Non-pharmacologic Treatments of Epilepsy: Neurostimulation, Surgery and Diet

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Non-pharmacologic Treatments of Epilepsy
Neurostimulation, Surgery and Diet

• Patricia Dean ARNP, MSN
• Miami Childrens Hospital
• Miami, FL

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Causes of Epilepsy

• Genetic
• Cortical malformation
• Inborn errors of Metabolism
• Infections
• Encephalitis
• Meningitis
• Trauma
• Vascular Malformations
• Tumors
• Cerebral vascular disease
• Degenerative disease

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Non-pharmacologic Treatments of Epilepsy
Neurostimulation, Surgery and Diet

• TWO TYPES OF EPILEPSY
• Generalized
• Focal

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PARTIAL SEIZURES

• Frontal Movement, inability to speak
• Temporal Automatisms, language disturbance,
  Behavioral arrest
• Parietal Tingling, numbness
• Occipital Lights, colors, visual
  hallucinations
• Secondarily All of the above followed by tonic
  Generalized clonic movements of both sides

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GENERALIZED

• Absence Brief staring with eye fluttering
• Atypical Absence Slightly longer with other
  features
• Atonic Loss of muscle tone
• Tonic Stiffening of muscles
• Clonic Rhythmic jerking of muscles
• Myoclonic Sudden twitching of muscle group
• Primary generalized Tonic followed by clonic
  movement at onset

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Non-pharmacologic Treatments of Epilepsy
Neurostimulation, Surgery and Diet

• Idiopathic
• Cryptogenic
• Symptomatic

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Treatment Modalities

• Anti-epileptic medications
• Surgery
• Neurostimulation
• Diet

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Epilepsy Treatment Options Antiepileptic Drugs
(AEDs)
1993
Tegretol Mysoline Depakote
Phenobarbital Dilantin Zarontin
TRILEPTAL Neurontin Zonegran Topamax Lyrica

• Felbatol
• Lamictal
• Gabitril
• Keppra

http//www.fda.gov - Accessed October 6, 2004.
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How Efficacious Are Anticonvulsants?
50 RESPOND TO 1st AED
30 OF PATIENTS REFRACTORY TO AED THERAPY
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Medically Refractory Seizures

• inadequate seizure control in spite of
  appropriate medical therapy with AEDS or
  adequate seizure control but with unacceptable
  adverse effects" (Shields, 1997)

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Medically refractory seizures

• Failure of 2 drugs
• Decision must be individualized
• Likelihood that surgery will work
• Risks of surgery
• Seizure frequency and severity

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Prognostic Indicators

• Frequent seizures
• Early seizure onset
• Secondary generalization
• Structural lesion
• Abnormal neurological status

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EPILEPSY SURGERY

• Treatment of last resort
• Earlier treatment of last resort
• Treatment of choice (sometimes)

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Surgery for Epilepsy

• Hemispherectomy Lobectomy Corpus
  Callosotomy

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Preoperational Testing

• Video electroencephalogram (VEEG)
• Neuropsychological evaluation
• MRI of brain
• Functional MRI
• Ictal SPECT
• PET
• MEG

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Surgery for Epilepsy

• Medically refractory seizures
• Consistent onset of localized epileptogenic focus
  or foci
• Epileptogenic focus or foci can be resected
  without causing neurological deficits

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Intracranial Electrodes

• Scalp EEG isnt always conclusive
• Epileptic area may be very close to or include
  areas of eloquent cortex
• Intracranial monitoring

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Intracranial Electrodes

• Electrodes wires are
• bundled and exposed
• through the skin
• Distal end of
• intracranial electrodes
• are connected to
• VEEG monitoring
• devices

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Temporal Lobe epilepsy

• 80 Adults with poorly controlled TLE
• (app. 70 Hippocampal Sclerosis)
• 1year wait for surgery in Canada
• Wieb et al NEJour 2001, 345 311-19

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Temporal Lobe Epilepsy

• Medical group 1 year wait before surgery
• N-40
• Surgical group expediated surgery within 4 weeks
  N-36

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Temporal Lobe epilepsy

• 64 were seizure free without loss of awareness
  at 1 year vs 8 in the medically treated group

