Blog #145: Epilepsy Patient Passes Driving Test After Brain Surgery

  

Several of my previous 144 monthly blogs on LanceFogan.com dealt with brain surgery as a chance to improve, or even cure, epilepsy in those whose epilepsy is poorly controlled. (See Blog # 89 December 26, 2017: Surgical Removal of Seizure Foci in Your Brain to Cure Poorly Controlled Epilepsy is Safe!; Blog # 101 February 26, 2019: Epilepsy—Fit to Drive?; Blog # 114 January 26, 2020: Epilepsy Surgery in Childhood and Long-Term Employment Is Encouraging.; Blog # 121 August 25, 2020: If Your Seizures Aren’t Controlled Epilepsy Surgery Is Safe and Really Can Help).

 

The greatest chance to cure your uncontrolled epilepsy is by successfully removing the seizure focus surgically.

My clinical experience has shown that there is so much that can physically alter the brain anatomically by surgery and by unintended trauma that surprisingly results in undetectable, or barely detectable, changes in a patient’s mental and physical capabilities. I have examined people who have been shot in the head, the bullet entering one side traversing through parts of the brain and exiting the other side of the head sparing sensitive brain areas. When neurosurgeons and neurologists perform specialized types of EEGs and imaging scans anticipating epilepsy surgery, sensitive parts of the brain can be identified and avoided.

The BBC on-line service recently reported that a man with epilepsy says he finally has independence. A surgical procedure removed his epilepsy focus and he then was able to pass his driving test.¹ The 40-year-old man had the brain operation eight years ago. Government rules meant the computer programmer from Birmingham was unable to take his driving test unless he was seizure-free for two years. But twice since learning to drive he had a seizure, setting him back each time and then Coronavirus lockdowns led to further delays. But eventually he was able to take the test and since passing, plans to take his young family on regular camping trips.

The man said he never thought he would be able to drive after living with epilepsy since childhood. But he underwent lesion resection, which involved inserting electrodes into his brain to detect electrical activity and carefully removing abnormal tissue.

Discuss possible epilepsy surgery with your neurological caregivers.

 

1)    Epilepsy Patient Passes Driving Test After Complex Surgery. https://www.bbc.com/news/uk-england-birmingham-62568014. Aug 16, 2022.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in a recent Publishers Weekly, New York Times Book Review and the Los Angeles Times Calendar section. DINGS teaches epilepsy and is now available in eBook, audiobook, and soft and hard cover editions.

 

 

 

 

 

 

 

 

 

   

 

Blog #129: IS YOUR SEIZURE FREQUENCY PREDICTABLE?

 

The longest seizure study yet finds daily, weekly, monthly, and yearly seizure repeating cycles based on continuous intracranial EEG data collected from 2004 to 2018. Patients often tell their doctors that their seizures come in cycles. Skeptical physicians may now acknowledge their patients’ reports and approach their patients with more effective treatment adjustments. ¹

Blog #41, December 24, 2013, appearing on LanceFogan.com describes an implantable neurostimulator approved by the FDA in November 2013. The device is called the Responsive Neurostimulation System (RNS NeuroPace, Inc.). It is surgically implanted into the skull bone—not under the bone—close to the brain location where the seizures are determined to originate. Two small holes are drilled into the bone through which two lead wire electrodes are placed on the brain, or within it, close to a seizure focus. The battery-powered stimulator positioned outside the brain on the skull monitors brain activity. When the onset of seizure activity is detected the electrodes deliver stimuli that short-circuit the abnormal brain activity and normalize it before a seizure manifests. The RNS System activates only when it detects seizure activity. It aborts many seizures from manifesting even before the person is aware of the imminent seizure.

The NeuroPace stimulator detects circadian cycle data in epilepsy. Circadian rhythm is a natural internal process that regulates sleep-wake cycles and other processes in an organism. It repeats roughly every 24 hours. In some people with epilepsy, seizures occur in predictable cycles. Have you noted some of your seizures are predictable?

Circadian seizure cycles showed five peaks of epileptiform activity: morning, mid-afternoon, evening, early night and late night. If these findings pan out on further research, perhaps augmenting anti-seizure medications at predictable times may prevent some of your seizures. Knowledge of when seizures can be expected should empower patients. This knowledge can boost self-confidence. Driving ability, employment, social disablement all impact the lives of people with epilepsy; this predictable-seizure knowledge can return confidence and independence. 

