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Video Transcript: Epilepsy Update

Ellen Beth Levitt: Welcome to "Maryland Health Today." I'm Ellen Beth Levitt. Epilepsy is a neurological condition caused by a disruption in the brain's electrical activity, resulting in seizures. Those seizures affect people in different ways. On the show today, we'll learn the latest information about the causes, diagnosis and treatments for epilepsy. My guest is Dr. Tricia Ting. She's a neurologist and epilepsy specialist at the University of Maryland Medical Center. Dr. Ting is also an assistant professor of Neurology at the University of Maryland School of Medicine. Welcome to the show.

Tricia Ting, M.D.: Thank you for having me.

Ellen Beth Levitt: How common is epilepsy?

Tricia Ting, M.D.: Well, in the United States today, there are about three million people who live with epilepsy, and they estimate about 200,000 new cases of epilepsy are diagnosed every year. The incidence has been about the same over time, but there may be a trend for more people developing epilepsy as elderly people because probably there is a large aging population with the baby boomers.

Ellen Beth Levitt: We might be seeing an increasing number of people with epilepsy, right?

Tricia Ting, M.D.: Well, when people think of epilepsy, they normally think of seizures. Certainly, seizures characterize epilepsy, but it is a prediction for having recurrent seizures that defines someone as having epilepsy.

Ellen Beth Levitt: How many seizures would someone have to have before they are diagnosed as having epilepsy?

Tricia Ting, M.D.: Typically, people like to see someone have at least two unprovoked seizures before they'll consider the diagnosis of epilepsy in them.

Ellen Beth Levitt: What is a seizure? Can you tell us what is going on in the body when somebody has a seizure?

Tricia Ting, M.D.: Sure, a seizure is generally an abnormal electrical storm that may occur either in part of the brain or spread throughout the brain.

Ellen Beth Levitt: So, there are different types of seizures?

Tricia Ting, M.D.: Certainly, we generally look at seizures as being partial seizures or generalized seizures, and there are many different forms that they come about clinically.

Ellen Beth Levitt: So, what are some of the types of general seizures? What would some names be that people might hear or be familiar with?

Tricia Ting, M.D.: The most common general type of seizure is a generalized convulsion. People see this called a grand mal convulsion. In people who have a genetic protensity for seizures, a person may have generalized stiffening and shaking. They are not aware of what's going on. They are unconscious and may have associated tongue biting and incontinence. And, after these generalized convulsions, a person may be very tired or confused afterwards. Those are the generalized grand mal type seizures. There are also other types of generalized seizures that are not as violent appearing clinically. These would include a petit mal, or where someone may just stare for a brief period of time and come right back, and that's frequently seen in children with generalized epilepsy type. Also, there are many very brief jerks and other kinds of generalized seizures, including drop attacks or what we also call atonic seizures where someone is walking along, maybe not have any warning, and they'll just fall, so those are very - can be very - disruptive as you can imagine. Different kinds of seizures from these generalized types are also partial seizures where just one area of the brain may be affected with an electrical storm, and these really can be very variable. It depends on what area of the brain is having the electrical storm. Someone may have just a little bit of focal twitching in one arm or leg, a focal motor seizure or a passing feeling, different sensation. Sometimes it is just a sense of nausea, or even something called Deja Vu. A sense of familiarity is commonly seen from tell temporal seizures depending on how far that electrical activity spreads. One may lose awareness of partial seizures as they have a great variability to them.

Ellen Beth Levitt: And it depends on where in the brain the electrical storm is occurring at that time?

Tricia Ting, M.D.: That's right.

Ellen Beth Levitt: How long do seizures normally last?

Tricia Ting, M.D.: Most seizures are very brief. Generally, anywhere from a few seconds to a few minutes at the most. So, once they go on, any seizure that goes on for several minutes - more than five minutes - we start getting worried about this becoming a prolonged seizure, or even something more dangerous like status epilepticus.

