By Tim Fox
Hope and Healing for Epilepsy
We’ve all been there.
You’re working on your mobile device, laptop or PC, when suddenly, something unusual happens.
It might be just a screen flicker that quickly resolves itself. Or you have to reboot your machine. Or maybe you lose your work altogether. Either way, you may have just experienced how an electrical disturbance can affect a complex piece of equipment.
The human brain is similar. Like a computer, it uses electronic messages to perform its functions. The messages interact with each other, turning systems on or off, releasing hormones, controlling movements and more. However, an electrical disturbance in the brain can cause a seizure — a much more significant event than the loss of a few hours’ work. People who have two or more similar seizures at least 24 hours apart are typically diagnosed with epilepsy.
Worldwide, some 50 million people live with epilepsy. They face increased risks of falls, car accidents, burns and more, potentially leading to significant injury or even death. For example, according to the American Academy of Neurology, people with epilepsy are at least 15 times more likely to drown, even while bathing. And, though it’s rare, some people with epilepsy can die unexpectedly from a syndrome called SUDEP: sudden unexpected death from epilepsy.
But there is hope. Thanks to work being done at Washington University School of Medicine and Barnes-Jewish Hospital, and at other academic health-care systems across the U.S., people with epilepsy now have many options for decreasing the frequency or severity of their seizures, or even removing them from their lives altogether.
“We have a lot more ways to improve people’s lives now,” says Brian Keith Day, MD, PhD, Washington University neurologist at Barnes-Jewish Hospital and fellowship program director of the Adult Epilepsy Center at Barnes-Jewish Hospital. “But too often, people don’t take advantage of those options as much as they could. There are much better treatments today than just ‘letting it go.’”
Seizures vs. epilepsy
Anyone can experience a seizure. A concussion, a new medication, dehydration: All of these conditions can trigger loss of consciousness, loss of awareness, strange sensations or sudden jerking, stiffening or weakening of the limbs.
When a seizure does not recur, neurologists call it a “provoked” seizure. Symptoms will resolve with time or when the trigger is removed. However, recurring, similar seizures with no clear precipitating cause are termed “spontaneous.” Spontaneous seizures may result from a tumor, scarring or other physical malformation in the brain. And while people with a family history of epilepsy are more likely to have the condition, it’s usually a case of greater susceptibility rather than genes directly causing epilepsy.
“We look for ‘stereotypical’ experiences for each patient—symptoms that are very similar every time, during every seizure,” says R. Edward Hogan, MD, Washington University neurologist and director of the Adult Epilepsy Center. Hogan explains further that, generally speaking, seizures involving fewer symptoms are more likely to be focal seizures, arising from only one part of the brain, while more symptoms suggest generalized seizures that occur across broad regions of the brain. Neurologists know that some seizure patterns map to specific parts of the brain, but they often need more precise knowledge of a seizure’s origination point to create a treatment plan.
But whether provoked or spontaneous, all seizures merit medical attention—and quickly.
“Don’t wait,” Day advises. “People sometimes have seizures for 20 years before they go to an epilepsy center. Others have been treated incorrectly for years before getting a referral. Don’t hesitate to seek treatment from a specialist.”
The path to treatment
Following the initial diagnosis, neurologists typically try medications to improve a person’s symptoms, which usually are successful.
“We now have more than 20 medications proven to reduce the number or severity of seizures,” Day says. “About 50% of all patients with epilepsy achieve results with the first medication they try. When we count those who achieve results by adding a second medication, the rate rises to around 60%. If we include those needing additional medications and combinations, we reach about 68%.”
For the remaining third of people with seizures not treated effectively with medication, the next step is a closer look at the brain, often using a combination of electroencephalography (EEG) and magnetic resonance imaging (MRI). EEG involves placing electrodes on the scalp to measure brain waves. A more recent version of EEG pairs brain-wave data with video of the seizure. Because the video is time-stamped, neurologists can track brain-wave activity with specific parts of the episode. MRI machines, in contrast, use powerful magnets and imaging technology to reveal the physical structures inside the brain.
“EEG and MRI are the best tests for identifying appropriate treatments,” Hogan says. “When we see how brain function and structure correlate, it helps us determine prognosis.”
Specialists may use two other tests to help them make decisions about treatment. Positron emission tomography (PET) uses a radioactive tracer to track metabolic activity, while single-photon emission computerized tomography (SPECT) uses nuclear technology to combine functional information with 3D images of brain structures.
But all these tools can only guide decisions. “Our approach to treatment brings together a team of neurologists, neurosurgeons, neuroradiologists and neuropsychiatrists. We meet in weekly conferences to consider the best options for patients, including surgery—usually for those who continue to have seizures despite appropriate medical treatment,” says Jon Willie, MD, PhD, Washington University neurosurgeon and director of stereotactic, functional and epilepsy neurosurgery at Barnes-Jewish Hospital.
“Medications are great for reducing seizure frequency and severity in many people,” Willie adds, “but only surgery has the potential to be curative. And we are developing new ways of making diagnosis and treatment safer, more effective and more tolerable for the people we treat.”