This new approach to assessing seizure-frequency by constant EEG recording with the NeuroPace device shows many individuals’ seizures occur every seven, 15, 20 or 30 days. Epilepsy researchers were surprised at this predictable cyclic information and are considering whether seizure forecasting over long time periods can be done. A seven-day cycle is often not precisely 7 days; it might be 6.5 or 7.5 days. As patient’s known cycles, i.e., weekly or 15 or 20 or 30 days or longer approaches patients may predict their seizure and take safeguarding action. Researchers are excited to follow up these findings.

 

1)      Neurology Today: Longest6 seizure study yet finds daily, weekly, monthly and yearly cycles. Reviewed by Dan Hurley in the March 18, 2021 issue, page 10-11.

 

 

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

 

 

 

Blog #111: MY EPILEPSY IS CONTROLLED. WHY DO I HAVE OCCASIONAL THINKING BLANK OUTS?

   The brains of people with epilepsy are not the same as the brains of the general population. 

   A new study by Stanford University epilepsy specialists⁽¹⁾ found electrical activity in epilepsy patients’ brains which can explain brief lapses in thinking, perceiving and remembering even in those whose epilepsy seems to be well-controlled by medication.

   High-frequency oscillations (HFO) are subtle, transient brain recording signals that erupt up to 100 times per minute in people who do not have epilepsy. However, these HFO “buzzes” are abnormal if they occur with an onset of a seizure in epileptogenic areas of the epilepsy patient’s brain. The HFO buzzes are not abnormal if they occur in parts of the epilepsy patient’s brain that are not associated with their seizures.

   In their study, the Stanford researchers tested six patients with intractable seizures who had sensors implanted in their brains for consideration for possible epilepsy surgery. Cognitive challenges were presented to the patients for them to solve during periods when a buzz of epileptic activity was interfering with their brains’ normal processes. Several HFOs per minute were seen on EEGs but clinical seizures were undetectable to observing neurologists. The researchers suggest that these HFOs could explain cognitive complaints from otherwise “normal-appearing,” epilepsy patients whose epilepsy is “controlled.” If the HFO occurred milliseconds before a seizure-prone brain area began processing information the HFO seemed to affect cognition The HFOs lowered the accuracy and speed of the patient’s thinking, i.e., the response time, even though visible seizure activity was not observed.

   The explanation for this brief deterioration is that HFOs within that period interfere with high-frequency broadband events, or HFBs. These healthy brain events occur in brain areas that are not affected by the epilepsy focus. HFBs are associated with a brain circuit beginning to do something the brain is supposed to do, as processing visual information or recalling previous experiences. HFOs can disrupt healthy brain activity for up to one second even though clinical seizure activity is not apparent.

   A computer was trained to accurately distinguish between HFOs and HFBs. In all six patients studied, if a spontaneous HFO occurred within one second before a task-elicited HFB should have arisen, it disrupted, delayed, diminished and often completely extinguished the HFB. Testing at these times showed this event slowed responses, showed poorer recall and reduced confidence in answering memory-evoking questions.

   The important conclusion from this study is that the epileptic tissue’s performance was normal outside the window of the HFOs. For the majority of the time when seizure-prone brain tissue isn’t experiencing HFOs, the brain tissue worked well in these test patients. Researchers advised that prior to surgery for its removal, physicians should weigh that much of the time the epileptic focus that is seizure-controlled can still have significant cognitive abilities. Is surgery to remove it still the best treatment considering side-effects?

   Bruce Goldman, a science writer in the Office of Communications at Stanford University, reviewed the researchers’ scientific article.

1)      Liu S,  Parvizi J. Cognitive Refractory State Caused By Spontaneous Epileptic High-Frequency Oscillations In The Human Brain. Science Translational Medicine Vol. 11, Issue 514, 16 Oct 2019.

 

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 #108: SUDEP—SUDDEN DEATH IN EPILEPSY―OCCURS IN ALL TYPES OF EPILEPSIES

            SUDEP, sudden death in epilepsy, has an incidence of 1-2 cases per 1,000 patients with epilepsy per year.¹

            The recent tragic death of Cameron Boyce, a popular 20 year-old Disney star, has brought SUDEP and epilepsy to the public eye.

