Obtaining an accurate diagnosis is key to determining the most appropriate and effective treatment. The Nebraska Epilepsy Program employs a comprehensive four-phase monitoring program that provides the most accurate evaluation and diagnosis possible.

Phase I

Phase I of the epilepsy treatment and monitoring program is the most critical. During this phase, our state-of-the-art EEG monitoring system, available at only a few centers across the country, an inpatient evaluation to determine important information about their seizures. This includes whether the patient is actually experiencing true epileptic seizures or pseudo seizures. The advanced video EEG monitoring can also pinpoint which episodes are actual seizures, which are not and the origin of the seizures. This information is critical in helping identify the type of seizure a person is experiencing and prescribing the appropriate medications.

In addition to EEG monitoring, Phase I also consists of:

• MRI with seizure protocol to identify any structural abnormalities of the brain.
• PET scan to view the metabolism of the brain. The malfunctioning area of the brain doesn't utilized glucose adequately.
• SPECT scan which detects blood supply to the brain. The area of the brain that triggers seizures has a decreased blood supply when the patient is not having a seizure and an increased blood supply during a seizure.
• Neuropsychological testing, performed by neuropsychologists to test brain function.

Based on findings from the tests discussed above, a treatment plan is developed and medications are prescribed. If medication therapy fails, it is determined whether the patient is a candidate for surgery. Surgery candidates move on to Phase II. Those patients who are not deemed good surgery candidates, may be considered for a procedure called vagal nerve stimulation (VNS).

Vagal nerve stimulation involves implanting a pacemaker into a patient's chest. Leads are placed on the vagal nerve in the neck which sends frequent electrical impulses to the brain to alleviate seizures. The electrical impulses are adjusted with each patient to provide optimal success.

Phase II

Patients entering Phase II are candidates for surgery. Approximately 25 percent of epilepsy patients are surgical candidates for resective surgery in which the tissue from the malfunctioning parts of the brain are removed. Phase II consists of additional testing to determine whether these parts of the brain affect speech or memory.

The primary test is the WADA procedure which localizes a patient's speech and memory functions. The procedure is performed by a neuropsychologist and interventional radiologist who perform a cerebral angiogram to show the circulation within the brain. They then "deaden" one hemisphere of the brain at a time and perform standardized memory and language tests for each side.

Phase III

This phase involves intracranial monitoring to further localize the seizure focus. This procedure is performed only in those patients in whom there is still a question as to the exact site of origin of the seizures. During the procedure, a flap of the cranial bone is removed so that electrodes can be placed directly on the brain to further pinpoint the seizure focus.

Phase IV

Patients entering Phase IV are those who have been determined to be candidates for resective surgery. A recent study published in the New England Journal of Medicine, found that 60 percent of patients who previously did not respond to medications, responded well to resective surgery if they have mesial temporal lobe epilepsy.

Resective Surgery

During this highly sophisticated surgery, parts of the brain that are triggering seizures are removed. Patients normally return home within a week after surgery and are fully recovered within six weeks. This procedure has been highly successful in helping patients who do not respond to medications and have helped these individuals go on to live a more normal and productive life. There are always risks involved with neurosurgery and they are discussed by the neurosurgeon.

Deep brain stimulation

Deep brain stimulation can also be used to treat patients with intractable epilepsy. The procedure is performed by only a few surgeons in the region, two of them at The Nebraska Medical Center, neurosurgeons Arun-Angelo Patil, M.D., and Kenneth Follett, M.D. Deep brain therapy stimulation and surgical treatment for epilepsy are Dr. Patil’s primary areas of focus.

How the procedure is performed

Deep brain stimulation uses mild electric pulses to stimulate the brain and block the signals that cause tremor. It involves implanting an insulated wire lead in one of several areas of the brain. The lead is connected to a pulse generator implanted beneath the skin in the chest area which can be controlled by the patient. Much like an advanced pacemaker, the pulse generator is a small, sealed, metal and plastic device with a battery. The procedure requires the use of a stereotactic frame, one of which was developed by Dr. Patil. The stereotactic frame stabilizes the head and helps the neurosurgeon locate the thalamus precisely.

Implantation into the thalamus provides effective stimulation for Parkinson’s and essential tremor. Implantation into the subthalamic nucleus is effective for controlling all types of Parkinson’s symptoms. It requires the implantation of two electrodes on each side of the brain. Physicians can also implant electrodes into the globus pallidus, primarily for treatment of dyskensia. The entire procedure normally takes three to five hours. Patients are usually required to stay in the hospital for one night after the operation.

Advantages

The procedure is highly effective in about 80 to 85 percent of patients. If symptoms come back, the stimulation can be adjusted to better manage the tremors. Most patients with Parkinson’s disease will still need to use medications but the amount needed is usually reduced significantly to about half the amount required before the therapy. In about 10 to 15 percent of patients, the therapy may have only minor success, oftentimes because the disease has progressed too far.

Risks and side effects

Like other types of stereotactic neurosurgery, this procedure carries the same kinds of risks which include: bleeding inside the brain, leakage of fluid surrounding the brain, seizure and infection. Although these risks are uncommon, they can be life-threatening.