Epilepsy Program

Epileptic seizures result from abnormal synchronized electrical discharges in the brain. These may be caused by a range of conditions affecting the brain, such as cortical malformation of the brain, stroke, scarring, vascular malformations, genetic mutations or an upset in the brain’s metabolic function (cellular processes).

Once diagnosed with epilepsy, patients are evaluated for the underlying cause, which is the first and most important factor for determining treatment options.

Diagnosis of Epilepsy

Evaluation of a patient with epilepsy at the Epilepsy Program starts with a thorough consultation performed by a neurologist with expertise in epilepsy. This is followed by careful selection of tests which may include:

• Electroencephalogram (EEG): Performed in the outpatient laboratory, this test measures the electrical discharges in the brain.
• Magnetic Resonance Imaging (MRI) with diffusion tensor imaging (DTI): This test uses magnets to create images of the brain in order to determine whether there is damage to the brain tissue that may be responsible for epilepsy. It also allows the surgeon to visualize significant white matter tracts in the brain, which plays a role in planning for surgery.
• Functional MRI: This test uses magnets and tracks blood flow during particular tasks to try to localize important regions in the brain for language, memory, and motor tasks.
• Voxel Based Morphometry (VBM): A neuroimaging technique that looks at focal differences in the brain’s cortical thickness and grey-white matter junction, helping to identify subtle structural abnormalities that are undetectable on routine MRI and may be associated with the underlying epilepsy.
• Positron Emission Tomography (PET) scans: This test uses a radiotracer to localize the area of the brain that is not taking up glucose (sugar) like the rest of the brain, and gives dotors a clue as to the region that is affected by the seizures.
• Ictal Single Photon Emission Computed Tomography imaging (SPECT) scans: This test is performed in the Epilepsy Monitoring Unit under the supervision of a team of experts (nuclear medicine technician, neurophysiology technician and a nurse) during which a radiotracer is injected early in the seizure to localize the blood flow, and is also helpful in giving doctors an idea of the region of the brain where the seizure begins and spreads.
• Epilepsy Monitoring Unit (EMU) Stay: This is the cornerstone or gold-standard examination during which the patient is admitted to the hospital and monitored 24/7 with close supervision by a nurse and continuous video and EEG to try to capture and characterize the seizures and classify the type of epilepsy.
• Electrical Source Imaging (ESI): An advanced electrophyiological-neuroimaging combined method that localizes the source of abnormal electrical activity in the brain obtained from scalp EEG, and generates a seizure focus that is then superimposed on the MRI image.
• Blood tests and other laboratory tests: These tests are used to check for genetic and metabolic (cellular process) abnormalities that may be responsible for epilepsy as well as to monitor for antiseizure medication levels in the blood.

Treatment of Epilepsy

Expert physicians at the Epilepsy Program tailor treatment options to the patient once an accurate diagnosis has been established. Treatment options may include:

• Dietary recommendations
• Medication: Recommendations for anti-seizure medications are based on a review of all test results, patient profile, side effect profile, and the classification of epilepsy. About two thirds of epilepsy patients can have their seizures controlled through a careful selection of the right medication for their condition.
• Surgical interventions: Approximately a third of patients will continue to have seizures despite being on 2 or more medications. These patients, referred to as having medically-refractory epilepsy, require additional, specialized testing (described above). Thorough multidisciplinary conferences review the patient’s clinical presentation, history, seizure semiology, video and EEG tracings as well as MRI and nuclear imaging to generate a robust hypothesis for where the seizures are beginning.This may result in direct resective surgery or stereoEEG (SEEG) implantation to better understand the seizures, their onset and propagation.Numerous studies have shown surgery to be superior to medical treatment in this subpopulation of patients and that early surgical intervention leads to better outcomes.
• Neurostimulation: This applies to patients who are not candidates for resective surgery but are experiencing a significant seizure burden or medication side effects, and involves surgery to implant a device that delivers electrical impulses to the brain or to the vagus nerve (in the neck) to reduce the frequency of seizures.