Ask Us Anything About… Epilepsy

Description – The video begins inside a conference room at the Epilepsy Center, Penn State Health Milton S. Hershey Medical Center. Two people are standing next to each other. Standing from left to right is Dr. Tiffany Fisher and Scott Gilbert.

Scott Gilbert – From Penn State Health this is Ask Us Anything About Epilepsy. I’m Scott Gilbert. Epilepsy is a group of disorders characterized by recurrent seizures. In fact, it’s the fourth most common neurological disorder and affects people of all ages. We’re going to learn more about epilepsy and how it’s diagnosed and treated from Dr. Tiffany Fisher. She’s a neurologist here at Penn State Health. Dr. Fisher, thanks a lot for your time today. Let’s start with kind of a general definition of epilepsy. What is it and how do you make that diagnosis?

Dr. Tiffany Fisher – Well, like you said it’s recurrent unprovoked seizures. And basically what you want to do is present to a neurologist. They can take a thorough history. They may require other labs to take as well. And based off of that they may ask for additional testing. And with that usually we ask for an electroencephalogram which is an EEG that looks at our brain activity. And then we also may want imaging. And typically that’s with an MRI so we can see the fine detailed structure of the brain to look for any abnormalities.

Scott Gilbert – And when you say abnormalities what are you looking for in there in lay terms?

Dr. Tiffany Fisher – Okay. So in lay terms sometimes there is a tumor that could cause it. Sometimes it’s some functional abnormality from development that was already there and just manifests at a later age. So all of those things that’s the things we’re looking for in an MRI.

Scott Gilbert – Sure. And how common is epilepsy in the general population?

Dr. Tiffany Fisher – All right. So like you said it’s the fourth most common neurological disorder. There is about 65 million people worldwide who have epilepsy and 3.4 million people here in the United States.

Scott Gilbert – So it’s not rare.

Dr. Tiffany Fisher – Not rare at all. There’s about 150,000 new cases diagnosed each year. And 1 in 26 people will have epilepsy in their lifetime.

Scott Gilbert – That sounds pretty high, but I imagine the severity of the condition probably varies from person to person, right?

Dr. Tiffany Fisher – That’s absolutely right. So sometimes depending on how frequent those seizures are for each individual person will vary. And sometimes it depends on actually the types of seizures they have which are more severe than others.

Scott Gilbert – And we’ll get into those in a moment. But right now I want to remind you you’re watching Ask Us Anything About Epilepsy from Penn State Health. We welcome your questions for Dr. Tiffany Fisher. She’s a neurologist here. You can just put those in the comment field below this Facebook post and we’ll get you some answers. That includes if you’re watching this video on playback we can still get you answers that we’ll add to the comment section. So, Dr. Fisher, what are the different types of seizures that you typically see in epilepsy?

Dr. Tiffany Fisher – So you can have what we think of as focal seizures that start in one place and they may spread. Or you can have generalized seizures that tend to start all over. So when you think of generalized seizures, the classic case that people think about are those grand mal seizures, the generalized tonic clonic seizures. And so with those you have tonic stiffening of the body followed by clonic jerks that can last usually from one to three minutes. And then there’s another generalized type of epilepsy that people know well and that is absence epilepsy. And that’s usually with children, and the teacher may come and say the child is not paying attention, they seem to be staring off. They can have a lot of eye blinks or eye flutter and then some odd mouth movements associated with that as well.

Scott Gilbert – So it could be harder to notice those.

Dr. Tiffany Fisher – Absolutely, and those tend to only last seconds making them even harder to delineate. And then as you move on you can have some atonic seizures which we call drop attacks where the first person may fall out and fall to the floor. So those last seconds. You can have some myoclonic jerks which is fast jerking movements of any body part. And then when we think about focal seizures we’re tending to think about the things that people used to know as complex partial or simple partial seizures. So with focal seizures when the person is unaware they have this staring and unresponsiveness. It looks like they’re gazing off. You might not notice it, but they’re not responding to you, they’re not answering questions. And that can last minutes as well. And then there is another type with focal where they’re aware and they can have movements of a single body part or a single side. And then also they can have these odd what we call paresthesias, so it’s like numbness, tingling, burning, crawling sensation on one side. So it all depends on where that seizure starts in the brain to depend on what symptoms, physical symptoms that are manifested.

Scott Gilbert – And so there’s so many different types of seizures, durations, severity. I imagine, though, it’s still important to note any of them, right?

