(December 22, 2008 - Insidermedicine) On a recent trip to Halifax, we caught up with Dr. Dr. David Clarke, MD, Associate Professor in the Department of Surgery, Division of Neurosurgery and Neurobiology, at Dalhousie University.
What constitutes uncontrolled epilepsy?
We know that many people have a seizure but do not go on to have epilepsy, which means having two or more unprovoked seizures, and uncontrolled epilepsy in terms of being a candidate for potential surgery means that despite various medications being given you still have seizures.
What should I do if I have a seizure?
For most individuals, a first seizure can be a dramatic event and it is certainly something that people would seek medical attention, often through their local emergency room. From there patients are often put on medication and would be seen by a neurologist who specializes in treating epilepsy. At that initial encounter, various kinds of investigations would be done including assessing the type of medication, whether the patient needs medication long term, and also assessment by some imaging studies.
What should I do after a second seizure?
After the second seizure, that means that person now has epilepsy by definition, and so the focus would then be on the control of the epilepsy via medication, again through the epileptologist, who’s a neurologist by training and has special knowledge or expertise in that area, and then also to make sure by neuroimaging studies, typically done by mri, to ensure that there is not a specific cause of that seizure that needs to be dealt with from a treatment point of view.
The main thing from a physician’s point of view is to identify that the patient has had a seizure, and then to make sure that that patient seeks appropriate help in terms of expertise through the neurologist. Once the person is in the proper stream, that person will have the appropriate investigations.
What treatment options are available?
Sometimes it is not that obvious that patients have had a seizure, and so one of the jobs that the epileptologist does is to confirm the diagnosis of a seizure. There can be other things that can mimic that (e.g. problems with the heart). An assessment by the neurologist might clarify whether it is a seizure by talking with the patient. Other investigations may also include an electro-encephelogram which records the electrical activity of the brain by putting electrodes on the surface of the skin over the scalp and also by imaging studies which is typically by MRI
How can uncontrolled epilepsy be treated?
Only about 10% of the patients who have epilepsy are not well-controlled by medication. The vast majority of patients with epilepsy are very well controlled by medication alone. We do know that about 10% are not well controlled, and for these patients, surgery is seriously considered as an attempt to control the epilepsy. Evaluation by the surgical team typically includes the neurologist, the epileptologist, the neurosurgeon, the neuropsychologist, as well as the neuro-imaging team. One of the challenges that we have is that we know that there are patients out there who continue to have seizures, and we have potentially effective treatment options for these patients and yet many people for one reason or another are not given the opportunity to have that treatment option, and the reasons can be varied; they may not be aware that there are options, their family physicians may not be aware that there are options, there may be fears of having investigations that might lead to brain surgery, and these kind of fears are understandable, but in today’s environment we do have effective treatments that, with very low chance of problems with brain surgery that have potentially huge benefits in a way that can really change this patient’s lifestyle.
If I had uncontrolled epilepsy…
If I had uncontrolled epilepsy, I think the most important aspects of that are that you are evaluated by a team that is used to dealing with that problem. This tends to be expertise that is centered in major centers, and so I think once that is evaluated, then all the treatment options can be explored or discussed with you and in many cases there may be surgical options that can prove to be very helpful.