Ellen Beth Levitt: We have video that shows what a seizure looks like, so for people who have never witnessed anyone having a seizure, this particular one is that of a grand mal perhaps?

Tricia Ting, M.D.: Correct. This looks like it is a generalized convulsion. The person is on the ground shaking all over. They are probably not aware. This one is different, this is - there was a brief jerk in this child who may have had a little bit of staring, perhaps atypical, and then has that little myoclonic jerk we were talking about, generalized seizure types. This gentleman was speaking with his family member and just stops and doesn't seem to respond to her. His unusual motions are typically what we see in someone with a complex partial seizure.

Ellen Beth Levitt: When people are having a seizure, are they aware of it?

Tricia Ting, M.D.: They can be, it is dependent on the spread of abnormal electrical activity. If it is very confined to a small area of the brain, then someone may very well be aware of what they are feeling, what they are going through. And sometimes, that kind of activity will then spread and involve more of the brain, at which point they may then lose awareness for what's going on. So, sometimes the very isolated seizures, those small partial ones where someone still knows what is going on, we can call those auras because they may lead up to bigger seizures. Auras can lead to bigger seizures where someone loses awareness.

Ellen Beth Levitt: They can happen in any age?

Tricia Ting, M.D.: Seizures may occur in young, the middle aged or the older population. Generally, people who are very young and have seizures may have an inherited type of epilepsy that they - but not all the time - can grow out of.

Ellen Beth Levitt: So you can grow out of it. That's very encouraging.

Tricia Ting, M.D.: Younger folks can, but they were saying that after they saw increased risk. It seems like the incidence is increasing in that age group, but really you can develop epilepsy anywhere along the spectrum, even in your teens, 20s, 30s, 40s. The large bulk of people developing epilepsy though is in the younger and the older.

Ellen Beth Levitt: Do we know what causes epilepsy?

Tricia Ting, M.D.: There are many different causes, it depends on the person. So again, I mentioned sometimes people are just born with the predilection, sort of a genetic propensity they may have inherited or a mutation, so that's one form of genetic epilepsy. And, people may acquire insults to the brain that may cause an area of scarring...

Ellen Beth Levitt: Like a trauma?

Tricia Ting, M.D.: Exactly, so traumatic brain injury. These are some of the risks that people can develop epilepsy from if they have had infections or traumatic brain injury, a stroke or tumor.

Ellen Beth Levitt: What about, can certain medications cause seizures?

Tricia Ting, M.D.: Certainly, some toxicity with some medications like a lithium overdose - medications taken too much - can cause it. Other, not real medicines - but toxins - can cause seizures, like alcohol being alcohol intoxicated or alcohol withdrawal can cause a seizure, but just because someone has a seizure doesn't necessarily mean that they have epilepsy.

Ellen Beth Levitt: Exactly, so many people may be at risk for single seizure in their life and that's why you mentioned what defines epilepsy as you were saying and that's why we like to see at least a couple of seizures that are unprovoked because, certainly, a greater proportion of people may have a single seizure, particularly one that is provoked that doesn't mean that they are at risk for having recurrent seizures or epilepsy.

Tricia Ting, M.D.: And some of those risks for developing just a single seizure may be from anything that makes you very ill, a high fever or derangement in your metabolic panel such as a very low sodium or abnormal sugars - my sort of things. Again, alcohol withdrawal is frequently associated with causing a seizure that may not be an indication of epilepsy.

Ellen Beth Levitt: What impact does having epilepsy have on somebody's life?

Tricia Ting, M.D.: Oh, unfortunately, since I work primarily with epilepsy patients, I really see a lot of affect on people's quality of life, and that's why we really try to - as much as we can - to get seizures under control. So many patients may lose their jobs from it. Often, this is related to the loss of driving privileges because someone cannot be driving if they have uncontrolled seizures that affect their awareness.

