Epilepsy

Diagnosis

When evaluating a patient for epilepsy, your doctor will likely review your symptoms and medical history to determine your condition. To identify the source of seizures and make a diagnosis of epilepsy, several tests may be performed. The assessment process may include the following:

• A neurological exam. This examination measures your behavior, motor skills, cognitive function, and other aspects in order to identify the type of epilepsy you might have and diagnose your illness.
• Blood tests. Blood testing can look for indications of genetic disorders, infections, or other illnesses that may be related to seizures.
• Genetic testing. Genetic testing may help certain epilepsy patients learn more about their illness and available treatments. Even though genetic testing is more frequently done on children, some adults with epilepsy may benefit from it.

You might also have one or more scans and tests for brain imaging that look for changes in the brain:

• Electroencephalogram (EEG). The most common test used for diagnosing epilepsy involves attaching electrodes to the scalp using a paste-like substance or cap. These electrodes record the electrical activity of the brain. People with epilepsy often exhibit changes in their usual brain wave patterns, even when they are not experiencing a seizure. To detect and record any seizures, healthcare providers may monitor patients on video during an EEG (electroencephalogram) test. This monitoring can occur while the person is awake or asleep. The recorded seizures can help determine the type of seizures or rule out other conditions. The test can be conducted in a healthcare provider’s office or a hospital. In some cases, a person may be given an ambulatory EEG, which they can wear at home while the EEG records seizure activity over several days. Patients may also receive instructions to provoke seizures, such as getting insufficient sleep before the test.
• High-density EEG. In an alternative form of EEG testing, a high-density EEG can be utilized. This variation involves placing electrodes in closer proximity compared to traditional EEG. The purpose of high-density EEG is to achieve greater precision in identifying the specific regions of the brain affected by seizures.
• Computerized Tomography (CT) scan. A CT scan produces cross-sectional images of your brain using X-rays. CT scans can find brain cysts, hemorrhage, or tumors that may be the source of epilepsy.
• Magnetic Resonance Imaging (MRI). An MRI produces a comprehensive image of the brain using strong magnets and radio waves. An MRI examines the anatomy of the brain to find anything that might be triggering seizures, similar to a CT scan. But compared to a CT scan, an MRI offers a more thorough view of the brain.
• Functional MRI (fMRI). When particular brain regions are active, changes in blood flow are detected using a functional MRI. Before surgery, this test may be used to pinpoint the precise locations of vital functions, such as voice and movement, so that the surgeons can operate without hurting such areas.
• Positron Emission Tomography (PET). PET scans can visualize the metabolic activity of the brain and identify changes by injecting a small amount of low-dose radioactive material into a vein. Low metabolic areas of the brain might be indicators of seizure activity.
• Single-photon Emission Computerized Tomography (SPECT). A SPECT test is utilized when MRI and EEG fail to identify the specific location in the brain where seizures originate. This test involves injecting a small amount of low-dose radioactive material into a vein to generate a detailed 3D map of blood flow activity in the brain during seizures. Increased blood flow in certain areas during a seizure may indicate the regions where seizures occur. To obtain more precise results, a subtype of SPECT known as subtraction ictal SPECT coregistered to MRI (SISCOM) combines SPECT and brain MRI results, overlapping them for enhanced detail.
• Neuropsychological tests. These exams measure one’s capacity for thought, memory, and speech. The test results assist in identifying the regions of the brain that are impacted by seizures.

Your test findings may also be analyzed using a variety of methods to help determine where in the brain seizures begin:

• Statistical Parametric Mapping (SPM). SPM is a technique for comparing the same brain regions in people with and without seizures that experience increased blood flow during seizures. This reveals the starting point of seizures.
• Electrical Source Imaging (ESI). ESI is a method that displays EEG data on an MRI of the brain to highlight regions of the brain where seizures are happening. Compared to EEG alone, this method delivers more exact information.
• Magnetoencephalography (MEG). The magnetic fields generated by brain activity are measured by MEG. This aids in locating potential epileptic initiation points. Because magnetic fields are less affected by the skull and brain tissue than electrical impulses are, MEG can be more accurate than EEG. Images produced by MEG and MRI indicate regions of the brain that are and are not impacted by seizures.

