What is epilepsy?
Dr. James White, Minnesota Epilepsy Group

Lessening the burden of epilepsy.
Dr. James White, Minnesota Epilepsy Group

How epilepsy is treated.
Dr. James White, Minnesota Epilepsy Group

Pregnancy and epilepsy.
Dr. Julie Hanna, Minnesota Epilepsy Group

Visit www.allinahealth.org/epilepsy for more info.

The post Common Questions About Epilepsy – Video Series appeared first on Minnesota Epilepsy Group.

The purpose of this article is to highlight a recent study which reviews the literature in tremendous detail in order to answer the following questions:

1) Does marijuana improve seizure control?
2) Is marijuana safe?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639568/pdf/i1535-7511-13-2-81.pdf

STUDY DESIGN
The authors did a very extensive review of the literature- in order to identify all papers that performed randomized control trials assessing marijuana in the treatment of epilepsy.

RESULTS
The study found: ” four randomized reports which included a total of 48 patients, each of which used cannabidiol as the treatment agent. (Cannabidiol is an important extract of marijuana). One report was an abstract, and another was a letter to the editor. Anti-epileptic drugs were continued in all. Details of randomisation were not included in any study. There was no investigation of whether control and treatment groups were the same or different. All the reports were low quality. ”

As far as seizure control, little information is provided: One study reported two of four treated patients becoming seizure free for 3 months. The other studies either reported no benefit, or the effect was not clearly stated.

CONCLUSIONS
“No reliable conclusions can be drawn at present regarding the efficacy of cannabinoids as a treatment for epilepsy. The dose of 200 to 300 mg daily of cannabidiol was safely administered to small numbers of patients, for generally short periods of time, and so the safety of long term cannabidiol treatment cannot be reliably assessed.”

Thus, at this time, there is a lack of scientific evidence to recommend marijuana for the treatment of epilepsy. To quote the American Epilepsy Society:

“The lack of information does not mean that marijuana is ineffective for epilepsy. It merely means that we do not know if marijuana is a safe and efficacious treatment for epilepsy. Healthcare professionals, patients, and caregivers are reminded that use of marijuana for epilepsy may not be advisable due to lack of information on safety and efficacy, and that, despite some states legalizing the use of medical marijuana, it is against Federal Law to possess or use marijuana.  In addition, little is known about the long term effects of using marijuana in infants and children, and chronic exposure during adolescence has been shown to have lasting negative effects on cognition and mood.  Such safety concerns coupled with a lack of evidence of efficacy in controlled studies result in a risk/benefit ratio that does not support use of marijuana for treatment of seizures at this time. The American Epilepsy Society is supportive of well-designed research to determine the safety and efficacy of marijuana in the treatment of epilepsy.”

https://www.aesnet.org/press-room/consensus-statements/marijuana-and-epilepsy

Please send in your comments on this important topic! Thank you!

The post Marijuana for the treatment of epilepsy appeared first on Minnesota Epilepsy Group.

John Bryson, Secretary of Commerce

A headline topping the news earlier this week:

“Commerce Dept. says Sec. Bryson suffered seizure.”

The U.S. Commerce Department Secretary was involved in two motor vehicle crashes over last weekend.  The accidents appear to be due to seizure activity. Secretary Bryson is 68 years-old.

This major news story brings up (at least) three important issues:

1)      The highest achievers in our society can have seizures/epilepsy.

2)      New onset-seizure activity in people over 60 years of age is associated with an increased risk of stroke (note- we have limited details on Secretary Bryson’s case).

3)      A seizure while driving can be dangerous.

Important/famous people and epilepsy

I think it is very important to point out how epilepsy can affect a wide range of people in our society.  Part of the stigma associated with epilepsy is the misconception by some that people with epilepsy cannot have high intelligence or great abilities.  That is absolutely wrong! People with epilepsy are well known to be among the best and the brightest.  Patients who have epilepsy are business leaders, musicians, doctors, lawyers, teachers and politicians.  For example:

• Coach Kill is the University of Minnesota head football coach-his seizure activity on the sidelines of football games has been the subject of recent national news.
• Supreme Court Justice John Roberts has had documented seizure activity (Time Magazine, 2007).

