Ask Us Anything About…Epilepsy

Barbara Schindo – Good morning and thank you for joining us. You’re watching Ask Us Anything About Epilepsy. I’m Barbara Schindo. According to the CDC, 3.4 million Americans, and about 50 million people worldwide have epilepsy. So, joining us today to talk about epilepsy and treatment, including new innovative treatment available at Milton S. Hershey Medical Centre is Dr. Mike Sather, who’s a neurosurgeon at Hershey Medical center. Dr. Sather, thanks so much for joining us today! Very much appreciate your time.

Dr. Mike Sather – Thanks, Barbara! Thanks for having me!

Barbara Schindo – And we do – Dr. Sather and I will talk here about epilepsy, we also welcome your questions for Dr. Sather and treatment. If you have any questions while you are watching, whether you’re watching this live, or watching on playback, feel free to put your question in the comment section, and we will get an answer for you. So, Dr. Sather, let’s start, you know, kind of with the basics here. Can you tell us what is epilepsy?

Dr. Mike Sather – So, epilepsy is a neurological condition. As you mentioned, it’s a really common neurological condition, although, you know, at first glance it may not seem so because, you know, in the past there used to be this taboo about epilepsy, and people used to hide epilepsy. I think it’s become now something that people are not afraid to share because people understand a little bit more about epilepsy. So, I think, you know, if you were to ask, and you were to think, you know, carefully about it, I think that most people either know somebody or know somebody who knows somebody with epilepsy. So, because it’s quite common, as you mentioned. You know, one in twenty-six people in their lifetime will develop epilepsy. While epilepsy is a condition characterized by seizures that recur, so a one-time seizure is not the same as epilepsy. And it’s actually a lot more common to have a one-time seizure. So, approximately ten percent of the population at some point in their life will have a seizure, so epilepsy is a neurological condition basically characterized by recurring seizures whereas a seizure is an, like, call that like an attack of the brain or an abnormal electrical storm where abnormal neural activity is occurring in the brain which results in something that happens from a standpoint of the signs or symptoms that you can see or recognize.

Barbara Schindo – Okay, and you kind of already answered my second question here, but just to clarify, this is a disorder that is recurring seizures, not just one time. So, not every single seizure could be epilepsy related, correct?

Dr. Mike Sather – Correct. Yeah. So, some examples of seizures that might be what we call provoked are a patient with diabetes that might have a low blood sugar or really low blood sugar, sometimes that can cause a seizure, and that’s just a one-time thing and it doesn’t result in the development of epilepsy. Another example would be an alcoholic who if they abstain from alcohol for a while can go into withdrawal, and they can have a withdrawal seizure. Other examples would be some electrolyte abnormalities that can result in a one-time seizure. So, those seizures don’t necessarily result in epilepsy. Just a one-time seizure.

Barbara Schindo – So, how do you know when it is epilepsy? By having more than one seizure? How does the diagnosis work?

Dr. Mike Sather – Well, yeah, you bring up a good point. It can be a very difficult diagnosis. Sometimes, it’s not uncommon for the diagnosis to be delayed. That’s not necessarily because it’s missed, it’s just because it could be difficult to diagnose. They can overlap with other conditions. Sometimes it’s thought to be other conditions. So, to give you an example would be, you know, patients that we see sometimes with epilepsy, and when I ask them when their seizures started and when their epilepsy started, they will often describe that they were diagnosed at a certain age, and then they’ll tell me, ‘But if I think back now, I realized I was having seizures three years before that, and that I had epilepsy three years before that, it just wasn’t diagnosed’. So, an example would be, you know, somebody – because not all seizures are characterized by generalized tonic, colonic seizures that you might see on TV where you see shaking of all four extremities and the whole body, and biting the tongue, and foaming at the mouth sort of thing, which is the most, you know, aggressive kind of seizure that you could have. Sometimes it’s just silent seizures which are just staring, unresponsive episodes. So, and if somebody’s sitting, you know, at work in their office alone, you know, or in school at a desk, you know during a classroom, you know, just a staring spell may be unrecognized or an individual could be diagnosed as having an attention deficit disorder. Another example would be, you know, somebody being misdiagnosed with panic attacks. So, there’s a form of seizures that can result in this intense feeling of fear and anxiety, so [inaudible] with what’s going on in the brain at the time, and obviously, those patients then can be misdiagnosed as having a panic disorder. The diagnosis is made clinically by a neurologist with the assistance of electrical information which is the EEG and then also an imaging study is often necessary to rule out any lesion or abnormality in the brain. So, there’s electrical information, clinical information that go along with all that.

