Epilepsy Care Brochure Inserts

NON-EPILEPTIC SEIZURES/ EVENTSNon-epileptic events have many names, including non-epileptic seizures, dissociative attacks, functional seizures, psychogenic non-epileptic events or psychogenic seizures. These events are quite disabling and look very similar to epileptic seizures. They can involve anything from ‘zoning out’ to fully blacking out and having violent movements similar to epileptic seizures.

However, unlike epilepsy, they are not caused by abnormal electrical firing in the brain. They are due to a temporary problem in how the brain is communicating within itself. This makes it difficult, or in many cases impossible, to stay awake or aware and control what the body is doing during an event.

To diagnose non-epileptic events, an EEG is done while the person is having one of these spells. The EEG will show normal brain activity during the event. Other tests may also be done, such as MRIs, and are usually normal.

Treatment for non-epileptic events is very different than treatment for epilepsy. Because the cause is not abnormal electricity, medications used for epilepsy will not work. Many patients with non-epileptic events have associated psychiatric problems such as depression or anxiety for which separate treatment may be needed. Learning biofeedback and going to a therapist who specializes in Cognitive Behavioral Therapy is the most effective known treatment for non-epileptic events. With treatment, people can learn to postpone, prevent, or even completely stop their events from happening.

Please visit www.neurosymptoms.org for more information on this disorder.

TEMPORAL LOBE EPILEPSYThe temporal lobes of the brain are behind the temples. They process hearing and memory. Specifically, the one on the left – or language-dominant – side helps to understand language and to retrieve verbal, i.e. language-related, memory.

Temporal lobe epilepsy is the most common epilepsy in adults. Seizures that originate in a temporal lobe can cause the following symptoms:

» A brief warning with an unusual feeling in the head or stomach, an unexpected taste or smell, fear or anxiety, a sense of confusion or that things are suddenly more familiar or unfamiliar

» Difficulty speaking or understanding language

» Loss of awareness and unresponsiveness, without collapsing

» Blank stare, lip-smacking, or fumbling

» Stiffening of one hand and extreme head turn

» Progression to a convulsion

» Afterwards, a period of confusion and inability to remember what happened

The seizures can occur at any time, even in sleep. They often start from one of the memory centers, the hippocampus, deep inside the temporal lobe. This is why people with temporal lobe seizures can develop severe memory problems, especially, when the seizures cause scarring with-in the memory center, which is termed “hippocampal sclerosis”. Once the tissue is visibly scarred the seizures are often difficult to control with medication alone and surgery should be considered.

FRONTAL LOBE

TEMPORAL LOBE

BRAINSTEM

CEREBELLUM

PARIETAL LOBE

OCCIPITAL LOBE

FRONTAL LOBE EPILEPSYThe frontal lobes of the brain are behind the forehead. In each half of the brain, the frontal lobe is the largest part. It controls movement on the opposite side of the body and it influences behavior. One of the frontal lobes also contains language function, usually the left.

Given the functions of the frontal lobe, seizures that start within it can cause:

» Abnormal, involuntary movements, such as stiffening, or jerking of the whole body or just a part of the body, e.g., one arm

» Yelling (vocalization), flailing, chaotic or bizarre movements of limbs on both sides of the body

» Difficulty speaking

» Loss of consciousness and progression to a convulsion

» Afterwards, the person may temporarily experience weakness in the primarily affected limb or side of the body

The seizures often occur during sleep, they are short, but they can cluster, i.e. seizures happen repeatedly, one after another.

Depending on the features of a seizure very different parts of the frontal lobe are suspected to be involved in the seizure onset. If surgery is considered, invasive monitoring frequently precedes any removal of brain. Invasive monitoring with implanted electrodes helps to determine the exact seizure onset area and to identify areas essential for motor and language function.

FRONTAL LOBE

TEMPORAL LOBE

BRAINSTEM

CEREBELLUM

PARIETAL LOBE

OCCIPITAL LOBE

PARIETAL LOBE EPILEPSYThe parietal lobes of the brain are located behind the frontal lobes and are responsible for processing all sensation, each from the opposite side of the body. For example, any feeling from the right side of the body is registered in the left parietal lobe. In addition, the left – or language-dominant – parietal lobe helps to understand language.