Epilepsy is relatively common- affecting 1-2% of the population.  Most people with epilepsy have well controlled seizures.  Thus, people do not usually know who has seizures and are often not aware of the accomplishments of a person with epilepsy.  I think that educating the general population about epilepsy is an important way to combat the stigma associated with the word “epilepsy.”

Dr. Robert Fisher, MD, PhD wrote an excellent review about famous people with seizures for Epilepsy.com (https://www.epilepsy.com/epilepsy/newsletter/Jan10_people). Did you know that the following people have been either suggested to have seizures or have clear documentation of epilepsy/seizures:

• Julius Caesar
• Napolean
• Vincent Van Gogh
• Leo Tolstoy
• Dostoevsky

Epilepsy as a warning sign for stroke

Having the first seizure of a person’s life after the age of 60 years of age is a real shock to the patient. They have lived their whole life without having a seizure, so it can be quite a surprise.  Not only is having a seizure a big deal for the patient, the patient also needs to contend with the following information:

• The onset of seizure activity after the age of 60 years is associated with a striking increase in the risk of stroke. The risk of stroke increases three-fold in patients who have their first seizure after the age of 60 years (Cleary et al, Late-onset Seizures as a Predictor of Subsequent Stroke, Lancet 2004;363:1184-1186).

The take home message of the study: if you have the first seizure of your life after the age of 60 years, you need to be evaluated for stroke risk factors and appropriate treatment given.  The last thing a patient needs is a stroke! The seizure activity may be a warning sign that may help prevent the stroke.

Driving and seizures

Patients with epilepsy list driving restrictions as one of their top concerns (Krumholz A, Driving issues in epilepsy: past, present and future. Epilepsy Currents 2009;9:31-35).  This of course makes sense- employment, taking care of family, seeing friends all are significantly limited if a person cannot drive.  Although driving is extremely important for quality of life, driving with uncontrolled seizures that could impair a person’s driving ability is high risk behavior—for the patient and for others on the road.  In the US, each state has its own driving rules as they pertain to epilepsy.  The Epilepsy Foundation has a very useful website to search for driving information by state: (https://www.epilepsyfoundation.org/resources/drivingandtravel.cfm)

Several studies confirm that epilepsy poses some risk for motor vehicle accidents, but that risk seems small, especially compared to alcohol.  For example, one study estimated that the percentage of fatal driver crashes caused by a seizure is only 0.2% as compared with 30% caused by alcohol (Sheth SG, Krauss G, Krumholz A. Neurology 2004;63:1002–1007). It has been reported that only 11% of all car crashes involving individuals with epilepsy are due to seizures.  The majority of car accidents involving patients with epilepsy are not due to seizures—but rather due to driver error.

Latest Update: 6/13/2012

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1-2% of the world’s population has epilepsy

9% of people will have at least one seizure in their lifetime

If you have a first seizure in your life, what is the chance you will have a second seizure in the next two years?

• If neurological exam, EEG and MRI brain are normal: 25%
• If  neurological exam, EEG and/or MRI are abnormal: may be > 40-50%

If you have had 2 or more seizures in your life, what is the chance that you will have more seizures?

• 70%

Percentage of patients with epilepsy who do NOT  have an identified reason for their seizures (unknown category):

• 50 %

If you have the first seizure in your life, what is the percent chance your seizures will be completely controlled?

• First seizure medication: 50%
• Second seizure medication: 10%
• Third seizure medication and combination therapy: 3%
• Total percentage of patients who continue to have seizures despite > 3 seizure medication trials: 30%

The typical seizure lasts 30-60 seconds.

30 minutes: This is the duration of essentially continuous seizure activity required to meet criteria for status epilepticus. Status epilepticus is prolonged seizure activity that can be severe and even life-threatening.

Approximately 50 million people have epilepsy, worldwide.

3/4 of people in developing countries do not get the treatment that they need.