Barbara Schindo – So, and I’m glad that you mentioned that a seizure does not always look like what we see or, you know, in a movie or on TV. That it’s not always this big, kind of noticeable thing. So, people could live for maybe years with having seizures and not even realizing that’s what was happening to them. Like, if somebody goes into, like you say, they kind of stare off into the distance and kind of disassociate for a minute and then come back around, like, do you think – are they realizing in the moment that’s what a seizure is happening to them?

Dr. Mike Sather – Often not. Often they might recognize at some point that they have lost some time, but may not recognize that they have had a seizure or that anything’s necessarily happened. The other reason that sometimes things can be, you know, delayed is that often the times that these seizures can happen are actually more common at nighttime, so when we go into sleep, the brainwaves change, and there’s this interaction between the way our brainwaves change, and the way our brain works when we have epilepsy that makes it a little bit more prone to having seizures at nighttime, so having seizures during your sleep, may not always be aware, although, you might wake up with a wet bed or some biting of your tongue. You might have known something’s happened, but you won’t realize actually what’s going on.

Barbara Schindo – Okay. You are watching Ask Us Anything About Seizures with Dr. Mike Sather, a neurosurgeon at Penn State Health Milton S. Hershey Medical Center. We welcome your questions for Dr. Sather whether you’re watching this live or on playback. If you have any questions, feel free to put your question in the comment field below this post and we will get an answer for you. So, Dr. Sather, let’s talk a little bit about treatment options and how people can manage epilepsy. First, we’ll start with, you know, the typical treatment and then we can get kind of into the new technology that you are using at Hershey Medical Center. So, what’s the typical treatment for epilepsy?

Dr. Mike Sather – Standard treatment is medical management with what we call AEDs which are anti-epileptic drugs. So, seizure medications, basically. Hopefully just one seizure medication. Hopefully a patient can be controlled with just one seizure medication. If not, then you’re looking at, you know, adding a second agent, and sometimes three medications, but there’s good data behind, you know, a nice New England Journal article and study that showed that once patients get to beyond two medications into a third medication, the success rate of adding that third seizure medication to stop the seizures is quite low on the order of only a couple of percent chance. So, we kind of deem those people medically intractable, or you know, not responding to medication management. And that’s actually about a third of patients with epilepsy. So, it’s a pretty big group of patients. Other than the medications are diet therapy, so the ketogenic diet is a type of seizure diet that we use here at Hershey Medical Center for – it’s more often utilized in children whose diet you can control a little bit easier. It’s really high fat, low carbohydrate diet. It can be sometimes unpalatable for adults and hard to stick with a diet. So, in situations where you can control the diet a little bit better actually works pretty well. They do have a modified – most people have heard of the Atkins’ Diet.

Barbara Schindo – Mhm.

Dr. Mike Sather – People used to, wait, there’s a modification of that for epilepsy which is somewhere between a ketogenic diet and an Atkins’ diet that allows it to be a little bit more palatable, and still offer some seizure improvement. So, those are options, as well, in addition to medications. But in about a third of patients even with diet therapy and medications, patients still have persistent seizures.

Barbara Schindo – Uh-huh. And before we get into the treatment that you’re using, we have a question from Brandy. Brandy is asking, so she says, ‘I’m a registered nurse and I was told I have conversion disorder, but with pseudo seizures, and an EGG saw spikes in the temporal lobe’, but her seizures are occurring. She says, ‘I feel like I’ve been having recurrent seizures for most of my life and having silent seizures’ and she doesn’t know what to do. Is there, you know, a possibility that she might have epilepsy? She says, ‘I’m wishing to have more info on the EEG as to align with a seizure because the neurologist says’ – one neurologist told her she is epileptic and one said she isn’t. So, any kind of advice or advice on the EEG or what Brandy could do?

