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Treating Epilepsy: From Drug Therapy to Surgery

Posted Aug 24 2008 1:49pm
DAVID FOLK THOMAS: Welcome to our webcast. I'm David Folk Thomas. The topic is epilepsy and, more specifically,the treatment of epilepsy. Over 2 million Americans have been diagnosedwith this disease, but the good news is that 80% of people can have their seizures controlled with medication. We're going to get into thevarious treatments for epilepsy.

Joining me, to give us the lowdown on all of this, to my left is Dr.Carl W. Bazil. He's an assistant professor of neurology at Columbia University. Next to Dr. Bazil is Dr. Sue Herman. She's alsoan assistant professor of neurology, but not at Columbia. She's atSUNY Downstate Medical Center in Brooklyn. They're both here, inNew York. Welcome, doctors. Sue, let me start with you. Can all epilepsies, just very briefly, what is epilepsy? And canthey all be treated with drugs?

SUSAN T. HERMAN, MD: Epilepsy is a disease that is characterizedby seizures, which are recurrent episodes of abnormal activity in the brain. We're probably most familiar with grand mal seizures, where people falldown and shake all over. Most people can have their seizures adequatelycontrolled with medications. Nearly 80% of patients can have no seizureson anti-epileptic medications.

DAVID FOLK THOMAS: What kind of medications are we talking about? Pills, what form, Dr. Bazil?

CARL W. BAZIL, MD, PhD: The medications that we use are all insome sort of pill or capsule, oral form. At least, for the outpatient. In the hospital and so forth, we sometimes use intravenous drugs. But what we're really talking about is pills and oral medications.

DAVID FOLK THOMAS: Sue, how do you know, if you have a seizure,how does the doctor begin to figure out what you have and what you need?

SUSAN T. HERMAN, MD: The first thing we need to do is get a gooddescription of what happened, from the patient or from somebody who sawthe seizure. That helps us to decide what kind of seizure it wasand whether or not it actually was a seizure. There are many otherthings that can sometimes be confused with seizures.

But once we've decided that it is a seizure, then we would do someother testing to determine what kind of seizure it is. We can doan electroencephalogram, which is a test of the brain wave activity. We can do a CAT scan or an MRI of the brain to look and see if there'sany abnormalities, if the person had had a stroke before or head trauma,to get a better idea of what kind of seizure they have and what their riskof having another seizure is.

DAVID FOLK THOMAS: If, say, somebody has had a seizure, or they'rediagnosed with epilepsy, give us examples, then, of what some of the diagnosesmight be, and then what the treatments would be.

CARL W. BAZIL, MD, PhD: If they're diagnosed with epilepsy, asSue just said, one of the first things we want to determine is, if there'ssomething else that's going on that's causing it. In most people,there isn't. They're what we call idiopathic seizures. Theycome from a relatively normal appearing brain. And then the nextquestion is: What is their chance of recurrence? Which is also whatSue was alluding to. If you've had two unprovoked seizures, yourchance of recurrence without treatment is fairly high, and most of thosepatients will receive a medication for it.

DAVID FOLK THOMAS: Let's start throwing out some of the treatments. Sue, why don't you start, and then you both can go back and forth.

SUSAN T. HERMAN, MD: The most commonly used treatments, thereare probably three. Dilantin, or phenytoin, carbamazepine or Tegretol,and one of the older medications, phenobarbital. These are the onesthat are in most common use in the United States.

DAVID FOLK THOMAS: Let me stop you there. When you weresaying this or that, what are we talking about?

SUSAN T. HERMAN, MD: The first one I said, Dilantin is the medication,the trade name, and the phenytoin is the generic name. So most peoplewould know it, at the store, as Dilantin or as Tegretol.

DAVID FOLK THOMAS: Now explain, say, take one of those and explainwho would use that.

SUSAN T. HERMAN, MD: The way that anti-epileptic medicines workis to decrease the activity of the brain. So they all work in a somewhatsimilar fashion overall, although they have specific activities on channelsin the brain, or the way cells communicate with each other. But becausethey all work on activity of the brain, to decrease the activity of thebrain, they have a similar side effect profile. They're very similar,in some ways, to each other.

Dilantin, the first medication, is a good medication because it's verylong acting. It only needs to be taken once a day, so people cantake all of their pills in the morning or in the evening. It's avery effective medication. It's been around for a long time, we knowa lot about it, how useful it is, what types of seizures it works for. It has some side effects. People can be allergic to it. Theycan have rashes. People can develop some cosmetic changes, gum changes.

DAVID FOLK THOMAS: What kind of gum changes?

SUSAN T. HERMAN, MD: Actually a sort of stimulation to the growthof the gums, so they actually can get very overgrown and sometimes overgrowthe teeth.

DAVID FOLK THOMAS: About what percentage of people suffer theseside effects?

SUSAN T. HERMAN, MD: Overall, the side effects are mostly cognitiveside effects. Problems with thinking, with memory. Troublewith being tired. Those are probably the most common. And thatoccurs in probably about 10% of people. The other side effects Iwas talking about are less common, and usually with long-term use of themedication.

DAVID FOLK THOMAS: Now, Carl, Sue was talking about decreasingthe activity of the brain. So are seizures, your brain is overactive? Is that the general cause?

CARL W. BAZIL, MD, PhD: Right. Seizures, as we said, cancome from many different reasons, but the end path is that one area thatis supposed to be communicating normally is communicating too much. It's like misfiring. What the drugs do is, they calm that down. They either keep it to a smaller area so the seizures are smaller, or hopefullyso small that they're not recognized at all.