Dr. Tiffany Fisher – Yes, absolutely, absolutely. So one of the things that we like to educate our patients on and their family is to take note of when a seizure starts and what you’re looking at, to know what side. If the head turns to a certain side, if the eyes turn to a certain place that helps us all to localize where the seizure may begin.

Scott Gilbert – So given that there are so many types of seizures, I’m curious are you able to explain in lay terms what’s happening in the brain that’s triggering these, or is it different causes?

Dr. Tiffany Fisher – So usually what we think of when seizures occur is this excessive synchronous excitation. So I like to explain to patients that if you think about a high school room and you walk into the classroom, and many people are having their normal conversations, and there may be subgroups in the classroom. That’s sort of like how our normal brain functions. But think about when you go into a chorus and they’re all singing a fast, upbeat song all together that’s what I think about as seizure activity, all that excessive synchronous excitation occurring together.

Scott Gilbert – You’re watching Ask Us Anything About Epilepsy from Penn State Health. I’m Scott Gilbert. This is Dr. Tiffany Fisher. She’s a neurologist here, and we welcome your questions for her. So put those in the comment field below this Facebook post. And if you find this information useful as we hope you do why don’t you share this on your Facebook page so we can help the information to reach more people. I’m curious what we know and perhaps what we don’t know about the causes of epilepsy including I guess hereditary links. Does that kind of run in the family?

Dr. Tiffany Fisher – Well, it can, you can have genetic causes. But for the majority of seizures about 50 to 60 percent of the causes are unknown, are idiopathic. For the remainder you can have a variety of reasons. You can have those genetic or hereditary factors. You can have brain tumors. You can have head trauma, whether that be a penetrating injury or blunt force trauma. You can have stroke, whether that be ischemia or hemorrhage or bleed into the brain. Other factors can include infection. As I talked about before you can have a malformation in a certain area of the brain. And then late stages of Alzheimer’s disease is associated with epilepsy as well.

Scott Gilbert – How about things like certain foods or other triggers that people may be able to control, are there some of those?

Dr. Tiffany Fisher – So, yes, so there are certain dietary factors that can come into play or bound nutrients that can result in seizure activity. There’s also triggers such as photic stimulation or flashing lights can trigger epilepsy, sleep deprivation, hyperventilation. Things that lower your seizure threshold are going to be alcohol intake or alcohol withdrawal. So all of those factors are important.

Scott Gilbert – Are there any other factors we should know about that may increase somebody’s risk of epilepsy, anything that people should know about?

Dr. Tiffany Fisher – So in addition to what I said before about things that you can’t control such as if you have a head trauma, if you have a stroke, there are other factors that you need to think about that can increase your risk. And so those can include medications that can lower our seizure threshold whether they be antibiotics, whether they be drug use such as cocaine. A stimulate such of that nature can definitely cause seizures.

Scott Gilbert – So we often associate epilepsy as being something that children have. Is that always true? I mean is it always true that I mean these are children, but I mean sometimes adults they can carry this into adulthood as well, right?

Dr. Tiffany Fisher – Yes, so some children such as those with absence epilepsy or even with juvenile maraconis epilepsy, JME, they may outgrow it. But in some cases they don’t. And then as we get older our risk of having some type of brain injury increases especially above the age of 60 where you have the increased risk factors of stroke, aneurism, bleed, things of that nature. So then you’ll see that there’s two populations. You’ll have a large increase as children who are born with it, genetic, hereditary factors, and then again as we reach elderly age due to acquired injuries.

Scott Gilbert – So onset can happen in childhood or adulthood. Adult epilepsy doesn’t have to be carried over from childhood?

Dr. Tiffany Fisher – Absolutely.

Scott Gilbert – All right. So if somebody believes they have a seizure, they believe their child has had a seizure, is that automatic you’ve got to seek medical attention?

Dr. Tiffany Fisher – I think it is. I think if you’re worried enough you should seek medical attention. You should try to talk to your primary physician, and then ultimately see a neurologist. The story is very important to us of if the child or the adult had nocturnal seizures or nighttime seizures that causes us to be on higher alert just based off the story. And then those other things that I tell you about about the electroencephalogram and the MRI looking for other causes of why they may have seizures.

Scott Gilbert – You’re watching Ask Us Anything About Epilepsy from Penn State Health. We welcome your questions for Dr. Tiffany Fisher a neurologist here at Penn State Health. Just add those to the comment field below this Facebook post. Let’s talk a bit about the treatment. Because I know in some cases or maybe in all cases there’s no cure per se but it can be treated usually, right?