Seizures that originate in a parietal lobe can cause the following symptoms:

» A brief warning with an unusual feeling, e.g., tingling in one part of the body, or dizziness

» Difficulty speaking or understanding language



» Afterwards, a period of confusion and inability to remember what happened, and occasionally numbness in the limb or body part in which the seizure sensation started

The seizures can occur at any time of day. If surgery is considered, invasive monitoring frequently precedes any removal of brain. Invasive monitoring with implanted electrodes helps to determine the exact seizure onset area and to identify areas essential for sensation and language function.

FRONTAL LOBE

TEMPORAL LOBE

BRAINSTEM

CEREBELLUM

PARIETAL LOBE

OCCIPITAL LOBE

OCCIPITAL LOBE EPILEPSYThe occipital lobes of the brain are at the back of the head and process vision. Each occipital lobe is responsible for the opposite visual field of both eyes, i.e., the right occipital lobe registers the left visual field of both eyes.

Seizures that originate in an occipital lobe can cause the following symptoms:

» Unusual visual symptoms such as stars, sparks, flashing lights, or sometimes visual hallucinations (seeing things that aren’t there)

» Severe headache, sometimes with nausea and vomiting



» Afterwards, a period of confusion and inability to remember what happened, and occasionally difficulty seeing affecting just one side

The seizures can occur at any time of day. If surgery is considered, invasive monitoring frequently precedes any removal of brain. Invasive monitoring with implanted electrodes helps to determine the exact seizure onset area and to identify areas essential for vision. If an occipital lobe is taken out, the person can still see with both eyes, but he or she can’t perceive things as well in the visual field opposite the surgery. This can interfere with driving.

FRONTAL LOBE

TEMPORAL LOBE

BRAINSTEM

CEREBELLUM

PARIETAL LOBE

OCCIPITAL LOBE

NEUROPSYCHOLOGICAL TESTINGTHE ROLE OF NEUROPSYCHOLOGICAL TESTING IN THE EPILEPSY SURGERY EVALUATION PROCESS

Neuropsychology focuses on cognitive functioning (thinking, memory, and learning). During testing, several different types of cognitive skills are assessed, including intellectual functioning, attention, information processing speed, reasoning, problem solving, learning and memory, language, visual-spatial skills, and motor functioning.

People with epilepsy may experience memory and word finding difficulties. In addition, medication side effects and depression may interfere with functioning, typically affecting attention, processing speed, learning and memory.

The first goal of neuropsychological testing in the surgical evaluation process is to collect additional information that may help determine where in the brain seizures are originating. The second goal is to establish a “baseline” before surgery, and to make predictions about potential post-surgical cognitive changes. After surgery, we re-administer our tests and make a direct comparison, to detect any improvement or problem.

The Day of TestingMake sure that you sleep well the night before the test and try not to worry about it. We ask that you come prepared to spend most of the day with us, dress comfortably, and take all of your medications on your regular schedule.

You will meet with the neuropsychologist who will conduct a detailed interview. We want to learn about your current difficulties; medical, neurological, and psychiatric history; your social history; and your social support network. A trained psychometrist will then administer a long battery of neuropsychological tests. You will also be asked to fill out a few short questionnaires. There is nothing invasive about our testing (no needles, no electrodes, etc.). The interview usually lasts one hour; the testing portion of the evaluation typically lasts between three and five hours.

We get our best information by “testing your limits”. This means that many of our tasks start out easy, but get harder and harder until you will not be able to answer questions correctly. Everyone performs somewhere “in the middle”. All you need to do is try your best. You don’t need to study and you cannot fail.

WADA TESTThis test uses a combination of brain imaging and neuropsychological testing to help identify which half of the brain, the left or right, is responsible for language and memory. It is an angiographic procedure during which the brain is approached through blood vessels. A catheter is guided from the groin to the neck and an anesthetic is injected in one half of the brain, putting it to sleep for a few minutes. The other side of the brain must then take over and is subjected to memory testing. This helps us to determine how each side of the brain performs with respect to memory and language.

The test is an invasive procedure and carries a 1% to 2% risk of a stroke. Therefore, we only do this test when absolutely necessary.

A Wada test takes about 2 hours, but preparation before and observation after the test takes additional time. Prepare to be at the hospital for a whole day. Take your regular medications before the test.

