Blog #42: Anti-Epileptic Drugs and Breastfeeding

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

 

Benefits of breastfeeding on the development of children are well-known. However, obstetricians and other physicians and nurses often warn women who take anti-epileptic medications to “never breastfeed.”  This is because the medical community is concerned about side effects of these medications in her breast milk that are passed on from the mother to the infant.

A study by Meador KJ, Baker GA, et. al., published in 2010 in the journal Neurology, volume 75, pages 1954-60, disputes these previously held beliefs. The study showed that children who were breastfed for an average of 6 months by mothers on anti-epilepsy medications did not have worse IQs when tested at 3 years of age compared with children born to mothers who did not breastfeed their babies but who were taking anti-epilepsy drugs during pregnancy. The mothers were taking carbamazepine (Tegretol), lamotrigine (Lamictal), phenytoin (Dilantin) or valproate (Depakote) while they were pregnant. A follow-up Multicenter Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) Study included medical facilities in the United States and United Kingdom. These NEAD researchers have now followed these children up to age 6 years without showing deleterious results on their IQ. The research groups’ abstract—not yet published―was reported on page 1 of the December 19, 2013 issue of Neurology Today by journalist Thomas R. Collins.

New mothers should discuss with their physicians that updated information supports the benefits of breastfeeding even while taking these drugs that were used in the study: carbamazepine (Tegretol), lamotrigine (Lamictal), phenytoin (Dilantin) or valproate (Depakote). Because of well-recognized teratogenic risks of congenital malformations and lowered IQ in offspring of mothers taking valproate during pregnancy, valproate should be avoided during pregnancy, if possible.

 

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 #41: New Hope for Refactory Epilepsy

(This blog was originally posted on December 24, 2013)

 

 

Epilepsy is a brain disorder causing seizures. It affects 1 percent, or three million, of the American population. Only half of these people can control their seizures with anticonvulsant medications or with surgical removal of the offending brain area.  The treatment efforts in approximately 20-30 percent of people with epilepsy are not effective. A new device offers hope for those whose seizures originate in parts of the brain not amenable to surgical removal. It is not recommended in generalized epilepsy where no isolated seizure focus can be detected.

The U.S. Food and Drug Administration (FDA) approved an implantable neuro-stimulator in November, 2013. The device, called the RNS System (Neuropace, Inc.), is surgically implanted into the skull bone close to the site where the seizures are determined to originate.  Lead wire electrodes from this stimulator extend through the skull bone and are placed on, or sometimes in, the brain. The battery-powered stimulator monitors brain activity. When the onset of abnormal activity is detected, even before the person is aware of the oncoming seizure, the electrodes deliver stimuli that short-circuit the abnormal brain activity and normalize it before a seizure can manifest. The RNS System activates only when it detects seizure activity.

The FDA based its approval on clinical trials of the RNS System involving 191 patients with drug-resistant seizures. They were aged 18-70 and many had uncontrolled epilepsy for years. Half of this patient population had their stimulator turned on and the other half’s stimulator was kept off. After 3 months the average number of seizures per month in the group with the activated stimulator decreased a median of 34 percent. For the patients with the turned-off device, the median reduction in seizure frequency was only 19 percent.

Researchers were encouraged by the significant improved quality of life provided by the RNS System, even allowing many to safely drive vehicles.

The device is designed for people 18 and older whose epileptic seizure onset can be localized by various neurological testing, e.g., EEG and various brain scanning.

According to Neuropace president and CEO Frank Fischer, NeuroPace has done studies involving a total of 256 patients who were monitored for 2-9 years without any significant problems. Its batteries can last several years and be replaced in an out-patient clinic. The cost of the RNS System is still under evaluation.

 

 

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

Blog #40: Epilepsy: Preparing for the Holidays

(This blog was originally posted on November 24, 2013)

 

The holidays are almost here. As many of us prepare to travel—and welcome—friends and family to share our Thanksgiving feast, people who have epilepsy should take some extra precautions to stay healthy and safe.