Dr. Mike Sather – Yeah, the best way to – so, regarding the EEG, the best way to diagnose epilepsy is the clinical information along with being able to witness a seizure on video and also see the seizure on EEG correlating all of those things together. So, what we call electro clinical correlation. So, the best way to do that is a video EEG and an epilepsy monitoring unit. So, you would be, you know, typically in the epilepsy monitoring unit for about a week, typically seizure medications are decreased or withdrawn a little bit to increase the chances of having a seizure in the hospital. The patient’s on video camera twenty-four hours a day during that whole time, and has continuous EEG monitoring. So, when these episodes occur that occur at home, then you know, the EEG is correlated to what is happening on video to make that correlation. In an instance where somebody would have a pseudo seizure, which is basically, you know, the appearance and the look of the seizure, but not a seizure, you wouldn’t see anything on the EEG. So, the best way to diagnose it would be a video EEG. Problem comes in is that it’s sometimes it’s not either or. So, sometimes it’s not uncommon for patients where the real seizures with epilepsy to also have pseudo seizures, that’s fairly common. And so that becomes – so, it’s not necessarily always either or. So, sometimes it’s trying to separate out which are the epileptic seizures and which are the non-epileptic seizures, but the video EEG is the best way to sort that out. And sometimes if a seizure is coming from deep within the brain, sometimes we don’t see a lot on EEG during the seizure and that makes it even more challenging, so you really need a, you know, a skilled epileptologist which is a neurologist who is focused on treating epilepsy fellowship training in epilepsy to try and parcel it out clinically, you know, what’s happening during a seizure, and does that really – does it look like an epileptic or does it look like a non-epileptic? Sometimes you can tell a part just by watching and witnessing a seizure. So, seeing that on the video.

Barbara Schindo – Okay. Thank you, Brandy for your question, and thank you, Dr. Sather, for that. If anybody else is watching this whether live or on playback and you have a question for Dr. Sather, just put your question in the comment field and we’ll get an answer for you. So, Dr. Sather, let’s talk now about there’s a new surgical treatment that you are using at Hershey Medical Center to treat epilepsy and that’s deep brain stimulation. Can you talk a little bit about that? How does that work?

Dr. Mike Sather – Sure. So, we talked about a third of patients don’t do well with medication management, continue to have seizures, and so when that’s the case, then we think about surgical options for the treatment of epilepsy, and when it comes to that, we’re looking at two different kind of broad categories. One would be what we call surgical resection or treatments to make render patients seizure free. And the other category is neural modulation and neural stimulation to try and attempt improved seizure control. So, first and foremost, you know, the best thing for seizure patients, epilepsy patients is to be seizure free. Sometimes, we can accomplish that through a safe surgery, then, you know, that’s the best option for the patient. So, and then in this category of neuro stimulation, DBS is a type of neural stimulation, or deep brain stimulation is a type of neural stimulation. So, when we get into that category, we’re looking at patients where maybe we don’t think they’re a great surgical candidate. Either we don’t think that we can render them seizure free with an operation, or we can’t identify that area where the seizures are coming from or we don’t think that we can safely do an operation without causing some harm to the patient. Then we’re looking at this category of neural stimulation and DBS, it’s a type of neural stimulation. There’s also vagus nerve stimulation, responsive neural stimulation. So, DBS or deep brain stimulation is just like it sounds. It’s stimulation of the deep parts of the brain. So, areas in the brain, very central, there’s an area called the thalamus which is basically a relay station in the brain. So, it has a lot of neurons going in and out of it to different areas throughout all of the brain. And we’ve been treating lots of different neurological conditions with deep brain stimulation since the 1980s, and even before that with research protocols. So, deep brain stimulation is currently approved for Parkinson’s disease, a central tremor, obsessive compulsive disorder, and now epilepsy within the last year and a half. By far the longest indication has been tremors and Parkinson’s disease which it works really well for. But two really good studies, long term studies now more than seven years out in the study show good reduction in seizures, a good improvement in seizure control with deep brain stimulation. It’s basically a surgical implant which we can also discuss a little bit more in detail.

Barbara Schindo – Can you talk a little bit about, like walk us through how does the – how do you do a deep brain stimulation? How does kind of the surgery work, and what do you do? What could a patient expect?