Dr. Tiffany Fisher – Absolutely. So things that people think about most of all are medications, right? So medications is at the forefront of all treatment of epilepsy. And you’ll try to use a variety of medications that can affect the channels that lead to seizure propagation. So usually that’s a good discussion with your neurologist about what medications are appropriate for the type of epilepsy you have, whether that be focal or generalized or absence seizures, okay? And then after that you can think about dietary restrictions such as a ketogenic diet where you’re mainly eating proteins and eliminating your carbohydrates. That’s another treatment for epilepsy and seizures. And then classically we think about if that is not handled with dietary restrictions as well as medications we can move onto surgery. So surgery we think about resection, taking out the tissue that’s actually seizing.

Scott Gilbert – That’s a very small amount of tissue we’re talking.

Dr. Tiffany Fisher – That’s absolutely right. It’s not the classic thought of lobectomies that people think that render them to institutions like the old days. It’s very methodical and localized. And then, again, with that you can think about laser ablation which is a new technique to use an actual laser to zap that piece of tissues that’s actually firing. And then basically we can move into devices. So devices people typically think about is the vagal nerve stimulator which is just like a pacer, like a pacemaker. It fits in the chest cavity wall. And then it has a wire that wraps about the vagus nerve and the neck. And so this delivers stimulation 24 hours a day throughout the day. So it’s on for a period of time, off for a period of time throughout your lifetime. There is a new device called the DBS, the deep brain stimulator which was approved for epilepsy in late 2018, last year, and people classically think of this as a device with Parkinson’s disease to help control the tremor, but it’s actually used with epilepsy as well. And then finally there’s an RNS device, a responsive neurostimulator which is also another type of device that delivers stimulation just at the onset of seizures when it detects it.

Scott Gilbert – And that’s amazing because it does, it does just that. It actually detects when the seizure is about to happen and then negates it.

Dr. Tiffany Fisher – Right, absolutely.

Scott Gilbert – That’s really something else. We have a question now from Jewel. She’s asking what makes Penn State Health a level 4 center and what does that mean to a patient? When we talk about that we’re talking about a comprehensive epilepsy center here. Can you talk a bit about that?

Dr. Tiffany Fisher – Yeah. So Penn State Health and the department of neurology has a level 4 epilepsy center. So that means that all of these things that I just discussed it’s able to provide for you. So whether that’s surgery, whether that’s medication use or it’s that dietary therapy we are able to do that. And that’s a comprehensive, accreditation approved epilepsy center. And so here you want to have neurologists that see all of these conditions and that are able to provide you with the pathway which is best for you.

Scott Gilbert – And this is all you do. You focus on epilepsy.

Dr. Tiffany Fisher – Absolutely.

Scott Gilbert – All right. I be a question a lot of people have is what should they do if they come across somebody or see somebody who is having what appears to be a seizure, especially a violent one where there’s some uncontrolled motions? There’s a lot of information out there. But the thought of, well, do we try to hold the tongue down with something? I mean there’s a lot of bad information out there.

Dr. Tiffany Fisher – Absolutely.

Scott Gilbert – Let’s set it straight.

Dr. Tiffany Fisher – So the first thing which is easier said than done is don’t panic. And to help the person out try not to crowd them. You want to support their head if possible with like a jacket and put it under their head. Remove any sharp objects surrounding them. Turn them onto their side. Remove their classes. If they have any tight clothing around them such as a tie you want to remove that as well. You don’t want to hold the person down or restrict them. And you do not want to put any objects in their mouth. It’s important that you look for any medical alert bracelets if they have a medical alert about epilepsy or seizures. You also want to time the seizure if you’re aware enough of that to time the duration of it. Because when seizures reach that five minute mark that’s when they’re going into what we call status epilepticus which is now a prolonged seizure and is more likely to pick up other networks in the brain to propagate, prolong duration seizures, and that’s harder to break. So that’s what you want to — at that point call 9- 1-1 if it reaches the five minute mark. If you can’t find an epilepsy bracelet on them you want to call. If they’ve had any injury at that particular time to the body or anywhere else you want to call. If you see that they aren’t breathing properly or maybe the seizure stopped and they’re not recovering and coming back to normal within a few minutes. Or maybe they stop that seizure and then quickly go into a second seizure.