·        Get enough sleep: Excitement, stress and jet lag can disturb sleep patterns. Extreme sleep deprivation is known to cause seizures. For example, soldiers returning home from Vietnam during the 1960s and ’70s were so excited that they would be up for 36 hours straight. This extreme lack of sleep caused a convulsion in people who do not have epilepsy; it could certainly precipitate seizures in people who have this condition.

·        Alcohol: Alcohol is often served at holiday meals. People with epilepsy can probably tolerate a beer or a small glass of wine or spirit. However, excessive use/abuse of alcohol is more likely to bring on a seizure than in a person without epilepsy.

·        Nutrition and hydration: In my experience, people who have epilepsy do not need to follow a special diet; just follow routine recommendations for good nutrition and water intake.

·        Bring an adequate supply of anti-seizure medication when you travel: Be sure to bring enough anti-seizure medication with you to last the duration of your trip plus a couple extra days to be safe. Keep the medications in their original bottle/container with the prescription (dosage) and your doctor on the label. (This information may be required if you must cross state or international borders.)

·        Stress: No matter how much you enjoy the festive season, holidays can be stressful for anyone. Emotional stress can definitely bring on a seizure in people who have epilepsy. If possible, minimize the amount of time you spend in a stressful environment. Meditation and light exercise are good ways to reduce stress.

·        Carry identification when you go out: People who have epilepsy can have a seizure at any time. During a seizure, a person cannot tell bystanders that he or she has epilepsy. When a seizure occurs, it’s usually not necessary to call an ambulance; the person will stop jerking and shaking after a minute or two and just sleep it off. A MedicAlert bracelet or necklace would reassure observers that the person has a known chronic condition that may not be that serious. This information is also useful if emergency personnel are called. Always carry a card in your wallet that states your condition (type of epilepsy) and up-to-date medications you take to control it. Be sure to include a contact address and phone number of one or two relatives that emergency personnel or a Good Samaritan can contact in an emergency. If you are away from home visiting friends or relatives, be sure to provide similar contact information about your hosts.

·        Wear a helmet: After eating the sumptuous meal, a lot of people like to get out and exercise to work off the calories they have just consumed. Everyone—and especially people with epilepsy—should wear protective headgear (a helmet) if you ride a skateboard, bicycle, horses and even ski. A helmet will protect your precious brain from injury if you fall and hit your head while participating in one of these activities.

 

 

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

Blog #39: Mimics of Nonconvulsive Epileptic Seizures in the Classroom

(This blog was originally posted on October 25 2013)

 

 

     A woman recently wrote a comment on Amazon.com concerning my epilepsy novel, DINGS. Her teenage grandson was newly diagnosed with epilepsy. Prior to that, he was thought to suffer a “learning disorder.” If she had read the novel earlier she would have considered nonconvulsive epilepsy as it affected the protagonist in DINGS. She suspected that her grandson’s true diagnosis could have been made much sooner.

     Parents, teachers, school nurses, psychologists, pediatricians and anyone who works with children commonly observe youngsters who are in the midst of an epileptic seizure that is not associated with convulsive jerking, tongue biting and loss of urine or bowel control. These can be difficult to recognize. These very common nonconvulsive seizures—temporal lobe or psychomotor seizures, and absence or petit mal seizures—are characterized by the child just staring, or stopping to walk, or smacking lips with swallowing movements. They have lost contact with their surroundings and do not respond when spoken to. They will have a blank and confused expression that can last 10-20 seconds up to several minutes.

     I know of people who had petit mal seizure blank outs lasting 5-15 seconds up to 30 or 40 times/day for years during childhood and their teens who assumed these frequent blank outs were normal. One said to me, “Doesn’t everybody have them?”