Accurate diagnosis of the type of seizures and their origin is crucial in increasing the likelihood of finding an effective treatment for epilepsy. Identifying the specific type of seizures and pinpointing the exact location where they originate provides valuable information for developing an appropriate treatment plan. A precise diagnosis allows healthcare professionals to tailor interventions, such as medications, lifestyle modifications, or surgical options, to target the underlying cause and effectively manage the seizures. Therefore, an accurate diagnosis significantly enhances the chances of finding a successful treatment approach for epilepsy.

Treatment

Epilepsy patients who receive treatment may experience fewer seizures or maybe no seizures at all. Treatment options include:

Medication

Many individuals with epilepsy can achieve a seizure-free life by taking a single anti-seizure medication, also known as anti-epileptic medicine. Others may need a combination of medicines to reduce the frequency and intensity of seizures. In some cases, children and adults who have been symptom-free for a certain period of time may be able to discontinue their medications under the guidance of their healthcare team.

Determining the right medication and dosage can be a complex process. Healthcare providers take into account various factors such as the type of seizures, frequency of seizures, age, and other medical conditions when prescribing medication. They also consider potential interactions with other medications the individual may be taking.

Typically, treatment begins with a low dosage of a single medication, which is then gradually increased until seizures are effectively controlled. There are over 20 different types of anti-seizure medications available, and the specific medication prescribed depends on the individual’s seizure type, age, and overall health.
While these medications can be beneficial, they may also have side effects. Mild side effects may include fatigue, dizziness, weight gain, loss of bone density, skin rashes, loss of coordination, and speech problems. More severe but rare side effects may include depression, suicidal thoughts and behaviors, severe rash, and inflammation of certain organs.

To maximize the effectiveness of anti-seizure medication, it is important to follow these steps:

• Take medications exactly as prescribed.
• Consult with your healthcare provider before switching to a generic version of the medication or taking other prescription or over-the-counter medications, including herbal remedies.
• Never stop taking the medication without discussing it with your healthcare provider.
• Contact your healthcare provider immediately if you experience new or increased feelings of depression, suicidal thoughts, or significant changes in mood or behavior.
• Inform your healthcare provider if you have migraines, as there are anti-epileptic medications that can both prevent migraines and treat epilepsy.

Around half of individuals newly diagnosed with epilepsy achieve seizure control with their first medication. If anti-seizure medications do not provide satisfactory results, alternative treatments such as surgery or other therapies may be considered. Regular follow-up appointments with a healthcare provider are typically necessary to assess the condition and the effectiveness of the medication.

Surgery

When seizures are not adequately controlled by anti-seizure medications and they have a severe and debilitating impact on an individual, surgery may be considered as a treatment option. Epilepsy surgery can be safe and effective, particularly when multiple trials of anti-seizure medications have failed to provide control. It is crucial to undergo evaluation at an epilepsy center to determine if surgery is a suitable choice. Various surgical options exist, including surgical resection (removal of abnormal tissue), disconnection (cutting fiber bundles that connect different brain areas), stereotactic radiosurgery (targeted destruction of abnormal brain tissue), or implantation of neuromodulation devices. These devices deliver electrical impulses to the brain, gradually reducing seizures over time.

For individuals with seizures originating from a small, well-defined area of the brain, surgery is typically recommended if the targeted area does not interfere with essential functions like speech, language, motor skills, vision, or hearing. In cases where open surgery carries significant risks, minimally invasive approaches such as MRI-guided stereotactic laser ablation can provide effective treatment. These procedures involve directing a thermal laser probe at the specific brain region causing seizures, destroying the problematic tissue to gain better seizure control.

Although some individuals may still require medication to prevent seizures after successful surgery, they may be able to reduce the number of medications and lower their doses. It’s important to note that there is a small risk of complications, including permanent alterations in thinking abilities, associated with epilepsy surgery. To make an informed decision, it is advisable to discuss the surgical team’s experience, success rates, and complication rates of the specific procedure being considered.

