Blog # 13- Insight into the Medical Management of Children and Adults with Epilepsy

Reference links:

Perucca, P., Sheffer, IE, Kiley, M (2018). “The management of epilepsy in children and adults”. U.S. National Library of Medicine. National Institutes of Health. Published 19 Mar 2018.

Seladi-Schulman, J., Ph.D. (2018). “Vagus Nerve Overview” Healthline. Published 31 Jul 2018.

“Epilepsy Prevalence in the United States” Data and Statistics. Centers for Disease Control and Prevention (CDC). Published 2019.

“Treatment Options” Epilepsy Foundation. Published 14 Mar 2014.

“Types of Epilepsy Surgery” Epilepsy Foundation. Published 2019.  

            When we think about people who have epilepsy, like me for example, we think about people who have a neurological disorder in which their brain cell activity is interrupted, and this results in false electrical impulses which result in adverse sensations, convulsions, and even, loss of consciousness. In the United States, estimates state that, “3 million adults and 470,000 children” (CDC, 2019), have epilepsy. Some people with epilepsy can properly manage seizure control with effective treatment options while other people with epilepsy have difficulty with maintaining seizure control regardless of the treatment options that are available to them. Treatment options for people with epilepsy generally include the following: anticonvulsants (i.e. Depakote); vagus nerve stimulation (VNS) device implantation; and surgery in the most profound cases of epilepsy. What implications can these treatment options have in terms of medically managing the symptomatology of epilepsy in children and adults?

            The first time an adult or a child has a seizure, and a diagnosis of epilepsy is suspected, generally doctors and neurologists will recommend anticonvulsants as the first recommended treatment option. Anticonvulsants are medications used to control seizure activity, and to stabilize brain cell activity to promote effective neurological functioning in an adult or child. While for some people the first medication they are prescribed is the most effective for them, for others, they, “often need to try a few different antiepileptic (seizure-preventing) drugs before the right one is found” (Epilepsy Foundation, 2019). People with epilepsy on different anticonvulsants may experience a variety of side effects such as, but not limited to: nausea, drowsiness, dizziness, tremor, rash, and weight gain. In addition, anticonvulsants can deplete the production of proteins in the liver and kidneys which can affect the metabolism of an adult or a child. Doctors and neurologists, however, use labs to evaluate the adult or child’s hepatic function panel (labs used to evaluate the functioning of the liver and the kidneys) in correlation with the dosage of the anticonvulsant prescribed to specified individuals to avoid drug toxicity. The goal of treating adults and children with epilepsy with anticonvulsants (i.e. Depakote is one brand/kind of anticonvulsant), is to not only stabilize brain activity, but to also maintain the health of the liver and the kidneys. While anticonvulsants may not be an effective treatment option for every adult and child with epilepsy, doctors and neurologists, “achieve seizure freedom in about two-thirds of patients” (Perucca, Sheffer, Kiley, 2018).

            Adults and children who still experience seizures despite the trial of several anticonvulsants (doctors and neurologists recommend adults and children trying at least two different kinds of anticonvulsants), which were unable to effectively stabilize brain cell activity and control seizures, then doctors and neurologists can recommend other treatment options. One alternative treatment option is vagus nerve stimulation (VNS) device implantation. The vagus nerve is one of the twelve cranial nerves (cranial nerves are responsible for sending sensory information as well as connecting electrical signals from the brain to glands and muscles to various organs in the body to promote motion), and the vagus nerve, “runs all the way from the brain stem to part of the colon” (Seladi-Schulman, 2018). The vagus nerve sends sensory information to the ear, the throat, the larynx, the esophagus, the lungs, the trachea, the heart, and the digestive tract. The vagus nerve stimulates muscle movement in the throat, the larynx, the soft palate, the heart, the esophagus, the stomach, and the intestines. When an adult or child has epilepsy, when there is a disturbance to brain cell activity which causes a seizure, impairments in sensory processing and muscle movement may occur. However, vagus nerve stimulation (VNS) device implantation can be effective in stimulating brain activity to stabilize bodily functioning as well as to control or prevent seizures. In vagus nerve stimulation, a, “device is usually placed under the skin of the chest, where a wire connects it to the left vagus nerve. Once the device is activated, it sends signals through the vagus nerve to your brainstem, which then transmits information to your brain” (Seladi-Schulman, 2018).

