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Epilepsy: Challenges & Therapies Orrin Devinsky, M.D. NYU Epilepsy Center

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Diagnostic Challenges Define epilepsy syndrome Video-EEG monitoring Understand the cause of epilepsy High resolution MRI Genetic studies (GEFS+, Chromosomal microarrays) Define factors that provoke seizures FAILURE Identify long-term effects of epilepsy &s its treatment

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Therapeutic Challenges No seizures, no side effects If patients had their choice: No doctors, No Medicines In general, would rather see doctor than take medication

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Therapeutic Challenges Ongoing assessment: consequences of seizures and therapy How aggressive to pursue seizure control? Do we treat interictal EEG? ? Benign rolandic epilepsy How to assess effects of long-term therapies?

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Alternative Therapies for Epilepsy Diverse group Osteopathy, chiropractic, homeopathy, herbs, EEG feedback (neurotherapy), stress reduction, magnetic stimulation, carbon dioxide therapy, fatty acids We need data!

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Common Errors that Doctors Make Misdiagnosis Is it epilepsy? Which epilepsy syndrome? Not noticing change Incorrect medication choice AEDs can exacerbate seizures Failure to reassess or consider VNS or surgery

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Mistakes Ive Made Mistakes Ive Made Relying on prior diagnosis Becoming invested in a course of action Not listening to the information Not challenging ones own conclusion Finding information that supports Explaining information that doesnt fit

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Physician Issues in Selecting AED AED relative efficacy:toxicity Knowledge Published studies Randomized v. open-label Dose range, methodology Statistical v. clinical significance Information from colleagues Personal experience Belief, Bias, & Comfort Zone

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Quality of Life: The Traditional View Medical Education - MD perspective Medical literature, clinical experience Disorders - signs & symptoms Evaluation - history, PE, Lab Therapy - studies of medical outcome

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QOL: A Different View QOL - Defined by patient not MD Should patients perspective be filtered through objective medical lens? - NO QOL is about listening, changing perspective, and using the patients view as the ultimate measure of outcome

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QOL: Relevance to Epilepsy? QOL issues most relevant to chronic disorders, problems beyond disease symptoms Epilepsy is the paradigm of such a disorder Seizures are infrequent,AED effects & psychosocial problems are chronic

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A Case Study 29 y.o. woman monthly CPS, rare GTCs Routine 6 mo. Checkup: complains of some tiredness, blurred vision, nausea Exam - mild nystagmus, tremor Labs - slightly elevated LFTs MDs perspective - doing great Womans perspective - doing poorly; not driving, underemployed, fearful of seizures, troubled by AEs

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Cognitive & Behavioral Changes in Epilepsy Cognitive & Behavioral Changes in Epilepsy Must diagnose to treat Cognitive-behavioral disorders are often overlooked - under appreciated Not spontaneously reported Not asked about by MD/RN Noted, but considered minor Noted, but considered untreatable

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Seizure Burden: The Great Lie Seizure Burden: The Great Lie Are complex partial seizures bad? Memory - long-term consequences Personality changes Affective changes Psychosis Are tonic-clonic seizures bad? You bet!

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PGE and Behavior: Absence Epilepsy (Wirrell et al, 1997) 56 absence epilepsy v. 61 JRA patient Pts with absence epilepsy had more academic, personal, and behavioral disorders (p