Dates are numbers (of course!).  Here are some dates that are very important in the history of epilepsy:

• 11^th century BC: Approximate date that the oldest known medical reference to epilepsy was written. It was written on two clay tablets found separately in Turkey and Iraq. The translation provides a clear description of seizure activity.
• 400 BC: Date Hippocrates wrote The Sacred Disease. This medical text was the first to describe seizures as coming from the brain. It should be noted that there is some controversy as to whether or not Hippocrates was the author of this important text
• 1857: Potassium bromide is introduced to treat seizures. This is the first scientifically validated seizure medication
• 1886: Modern era of epilepsy surgery begins: Sir Victor Horsley successfully performs brain surgery on a patient with focal seizures due to a depressed skull fracture.
• 1929: First EEG was used to record human brain waves.

LATEST UPDATE: 6/6/2011

Seizures By The Numbers - Infographic

Seizures By The Numbers Infographic on Visual.ly

The post Seizures By The Numbers appeared first on Minnesota Epilepsy Group.

Photo by: Dreamstime

ARTICLE HIGHLIGHTS

• Head trauma is one of the most commonly identified reasons that patients develop epilepsy. Most studies suggest that approximately 6% of patients with epilepsy have TBI as the cause.
• The more severe the head trauma, the higher the risk of developing epilepsy. For example, patients with penetrating brain injury have a 53% chance of developing epilepsy.
• Epilepsy does not typically develop immediately after head trauma. Often, there are a few months, or even longer, before recurrent seizure activity is noted.
• Medication or surgical treatment can effectively control seizures in many patients.
• The hope for the future is to develop treatments that will stop the development of epilepsy before it starts!

INTRODUCTION

In a fraction of a second, head trauma can dramatically change a person’s life. Traumatic brain injury (TBI) is associated with an increased risk of developing epilepsy. The more severe the head trauma, the higher the risk of having seizures. For severe head injuries (for example, a patient with shrapnel piercing their brain), the chance of developing epilepsy can be as high as 50%! In addition to seizures, head trauma can result in significant neurologic impairment:

• Paralysis, weakness
• Coordination problems
• Problems with sensation
• Headaches
• Memory problems
• Concentration problems
• Depression and anxiety

The purpose of this article is to provide information on TBI and epilepsy. In a future article, information on the short-term and long-term cognitive issues related to concussion will be provided.

Illustrative Case

A 68 year-old male was involved in a serious motor vehicle accident. He was “T-boned” by a truck that did not stop at a stop-light. The patient was wearing a seat-belt. The airbag deployed. He was knocked unconscious due to head trauma. He was transferred to the local hospital. Because of his unconscious state and fluctuating blood pressure, he was admitted to the neuro ICU. CT of the brain demonstrated a right frontal region skull fracture and a small right frontal lobe contusion (this is like a bruise on the surface of the brain).

Approximately 5 hours after the accident, the patient began to regain consciousness. Initially, he was confused, and was slightly combative. He required sedation for the first 24 hours. Within 48 hours of the trauma, the patient was awake, following commands, and speaking. He had mild weakness to his left hand, which resolved by the time he was discharged from the hospital.

Upon admission to the ICU, the patient was placed on a seizure medication (levetiracetam = Keppra). He was started on the seizure medication to prevent early seizures—these are seizures that can occur shortly after head trauma. Seizure activity can worsen brain swelling. Given that the patient already had some brain swelling related to the contusion, preventing seizures was very important. Increases in brain swelling can produce high pressure on the brain- and result in shifting of brain tissue and possible permanent damage. The patient had no seizures while in the hospital. His seizure medication was stopped after 1 week of treatment.

The patient was discharged from the hospital after a 10 day admission.  His neurologic recovery was considered excellent. Three months after the motor vehicle accident, the patient experienced his first seizure. The seizure started with minor jerking in his left arm. He then lost contact, collapsed, and had a full-body convulsion. The seizure lasted for 1 minute. The patient was started on a seizure medication (levetiracetam = keppra). His seizures have been completely controlled for > 1 year.