POSITRON EMISSION TOMOGRAPHY (PET)Positron Emission Tomography (PET) scanning is an imaging technique that tells us how the brain is functioning. We use this information to help us understand where seizures originate. A PET scan is an outpatient test which gives us a picture of how the brain works between seizures.

Areas of the brain that trigger seizures have a lower metabolism and therefore take up less sugar (glucose) than normal brain. For a PET, a low, safe dose of radioactively labeled sugar (called fluoro-deoxy-glucose or FDG) is injected and allowed to accumulate in the brain. A scan taken about 30 minutes later shows us which part of the brain is using less sugar. These areas with lower metabolism – compared to healthy brain – are potentially the areas where seizures start. The sugar decays quickly and there are no harmful effects for you or your family.

This is an outpatient test and takes about two hours.

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT)Single Photon Emission Computed Tomography (SPECT) is used to help us identify the area of the brain that triggers seizures. It is a test done in the Electrodiagnostic Monitoring Unit and requires admission to the unit for several days.

Two different SPECT scans are needed: one during a seizure (ictal) and one at baseline (interictal). During a seizure, blood flow is increased in the part of the brain that generates the seizure. We inject a small amount of radioactive tracer in a vein as close to the beginning of a seizure as possible, and the tracer collects in the region of the brain where the seizure starts. We can then take a picture of your brain to see where the tracer has gathered. We compare that picture to a second image that is taken when you are not having a seizure to accurately interpret the study.

MAGNETOENCEPHALOGRAPHY (MEG)The University of Colorado Comprehensive Epilepsy Center is one of only a few top-ranked National Association of Epilepsy centers (NAEC) offering magnetoencephalography (MEG). MEG is similar to EEG. It records the brain’s electrical activity and then combines it with MRI to show the exact location of abnormal brain signals.

Our team uses the data obtained with MEG, and other tests, to guide us to the precise location of the area that starts seizures.

It is an outpatient test and takes about two hours to complete.

INTRACRANIAL MONITORING – PHASE 2 MONITORINGIntracranial monitoring refers to seizure monitoring done with electrodes placed inside the skull, on the surface of the brain. This is not done on all patients being evaluated for epilepsy surgery, but only when the seizure onset is not clear after regular monitoring with scalp EEG (“Phase 1”). Intracranial electrodes are placed by a surgeon in the operating room with the patient asleep under general anesthesia. The electrodes are put over the areas of the brain where the seizures are expected to start. Then patients are monitored again in the Electrodiagnostic Monitoring Unit (EMU) to determine the seizure origin. This typically takes several days, and afterwards the seizure onset area is removed along with the electrodes. Monitoring with intracranial electrodes is the most precise way of localizing the seizure onset.

In addition to allowing for exact localization of the seizure origin, intracranial electrodes can help in identifying critical functional areas of the brain. By using the intracranial electrodes to stimulate the brain, regions that are controlling speech and movement can be identified and avoided in a later surgery. This procedure is called cortical mapping (or functional mapping).

Identifying the area of seizure origin that needs to be removed and the areas of critical brain function that need to be preserved leads to the best possible seizure outcome and prevents neurologic deficits after surgery.

The neurologists and neurosurgeons at the Comprehensive Epilepsy Center at the University of Colorado Hospital have extensive expertise in evaluating patients and performing intracranial monitoring.

CORTICAL MAPPINGWhen we are considering a neurosurgical resection of the surface of the brain, an important goal is to avoid removing areas that serve important activities and cannot easily be taken over by other parts of the brain. We pay particular attention to regions that control motor and language function. The location of these areas is fairly predictable in a normal brain, but in the presence of an underlying problem, such as a tumor or another abnormality causing epileptic seizures, the “normal” location can shift. If the tissue that needs to be removed is near one of these important areas, we perform cortical mapping to precisely locate areas that control motor or language function to avoid them during surgery.

For language mapping, the patient is given language tasks such as speaking, reading, naming items on pictures, and following commands. When areas that control these functions are electrically stimulated, the patient will not be able to speak or complete the task. During motor mapping, the electrical stimulation leads to stiffening or twitching of the body part that is controlled by that part of the brain.

