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Managing Epilepsy in Children

Advances in Diagnosis and Treatment

New York (Jul 31, 2009)

Teenage girl holds a bottle of water

Today, more than ever before, there is hope and help for children living with epilepsy. With education and the latest diagnostic and treatment approaches available at such specialty centers as the Pediatric Comprehensive Epilepsy Center (PediCEC) at the Komansky Center for Children's Health, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, children with epilepsy and their families can find comprehensive and consolidated state-of-the-art services.

Understanding Seizures and Epilepsy

According to Steven Weinstein, MD, Director of the Pediatric Comprehensive Epilepsy Center at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, it is important for parents to first understand epilepsy and the multiple causes for a seizure.

"The study and care of an individual with epilepsy is like looking through a window to the brain," says Dr. Weinstein. "The brain is an electrical organ, it generates electricity. Within that organ there are numerous batteries with positive and negative ends and chemicals on the inside that generate that electricity. Just like Tinker Toys with little motors, those batteries get wired up and form networks and somehow those networks feed different parts of the brain and body.

"Epilepsy occurs when those networks – either one of them or a whole group of them – begin to do the same thing at the same time. This results in a seizure that causes uncontrollable changes in body movements, behavior, awareness or sensation," continues Dr. Weinstein. "As scary as a seizure looks – and parents can only imagine all the bad things that might be going on inside their child's brain – it is about as far away from the truth as can be. It isn't that everything is chaotic in the brain, it's that the networks are firing together. Seizures and epilepsy aren't a disease. Epilepsy is a reflection that there is something different about that person's brain functioning."

Pediatric epilepsy may be related to a temporary condition, such as withdrawal from certain drugs, or abnormal levels of sodium or glucose in the blood. In such cases, repeated seizures may not recur once the underlying problem is corrected. In other cases, an injury to the brain, for example, a stroke, head injury, or infection, can cause brain tissue to be abnormally excitable. In some people, an inherited abnormality affects nerve cells in the brain that leads to seizure.

Before a seizure occurs, there may be warning signs known as an aura – unusual smells, tastes or sensations. After effects of a seizure can include a headache, confusion, fatigue, sore muscles, and unusual sensations. Not all epilepsy syndromes are lifelong – some forms are confined to particular stages of childhood. Epilepsy should not be understood as a single disorder, but rather as a group of syndromes with very different symptoms, but all involving episodic abnormal electrical activity in the brain. When seizures recur, the condition is known as epilepsy.

Generally, 50 to 65 percent of individuals have no identifiable cause for their seizures. In this category, children are more likely to outgrow the seizure activity or to easily control it. However, over 30 percent of people with epilepsy do not have seizure control even with the best available medications.

Diagnosing Epilepsy

The PediCEC offers a full range of services to care for the most complex cases. It begins with an accurate diagnosis of the underlying cause of the epilepsy and identification of associated learning and behavioral conditions to help define a patient's seizure type. From there, physicians can develop a tailored plan of treatment.

To diagnose and locate epileptic foci – the parts of the brain where a patient's epileptic seizures originate – the pediatric epilepsy team uses a combination of video electroencephalogram (EEG) recordings and 3T magnetic resonance structural, chemical, and functional imaging, single photon emission computer tomography (SPECT), and positron emission tomography (PET).

"Our pediatric neurologists and neuroradiologists use all of the latest technologies available to look at brain function," says Barry E. Kosofsky, MD, PhD, Chief, Division of Pediatric Neurology at NewYork-Presbyterian/Weill Cornell. "That could be as simple as looking at the structure of the brain on an MRI scan, or it could be looking at brain metabolism using a PET scan examining blood flow. We look at brain function in terms of cognitive abilities, emotional abilities, and motor skills."

Such radiologic studies are supplemented by sophisticated neurophysiologic assessment of brain function including prolonged extracranial and intracranial EEG monitoring, and electrophysiologic mapping techniques to identify the origin and spread of seizures thereby providing prognostic information necessary to determine the future course of management.

"Our physicians bring to bear all the tools necessary to address what's wrong," says Dr. Weinstein. "The child needs to fit into the family, the school, and the world. When we talk about how to take care of kids with epilepsy, we want the child to be as functional as possible and to achieve his or her full potential."

Treatments for Epilepsy

A number of antiepileptic medications may be considered, depending on factors specific to each patient, such as which side effects are tolerated by the patient and which delivery method is acceptable.

For difficult-to-control (refractory) epilepsy, physicians may prescribe a ketogenic diet – one that is a high fat, low carbohydrate, and high protein diet. The ketogenic diet forces the body to burn fat rather than carbohydrates. Normally, the carbohydrates in food are converted into glucose, which is particularly important in fueling the brain. However, if there is very little carbohydrate in the diet, the liver converts fat into fatty acids and ketone bodies that pass into the brain and replace glucose as an energy source. When the body produces ketone bodies – a state known as ketosis – this has an anticonvulsant effect. Every step of the ketogenic diet process must be managed by an experienced treatment team.

When diet or two to three medications fail to control a child's seizures, surgical intervention may be recommended. During surgery, additional techniques such as electrocortiography and brain mapping are used to identify and avoid injury to sites of language, motor, and sensory function during surgery. Surgical procedures can be done directly on the brain or by implanting a stimulator of the vagus nerve in the neck (vagal nerve stimulation). "Having said that surgery is an option, it's then that you need to be able to demonstrate that you can correctly identify where the seizures are coming from and that portion of the brain can be safely taken care of without harming the patient," noted Dr. Kosofsky.

Growing Up With Epilepsy

Beth Jacques, 45, first began having seizures at the age of 13. "I would zone in and out at various times, and wasn't even aware of what had happened," said Ms. Jacques. Finally, one day in shorthand class in high school, a day she remembers vividly, she experienced a seizure that temporarily impaired her speech. That episode got her to the hospital. Diagnosed with epilepsy, Ms. Jacques began taking medications that would help to some degree, but never fully stopped the seizures. In her 20s, Ms. Jacques married and had two boys. "Surprisingly, my seizures were less during my pregnancies," she said. She went on to have another child, a girl, who she calls her miracle baby. During periods when she was not pregnant, however, Ms. Jacque's seizures were uncontrollable. At the age of 29, she was referred to neurologist Douglas R. Labar, MD, PhD, at NewYork-Presbyterian/Weill Cornell. After trying a series of the latest medications, Dr. Labar recommended that she undergo a left temporal lobectomy. For a number of years her seizures were more under control. At the age of 42, she underwent another left temporal lobectomy. "It's amazing," she said. "Now I am off all my medications, and haven't seized in three years."

Today, Ms. Jacques is grateful for all the help she has had along the way, and the advances in medicine. "If I can tell parents of children with epilepsy anything, it is to never lose faith. You've got to believe...never stop believing. I'm here today, and doing great."

Faculty Contributing to this Article:

Steven Weinstein, MD, Director of Pediatric Neurology, NewYork-Presbterian Hospital/Weill Cornell Medical Center, and Professor of Clinical Pediatrics and Assistant Professor of Pediatrics in Neurology, Weill Cornell Medical College

Barry Kosofsky, MD, PhD, Chief, Division of Pediatric Neurology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and Professor of Pediatrics and Professor of Pediatrics in Radiology, Weill Cornell Medical College

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