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.

Blog #88: Epilepsy in Life and in Literature: Dostoevsky

          Fyodor Dostoevsky (1821-1881) is among the world’s greatest authors. He is especially famous for Crime and Punishment, The Idiot, and The Brothers Karamazov. The central character in The Idiot, Prince Myshkin was beleaguered by epilepsy as was one of the Karamazov brothers, Smerdyakov. So, too, was their creator, author Fyodor Dostoevsky.

            Dr. Howard Markel recently reviewed Fyodor Dostoevsky’s life with epilepsy on the PBS NEWS HOUR. His review is available on-line. ¹  Markel noted that Dostoevsky wrote he was grateful for his seizure disorder because of the “abnormal tension” the episodes created in his brain, which allowed him to experience “unbounded joy and rapture, ecstatic devotion and completest life.” At other times, the author regretted the disability because he thought it had wreaked havoc with his memory.

            Thoroughly familiar with epilepsy, Dostoevsky’s descriptions are spot on. For example, the fictional character Smerdyakov was said to, “…sometimes stop suddenly…and stand still for ten minutes, lost in thought. Studying his face one would have said that there was no thought in it…” (page 123). ² A classical description that defines a complex partial seizure with post-ictal confusion. Some of his seizures are followed by headaches, which is a known post-ictal phenomenon.

            Smerdyakov makes prior plans to kill his father, the loathsome buffoon, Fyodor Karamazov, whose life is driven by narcissistic greed and lust. Smerdyakov will then blame the murder on one of his seizures. But, Smerdyakov tells a brother of a forthcoming seizure to the hour that will occur on a particular day. He is suspected of feigning some of his seizures, i.e., they are pseudoseizures. And, indeed, he later admits (page 570) to a brother that he did feign that seizure and that he consciously did murder Fyodor. ²

            Neurologists’ experiences lead us to believe that one-third of seizures in well-documented epilepsy patients whose seizures have been EEG-verified, are psychogenic or pseudoseizures, i.e., they are not true seizures. In these situations the patient is seemingly in the midst of a seizure but the EEG remains normal. Additionally, the patient can be susceptible to voice communications during the “seizure.” These pseudoseizures can have psychological causes beyond the patients’ conscious control; these are termed “conversion-type” seizures. I describe this phenomenon in greater detail in previous blogs at LanceFogan.com: # 10, September 23, 2011: “Is It a True Epileptic Seizure or a Faked, Psychogenic Seizure with a Psychological Cause?” and Blog # 49 August 27, 2014: “Psychogenic ‘Fake’ Non-Epileptic Seizures.” 

            In The Idiot, Prince Myshkin described after-effects of his seizure―a description of the classical post-ictal state (page 52): “…after a long series of fits. I always used to fall into a…torpid condition…and lost my memory almost entirely…I had no logical power of thought…I remember my melancholy was intolerable; I felt inclined to cry…” ³

             My blog followers who have epilepsy will be able to identify with these fictional characters’ epilepsy. I encourage you to explore Dostoevsky’s writings. Although he created these works over one and a half centuries ago, all of us can relate to his characters’ personalities and motivations. He describes us humans and our natures as we are.     

1. Dr. Howard Markel. “For Dostoevsky, epilepsy was a matter of both life and literature.” PBS News Hour. Health: Nov 10, 2017 3:05 PM EST.

2. The Brothers Karamazov by Fyodor Dostoyevsky. A Signet Classic published by the New American Library: 1957.

3. The Idiot by Fyodor Dostoyevsky. Everyman’s Library #682 published 1914.

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