By using these techniques, we can more safely remove an adequate amount of abnormal brain. In the case of epilepsy surgery, these techniques result in a higher percentage of patients becoming seizure-free. In case of tumors, they promote better tumor resection and better long-term outcomes.

This testing may be done in the operating room with the patient awake, just prior to the actual surgery. If we have implanted electrodes to monitor seizures, it can be done at the bedside.

PREFRONTAL AREA

PREMOTOR AREA

PRIMARY MOTOR CORTEX

CENTRAL SULCUS

PRIMARY SOMATOSENSORY

CORTEX

VISUAL ASSOCIATION

AREA

PRIMARY VISUAL CORTEX

SENSORY LANGUAGE AREA

(WERNICKE’S AREA)PRIMARY

AUDITORY CORTEX

AUDITORY ASSOCIATION

AREA

MOTOR LANGUAGE AREA (BROCA’S AREA)

LASER SURGERYLaser surgery is a newer minimally invasive surgical technique which can be used in patients who have small (2 cm diameter) lesions that cause seizures. With a guidance system (stereotactically), through a small hole in the skull, a laser tip is placed in the middle of the target area. Then, high energy from the laser burns the lesion from within. The amount of energy transferred is monitored by MRI to allow precise control of the laser. The destruction of the lesion by heat is called thermal ablation. Because there is only a small surgical wound, there is less risk, and the length of stay is reduced. Recovery times are expected to be faster than with regular brain surgery.

EPILEPSY SURGERY – PHASE 2 MONITORINGWHAT TO EXPECT AND INSTRUCTIONS

Step I: Phase 2 Monitoring: » On the afternoon before your surgery, if you haven’t already been called, between 2 p.m. and 4 p.m. call

720-848-6070 to find out the time of your surgery and when to check in. Generally, this is two to three hours prior to the surgery start time.

» For 7–10 days prior to surgery we will ask you to stop taking aspirin, aspirin products or other medications that may increase your bleeding risk. You will also be asked to use an antibiotic ointment in your nose and Hibiclens body wash. This is to help reduce your infection risk.

» Check In: On the day of surgery, go to the Anschutz Inpatient Pavilion, follow signs to AIP 2 and Elevator E. Take Elevator E to the 2nd floor and go to Room 2.604 to check in.

» Pre-op Unit: Following check in, you will be brought to the Pre-op Unit, change into a hospital gown, and have an intravenous line started. During this time, one of the neurosurgery residents will be placing markers (stickers) on your head.

» Radiology: You will be brought to Radiology for a Computerized Tomography (CT) scan and a Magnetic Resonance Imaging (MRI) scan.

» Operating Room: You will be transported to the operating room. In the OR we will give you a bad haircut. We will buzz the portion of your head where we will be operating. In the surgery we will make an incision through your skin and remove a portion of your skull. Then we will place electrode grids and strips onto the surface of your brain. Prior to leaving the OR we will put the skull back in place and suture your skin back together, but you still will have the tails of the electrodes coming out near your incision.

» Recovery: You will be taken to the Post Anesthesia Care Unit (PACU) where you will recover under close observation for about two to three hours. You will then be brought to the Neurosurgical Intensive Care Unit (Neurology ICU), likely for one night, prior to moving you to the monitoring unit (EMU).

» Post-op MRI: Within the first 24 hours you will be taken back to Radiology for a post-operative CT and MRI. These will help us map the placement of the electrode grids and strips.

EMU Monitoring: » Within 24 hours of placing the electrode grids and strips you will be hooked up to the EMU monitors and the epilepsy

neurologist will begin to wean you from your anti-seizure medications.

» Over the next week you will be closely monitored and any seizures you have will be analyzed and carefully mapped. PLEASE NOTE: our hope is to capture your normal seizures within the first five to seven days after the electrodes have been placed, but occasionally this can take longer.

» At the conclusion of the monitoring one of two things will happen: 1. We will have gathered all the appropriate information and we will feel confident that your seizure focus is operable, at which point we will discuss resection surgery, or 2. We will have gathered all the appropriate information and we feel that your seizure focus is not operable.

» If you are not a candidate for surgery we will take you back to the OR to remove the grids and strips. You will then spend at least one more night in the hospital prior to discharge (see discharge section below for more information).