More mature technology, greater precision
Precision is essential for treating epilepsy with surgery. While EEG can identify the general location from which a seizure spreads, a neurosurgeon often needs to augment EEG with stereotactic electroencephalography (SEEG), a form of EEG that measures brain waves deep inside the brain, to pinpoint a precise source. “SEEG is a relatively safe and effective tool whose underlying principles have been evolving for more than a hundred years,” Willie says. “It’s the gold standard for examining the brain’s electrical activity and identifying abnormalities that we can then target with treatment.”
During SEEG, Willie surgically places electrodes—narrower than the diameter of a pencil lead—in the brain through small incisions. Patients are then admitted to Barnes-Jewish Hospital’s intracranial epilepsy monitoring unit, one of a handful of such specialized units in the U.S., for carefully controlled seizure detection. Using arrays of SEEG electrodes, a clinical team can then triangulate the locations of seizure onset and spread.
“In addition to mapping seizures, we can also confirm the locations of critical brain functions to be protected—such as language and memory—by directly and painlessly stimulating the brain, In addition to mapping seizures, we can also confirm the locations of critical brain functions to be protected—such as language and memory—by directly and painlessly stimulating the brain,” Willie explains. “Having mapped the patient’s brain, the epilepsy team can tailor their strategy for surgery with maximum safety and precision.”
Similarly, advancements in MRI technology and computational methods are improving the effectiveness of clinical MRI scans as a diagnostic tool. Functional MRI (fMRI), for example, tracks dynamic changes in blood-oxygen-level-dependent (BOLD) MRI signals when the brain is at rest and when engaged. During the test, the patient is asked to perform specific tasks while in the MRI machine. Neuroscientists use computational models and machine learning—the use of computer systems that can learn and adapt—to correlate the function and structure of a person’s brain.
“BOLD MRI sequences measure brain function in different areas,” Hogan says. “Scientists and clinicians at Washington University and collaborating institutions gather millions of MRI samples that allow us to better recognize when one patient’s brain shows an abnormality relative to a large bank of samples from healthy control subjects.”
Willie has spent the last decade testing and publishing outcomes of a suite of technologies that have led to advances in epilepsy surgery. Intraoperative and interventional MRI (iMRI), laser interstitial thermal therapy (LITT) and neuromodulation through direct brain stimulation are making epilepsy surgery safer and potentially more effective for a wider group of patients, including those who may not have qualified for epilepsy surgery before.
The prospect of brain surgery can be intimidating. Fortunately, Willie notes, “we utilize multiple surgical technologies for planning and carrying out safe, effective and minimally invasive epilepsy surgery.” He adds: “Today, most of the epilepsy surgeries we perform require only small holes and are closed with a single stitch. Most patients go home from the hospital the following day with minimal pain, while still benefiting from procedures that can treat—and very often eliminate—their epilepsy.”
One example of this kind of precision is LITT, which uses tiny optical fibers to deliver laser energy that gently heats and ablates seizure-causing tissues. It offers significant advantages over older ablation methods and has the potential to conserve more tissue and be more comfortable than open surgery.
While laser ablation is increasingly available at hospitals across the country, Washington University physicians at Barnes-Jewish Hospital were some of the first to combine laser ablation therapy with iMRI. More than a decade ago, they began using iMRI for LITT procedures, providing additional safety and efficiency. When the MRI scanner is moved from its garage-like storage area into the operating room, it is positioned to surround the patient’s head. Only minutes pass between placement of the laser probe and onset of MRI-based thermal therapy. Without the use of iMRI, scanning and surgery take place in separate areas.
Some people with epilepsy, Willie notes, historically have not been candidates for epilepsy surgery. However, new treatments have recently become available that can be effective for these people. Both deep-brain stimulation (DBS) and responsive neurostimulation (RNS) have the potential to offer relief. In the last year, Willie and colleagues have published patient outcomes following DBS and RNS treatments. “In appropriately selected cases, we observed seizure reductions of 60% to 80% with minimal or no side effects, and these outcomes are only improving with time,” Willie says. “Thanks to medications and surgical strategies, we have the potential to improve the lives of the majority of people living with epilepsy.”
Education = understanding
Research at Washington University and new technologies at Barnes-Jewish Hospital have allowed Day, Hogan and Willie to make great strides in diagnosing, treating and curing epilepsy. But what about one of the most difficult symptoms to treat— the stigma that has long been associated with the condition?
Gabriela de Bruin, MD, Washington University neurologist at Barnes-Jewish Hospital and vice chair of neurology and of clinical affairs at Washington University School of Medicine, says, “The stigma surrounding epilepsy has been slow to change, but it is getting better. As more therapies become available and as more people with epilepsy live full, productive lives, the more that stigma will diminish.” Education, she adds, is key to the process.
How to Help Someone Having a Seizure
Don’t panic. Seizures can be frightening, but most pass quickly.
Help the person carefully to the floor, or a bed or chair, if available.
Turn the person’s head to the side if possible.
Avoid inserting anything into the person’s mouth, including your fingers.
Remove sharp or hard objects from the immediate area.
If you can, record a video of the seizure. Every detail counts for diagnosis and treatment.
Watch the person and the clock. Call 911 if the seizure deviates from an established seizure pattern or lasts more than five minutes.
Call 911 if the person is not breathing or you can’t find a pulse.
Contact a doctor as soon as the seizure has ended.