Therapies

In addition to medications and surgery, there are alternative therapies available for treating epilepsy:

• Vagus Nerve Stimulation: When medications and surgery are not effective, vagus nerve stimulation can be considered. This therapy involves implanting a device called a vagus nerve stimulator beneath the skin of the chest, similar to a heart pacemaker. Wires from the stimulator are connected to the vagus nerve in the neck. The device delivers electrical energy to the brain through the vagus nerve, which helps reduce seizures. While it’s not fully understood how it works, vagus nerve stimulation can typically decrease seizures by 20% to 40%. In most cases, anti-epileptic medications still need to be taken, although some individuals may be able to lower their dosage. Possible side effects of vagus nerve stimulation include throat pain, hoarse voice, shortness of breath, or coughing.
• Deep Brain Stimulation: This therapy involves the surgical placement of electrodes into a specific part of the brain, usually the thalamus. The electrodes are connected to a generator implanted in the chest, which sends regular electrical pulses to the brain at timed intervals. Deep brain stimulation is often used for individuals who have not experienced improvement in their seizures with medications. It can help reduce the frequency of seizures.
• Responsive Neurostimulation: Responsive stimulation devices, similar to pacemakers, can be implanted to significantly reduce the occurrence of seizures. These devices analyze brain activity patterns and detect the onset of seizures. Once a seizure is detected, the device delivers an electrical charge or medication to halt the seizure before it leads to impairment. Research has shown that this therapy has minimal side effects and can provide long-term relief from seizures.

These alternative therapies offer additional options for individuals with epilepsy who have not achieved adequate seizure control through medication alone or for whom surgery is not feasible. It’s important to consult with a healthcare professional to determine the most suitable treatment approach based on individual circumstances.

Ketogenic diet

A ketogenic diet has shown promise in reducing seizures for both children and adults with epilepsy who haven’t responded well to medication. This diet involves consuming high amounts of fats and limiting carbohydrates, causing the body to use fats for energy instead. While the exact mechanisms behind its effectiveness are not fully understood, experts believe that the ketogenic diet brings about chemical changes that help suppress seizures and alters the actions of brain cells.

It’s crucial to consult with healthcare professionals before considering a ketogenic diet to ensure it is suitable for you or your child. Proper medical supervision is essential to prevent malnourishment and manage any potential side effects. Although side effects such as dehydration, constipation, slowed growth, and increased uric acid levels in the blood (leading to kidney stones) can occur, they are relatively rare when the diet is followed correctly and under medical guidance.

In addition to the ketogenic diet, other less restrictive alternatives like the modified Atkins diet and low-glycemic index diets can also offer some benefits for seizure control. These diets involve similar principles of high fat, moderate protein, and low carbohydrate intake. While the ketogenic and modified Atkins diets are the most commonly recommended for epilepsy patients, especially children who haven’t responded to medication or aren’t surgical candidates, low-glycemic index diets may also be effective in reducing seizures for some individuals with epilepsy.

Potential future treatments

Numerous potential novel treatments for epilepsy are being researched by scientists, including:

• Subthreshold stimulation, or continuous stimulation of the seizure start zone. Some persons with seizures appear to benefit from subthreshold stimulation, which is continuous stimulation to a part of the brain below a level that is physically perceptible. Subthreshold stimulation aids in preventing seizures before they start. This method of treatment may be effective for patients who experience seizures that originate in the eloquent part of the brain, which cannot be surgically removed because doing so would impair speech and movement skills. Or it might help those whose seizure characteristics make it unlikely that they will respond well to responsive neurostimulation therapy.
• Minimally invasive surgery. Seizure treatment may benefit from new, minimally invasive surgical methods like MRI-guided targeted ultrasound. In comparison to conventional open brain surgery for epilepsy, these procedures carry lower risks.
• Transcranial Magnetic Stimulation (TMS). To cure seizures without surgery, TMS uses focused magnetic fields on the parts of the brain where they occur. Patients whose seizures take place at the surface of the brain and cannot be treated surgically may benefit from it.
• External trigeminal nerve stimulation. A device that stimulates particular nerves works similarly to vagus nerve stimulation to lessen the frequency of seizures. Contrary to vagus nerve stimulation, however, the device is worn externally, requiring no surgery to implant it. Studies have shown that external trigeminal nerve stimulation can improve mood as well as seizure management.