Neurosciences

St. Luke’s Epilepsy Program

Neurosciences

The St. Luke’s Epilepsy Program is a National Association of Epilepsy Centers accredited Level 3 Epilepsy Center. Our program has four fellowship-trained epilepsy specialists, Kuei-Cheng Lim, MD (medical director of the program), Lizbeth dePadua, MD, Scott Kohler, MD, and Chad Saunders, MD. Our program is supported by a dedicated team of EEG technologists, nurse specialists, functional neurosurgeon Roy Hwang, MD, neuro-psychologists, neuroradiology, and social services. Our program manages a wide range of epilepsy patients, including those with intractable epilepsy, epilepsy surgery evaluation, and evaluation of episodic spells that are concerning for seizures.

Seizures

Seizures are clinical symptoms caused by abnormal synchronous neuronal activity of the brain, sort of like an electrical storm of the brain. These clinical symptoms can manifest in a variety of ways including generalized convulsions (grand mal seizures), behavioral arrest or altered awareness (absence or petit mal seizures), recurrent sensory changes, focal or generalized rhythmic muscle contractions, recurrent intense unexplained emotional sensations (such as a sense of impending doom), sudden rigid body contractions, sudden body spasms, or sudden loss of body tone. Sometimes seizure evolve from one type to another such as starting with a staring spell, altered awareness, and then becoming a generalized tonic-clonic convulsion.

Seizures can be cause by an acute neurological insult (provoked) such as acute stroke, acute head injury, metabolic derangements (for example, abnormally high or low blood sugar or sodium levels), acute intoxication from drugs or medications, or acute withdrawal from alcohol or certain types of medications. Sometime seizures are not caused by any known immediate physiologic factor (unprovoked). Seizures that are unprovoked can be due to an underlying seizure disorder, otherwise known as epilepsy.

There are conditions that frequently mimic seizures including transient ischemic attacks (TIA, a type of stroke that is typically less than one hour in duration), syncope (sudden loss of consciousness due to sudden decrease in delivery of blood supply to the brain), sleep disorders (night terrors or REM behavior sleep disorder), or psychological stress (non-epileptic psychogenic attacks or fits).

Epilepsy

Epilepsy is an underlying neurological condition that predisposes someone to recurrent seizures. Although seizures are the primary symptom of epilepsy, patients with epilepsy can also have cognitive difficulty, psychiatric co-morbidities including depression, anxiety, attention deficit, and personality traits, and challenges with their social lives.

Epilepsy can develop at any age; it is the fourth most common neurological condition. Currently, about 3.4 million people in the United States have a diagnosis of epilepsy and about one in 26 people in the United States will develop epilepsy at some point in their lifetime. Epilepsy may be the result of genetics, congenital brain malformations, or prior brain injury (traumatic brain injury, prior strokes, central nervous system infections). For a large majority of patients with epilepsy, the underlying cause is unknown. There are several well-established epilepsy syndromes that are characterized by the type of seizures, the patient’s medical history, provoking factors, and electrophysiology findings.

Epilepsy is generally diagnosed after taking a clinical history and comprehensive neurological evaluation, and supported by findings from an EEG (electroencephalogram) and imaging study of the brain such as CT (computed tomography) scan or MRI (magnetic resonance imaging). Sometimes, assessment of the cerebral spinal fluid (CSF) by a lumbar puncture is indicated. The diagnosis of epilepsy is ultimately based on clinical history of at least two unprovoked seizures. Some patients with epilepsy will have normal EEG and brain imaging studies.

Epilepsy is generally treated first with medications, known as anti-convulsant, anti-seizure, or anti-epileptic drugs. The goal of epilepsy management is “no seizures, no side effects.” Depending on the type of epilepsy and medical history, the physician will help determine the most appropriate medication. There are at least 25 different medications currently available for the management of epilepsy. About seven out of 10 patients with epilepsy can achieve seizure freedom with medication alone.