            A study reviewed 237 SUDEP cases between October 2011 and June 2017 in the North American SUDEP Registry. Subjects were ages 1-70 years, the median age was 26. Women made up 38% of the study population.²  Researchers found that night sleep, usually considered the usual situation related to SUDEP deaths, is not necessarily the most common time when SUDEP occurs. Many patients in this registry died during daytime. Additionally, the mechanism of death may not be due to an obstruction of the airways but more likely is related to cardio-respiratory phenomena.

            The study showed all ages and all epilepsy severeties are affected by SUDEP; it is not restricted to chronic poorly-controlled epilepsies. Anybody with epilepsy can experience SUDEP including patients with well-controlled or benign epilepsies, i.e., those with centrotemporal EEG spikes (the Rolandic Epilepsies that primarily occur during sleep and not while awake). The reported lifetime number of generalized tonic-clonic grand mal seizure counted in the study population ranged from zero to more than 500.

            The most notable observation in the study was that a majority of these deaths occurred in people who did NOT take their last dose of antiseizure medication. This presents a chance to minimize the risk of SUDEP. Take your medications as prescribed!

            Physicians need to discuss the risk of SUDEP with their patients, emphasizing the importance of never skipping an antiseizure medication dose. If your doctor doesn’t bring SUDEP up, YOU, the patient, should ask about it. Minimize alcohol and, additionally, get enough sleep.

            Epilepsy surgery can be curative of epilepsy if you are a candidate. Discuss this option with your doctor. The shorter time interval between the onset of your epilepsy and the epilepsy surgery can achieve better results from surgery.³

1)      Thurman DJ, Hesdorffer DC, French JA. Sudden unexpected death in epilepsy: assessing the public health burden. Epilepsia 2014;55: 1479-85.

2)      Verducci C, Hussain F, Donner E et. al. SUDEP in the North American SUDEP Registry: the full spectrum of epilepsies. Neurology 2019;93:e226-e236.

3)      Bjelivi J, Olsson I, Malmgren K, et. al. Epilepsy duration and seizure outcome in epilepsy surgery. Neurology 2019;93:e159-e166.

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 #105: TRAINING SEIZURE DOGS

      The Epilepsy Foundation visited trainers and staff of Canine Partners for Life, Cochranville, Pennsylvania. This is what they learned about training these amazing seizure-alert dogs:

• Certified seizure-dog trainers do not require a specific educational degree. However, some states require licensure and others have voluntary certification programs for the dogs. Other states have accredited college and community college programs to train service dogs for various disabilities. 

•  Seizure-dog resources can be found on line: www.epilepsy.com/learn/seizure-first-aid-and-safety/seizure-dogs/perspective-training-seizure-dogs

•  Seizure-dogs are trained to help or to alert for help when their human partner is having a seizure. Some animals can even predict a seizure within minutes or an hour before it occurs and warn their handler. How dogs do this is not precisely known. Do they pick up some signal? Do they detect a smell? Can they be trained to detect an imminent seizure or are they born with that ability? Barking and licking are anecdotal tales of dogs responding to seizure-warnings, but even trainers cannot guarantee the dog will predict every seizure.

•  One facet of training can be to expose the dog to a person who has active epilepsy. That person can judge if the dog reacts in any way prior experiencing an aura or seizure. However, ambulatory EEGs running continuously in a patient with the seizure-dog nearby often show no response in the dog.

•  Dogs are trained to alert, respond and retrieve items in interacting with their human partner. While any dog can potentially be trained to become a seizure-dog, favorite breeds include Labrador and Golden Retrievers and Collies. Dogs start their training with organizations that provide seizure-dogs as puppies where they are assessed for temperament and personality. Serious specialized training begins around 14 months of age. Dogs are trained to: fetch, push buttons, open doors, turn off lights, pay a cashier and carry things. In harness they can help balance and support their handler. The dogs are placed in their partner’s home to build bonds during training and to learn what their partner needs.

•  Another useful website to acquire a seizure dog is: assistancedogsinternational.org.

•  Anyone over 11 years of age and who can communicate at least at a sixth-grade level is eligible to be partnered with a seizure dog because certain levels of maturity/ability are required. The cost of training a dog is around $26,000. Donations subsidize many dogs. The cost to the person with epilepsy ranges from free to $20,000 depending upon ability to pay. 

 

    The impact a seizure dog can have on an individual or family can be life changing. The dog can bring a sense of relief with more safety, independence, confidence and love.

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.