Welcome to the TBI-HELP Live Chat
Today's topic is: "Post Traumatic Epilepsy"
Our Guest is: Dr. Neil
Schaul, Director of the Comprehensive Epilepsy Center at New York Hospital
[19:01:42] Mod: Good evening everyone! Welcome to our moderated chat session. Tonight we are very happy to have Dr. Neil Schaul, Director of the Comprehensive Epilepsy Center at New York Hospital as our guest. Welcome Dr. Shaul!
[19:04:46] DrSchaul: It is nice to be here this evening - hopefully this will be a relaxed and open chat
[19:05:05] Mod: What is epilepsy? Ans what is the difference between seizures and epilepsy?
[19:05:51] DrSchaul: Epilepsy comes from the greek word "epilepsia" and means "taking hold of or seizing".
Most people define epilepsy as recurrent seizures (more than 1).
A seizure is a phenomena induced by the abnormal discharge of brain cells (neurons); the discharge can cause movement (shaking) or even just a change in thought processes
[19:08:33] Mod: Can epilepsy be induced by TBI or is it that we all have it and the TBI removes the Brain's ability to control it?
[19:09:19] DrSchaul: TBI can cause seizures - the mechanism responsible is not fully known. TBI accounts for about 4% of all the epilepsies. Probably hemorrhage at the time of injury leads to hemoglobin breakdown and effects cells in the brain. Some think that some individuals are more susceptible to TBI seizures but this is debatable.
[19:12:21] Mod: Doesn't' Epilepsy have a more precise definition to distinguish it from episodic seizures?
[19:13:12] DrSchaul: The brain has inhibitory systems - some think that these fibers may be preferentially damaged in some forms of trauma and this will lead to seizures. The
epidemiological definition is "recurrent seizures" - a seizure is a phenomena due to an abnormal electrical discharge from neurons in the gray matter of the brain.
About 1 in 100 people have epilepsy - about 3 in a 100 have a seizure at one time in their life.
Individuals who have not had a seizure for 5 years are no longer consider having epilepsy.
[19:20:57] DrSchaul: I think there is fairly convincing evidence that when patients do not respond to 2 different anticonvulsants they probably will not respond.
Seizures are pretty devastating phenomena - they alter ones social and professional life.
They often occur during the crucial years of social development - 15-25.
[19:23:19] DrSchaul: Most of us now believe that if 2 or 3 anti epileptic drugs have not shut off the seizures a detailed evaluation and consideration of epilepsy surgery is in order.
Epilepsy can be focal (coming from one area) or generalized (diffuse).
About 70% of seizures are focal - these if unresponsive to meds should be evaluated for surgery. Evaluation includes observing and recording seizures (video EEG monitoring). We can see small area's of damage - such as an injury due to old trauma, scarring from childhood (hippocampal atrophy), or abnormal configurations of brain tissue.
[19:30:37] Mod: What individuals are at the greatest risk for post traumatic seizures?
[19:31:52] DrSchaul: The crucial determinants
are - degree of trauma, type of injury (penetrating worst), blood in the brain, depressed skull fracture, and focal neurological damage.
[19:32:32] Mod: James: Will the epilepsy emerge immediately after the Trauma -or might it be masked by coma, and emerge later?
[19:32:52] DrSchaul: The glasgow coma scale is used to define degree. Seizures after head injury can occur early (less than 7 days) or late (after 7 days).
In the early category about 1/3 occur in the 1st hour, and 2/3rd in the 1st 24 hours.
A subcategory of early is" immediate" - this refers to the seizures in the 1st hour.
[19:35:48] Mod: James: Can coma mask the seizures?
[19:36:46] DrSchaul: Most seizures have some manifestation - but yes if the patient is very obtunded either from the trauma or drugs used it is possible to not know a patient is seizing.
Ideally good EEG would be available for someone in deep coma - the EEG would detect seizures and allow treatment even if the seizures are clinically "silent".
Continuous EEG monitoring is available in some institutions and can be very useful.
[19:40:16] Mod: What do you do if post traumatic epilepsy does not respond to antiepileptic medications?
[19:41:14] DrSchaul: If post traumatic seizures do not respond it is necessary to evaluate an individual in a unit that can do video EEG monitoring.
The precise area of seizure can be mapped - this usually corresponds to the damaged brain.
If the focus is an area of the brain that is not involved with some critical function (language, movement) it can be removed and the seizures may be cured.
[19:44:18] Mod: James: What is Video EEG Monitoring?
[19:44:50] DrSchaul: Video EEG monitoring refers to continuous recording of brain activity (EEG) with simultaneous video - a routine EEG lasts 20 min - continuous EEG is as the word suggests - continuous.
Patients having seizures often only have 1 to 4 a month - so the likelihood of seeing one with routine 20 min EEG is quite low.
When we eval patients for seizures in the hospital we reduce antiepileptic agents so we may observe and record a seizure (both on EEG and video).
Actually the availability of inexpensive video (vcr's) in the last 15 years has allowed us to see things that are quite infrequent.
[19:48:31] Mod: Syd: I've heard that a diet can often be used to control epilepsy-is this true and what can be done in that regard for the
TBI patient?
[19:48:54] DrSchaul: There is a subgroup of individuals that do respond to diet - specifically the ketogenic diet.
This is generally used in young children with generalized seizures secondary to brain damage in whom drugs do not work.
The diet is quite unpleasant - it consisted of a very high proportion of fats.
Most adults or older children cannot tolerate it - and it is hard to keep people on it unless you can lock the refrigerator.
Several TV shows were done on the diet (I think some big owner at CBS had a relative on the diet).
The news media have suggested that it is a cure all and used considerably more frequent than it really is
[19:55:05] Mod: James: Are there any innovative or new treatments being studied?
[19:55:16] DrSchaul: The main stay of epilepsy treatment is first to be sure the individual has epilepsy.
About 25% of people with "intractable seizure" actually do not have epilepsy.
They have event that look like seizures but are emotionally based.
After one decides the problem is epilepsy we usually use an antiepileptic agent.
In the US dilantin, tegretol, and valproate are the most used.
There are 5-6 new ones available - efficacy is similar to the old ones but some have less side effects and they are quite expensive.
The anti epilepsy are used by increasing the dose until they totally stop seizures or cause a side effect.
At the that point the dose is dropped and another agent tried.
If 2 or 3 drugs fail the individual should be seen in a dedicated epilepsy unit (by someone dealing with epilepsy all the time).
Another treatment developed in the last few years in the vagal nerve stimulator
(vns). This has gotten a lot of press but effectiveness is questionable.
My approach is 1) definite diagnosis 2) drug 1 then drug 2 3) inpatient evaluation 4) in selected cases consider epilepsy surgery.
[20:02:31] Mod: Our time is almost up. I would like to thank James, Syd and Rail for providing very good questions and I would like to thank Dr. Schaul for providing us with a very informative session. Good night and be safe!