Scott Gilbert – So it’s really about trying to keep that person safe for the duration of their seizure. Like you say not trying to do anything interventional, anything in the mouth, just trying to get sharp objects and things away from them.

Dr. Tiffany Fisher – Absolutely.

Dr. Tiffany Fisher – All right. I also understand that the folks with epilepsy sometimes are at higher risk of, for example, drowning or falling. Can you talk about some of those risks? And I guess this all points back to the importance of getting diagnosed.

Scott Gilbert – Absolutely. So we tell our patients about seizure precautions. And so those seizure precautions can include not driving a vehicle because they have either loss of consciousness or loss of awareness in their surrounding. It could be not operating heavy machinery because that could fall on you and injure you. Climbing heights, that’s important. Also not taking a bath or swimming unattended because you could drown. Cooking over open flames that’s really important. I tell my epilepsy patients to cook on the back burner and not the front burners in case they have seizures because then they can fall or knock over the pot and result in burn injuries. So those are all important.

Scott Gilbert – Wow. And you’re watching Ask Us Anything About Epilepsy from Penn State Health. Your questions for Dr. Tiffany Fisher are welcomed here. Just make sure you add those to the comment field below this Facebook post and we will get those asked here. How about pregnancy, is there a risk with women who have epilepsy getting pregnant?

Dr. Tiffany Fisher – So there’s risk to the fetus with epilepsy drugs not per se with seizures unless it’s more of a risk if the person had uncontrolled epilepsy at the time that they’re pregnant. Because, as you can imagine, if you have the generalized tonic clonic seizures you can either injure the fetus, or it can result in a lack of oxygen and blood flow to the fetus during that time. So the greatest thing we want to do is to help to control seizures before they go into pregnancy. Once pregnant and they have the child we talk about seizure precautions for that mother. So you want to think about taking the baby up and down the steps in their carrier in case you have a seizure so you won’t drop them holding them. Having someone around you when you bathe the child such that if you have a seizure you won’t drowned them. Changing them on the floor, on a low surface, again, so you won’t drop the baby. So those are all precautions we talk about with women and pregnancy.

Scott Gilbert – Does epilepsy come with an elevated risk of emotional health issues?

Dr. Tiffany Fisher – Absolutely. So the two common most co-morbidities associated with epilepsy are depression and anxiety. And so it’s fairly common for our patients to talk about that. And fortunately here at Penn State Health we have an epilepsy psychiatrist that strictly sees our epilepsy patients because those co-morbidities are so high.

Scott Gilbert – So as you mentioned before in up to half of all seizure cases we don’t know what causes them, and I’m sure there’s room for improvement with treatment. So what kind of research is under way to try to improve all this?

Dr. Tiffany Fisher – So research is always going on. We have research trials here talking about new drugs and new mechanism of drug actions, new devices just like the DBS that was approved last year. So those are new ways to get drugs to their target. So there’s always ongoing research. The best that you can do is to come to a level 3 or 4, hopefully Penn State Health Epilepsy Center so we can engage you in those research projects.

Scott Gilbert – Some of those dangers you mentioned like falling, drowning, even cooking in your own stove, when you try to take certain precautions it seems like it could be perceived as trying to take away someone’s independence. So part of what you do is work to give people their independence back.

Dr. Tiffany Fisher – Absolutely. So the thing is is that all epileptologists want you to have zero seizures. That’s always our goal. But we know that there has to be a quality of life balance. So there are side effects from medication such as fatigue and sleepiness. So we have to balance what’s best for you and controlling your seizures. So we always thing about that when we’re treating you.

Scott Gilbert – And, again, why it’s so important to go somewhere where there are so many options available, not just medication, not just one or two things but the whole gamut.

Dr. Tiffany Fisher – Yes, sir.

Scott Gilbert – Okay. And, by the way, if you like the information you’re hearing tonight from Dr. Fisher we encourage you to tune in tomorrow which is Wednesday, March 13th to ABC 27 at 7:30 p.m. for Brainstorm. This special half hour program from 7:30 until 8 will focus on a few different neurological issues including epilepsy. So that’s from 7:30 until 8 on Wednesday the 13th. We’ll also put the information and the link to that program in the comment field below this Facebook post. And just a reminder also for that call in show you can call in and talk to experts from Penn State Health from 7 to 8 p.m. tomorrow even with ABC 27. Well, my thanks a lot to Dr. Tiffany Fisher. She’s a neurologist here at Penn State Health. And our thanks to you for watching Ask Us Anything About Epilepsy.