Ellen Beth Levitt: And the loss of independence?

Tricia Ting, M.D.: Absolutely, and, you know, just all of the toxic effects from medicines often that have to be maximized to control the seizures can affect their lives as well.

Ellen Beth Levitt: How can seizures be controlled?

Tricia Ting, M.D.: Well, there are many ways that we go about it. Primarily, we use medicines to control seizures. Some people may be candidates for surgery to control seizures, and that surgery can involve resective surgery, where we take out areas of abnormal brain or implant devices, and we can talk about that a little more later.

Ellen Beth Levitt: Let's talk about the diagnosis of epilepsy.

Tricia Ting, M.D.: Sure.

Ellen Beth Levitt: How do you actually determine that someone does indeed have epilepsy? You were saying that the number of seizures that a person might have and, I guess, if you rule out some of those other causes for just one seizure...

Tricia Ting, M.D.: Right. Yes, we really depend a lot on the clinical history alone.

Ellen Beth Levitt: There isn't like a blood test or brain scan?

Tricia Ting, M.D.: We use a lot of different tests to that point - to bring together, to create a picture - and let us get to the diagnosis, but generally we rely heavily on the clinical history. What were the circumstances around someone's seizure? What age it occurred in them? And then we look at risk factors like family history of epilepsy or whether the person had an infection before - any sort of reasons they might have some injury to the brain - and then we pull in diagnostic testing to help us further. And that testing includes EEG or electroencephalography and many other different neuroimaging exams.

Ellen Beth Levitt: What does that involve, and do you have to actually watch someone having a seizure to know what is going on with them?

Tricia Ting, M.D.: Well, that would be nice, be the gold standard really, for a medical person to see a seizure and to - even better - to have the EEG hooked up at the time, but it is so rare. Again, seizures are very unpredictable, and that's the problem. So, we have to rely on any information that we can get between seizures, because the likelihood of actually catching a seizure is pretty low. Here, you can see a video of someone who is having an EEG applied in the epilepsy lab, and this is during just a routine EEG that's done between events for the most part.

Ellen Beth Levitt: And that's a non-invasive test?

Tricia Ting, M.D.: Exactly, so that allows us to actually look at the brain waves. Right here, you can see a sample of an EEG in someone who is sleeping, and during the testing, they can even try to flash lights to provoke different electrical discharges, and possibly seizures even.

Ellen Beth Levitt: Right. When someone is having a seizure, what do we need to keep in mind in terms of first-aid for that person?

Tricia Ting, M.D.: Well, the most important thing is to try to keep them safe from falling or hitting themselves up against something that is hard or like a very sharp corner. So, generally we ask that people be attended to and take glasses off, have them get as low as possible so they don't crash downstairs or anything - preferably on the floor or on the bed - roll them to the side so if they vomit they don't aspirate that vomit, and then, most importantly nothing to be stuck in the mouth. It is always been taught to put a spoon or a belt in someone's mouth to prevent them from biting their tongue...

Ellen Beth Levitt: Right.

Tricia Ting, M.D.: But we know now that that can cause more trouble than really protecting the tongue, because you could knock their teeth out and obstruct their airway. Really, we want to make sure that they are just safe and on their side.

Ellen Beth Levitt: You were saying the good thing is that most seizures don't last very long, less than a minute would you say?

Tricia Ting, M.D.: That's right, so most of the time it will stop on its own anyway, in which case, you can call the doctor or talk to them. If it doesn't stop, that's when we ask you to - after a couple of minutes the person is not coming around - then really, people should consider calling 911 or activating emergency services.

Ellen Beth Levitt: What is the risk if someone is having a prolonged seizure?

Tricia Ting, M.D.: Well, prolonged seizures can be very dangerous. We call prolonged seizures that last longer than five minutes status epilepticus. The most generalized kind is the convulsion that doesn't stop, and that can be very life threatening. Others - if it goes on for very, very long - people also often worry about injury to the brain itself.