About a third of patients will have refractory (intractable) epilepsy, which is a condition when a patient continues to have seizures despite an adequate trial of at least two appropriate antiepileptic medications. For these patients other treatments may be necessary such as ketogenic diet, epilepsy surgery, or neuromodulation therapy. If your doctor cannot suppress the seizures after two medication trials, then you should be referred to a Level 3 or Level 4 epilepsy center. Neuromodulatory therapy including vagus nerve stimulation (VNS) and responsive neurostimulation (RNS) are other treatment options.

Epilepsy Center

St. Luke’s Epilepsy Program is a Level 3 Epilepsy Center accredited by the National Association of Epilepsy Centers, or NAEC. The Level 3 designation means that our center provides a wide range of medical expertise to treat refractory epilepsy. This includes fellowship-trained and board-certified epileptologists (clinicians who have gone through training in neurology and with specific training in epilepsy), advanced practitioners who focus on epilepsy patients, a neurophysiology staff, neurosurgeons, neuroradiologists, neuropsychologists, and psychosocial services.

Diagnostic testing includes routine, ambulatory, and outpatient continuous video EEG (electroencephalography) studies as well as imaging studies of the brain including CT (computed tomography) scan, MRI (magnetic resonance imaging), and PET/CT brain imaging. Other tests that can be performed include a neuropsychological assessment, a functional MRI brain study (to assess location of language, motor, and sensory areas of the brain) and an intracarotid sodium amobarbital procedure, known as the Wada test, to help determine the memory and language dominant side of the brain).

Our center has an epilepsy monitoring unit (EMU) located at St. Luke’s University Hospital in Bethlehem. The EMU provides noninvasive continuous video EEG monitoring to evaluate seizures, determine a possible differential diagnosis, characterize the seizure type, and localize seizure onset for surgical evaluation of epilepsy.

Once the seizure type(s), localization of seizure onset, and patient factors are determined, your St. Luke’s epilepsy team will determine the most appropriate therapy of medications, surgical intervention, or other treatments , or referral to a Level 4 epilepsy center if necessary. In general, patients with epilepsy who have failed two or three medication trials should at least be considered for epilepsy surgery.

Epilepsy Monitoring Unit (EMU)

The EMU is a specialized inpatient unit is designed for computer-based 24 hours continuous video-EEG monitoring with the patient’s safety in mind. The objective of this unit is to trigger and record a seizure or event in a safe and controlled environment, which is then used to make a diagnosis, determine the type of epilepsy, localize the onset of focal seizures, or medication adjustment.

Your doctor may recommend and EMU admission if you have intractable seizures, spells that are concerning for seizures but difficult to diagnose, or for pre-surgical evaluation. Your length of stay depends on how long it takes to record seizures or spells. The typical admission varies between three to seven days, which can be shorter or longer. The treatment team involves the epileptologist, EEG technologists, and EMU nurses.

Patients are admitted to a private room. During this admission, patients are under 24 hours of continuous observation by a technologist, intercom and direct communication, and audio-video-EEG recording. Patients are connected to an EEG machine to help determine the source of the seizures. To increase the chance of recording a seizure, your treatment team may decide to reduce the dose of your anti-epileptic medication(s), sleep deprivation, or other triggers of seizures. If you have a warning or aura to your seizure, there is a button for you to push to activate an alarm for immediate response and attention.

At the end of the admission, your physician will discuss with you the result of the study. Sometimes, in spite of the length of stay for this study, we are unable to record a seizure or event to provide a diagnosis or some focal epileptic seizures may be too short to be visible on scalp EEG. Your physician will provide options as to treatment recommendations and/or further testing.

Additional Resources

The Epilepsy Foundation is a great resource for further information about epilepsy, seizures, treatment, community and social support groups, patient assistance programs, and recommendations regarding living with epilepsy.

Additional information about epilepsy can be found at these websites:


Information about regional support group meetings, education programs, and events can be found at the regional branch websites:


The Epilepsy Foundation runs the Epilepsy & Seizures 24/7 Helpline for more information and referral line to help answer questions about epilepsy and seizures, and offers support and guidance. The toll-free helpline 1-800-332-1000 or visit https://www.epilepsy.com/living-epilepsy/247-helpline

More information about accreditation and description of the different levels of epilepsy center can be found at the National Association of Epilepsy Centers website: https://www.naec-epilepsy.org