnosis opens the physician to liability if car accidents occur. The other 44 states request patients to report themselves to the DMV. Facing loss of jobs, income and losing their driving privilege makes it very tempting not to report their epilepsy diagnosis. But, this compromises their own safety, the safety of their passengers and of the public. I have had patients who had their driving licenses revoked for a period of observation of six to twenty-four months. If they were seizure-free the DMV returned their driving privilege. In my follow-up, I would query, “Have you had any seizures or spells?” Some had responded, “Would you have to report anything to the DMV?” When I affirmed that I would, they then told me, “No, I’m doing fine, Doctor.”

            The patient’s doctor, usually a neurologist, is asked on the DMV’s forms whether the patient is safe to drive: “yes, no or unsure.” Physicians base their judgement on the patient’s and observer’s histories if loss of awareness has occurred. The DMV’s medical consultant committee, however, makes the ultimate driving decision.  

            The EEG is normal in up to 50% of epilepsy patients on any one test. Abnormalities may not appear except during seizure activity in the brain. EEG abnormalities of other types are not always diagnostic. Brain scans and blood and cerebrospinal fluid testing are commonly normal, too. So, a normal EEG does not rule out epilepsy. The clinical history is how the diagnosis of epilepsy is made.

            Petit Mal, or Absence, seizure patients usually have no warning-prodrome or post-ictal (after the seizure stops) confusion state or any obvious physical changes during their seizure. Also, these patients are oblivious of their loss of awareness which usually last just 10-15 seconds. Observers who are unfamiliar with epilepsy―often their juvenile friends—commonly miss the brief seizure; they consider the patient “weird” and “different.” Complex partial seizures can be hard to identify because the person does not convulse but just seems to be confused and to have lost contact with their environment.

            The lack of data about driving performance during seizures, and during the post-ictal period, makes it difficult to determine driving safety. A study of patients who performed a driving simulation test during inpatient video-EEG monitoring was recently reviewed.¹ Hal Blumenfeld, MD, PhD and colleagues studied 20 patients during simulated driving in the Yale New Haven Hospital Epilepsy Monitoring Unit. Patients “drove” an average of three hours. Some seizures showed obvious impairment and others showed none. Several of the patients’ seizures resulted in “crashes.” Seizures lasted an average of 75 seconds in those patients who crashed, compared with an average of 30 seconds in patients who did not crash. Blumenthal concluded that “…more data is required to learn if there are people with epilepsy who are driving who shouldn’t be driving, as well as those who are not driving who can safely drive.”

            Another similar study also questions the long-held belief of a protective role of reliable auras against motor vehicle accidents in people with epilepsy.² 

1.      “Which Patients with Epilepsy Can Safely Drive” Neurology Reviews: January 2017, page 8.

2.       Punia V, Farooque P, Chen W, et. al. Epileptic auras and their role in driving safety in people with epilepsy. Epilepsia. 2015 Nov; 56(11): e182–e185. Free at Epilepsia.

 

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 #89: Surgical Removal of Seizure Foci in Your Brain to Cure Poorly Controlled Epilepsy is Safe!

            Only half of people with epilepsy are seizure-free even if they are taking the best anticonvulsant in the correct dosage for them. This “best” regimen is usually a trial and error exercise. Another 30 percent of patients find that anticonvulsant medications improve their seizure control but not completely. Another 20 percent do not respond at all to anticonvulsants and experience frequent seizures.

            Children and adults that undergo surgery to treat their poorly controlled epilepsy can find it to be life-changing. Anticonvulsant dosages and drug side-effects can diminish―the medications may even be stopped completely. Patients then feel confident to be alone at home and may even safely drive vehicles. What may surprise people is that brain surgery causes few or no observable side-effects and can lead to improved quality of life. IQ, too, is little, if at all, affected by surgery, and the surgery has been found to have less effect on IQ compared to those only treated with long-term medical therapy. Dan Hurley reviewed this topic in, “Surgery for Pediatric Epilepsy Found to Have Better Outcomes than Medication Management Alone” in Neurology Today, December 7, 2017, page 17-18.

            One patient told her personal story in Neurology Now, December 2017-January 2018, page 38. She developed convulsions at age 31. Anticonvulsant medications helped but she still averaged 3-4 seizures per month. Her job as a nursing assistant ended because of the danger her epilepsy posed working with her patients. MRI, EEG and neurological evaluations with further testing suggested her seizures originated in a part of her brain that epileptologists and epilepsy neurosurgeons felt confident that its removal could lessen her seizures or even make her seizure-free. Following her right temporal lobectomy she reported that she has been free of seizures for six years. She is still on medication but at a lower dose. She advocates for her treatment by speaking to patient groups considering surgery.

            If uncontrolled epilepsy is your experience you should definitely consider the surgical option. As scary as it sounds, this treatment has been time-tested over decades. The neurological community finds this life-changing option is under-utilized. Discuss this possible treatment with your neurologist. If testing shows that you would be a good candidate, you will probably wonder why it was not recommended before or why you hesitated for so long.

            Epilepsy centers that perform this surgery are available throughout the United States and the developed world. If your neurologist believes that you would be a candidate, ask for a referral.

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.