Step II: Resection Surgery

» If you are a candidate for resection surgery, we will review our findings and our plan in detail with you and your family or support persons and if you agree to resection surgery we will have you sign consent forms and put you on the schedule for surgery.

» Operating Room: You will get another set of scans for the operation and then you will be transported to pre-op and the OR. In the OR we may have to make your haircut worse. In the surgery we will re-open your incision and once again remove the portion of your skull that we took out previously. Then we remove the part of your brain that is causing the seizures. Before leaving the OR we will put the skull back in place and suture your skin back together. When you leave the OR, your head will be wrapped with bandages.

» Recovery: You will again be taken to the PACU where you will recover under close observation for about two to three hours. You will then be sent to the Neurosurgical ICU, likely for just one night, prior to moving you to the regular floor.

» Post-op MRI: Within the first 24 hours you will be taken back to Radiology for a post-operative CT and MRI. These scans will help determine if there is any bleeding or complications from the surgery.

» Hospital Stay: Typically patients stay in the hospital for three to four days before being discharged home.

Discharge from University of Colorado Hospital

» You will be discharged with a prescription for pain medications and steroids, if needed, and with instructions to take your anti-seizure medications.

» Keep your incisions dry until sutures are removed in about two weeks. We encourage bathing/showering, but the incision must be kept dry by using a sponge or washcloth, a hand-held showerhead, or by covering it with a waterproof bandage.

» We recommend that you leave your incision open to air. You do not need to put ointment or cream on the wound. If you are concerned about the cleanliness of an environment or you would rather not be seen in public with an incision, you may cover it loosely with a clean cotton hat.

Approximately 14 Days Post-op

» You will return to the neurosurgery clinic for a post-operative visit and to have sutures removed.

» You will also have a follow-up examination in the neurology clinic.

Approximately 6 Months Post-op

» Follow up EEG

» Follow up neuropsychological testing

Expected Results from Surgery:

» If you were a candidate for resection surgery, our hope is that by doing the surgery we will be either stopping your seizures or reducing their frequency. You will need to continue to take your anti-seizure medications. Depending on your results, medications may be weaned about 1 to 2 years after your surgery.

» If you were NOT a candidate for resection surgery, you will remain on your current anti-seizure medications and your neurologist and neurosurgeon will discuss the next steps in treatment.

Abbreviations:AIP: Anschutz Inpatient Pavilion; CT: Computerized Tomography; EMU: Electrodiagnostic Monitoring Unit; ICU: Intensive Care Unit; IV: Intravenous; MRI: Magnetic Resonance Imaging; OR: Operating Room

EPILEPSY SURGERY – RESECTIONWHAT TO EXPECT AND INSTRUCTIONS

Resection Surgery: » On the afternoon before your surgery, if you haven’t already been called, between 2 p.m. and 4 p.m. call 720-848-

6070 to find out the time of your surgery and when to check in. Generally, this is two to three hours prior to the surgery start time.

» For 7–10 days prior to surgery we will ask you to stop taking aspirin, aspirin products or other medications that may increase your bleeding risk. You will also be asked to use an ointment in your nose and Hibiclens body wash. This is to help reduce your infection risk.

» Check In: On the day of surgery, go to the Anschutz Inpatient Pavilion, follow signs to AIP 2 and Elevator E. Take Elevator E to the 2nd floor and go to Room 2.604 to check in.

» Pre-op Unit: Following check in, you will be brought to the Pre-op Unit, change into a hospital gown, and have an intravenous line started. During this time, one of the neurosurgery residents will be placing markers (stickers) on your head.

» Radiology: You will be brought to Radiology for a Computerized Tomography (CT) scan and a Magnetic Resonance Imaging (MRI) scan.

» Operating Room: You will be transported to the OR. In the OR we will give you a bad haircut. We will buzz the portion of your head where we will be operating. In the surgery we will make an incision through your skin and remove a portion of your skull. Then we will remove the part of your brain that is causing the seizures. Prior to leaving the OR we will put the skull back in place and suture your skin back together. When you leave the OR, your head will be wrapped with bandages.

» Recovery: You will be taken to the Post Anesthesia Care Unit (PACU) where you will recover under close observation for two to three hours. You will then be moved to the Neurosurgical Intensive Care Unit, likely for just one night, prior to moving you to the regular floor.