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Temporal Lobe epilepsy

• Small thalamic infarct (1)
• Decreased Verbal Memory function (2)
• Wound infection (1)
• Asymptomatic visual field defect (22)
• 1 death in the medical group

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Surgical Series

• Seizure freedom gt90
  improvement
• Infants (Chugani 97) 65 13
• Infants (Wylie 98) 60 20
• Infants (Duchowny 98) 61 15
• Children (Wylie 98) 67 11
• Children (Paolichi 00) 59 19
• Adolescents (Wylie 98) 69 20
• Adults (Engle 98) 64 26

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Hemispherectomy

• Catastrophic cases
• Usually done when the person already has weakness
  on affected side
• Rasmussens encephalitis

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CorpusCallosotomy

• Disruption of one or more of the major central
  nervous system pathways used in the
  generalization or spread of seizures.
• Palliative
• Drop attacks

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VNS Therapy Implant Procedure

• The surgical procedure takes approximately 1 hour
• Performed under general anesthesia
• Often performed as an outpatient procedure
• Small chest/axillary border incision for pulse
  generator
• Neck incision for lead

A patient at 3 months
Epilepsy Patients Manual for Vagus Nerve
Stimulation with the VNS Therapy System,
Cyberonics, Inc. 2005.
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VNS Therapy

• The VNS is programmed over a number of visits
• Program algorithms have been established

For the full range of settings in relationship
to battery life, see the Physicians Manual.Data
on file. Cyberonics, Inc. Houston, TX.
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Efficacy Improves Over Time
Patients With ?50 Seizure Frequency Reduction
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Patients,
25
20
23
15
10
5
0
3 Months
1 Year
2 Years
3 Years
Morris GL, et al. Neurology. 1999531731-1735.
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Vagus Nerve Stimulator

• Low chance of seizure freedom
• Generally well tolerated
• Common adverse side effects
• Hoarseness
• Paresthesia
• Dyspnea
• Surgical Complications
• Vocal Cord Paralysis
• Infection

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Newer stimulation treatments

• Deep Brain Simulator Cortical Stimulator

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Deep Brain Stimulation

• DBS is a medical therapy in which an implanted
  device delivers electrical stimulation to regions
  deep in the brain.
• DBS is used to treat movement disorders such as
  tremor and Parkinsons disease
• DBS to treat epilepsy is in the early stages of
  research

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Deep Brain Stimulation

• Evidence from animal studies shows that the
  delivery of electrical stimulation ot certain
  brain targets can sometimes stop electrical
  hyperactivity, ending seizure symptoms that are
  underway.

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Deep Brain Stimulation

• The most recent reports in patients with
  refractory epilepsy
• suggest that deep
• brain stimulation and
• cortical electrical
• stimulation of the
• anterior thalamic nucleus
• and hippocampus may
• reduce seizure frequency
• in patients with refractory
• epilepsy.

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Cortical Stimulation

• The Responsive Neurostimulation System (RNS) is
  designed to detect abnormal activity in the brain
  and deliver small amounts of electrical
  stimulation to suppress seizures before there are
  any seizure like symptoms

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Deep Brain Stimulation

• One or two wires containing electrodes are placed
  on the seizure focus

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THE KETOGENIC DIET

• The Ketogenic Diet is a high fat low
  carbohydrate/adequate protein, low calorie diet
  used as a non-drug treatment for epilepsy.

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THE KETOGENIC DIET

• Classic Ketogenic Diet
• Medium Chain Triglyceride
• Modified Medium Chain Triglyceride

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THE KETOGENIC DIET

• Children who have failed multiple antiepileptic
  drugs (AEDs) or find the side effects of AEDs
  intolerable are candidates for the diet.

