Epilepsy – Accurate
Diagnosis is Half the Battle

One third of epilepsy patients suffer from uncontrollable seizures or severe toxic reactions to current medications. “Despite advances in epilepsy treatment, there is a large, needy group of
patients who do not respond to current therapies,” says Robert Fisher, MD, PhD, director of the Stanford Epilepsy Center.

Epilepsy affects nearly one percent of the U.S. population, or about 1 in 100 people. And while the majority of these individuals
can be managed successfully with existing medications and treatments, there is a subset of patients seizing uncontrollably, losing their drivers’ licenses, injuring themselves from seizures, and generally living in fear of their illness. “It’s not a good life,” explains Fisher.

These are the patients who are most often referred to the Stanford Comprehensive Epilepsy Center. Stanford treats several thousand patients each year, with a special focus on patients whose seizures are not controlled by drugs or whose
side effects render anti-epileptic drugs unworkable. Stanford
provides comprehensive clinic and outpatient care, testing,
neuro-imaging and surgical services. “Our goal is to help patients
gain control of their seizures and optimize their quality
of life,” adds Fisher.

Advanced diagnostics uncover epilepsy’s imitators
“One of the most challenging aspects of epilepsy is its diagnosis,” says Fisher. “We can empathize with busy community
neurologists and primary care physicians who in the course
of their busy practices must sort out the root causes of a patient’s
unpredictable and potentially devastating episodic
seizures.”
The Epilepsy Center at Stanford can help community physicians determine the underlying cause of their patient’s epilepsy, or determine whether the patient suffers from epilepsy or one of its many imitators. “Other disorders such as fainting spells, sleep disorders, hypoglycemia, psychological episodes, and complicated migraines can all mimic the symptoms of epilepsy,” he explains. Some of the time, when epilepsy is not responding to available treatments, it’s because the patient actually suffers from an imitator of epilepsy. These patients may have been on antiepileptic medications inappropriately for decades for conditions that are not, and never were, seizures.

These imitators of epilepsy can be very difficult to distinguish
from seizures. To get at an accurate diagnosis, physicians in
the Stanford Epilepsy Center conduct an extensive intake visit
and perform neurologic exams and routine tests.

If there is any question whether the patient has epilepsy or
one of its many imitators, Stanford will admit the patient into
its inpatient Epilepsy Monitoring Unit (EMU). Computer-enhanced
video EEG monitoring is used to determine what type
of epileptic seizures patients are having, if patients are indeed
having more seizures than recognized, and to localize where
seizures come from in the brain. Imaging technologies may
show a cause for the seizures. “We have technologies available
to visualize pathways and abnormalities in the brain that
are not detectable with standard imaging technology,” notes
Fisher.

Advanced treatment options
For a small group of patients with epilepsy, a surgical “cure” is a real option. “If we discover and can map that the seizures all come from one spot in the brain, called the seizure focus, and that seizure focus is not in a critical speech, motor or sensory area of the brain, then surgery may cure the epilepsy and turn somebody’s life around,” Fisher explains. “But a very small
percentage of patients are ideal candidates for this surgery.”
Even a large center like Stanford only conducts about 30 epilepsy
surgeries per year.

Other patients may benefit from treatment with vagus nerve
stimulation (VNS), which is designed to prevent seizures by
sending regular, mild pulses of electrical energy to the brain
via the vagus nerve. It is currently the only approved device
for epilepsy treatment. “But, it only helps about half of the people
who try it,” says Fisher. “That’s why my main area of interest
is developing new devices to treat epilepsy.”

To that end, Fisher and his colleagues at Stanford have completed two pivotal studies using electrical stimulation of the brain to control seizures.Much like deep brain stimulation (DBS) is used to control movement in patients with Parkinson’s disease, DBS is being applied to a different part of the brain in epilepsy patients. This new treatment is currently under review by the FDA.

Fisher is also testing a new way of delivering drugs by a
catheter implanted directly in the brain. The goal is to target
high doses of medications to the seizure focus in the brain
through a pump, without intoxicating the entire body with medication.

For women who want to have families, epilepsy poses a difficult challenge; anti-seizure medications are known to increase
the risk of birth defects. Stanford has a world renowned expert
on women and epilepsy, Martha Morrell, MD, on staff. She
works with patients to manage their medications during pregnancy to improve their safety and decrease the risk of birth
defects. Dr. Kevin Graber is studying the ways that brain injuries
can lead to epilepsy, in hopes that the epilepsy could
be prevented rather than just suppressing seizures once they
have emerged. Dr. Joseph Parvizi is studying why people behave
as they do during a seizure, by analyzing the brain circuits
involved. Dr. John Barry is an expert on the overlap between
epilepsy and psychiatric conditions. The team is complemented by three experienced neurosurgeons, Drs. Lawrence Shuer, Michael Edwards and Jaimie Henderson, and several indispensable nurse clinicians, neuropsychologists and
technologists. Stanford remains one of the world’s leading centers for basic epilepsy research, under the direction of David
Prince, John Huguenard and Paul Buckmaster.

Although medications remain the mainstay of epilepsy treatment
today, finding the right combination and dose can sometimes
be difficult. “None of these medications is yet the magic
bullet,” says Fisher. “But every new medicine might present
hope for those patients who don’t respond to anything
else.”