Ellen Beth Levitt: If someone calls 911 and the paramedics show up, what would they typically do to stop the seizure.

Tricia Ting, M.D.: The paramedics nowadays have very - not a really set - protocol for how they treat seizures out of the hospital before someone gets there. In general, they may try an intravenous administration of a drug called a Benzodiazepine, but it varies whether it is - it is not absolutely established yet - it is different county to county.

Ellen Beth Levitt: And I understand that there are different methods of administration, either an IV or an intramuscular injection, could be given?

Tricia Ting, M.D.: Right now, most of the approved methods would be intravenous Benzodiazepine or a rectal gel called a Rectal Diazepam.

Ellen Beth Levitt: You're going to begin a study to look at the best way to help people who are having a prolonged seizure, is that right?

Tricia Ting, M.D.: That's right. At the University of Maryland, we're hoping to participate in a national study by the National Institute of Health, looking at trying to do research on what's the best method to rescue someone through a paramedic out of the hospital. Right now, we have many very well established protocals that are used when someone is already in the emergency department or in the hospital, but it is not known yet what is the best treatment outside of the hospital, and so this study we're interested in participating in would compare two kinds of treatment - one would be intravenous administration of Benzodiazepine, and another would be an intramuscular administration, much like an EPI pen for someone with a peanut allergy - and you can imagine how tough it would be in someone seizing and shaking for a paramedic to try to get the IV in.

Ellen Beth Levitt: Sure.

Tricia Ting, M.D.: We really want to establish which method is the safest and most effective for stopping seizures quickly.

Ellen Beth Levitt: One really interesting aspect to this is that the people who are having a seizure, they can't give consent to be part of this study.

Tricia Ting, M.D.: That's right, and this is - this study is called rampart - and that's a very unique aspect of the study. Most of medical research is done in patients who are able to spend lots of time looking at a study, understanding it, and consenting to participate as a research study participant. In this case, patients who are found by paramedics seizing on the field are not of the ability to read anything or to consent for anything, and it is often so emergent they get treated quickly that paramedics cannot search for family members to do it instead. So, really we have to do this without their consent, and talk to them afterwards. And so, to get around that difficulty of not having individual consent, we're trying to do a community consultation to let people know that this is a study that's maybe happening in your community, and also getting feedback for how they feel about that, and understanding how we can best educate them about it.

Ellen Beth Levitt: That's very interesting. We have to take a break. When we come back, we'll talk about the latest treatments for epilepsy, so stay with us.

Part Two:

Ellen Beth Levitt: Welcome back. I'm Ellen Beth Levitt. We're talking about seizures and epilepsy on the show today. My guest is Dr. Tricia Ting. She's a neurologist and epilepsy specialist at the University of Maryland Medical Center. Dr. Ting is also an assistant professor of Neurology at the University of Maryland School of Medicine. Let's move on then, and talk about treatments for epilepsy, what can you and your colleagues offer?

Tricia Ting, M.D.: Well, certainly there are, in general, people are offered medicines. We have many different kinds of medications that are useful for different kinds of epilepsy and different seizure types. And, there are also surgery options, and these might include resective surgery or even implantation of different devices for seizures.

Ellen Beth Levitt: I've heard that medicine can help about 70 percent of people who have epilepsy to avoid seizures.

Tricia Ting, M.D.: Right. Most people will respond to medicine, so we don't have to resort to something that's more invasive like surgery, and so, yes, it is the majority of people who will respond to the very first kind of medicine that you give them, so then our job is really to try to help them to find a medicine they can live with that won't cause a lot of long term side effects or problems for them and, luckily nowadays, there have been many new drugs that have been evolved over time and been FDA approved that work well for seizures with relatively few side effects.

Ellen Beth Levitt: What are some of the side effects that people might experience with drugs for epilepsy?