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THE KETOGENIC DIET

• OPTIMAL SITUATION
• RESOURCE TEAM
• FAMILY UNIT
• MYOCLONIC/ATONIC SEIZURES
• lt10 YEARS OF AGE

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THE KETOGENIC DIETPARAMETERS FOR CALCULATION
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THE KETOGENIC DIET

• Acidosis
• disappears after several weeks
• ph not related to seizures
• Dehydration
• Removal of sodium from the body

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THE KETOGENIC DIET

• Calculate caloric need (75 RDA)
• 15kg child X 68cal/kg/d1000 cal day
• Calculate the number of dietary units needed per
  day
• 41 diet each unit 40 cal
• 1g fat9 cal 1g protein or carb4 cal
• (1000 cal/d)(40cal U)25 U
• 25U/d X 4g U cal100g/d

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THE KETOGENIC DIET

• Protein Carb 25U/d X 1gU25 g/d
• Protein requirement 1g/kg/d x1515g/d
• Carbohydrates 25g/d-10g/d

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THE KETOGENIC DIET

• Divided into three meals
• Food g/d cal/d g/meal
• FAT 100 900 33.3
• PROTEIN 15 60 5.0
• CARBS 10 40 3.3

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THE KETOGENIC DIET

• Medium Chain Triglyceride
• 60 cal given as oil
• 71 given as fat instead of 87
• 10 protein 19 carbohydrate
• Modified Medium Chain Triglyceride
• 30 medium chain triglyceride oil
• 40 long chain saturated fats
• 10 Protein 19 Carbohydrates

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Ketogenic meals from various countriesAdapted
from Kossof McGrogan Epilepsia, 46 (2)280-289

• Singapore South Africa
• 8g Beehoon 160g gemsquash
• 17g pork,boiled 8g fish bitlong
• 20 cabbage 2g butter
• 33g sesame oil 160g Orley whip
• (364 kcal,2.51) (442 kcal, 41)
• Sweden United States
• 29g octupus 41g Beef Frank
• 9g canola oil 11.7g Strawberries
• 11g crème fraiche Iceberg lettuce
• 3g tomato sauce 11.4g Margarine
• 34g calogen 40g Heavy Whipping Cream
• 1g omega-3 (356kcal, 41)
• 14g squash
• 10g tomato
• (460 kcal, 3.71)

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Ketogenic Diet

• Should be initiated in hospital
• Screening-CBC, Chemistry profile, EEG
• Close follow up
• All carbohydrates need to be included in dietary
  calculations..Medications, tooth paste

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Ketogenic Diet

• Decrease in linear growth
• Menstrual irregularites
• Acidosis
• Increased LFTs
• Proteinuria
• Hypokalemia
• Hyperlipidemia
• Bruising
• Macrocyticanemia
• Prolonged QT interval
• Kidney stones
• Fractures

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THE KETOGENIC DIET

• Complete seizure freedom 20-30
• Improvement 60-80
• No improvement 20-40

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Newer dietary treatments

• Modified Atkins
• Low Glycemic Index

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Modified Atkins

• Absence of protein, fluid, or calorie restriction
• 64 fat
• 30 protein
• 6 carbohydrate

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Modified Atkins

• 58 children
• 34 (59) have had a gt50 reduction in seizures at
  6 months

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Adult data

• Ketogenic diet study Jefferson Hosp Philadelphia
• 11 adults age 19-45
• At 8 months 6 (55) had gt50 reduction
• 3 (27) had gt90 reduction
• Modified Atkins JohnsHopkins Baltimore
• 30 adults
• 47 gt50 reduction

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Low Glycemic Index Treatment

• Developed in 2002 as an alternative medical
  nutrition therapy to the ketogenic diet
• The LGIT monitors not only the total amount of
  carbohydrates consumed daily, but focuses on
  carbohydrates that have a low glycemic index
• The glycemic index refers to how high that food
  raises your blood glucose after ingestion
  compared to a reference food such as sugar

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Low Glycemic Index Treatment

• HIGH 70 and above
• MEDIUM 55-69
• LOW 55 and under

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Low Glycemic Index Treatment

• Allows for increased intake of carbohydrates
  40-60 grams a day
• Food not weighed, based on portion sizes
• Percentage of calories derived from fat 60

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Low Glycemic Index Treatment

• 2005 study at Mass General
• Ten of 20 patients treated with this regimen
  experienced a greater than 90 reduction in
  seizure frequency.

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Summary

• Patients need to be offered various treatment
  options. If medication is not working they need
  to be referred to a Comprehensive Epilepsy Center
  sooner rather than later.