DAVID FOLK THOMAS: Let's go on, then, to another one. Suewas just talking about Dilantin. What's another treatment for seizures.

CARL W. BAZIL, MD, PhD: The most common medication worldwide forseizures is actually carbamazepine, or Tegretol. Chemically, it seemsto act very similarly to Dilantin. But it is a different drug. The side effects are a little bit different. It doesn't cause thecosmetic changes. It can also cause sedation, double vision and soforth when the dose is too high. But for both of these drugs, ingeneral, they're tolerated very well.

Tegretol used to be taken three times a day because it was short acting. Now they have long-acting forms that can be taken twice a day, which isa big advantage.

DAVID FOLK THOMAS: Now, if you are on these medications, can youstill experience seizures, Sue?

SUSAN T. HERMAN, MD: Yes, you can. What we usually do is,we start people on a dose of the medication that we think will controlseizures in the vast majority of people. And then if the patientcontinues to have seizures, we'll increase the dose, either until the seizuresgo away, or until the person experiences side effects. And at thatpoint we'll know that we can't go up any higher on the dose, and we wouldchange them to another medication.

DAVID FOLK THOMAS: Now then, once they reach that level of medication,are they taking this for the rest of their lives?

CARL W. BAZIL, MD, PhD: That's another good question. Statistically,most patients will spontaneously get better. Not over weeks, probably,but over years, they may not need to take the medication. But thereare a substantial number of people who need to continue taking it, andthere's a number of tests that we do to try to determine that as thingsgo on. But the main thing is to keep the patient seizure-free.

DAVID FOLK THOMAS: We've spoken about the drugs, but what aboutsurgery to help alleviate seizures? We have a model of a brain here. It's not based on my brain, but Carl, why don't you explain some of thesurgeries. And feel free to use our helpful model.

CARL W. BAZIL, MD, PhD: I'll give you an example. Say someonehas epilepsy. They're having recurrent seizures. They've beenon a couple of medications. They've taken Dilantin to a point wherethey become tired, so we know they can't take enough of that to stop theseizures. And probably one or two other drugs have been tried. At that point, we have to consider whether surgery may be an option forthem. In the best cases, there is up to a 90% chance of cure withepilepsy surgery. So it's very important to find that out.

The best cases are patients with temporal lobe epilepsy. Thatwould be this part of the brain, which is called the temporal lobe. It's sort of beside your ear, if you can imagine from the head here. This is an important surgical type for a couple of reasons. One isthat it's very common. It's the most common type of partial epilepsy. Secondly, it's also the type that tends to be refractory to medicine. So a lot of these patients may not fully respond to medicine.

And thirdly, this area can generally removed without any effects thatwe can tell. It sounds bizarre. You can cut out part of yourbrain and not have any effects from it, but we do very careful testingof these patients, psychological testing and so forth. And most ofthe time, they won't notice anything, and if we see any difference in thetests before or after surgery, they're minor.

DAVID FOLK THOMAS: Now, is that what surgery is all about, takinga part of the brain that may be the trouble spot out? You're notfixing it or doing anything?

SUSAN T. HERMAN, MD: Right. We actually do a lot of testing before the person goes to surgery, to make sure that we have the exact area of the brain that's causing the seizures, and to make sure that thatarea of the brain isn't involved in any other important functions. So there's a whole series of tests that patients would go through before they would be considered to be a surgical candidate.

As opposed to medications, which just suppress the symptoms of epilepsy, surgery is a cure. Many of the patients who have had successful surgery don't need to take anti-epileptic medications after their surgery.

CARL W. BAZIL, MD, PhD: Not only are they not suffering adverse effects from the surgery itself, we hope, but many of these patients area lot better. They may be having seizures all the time, they're on high doses of medication. Once they have the surgery, the bad part of the brain is removed and the effects of the seizures, which were affecting the entire brain, and the drugs which were affecting the entire brain, are gone. So they can actually be substantially better after surgery.

DAVID FOLK THOMAS: We're almost out of time. So just toclose, what about lifestyle changes? Can you ever control seizures without the medication, without the surgery?

CARL W. BAZIL, MD, PhD: Interesting and controversial question. There are a lot of things that increase your risk of seizures, and the simple ones are sleep deprivation and alcohol. That's what people always worry about. But that's not the only thing that causes a seizure.

In general, people with epilepsy need to be, maybe, a little bit more careful about their lifestyle, try to get enough sleep, try not to drink too much alcohol or, certainly, take recreational drugs. But they shouldn't need to change their lifestyle tremendously, and that's really the goal of our treatment. They should be able to live a normal live.

DAVID FOLK THOMAS: Sue, the final word.

SUSAN T. HERMAN, MD: What we usually ask is that our patients follow simple, common sense safety measures. So if they have frequent seizures, not to go swimming alone in the ocean, but only in a pool with somebody supervising them. Or not to ride a bicycle in traffic, buton quiet streets. Things that are pretty common sense, to keep them from injuring themselves if they should have a seizure. But this is usually just for patients who have very frequent seizures. If someone has infrequent seizures, those changes may not even be necessary.

DAVID FOLK THOMAS: Okay, that's all the time we have for our topic, epilepsy, and the treatment of epilepsy. I want to thank my guests,Dr. Carl Bazil, and Dr. Sue Herman. I'm David Folk Thomas. We'll see you next time.

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