» Post-op Scan: Within the first 24 hours you will be taken back to Radiology for a post-operative CT and MRI. These scans will help determine if there is any bleeding or complications from the surgery.

» Hospital Stay: Typically patients stay in the hospital for three to four days before being discharged home.


» You will be discharged with a prescription for pain medications and steroids, if needed, and with instructions to take your anti-seizure medications.

» Keep your incisions dry until sutures are removed in about two weeks. We encourage bathing/showering but the incision must be kept dry by using a sponge or washcloth, a hand-held showerhead, or by covering it with a waterproof bandage.

» We recommend that you leave your incision open to air. You do not need to put ointment or cream on the wound. If you are concerned about the cleanliness of an environment or you would rather not be seen in public with an incision, you may cover it loosely with a clean cotton hat.



» You will also have a follow-up examination in the neurology clinic.

Approximately 6 Months Post-op

» Follow-up EEG

» Follow-up neuropsychological testing


» After resection surgery, our hope is that your seizures will stop or their frequency will be reduced. You will need to continue to take your anti-seizure medications. Depending on your results, you may be weaned off medications about 1 to 2 years after your surgery.

Abbreviations:AIP: Anschutz Inpatient Pavilion; CT: Computerized Tomography; ICU: Intensive Care Unit; IV: Intravenous; MRI: Magnetic Resonance Imaging; OR: Operating Room; PACU: Post Anesthesia Care Unit

VNS SURGERY WHAT TO EXPECT AND INSTRUCTIONS

Vagus Nerve Stimulator (VNS) Surgery: » Check in: On the day of surgery, go to the Anschutz Inpatient Pavilion, follow signs to AIP 2 and Elevator E. Take

Elevator E to the 2nd floor and go to Room 2.604 to check in.

» Pre-op Unit: Following check in, you will be brought to the Pre-op Unit, change into a hospital gown, and have an intravenous line started.

» Operating Room: From the Pre-op area you will be transported to the OR. In the OR we will remove any hair from your neck and chest area. In the surgery we will make an incision on your neck to gain access to your Vagus nerve and on your chest to make an area under your skin for the battery. Once we get to the nerve in your neck, we will attach the stimulator wire. Then we will tunnel the tail of the wire under your skin to your chest and connect it to the battery. Prior to leaving the OR, the incisions on your neck and chest will be closed with sutures. At the conclusion of your surgery, all components of the stimulator will be under your skin.

» Recovery: You will be taken to the Post Anesthesia Care Unit (PACU) where you will recover under close observation for several hours. We expect that you will be discharged home the same day.


» Most patients are discharged the same day.

» You will be discharged with a prescription for pain medications, if needed, and with a prescription for antibiotics. It is critical that you take your antibiotics as directed and that you finish the entire supply.

» Keep your bandage on for three days. Leave the steri strips over your chest incision in place.

» Keep your incisions dry until sutures are removed in about two weeks. We encourage bathing/showering but the incision must be kept dry by using a sponge or washcloth, a hand-held showerhead, or by covering with a waterproof bandage.

» We recommend that you leave your incision open to air. You do not need to put ointment or cream on the wound.



» You will also have a follow-up visit in the neurology clinic.

» From then on, you will have the VNS setting increased about every two weeks for approximately six visits.


» VNS does not cure epilepsy; only 5% to 10% of patients will be seizure free, but for many people it can help reduce the frequency and severity of seizures. It can also be used to help interrupt and stop seizures.

» The VNS delivers pulsed stimulation. During the “pulse-on” time, it is very common that your voice will sound hoarse. When the pulse ends your voice should return to normal.

RESPONSIVE NEURO-STIMULATION (RNS)

Responsive Neuro-Stimulation (RNS, Neuropace©) is a stimulation technique in which electrodes are placed directly on or in the brain and remain there in order to stimulate brain areas that have been found to trigger seizures. The stimulation is aimed at interrupting seizures and was shown to reduce seizure frequency.

The electrodes have to be placed with a good understanding of where the seizure starts from and most patients will need invasive seizure monitoring to identify the area or areas.

Documents

Epilepsy Care Brochure Inserts