Illustrative points:

• Seizure medications are often used to prevent early seizures.
• Early seizures can contribute to brain swelling—this can be dangerous in patient with significant head trauma.
• Patients with head trauma are at significant risk to develop seizures-often a few months after the head trauma.

DEFINITIONS

A wide variety of definitions for head trauma are used in the literature. The table below summarizes definitions in current use by many investigators.

IMPORTANT CLINICAL ISSUES

Head trauma is one of the most commonly identified reasons that patients develop epilepsy. Studies suggest that approximately 6% of patients with epilepsy have TBI as the cause.

Based on: Hauser, Epilepsia, 1993

 TBI causes epilepsy most commonly in the following age groups:

• < 5 yo
• 15-24 yo
• > 65 yo

Males are at higher risk than females to have TBI. Approximately 15-25% of soldiers in the Iraq and Afghanistan wars report TBI. These soldiers are at increased risk to develop epilepsy. As noted, the more severe the head trauma, the higher the risk that a patient will develop posttraumatic epilepsy. For example, patients with penetrating brain injury have a 53% chance of developing epilepsy. The following table describes the percent chance of developing epilepsy- 5 years and 30 years after the head trauma (Arnold, Atlas of Epilepsies, 2010).

Epilepsy does not typically develop immediately after head trauma. Typically, there are a few months, or even longer, before recurrent seizure activity is noted. Approximately one-third of patients who develop posttraumatic epilepsy have their first unprovoked seizure within 4 months of the trauma. Two-thirds have their first unprovoked seizure within 24 months of the head trauma (Temkin, Epilepsia, 2009). Some patients may go several years before epilepsy finally develops.

MECHANISM (= how trauma can result in seizure activity)(Arnold, Atlas of Epilepsies, 2010)

TBI results in damage to the neurons on the surface of the brain. Over time, this damage results in the potential for abnormal flow of electricity. The abnormal flow can lead to surges of electrical activity from regions of the brain—resulting in seizure activity.

The neurons are damaged by several possible mechanisms. Direct damage can be due to bone fragments, bullets, shrapnel or a wide range of insults. Arterial or venous bleeding can place high pressure on the brain, resulting in damage. The twisting and stretching forces on the brain tissue can result in shearing damage. Blood products, such as hemoglobin and iron, can have a toxic effect on brain tissue.  Normal blood flow to brain tissue can be disrupted- causing oxygen deprivation and neuronal death. Trauma to the brain can result in swelling of brain tissue (brain contusion—like an expanding bruise)—resulting in high pressure to brain tissue and damage to neurons.

The damaged areas of the brain, over time, may change their chemical composition and their wiring patterns. These changes are associated with having an increased potential to produce abnormal electricity- the electrical power surges that produce seizures.

TREATMENT

Medical Treatment

Photo by: vichie81

Seizure medications can control a significant proportion of patients with posttraumatic epilepsy. Treatment of epilepsy due to TBI is similar to the treatment of focal seizures due to other causes. Thus, at this time, there is no specialized/specific medication for posttraumatic epilepsy (unfortunately!). Standard seizure medications, such as phenytoin (=Dilantin), carbamazepine (=Tegretol) or levetiracetam (=Keppra) are commonly utilized. These three medications are listed as examples—a patient’s doctor will analyze the patient’s clinical features to pick the best medication. Factors to consider: side effect profile issues, drug interactions, age, gender, weight, and seizure types. By taking a careful history, performing a neurological exam, and performing testing, such as EEG and MRI, the best antiepileptic drug can be chosen.

Surgical Treatment

Photo by: Apple’s Eyes Studio

Selected patients with posttraumatic epilepsy can undergo successful epilepsy surgery. The key is to find a relatively small area of the brain where the seizures are coming from. Once this area is identified, testing is performed to make sure that removing this part of the brain is safe. This area of the brain should not overlap with critical function- such as areas important for speech, memory or movement. If it is determined to be safe, this small area of the brain is removed by the surgeon. Ideally, the patient can become seizure free and have no neurological deficits related to the surgery.