            Surgery is another option for adults and children with ongoing seizures associated with epilepsy. Previously, I did explain about vagus nerve stimulation (VNS) implantation, but there are also several other surgical options in which people with epilepsy may consider as well such as the following: Focal Resection; Leisonectomy; Multiple Subpial Transcetions; Laser Interstitial Thermal Therapy; Anatomical or Functional Hemispherectomy and Hemispherotomy; Corpus Callosotomy; and Stereotactic Radiosurgery. What are the implications for each of the following surgical procedures for people with epilepsy? Focal Resection is, “Surgery that removes the area of the brain causing seizures” (Epilepsy Foundation, 2019). While this procedure may be an effective treatment option for people in which their seizures are located in one area of the brain, this procedure is, “reserved for people whose seizures rise from non-critical brain regions. Examples of critical brain regions include areas that control speech, movement, memory, and vision” (Epilepsy Foundation, 2019). People that have seizures in the frontal lobe, the occipital lobe, and the temporal lobe for example may not be the best candidates for this surgical procedure as trying to remove the section associated with one of these lobes may cause serious complications such as impaired memory and cognition, blurry or impaired vision, and difficulty with gait and motion. Temporal Lobe Resection, “is removing a portion of the temporal lobe of the brain” (Epilepsy Foundation, 2019). One of the benefits of this surgical procedure is that, “more than 85% will have a significant improvement in seizure control” (Epilepsy Foundation, 2019). However, removing a portion of the temporal lobe of the brain could cause some speech and hearing impediments to some individuals after they have this procedure. Frontal Lobe Resection involves, “removing an area in the frontal lobe where seizures begin” (Epilepsy Foundation, 2019). What should be noted about this procedure is that about, “70% of people who do have a great improvement in seizure control” (Epilepsy Foundation, 2019). However, in this situation, removing an area in the frontal lobe could promote some memory and cognition issues for individuals. Parietal and Occipital Lobe Resection is another surgical option for people with epilepsy who have, “a structural abnormality like a tumor of scar tissue” (Epilepsy Foundation, 2019). However, with this procedure, there could be issues with vision as well as sensory processing.

            A Leisonectomy is another option for people with epilepsy to remove a tumor or lesion in the area of the brain that is involved. Multiple Subpial Transections (MST), “are an alternative type of surgery that is used if seizures begin in a region of the brain that cannot be removed safely” (Epilepsy Foundation, 2019). In Multiple Subpial Transections (MST), “the neurosurgeon opens the skull and makes a series of fine shallow cuts (transections) into the brain’s gray matter just below the pia mater. The pia is a delicate membrane that surrounds the surface of the brain. The cuts (transections) work by interrupting fibers that are thought to be involved in the spread of electrical seizure activity” (Epilepsy Foundation, 2019). Laser Interstitial Thermal Therapy (LITT), happens when, “a MRI (magnetic resonance imaging) is used to precisely map out the exact area of the brain to operate on. Laser is then delivered with pinpoint accuracy to this area to eliminate the seizure focus. All of this is done without needing to open the skull, making it a minimally invasive procedure” (Epilepsy Foundation, 2019).

            Anatomical Hemispherectomy, “involves removing the frontal, parietal, temporal, and occipital lobes on one side of the brain” (Epilepsy Foundation, 2019). Functional hemispherectomy, “involves removing a smaller area of the affected hemisphere and disconnecting the remaining brain tissue” (Epilepsy Foundation, 2019). Hemispherotomy is a procedure in which, “the surgeon is making a hole or several holes in the hemisphere instead of removing large sections of the brain” (Epilepsy Foundation, 2019). The majority of people that undergo these procedures for epilepsy either regain seizure control, or they are seizure-free, which in fact is, “over 80%” (Epilepsy Foundation, 2019). People who have seizures who consistently fall on a regular basis may be a great candidate for a procedure called corpus calllosotomy. In Corpus callosotomy, the procedure involves, “splitting the main connection pathway between the two cerebral hemispheres (sides of the brain)” (Epilepsy Foundation, 2019). Stereotactic Radiosurgery is a surgical procedure in which, “focused radiation beams” (Epilepsy Foundation, 2019), are used to treat the area of the brain in which seizures occur. The goal of this procedure is for the surgeon to use a high dose of radiation to treat the area of the brain that is affected without damaging healthy tissue. People with epilepsy need to consider the symptoms and life implications that could occur as a result of undergoing one of these surgical procedures to treat the epilepsy. People with epilepsy should be advocates for themselves and do research and evaluate the pros and the cons of each procedure before going forward. While surgery could help to promote seizure control, these surgical procedures for epilepsy does not guarantee complete freedom of seizures.

            Adults and children with epilepsy have a variety of treatment options. However, I would agree with the doctors and neurologists that the first step to take when trying to manage seizure control is utilizing anticonvulsants, or antiepileptics, such as Depakote, to stabilize the brain cell activity to prevent disturbances to the electrical impulses that regulate the brain cell activity. Doctors and neurologists do need to monitor liver and kidney functioning of adults and children on anticonvulsants to avoid drug toxicity. However, in situations where multiple anticonvulsants have been tried by people with epilepsy; even in situations where people with severe epilepsy that significantly affects their ability to live independently are at risk of complications leading to potential injury or death, then doctors and neurologists could discuss surgical options to adults and children and determine the type of surgery that would best suit the adult or child depending on the specific type of epilepsy that they have. Medically managing epilepsy can be a complicated process, but it could benefit a lot of children and adults in the hopes of leading productive lives by seeking the best quality treatment possible.