Tricia Ting, M.D.: Unfortunately, many times people may have a lot of cognitive side effects. They can be very tired, have trouble concentrating, they may have slowing of their speech. Other times, other kinds of side effects may include feeling a lot of GI problems, nausea, or lots of fatigue or sleepiness, drowsiness. The worst kind of side effects would be dangerous allergic drug reactions. Sometimes, we have to watch out for that as well.

Ellen Beth Levitt: Sounds like you have a lot of different options, so if one drug is causing a lot of side effects for somebody, they could switch to another one and see if that works?

Tricia Ting, M.D.: That's right.

Ellen Beth Levitt: But, I guess people have to take these medicines for the rest of their lives, right?

Tricia Ting, M.D.: In general, they do have to, there is only a small proportion we mentioned earlier of some children who might grow out, so to speak, of their epilepsy, but most people who have seizures into their adulthood do, unfortunately, need to consider being on medicines for many, many years.

Ellen Beth Levitt: And these just control the seizures, there is no real cure yet for epilepsy, right?

Tricia Ting, M.D.: That's right. Well, yes and no. As you said, they need to be on medicines all the time to really control the seizures, but there is a cure, and that cure is resective surgery. So, the idea is that the few patients that are amenable to surgery for epilepsy can have a focus of abnormal functioning brain taken out, and essentially they are cured, but even then we do try to keep them on some medicine to make sure that they are seizure free.

Ellen Beth Levitt: Tell us a little bit about the surgery, so some of the brain tissue is actually taken out; the place in the brain where the seizures begin.

Tricia Ting, M.D.: That's right. We really try to make sure that we know which patients are candidates for this, and the idea is to the take out abnormal, not functioning, brain, so we don't want to leave anyone with a deficit.

Ellen Beth Levitt: Sure.

Tricia Ting, M.D.: That would leave them, like with a stroke, trouble moving or talking. So, we do lots of tests ahead of time to make sure that we are clearly certain where the seizures are coming from and that they are coming from a resectable area of the brain such as a temporal lobe. That's one of the most commonly done surgeries.

Ellen Beth Levitt: Someone has the generalized seizures where the electrical activity can be abnormal in different parts of the brain, I would think, wouldn't be...

Tricia Ting, M.D.: That's right. You cannot be taking out multiple parts of the brain, like, so if they have multiple areas of brain cause for seizure, they would probably have to go with either medicine or some of the other surgical options, which are more implanted devices.

Ellen Beth Levitt: Right.

Tricia Ting, M.D.: There is something called Vagus Nerve Stimulation. It has been, for many years now, and it is a device that has been approved in ages twelve and over for people with partial seizures that are not controlled with medicine. And, what it is, here you see video. It is a pacemaker-like device that is implanted in the chest wall, and a wire from it is wrapped around the Vagus Nerve in the neck.

Ellen Beth Levitt: In the neck?

Tricia Ting, M.D.: That's right. You can see a diagram of that right there, and the idea is that this pacemaker-like device is programmed to stimulate on its own every few minutes, and that stimulating the Vagus Nerve is believed to somehow disrupt electrical impulses in the building electrical storm that makes a seizure happen, and hopefully abort the seizure from really blooming.

Ellen Beth Levitt: So, does somebody activate that when they think a seizure is coming on or something that works continually?

Tricia Ting, M.D.: It is both. So, on its own, it is in case someone is not having enough warning or is unable to trigger it themselves. The pacemaker-like device, the VNS, is programmed to go off on its own every few minutes in case, between the stimulation, someone feels one of the typical seizures starting to come on and they are able to - they can take a magnet and swipe it across the chest and bring on an extra stimulation just in case.

Ellen Beth Levitt: So, just the use of a magnet will do that?

Tricia Ting, M.D.: That's right.

Ellen Beth Levitt: That's pretty interesting. I guess these devices have to be programmed in advance, for the specific patient, right?

Tricia Ting, M.D.: That's right.