Dr. Mike Sather – Yeah, so you need a good imaging study ahead of time, and that imaging study would get loaded on to what’s called the stereotypic robot that we use in the operating room. So, we can load all of our imaging sets and MRI scan and a CT because we can actually see this nucleus that we’re aiming for called the anterior nucleus of the thalamus, so it’s just – it’s one of the nuclei in the thalamus. So, small spinner in the thalamus that we can actually see on imaging, so we can see that on imaging, we can localize it on the imaging, we can put that into the robot system, and then I can – using that system, localize that and determine how I want to get there surgically, and that’s all planned ahead of time so that when the patient comes into the operating room then the robot has to register where they are in space. We use laser tracking to kind of register where that head is in space and then this robotic arm will drive into the position that we’ve preset and pre-chosen to get this electrode into the deep part of the brain, the anterior nucleus of the thalamus, and it’s placed on both sides bilaterally. So, you’re looking at about a two-inch incision or so on each side of the head, each side of the midline to put one of these wires in, and the wire is about the thickness of a spaghetti noodle just as you see there on the picture. It’s implanted on both sides, and then both the wires will go down underneath the skin on one side to a pacemaker like battery device that sits in the chest region, and that’s the brains of the operation, if you will. It’s called the generator. It generates the electricity. It has the battery in it. It has all the computing power, so it’s the thing that delivers the electrical stimulation through the wires that are implanted in the head, and it’s stimulating that nucleus of the thalamus to inhibit seizures.

Barbara Schindo – Okay, thank you, Dr. Sather. That sounds like some really kind of new age, cool technology to treat epilepsy, and I know you’ve said we’ve been using it in some form for quite some time, but if it is relatively new for epilepsy, so…

Dr. Mike Sather – That’s true. It’s amazing and it sounds new age and it sounds very new, but it’s actually been around like you said for quite a while. It’ s just a new indication for epilepsy. So, you know, the FDA doesn’t just allow us to just implant wires anywhere in the brain just willy-nilly, so we have to have good data behind where we’re putting these for different neurological conditions. I think over the next few decades, you’re going to see an increase in deep brain stimulation for lots of other neurological conditions as it gets studied for different things, but for now, we have good data that it helps epilepsy, so now we have another way to help patients with uncontrolled epilepsy.

Barbara Schindo – And so, the patients that you have worked with to use DBS for epilepsy, what kind of results have they been seeing?

Dr. Mike Sather – So, the results that you see with DBS, that we’re seeing with DBS are the same that are published which is some of the numbers that you’re seeing there, and now, this here is showing you the seven-year data. What’s interesting about neuro stimulation is that seizures improve and decrease in sort of the step wise fashion over time. So, there’s this continuous interplay with what’s going on with the stimulation in the brain and then how that is interacting with things that are happening in the brain that want to give you seizures, and so, you see that if you look back at the data for Year 1 to Year 3 of an implant of a deep brain stimulator, you see about a fifty percent reduction in seizures, and then as you get into that sixth, seventh year, it gets up to seventy-five percent, and so, you see this improvement over the years, and it’s around seventy percent at five year. So, it really sort of peaks at five to seven years. What’s interesting about that is this is really early data and of course, when this study came out it was the first few patients treated with epilepsy and what we’ve seen with other types of devices is that over time as physicians learn how to work with the devices a little bit more as we understand more about how the device interacts with the brain, we can improve the setting such that we can get numbers like the seventy-five percent that you see sooner than seven years, and we’ve seen that with lots of other devices that we’ve implanted. So, I think the fact that it improves over time is a good thing and the fact that we have learned and we’ll continue to learn more and be able to improve seizures in a faster time frame than during the study.

Barbara Schindo – Wow! That is very interesting. Like I said, you know, hearing about there’s going to be a robot in the OR, you know working with you, that you’re kind of controlling and working on the patient, that’s very cool and very exciting. So, it’s very exciting that we have this kind of technology available at Hershey Medical Centre. So, Dr. Sather, I do very much appreciate your time today. Appreciate everybody watching at home. Again, this has been Ask Us Anything About Epilepsy with Dr. Mike Sather. If there’s any questions that you have if you’re watching this on playback, feel free to do that. We’ll still get an answer for you even if you’re not watching live and we do have – we wanted to let you know about this comment, Dr. Sather, that came in as we wrap up here. Jen says, ‘Dr. Sather, Happy Thanksgiving! One-year seizure free thanks to the doctors at Hershey Medical Center.

Dr. Mike Sather – That’s great!

Barbara Schindo – So, Jen, thank you very much for your comment.

Dr. Mike Sather – Yeah, Happy Thanksgiving to you, too!

Barbara Schindo – As always, good to see things like that. So, Jen, thank you for joining. Thank you, Dr. Sather, everybody, Happy Thanksgiving. Thank you!