     The following symptoms for which absence and complex partial seizures are commonly mistaken include:

 

• Stuttering: some children will utter the same sound repetitively without responding when spoken to. They will have no recollection of what happened during that time.
• Hearing problem: since the child doesn’t respond or answer when addressed, people unfamiliar with nonconvulsive epilepsy might assume some hearing difficulty.
• Daydreaming: the child will appear to absently look off and not respond when addressed. Individuals are aware of their thoughts during true daydreaming. However, the mind is blank during a nonconvulsive seizure.
• Learning disorder: children who experience frequent unrecognized blank outs will fall behind in their class work. It is common for the child not to understand his confusing blank out experience and will not complain of it.

• Attention Deficit disorder (ADD): the child’s transient lack of attention due to a nonconvulsive seizure can be confused with ADD.

 

     Now that you know which behaviors can mimic the nonconvulsive forms of epilepsy, it is worth investigating. This common elusive form of the condition could be the cause of the child’s lack of classroom success.

 

 

 

 

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

 

 

 

 

 

Blog #38: Football Coach Has Convulsion on the Field. What Happens Next?

(This blog was originally posted on September 18, 2013)

 

University of Minnesota football coach, Jerry Kill, recently had a convulsion on the field. Known to have chronic epilepsy, he was transported to a local hospital. If a person with epilepsy has a convulsion, what happens next?

            If the seizure occurs at home in the presence of family who are experienced with their loved one’s epilepsy history, the person is protected from harm and just observed. The seizure is self-limited and after a minute or two, the patient sleeps. Upon awakening in minutes to hours, the patient resumes normal activities.

 If the convulsion occurs outside the home, the patient generally is brought to a hospital emergency room. Convulsions usually end by themselves in one or two minutes and then require very little first aid. But, if the convulsion continues in the emergency room, the medical staff will ensure that an open airway is provided with appropriate head positioning. They will insert a plastic piece that fits in the mouth to keep the tongue from obstructing the throat passage. A simple oximeter is attached to a finger to determine if adequate oxygen is entering the body. Vital signs (blood pressure, heart rhythm and temperature) are monitored. An intravenous line is started to ensure that anticonvulsant and other medications can be administered if necessary. Blood will be drawn to test for possible serious medical conditions. Restraints on limbs aren’t used. These can cause fractures or dislocate flailing limbs.

Information from a patient’s medic-alert bracelet/necklace, wallet or from relatives/friends can help the medical staff make a faster diagnosis if they are available.

            In most cases, by the time the ambulance or private car arrives at the hospital, the convulsion has ended; the person will be in a post-ictal state and appear confused. In this situation, no extreme first aid measures are required. The patient is evaluated as he regains alertness. When the staff learns that the patient is known to have epilepsy, and is on anticonvulsant medications, the patient is discharged home as soon as he is alert, which generally is after an hour or two. The patient is advised to consult with his physician or neurologist to evaluate any need for change in medication(s) and, or dosages, in order to gain better seizure control, if possible. Brain scans and EEGs usually have been done in the past and are not repeated unless a change in the patient’s condition is found.

            Best advice: Take prescribed medications correctly; don’t drive if seizures aren’t controlled; don’t bathe/shower unless the bathroom door is open and someone is at home AT ALL TIMES, if possible (I know of 12 drownings at home—5 fell face-down blocking the shower drain); obtain medic-alert bracelet/necklace that reflects diagnosis and medications; wear helmets when biking; get adequate sleep and minimize alcohol intake.

 

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

         

Blog #37: Status Epilepticus

(This blog was originally posted on September 3, 2013)

 

Approximately 1 to 16 percent of people with epilepsy experience seizures that last five or more minutes. This prolonged seizure is referred to as “status epilepticus,” and the seizure will be characterized by either convulsions (tonic-clonic seizure, See Blog #33) or periods of blanking out (complex partial seizure, See Blog #35). Each event originates in a different area of the brain and can last many minutes or even several hours.