Ellen Beth Levitt: Is there any other device on the horizon or that is kind of new that can help people to control seizures.

Tricia Ting, M.D.: Right, well, in addition to VNS, there is a device under investigation now called the Deep Brain Stimulation or DBS. It is already currently being used and DFD approved for Parkinson's and tremors, but we're looking for help with seizure control and, essentially, instead of wrapping the electrode and stimulating around the Vagus Nerve, they put it into a deep brain structure called the thalamus and it is programmed to stimulate intermittently with the idea to disrupt a blooming seizure as well.

Ellen Beth Levitt: And does that go on continuously, or does the device sense that one of these electrical storms is about to happen?

Tricia Ting, M.D.: That's a great question. That type, the DBS, would be programmed to just go on on its own, but they are looking even further on the horizon. Another very investigational device called the Responsive Neurostimulation, RNS, in which case is similar to the DBS device, the electrode will also sense and pick up brain waves and sense when an electrical storm is brewing, and then trigger itself to stimulate at that time point, so much more sophisticated in some ways.

Ellen Beth Levitt: It almost sounds like a pacemaker that people have in the heart to send...

Tricia Ting, M.D.: Very similar.

Ellen Beth Levitt: ...slow down or speeding up of the heart rate.

Tricia Ting, M.D.: That's right, but it is very much under investigation now, so it is not at all close to being established yet.

Ellen Beth Levitt: We only have about a minute left, but I wanted to ask you about diet. If people make dietary changes, can they affect the amount of seizures they have?

Tricia Ting, M.D.: The only established dietary treatment is something called the Ketogenic Diet, which has been laborious, very difficult to stay on, for adults. And, largely unpalatable for adult patients, it has become mostly an option for younger children because it is a high fat, very low carb, low sugar kind of diet that requires hospitalization and fasting and so forth. The newer research is being done into more useable types of diets that adults might be able to use, and that would include Atkins-like low-carb diets that anyone really can do at home, and not require hospitalization or as close monitoring.

Ellen Beth Levitt: So that's being studied now?

Tricia Ting, M.D.: That's being studied and seems promising for all ages really.

Ellen Beth Levitt: All right, because obviously, just a lot of high fat you can cause other health problems.

Tricia Ting, M.D.: That's right. There are other risks as well. Any treatment for epilepsy, we have to weigh the risks and the benefits.

Ellen Beth Levitt: For women who are pregnant, what do they need to know if they have epilepsy?

Tricia Ting, M.D.: Well, there was just a practice parameter that I participated in helping to bring together on how to manage women with epilepsy, and some of the concerns - clearly the medicines and the effects on the baby and any risk for birth defects - but what we know now is that most women with epilepsy can have a very healthy baby, and we ask that they act together with their doctors in planning the pregnancy if possible. And, are then, avoiding certain drugs, such as Valproic Acid which is more highly associated with risk to the fetus. They probably should follow a high risk OB and consider taking supplements such as folic acid which is hopefully will help them to again have a healthy pregnancy down the road.

Ellen Beth Levitt: Great, so they can manage their epilepsy and still have a healthy baby.

Tricia Ting, M.D.: Absolutely.

Ellen Beth Levitt: Great. Well, thank you so much for joining us.

Tricia Ting, M.D.: Thank you very much.

Ellen Beth Levitt: My guest has been Dr. Tricia Ting. She's a neurologist and epilepsy specialist at the University of Maryland Medical Center. She's also an assistant professor of Neurology at the University of Maryland School of Medicine. If you have any comments or questions about this program, please contact me at e-mail at eblevitt@umm.edu. If you'd like to reach Dr. Ting or any other University of Maryland physician, call 1-800-492-5538 or visit the web site where you'll find a great amount of health information. The address is www.umm.edu. Take good care of yourself. We'll see you next time for "Maryland Health Today."

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This page was last updated on: August 25, 2009.

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