Good results can be achieved with surgery. It appears to be important to remove the entire area of abnormal brain tissue that can be seen on MRI-if possible. For patients with a clearly identified seizure onset area in a single region of the brain that is safe to remove, > 70% of patients can become seizure free (Kazemi, Epilepsia, 1997). It should be noted that TBI can often times result in multiple areas where seizures can start—and thus some patients are not candidates for surgery or can only hope for a reduction in seizures if they undergo epilepsy surgery.

Another option to consider, for a significant percentage of patients, is Vagus Nerve Stimulation therapy. This is a device that stimulates a nerve in the neck. This stimulation is then transmitted to the brainstem and the cerebral cortex. This electrical stimulation is typically programmed to stimulate for 30 seconds, and then be off for 5 minutes. This stimulation pattern continues throughout the day. The stimulation is associated with a reduction in seizures in a significant number of patients.

HOPE FOR THE FUTURE: USING A WINDOW IN TIME TO PREVENT EPILEPSY

Question: If a person has head trauma, can I place the patient on a seizure medication and prevent the patient from developing epilepsy?

Answer: No (not at this time!).

As noted above, there is a time lag between the head trauma and when epilepsy eventually could develop. This “window in time” allows investigators to study if medications can prevent the development of epilepsy before it starts- very exciting stuff! This is studied by giving a medication immediately after the head trauma. So far, the prevention of epilepsy has not been proven. Studies have been performed that show that starting a seizure medication immediately after head trauma will reduce the frequency of seizures in the first week after the trauma. Unfortunately, over the long-term, seizure medications do not prevent the development of epilepsy. Thus, the current literature does not support the use of seizure medications as preventative therapy for late seizures. In general, seizure medications should not be used long-term in TBI patients, unless they have had seizures.

The exciting hope for the future is that therapy to prevent epilepsy can be developed. Consider this possible futuristic approach: We know that patients with severe head trauma are at high risk to develop epilepsy. Perhaps this group of patients could be treated with a medication that prevents the process that leads to seizure activity (stops epileptogenesis). This would be a wonderful advance over just waiting for the first seizure! Experts in the field are studying how to accomplish this important goal.

CONCLUSIONS

Head trauma is a frequent and important cause of epilepsy. Medication and surgical treatment can effectively control seizures in many patients. The hope for the future is to develop treatments that will stop the development of epilepsy before it starts!

REFERENCES

Arnold FJL, McEvoy AW. Traumatic brain injury and epileptic seizures. In: Panayiotopoulos CP, ed. Atlas of epilepsies. New York: Springer-Verlag London Limited 2010;p. 129-135.

Hauser WA, Amnegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota:1935-1984. Epilepsia 1993;34:453-468.

Kazemi NJ, Elson LS, Mosewich RK, et al. Resection of frontal encephalomalacias for intractable epilepsy: outcome and prognostic factors. Epilepsia 1997;38:670-677.

Lowenstein DH. Epilepsy after head inury: An overview. Epilepsia 2009; 50 (suppl 2):4-9.

Ropper AH, Gorson KC. Concussion. New England Journal of Medicine 2007;356:166-72.

Temkin N. Preventing and treating posttraumatic seizures: The human experience. Epilepsia 2009; 50 (suppl 2):10-13.

Credits for photos:

Dreamstime:

https://www.dreamstime.com

vichie81:
https://www.freedigitalphotos.net/images/view_photog.php?photogid=2023

Apple’s Eyes Studio:
https://www.freedigitalphotos.net/images/view_photog.php?photogid=2000

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MINNEAPOLIS (WCCO) – For Gopher football coach Jerry Kill, the sudden spike in seizures has been a mystery. For scientists looking into seizures, the inner-workings of the brain is always a mystery. So what is a seizure and what happens inside the brain?

“Everything gets excited, everything gets stimulated like being hit by lightning,” said Dr. Michael Frost, a neurologist with Minnesota Epilepsy Group in St. Paul.

According to Frost, not all seizures are epilepsy, but most seizures that aren’t linked to diabetes are.

He explained epilepsy as “somebody who’s had at least a seizure and is at risk for more.”

[FULL STORY]

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