·         Tonic-clonic status epilepticus: This type of seizure emanates from the central depths of the brain, but it can spread to both hemispheres and affect the whole brain. This form of epilepsy can be lethal if it goes on for too long because the convulsions impede/prevent breathing. If someone is convulsing for more than several minutes, it is important to get the patient medical help as soon as possible: intravenous anti-seizure medications can be given to help stop that seizure. If this fails, general anesthesia is used to try to stop the seizure and to preserve the brain cells that have not already been damaged by oxygen deprivation that occurred during the seizure.

·         Complex partial status epilepticus: This seizure begins in the temporal lobe, and occasionally in the frontal lobe. It may last several minutes, many hours or even days. To the uninitiated observer, someone who is in this state may appear to have a psychiatric problem, where the patient has “freaked out” and just acts strangely. The patient may even be referred to psychiatrists because of the unrecognized seizure. As oxygenation is not compromised in complex partial status epilepticus, anti-seizure medications may be administered orally or intravenously, as per the medical team’s judgment.

·          Subclinical, non-convulsive status epilepticus is believed to be the cause of coma in many seriously ill, unresponsive patients in the intensive care unit (ICU). These patients lie still, without responsiveness, yet they can be having continuous seizure activity seen if an electroencephalogram (EEG) is done. A routine eye examination with an ophthalmoscope at the bedside could diagnose this condition. I have occasionally been surprised to find that the optic disc—a structure in the back of the eyeball—is jerking back and forth in comatose patients. This may be the only part of the body demonstrating epileptic activity, which will be confirmed on the EEG.

 

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

 

Blog #36: Hard to Believe: Worms in the Brain Cause Epilepsy

(This blog was originally posted on July 30, 2013)

 

 

 

 

Cysticercosis was not on our diagnostic radar screen in the eastern half of the United States during my neurology training in Cleveland over 40 years ago. Once I began practicing in Southern California, however, I found this affliction was common. Anyone who developed seizures would have a CT image of the brain. I soon learned that if small, white calcification spots appeared on the scan of someone who came from a Third World country, especially Latin America, it was most likely a case of cysticercosis in the brain, or neurocysticercosis. The white spots are old scars caused by dead, calcified pig tapeworm larvae. Colleagues in the Eastern United States were intrigued when we discussed this condition as so few Latin Americans resided in those regions several decades ago. Currently, neurocysticercosis is diagnosed throughout the United States.

Cysticercosis is infestation with the pig tapeworm whose larvae have spread throughout the victim’s body. Poor personal hygiene and inadequate food preparation is the usual mechanism for this illness. It occurs when a person ingests the microscopic eggs of the pig tapeworm (Taenia solium) which are eliminated from the intestines with bowel movements. Poor farmers throughout the world commonly fertilize their gardens with their families’ feces (commonly referred to as “night soil”). It is an inexpensive fertilizer. If the feces are contaminated with the T. solium eggs, they are likely to ingest the eggs with these vegetables or from unclean hands. Tapeworms have “learned” to survive through evolution, i.e., the worms live for years symbiotically with their human or pig hosts and cause very few symptoms.

Following ingestion, the eggs develop into tiny worm larvae that migrate through the stomach lining of the pig or person into the bloodstream and spread to the rest of the body, especially to muscles and the brain. If contaminated pork muscle infected with living larvae is eaten undercooked, the live larvae mature into tapeworms in the host’s intestines. These tapeworms give off eggs to continue the cycle. Lack of sanitary meat inspection contributes to the problem.

Cysticercosis is the most common cause of epilepsy in Latin America. The little worms in the brain can cause serious paralysis or even death. More often, they are enclosed by scar tissue, die and form calcified, shrunken corpses that remain throughout the patient’s lifetime. These scars frequently, but not always, irritate brain cells, resulting in epilepsy. This epilepsy can usually be controlled with anticonvulsant medications.

 

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