Alternate Treatment Options

The Ketogenic Diet

The ketogenic diet changes the way your body gets energy from food by burning fat instead of sugar, It is usually tried in children between the ages of one and twelve years who have seizures that are hard-to-control or who have severe side effects from anti-seizure drugs.

The diet is very high in fats and low in protein and carbohydrates. It produces a change in the body’s chemistry called ketosis. This has the effect of controlling seizures, or reducing their frequency, in about two out of every three children placed on the diet.

Doctors don’t yet know why a diet that burns fat for energy prevents seizures, or why it works for some children and not for others.

The ketogenic diet must be individualized by a dietician and overseen by a doctor just as if it were a course of drug treatment. It is not a do-it-yourself diet. The amounts of food and drink at each meal have to be carefully calculated and weighed. Meal plans combine small amounts of fruits or vegetables (carbohydrates), meat, fish or chicken (protein), lots and lots of fat (often in the form or cream, butter, eggs or mayonnaise) and no sugar.

Like other treatments, the ketogenic diet has some side effects which the medical team monitors through blood and urine tests and follow-up visits. The diet is primarily used to treat children for a limited period of time. Then the diet may be slowly tapered and regular food slowly re-introduced. If seizures return, the diet may be started again.

Early results of studies suggest that the ketogenic diet may help adults as well, but the long-term effects of such a high-fat diet are unknown. Also under active study is whether less restrictive high-fat, low-carbohydrate diets may be of benefit to children or adults in controlling seizures.

Taken from Beyond Medication, published by Epilepsy Foundation of America. For more information, visit the Resources page at www.EpilepsyFoundation.org/Beyond.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) is currently approved for use in adults and children over the age of 12 who have partial seizures that are not controlled by other methods. A pacemaker like device, about the size of a half-dollar, is typically placed under the skin in the left side of the chest area. A thin, flexible wire from there connects the generator to the left of the vegus nerve in the neck. Implanting the device takes about an hour and as a standard outpatient procedure under general anesthesia. The device is programmed to deliver pulses of electrical stimulation automatically, 24 hours a day. Programming is a simple procedure done in the doctor’s office by the physician or nurse, who adjusts the “dose” of the device for the best seizure management. A typical stimulation “dose” is about 30 seconds on and five minutes off, but the settings may vary based on individual results. The device continues this cycle until the neurologist reprograms it or until the battery must be replaced, usually in about 3 to 8 years.

During office visits, the doctor or nurse checks the device to make sure it is working properly and that the treatment is not making the patient uncomfortable. The most common side effects are temporary hoarseness/changes in voice tone, coughing, tickling in the throat and shortness of breath, all of which occur only during stimulation and typically decrease over time.

Studies show 4 out of 5 patients experience some improvement in their seizures as a result of VNS therapy. Seizure control with VNS has been reported to significantly improve over time. Many patients using VNS therapy experience less severe and shorter seizures. Benefits may not be immediate and often take several months to be noticed. In addition to the automatically programmed stimulation, a magnet can be used to deliver additional stimulation if a person senses a seizure is about to happen or during a seizure. This is done by the person or caregiver passing the magnet over the chest area where the device is implanted. For some, the additional stimulation stops the seizure, shortens it, makes it less severe, or reduces the time it takes to recover afterwards.

As with surgery and the ketogenic diet, people usually continue with some anti-seizure medication in addition to VNS therapy. To learn more about vagus nerve stimulation therapy and see what others have top say about it, visit the Epilepsy Foundation at www.EpilepsyFoundation.org/Beyond.

Surgery

Surgical removal of the area of the brain that causes seizures has been an accepted form of treatment for over 50 years. Because of new surgical techniques and new ways of identifying areas to be removed, more of these operations are being done now than ever before, and with greater success. Surgery is not a last resort in the treatment of epilepsy, nor is it experimental. It is a standard medical therapy and is the treatment of choice for some forms of epilepsy.

Surgery can be performed on both children and adults. However, it is not a suitable treatment for everyone who has epilepsy, or for everyone with poor seizure control. Surgery is most likely to be considered when someone with epilepsy:

  • Has already tried the appropriate medicines without successful seizure control
  • Has seizures that start in one part of the brain
  • Has seizures in a part of the brain that can be removed without damaging important functions like movement, speech, memory, or vision.

Surgery for epilepsy is a delicate, complicated operation. It must be performed by a skilled, experienced surgical team. It is usually done at specialized medical centers rather than at local hospitals.

In general, the types of surgery for epilepsy fall into two main groups:

  • Removal of the area of the brain that is producing the seizures
  • Interruptions of nerve pathways which seizures impulses spread.

The brain is divided into areas called lobes which are called temporal, frontal, parietal, and occipital. A lobectomy is an operation that removes part (or rarely all) of one of these lobes. This type of surgery may be performed when a person has seizures that start in the same place within a lobe every time, if it can be safely done without damaging other vital functions like speech or memory.

Another kind of surgery for epilepsy is called a corpus callosotomy (split brain surgery). This operation interrupts the spread of seizures by cutting the nerve fibers connecting one side of the brain to the other. Epileptic “drop attacks” (sudden falls caused by seizures) and generalized tonic-clonic seizures (grand mal) or myoclonic (massive jerking) seizures may respond to this type of surgery. After a corpus callosotomy, some type of seizure activity on one side of the brain or the other is likely to continue, but the effects are generally less severe than before.

Some seizures originate in or spread to parts of the brain that are responsible for functions such as a movement or language. Removing these areas would lead to paralysis or loss of language function. A surgical technique called multiple subpial transection (MST) may be performed in these situations. It involves making small incisions in the brain which interfere with the spread of seizure impulses, but not the normal functions of the brain.

In rare cases, a child or adult may have severe brain disease on just one side of the brain which produces uncontrollable seizures and paralysis (weakness) on the opposite side of the body. When this happens, a much more extensive operation called a hemispherectomy – which removes almost all of one side (hemisphere) of the brain may be considered. It seems impossible that someone could function with only half a brain, but in children typically under five, the half that is left takes over most of the functions of the part that was removed. However, there may be weakness and loss of some movement on one side as well as loss or peripheral vision after the surgery.

Before any operation for epilepsy can be performed, there is a period of careful testing and evaluation. These are done to make sure the surgery has a good chance of being successful and won’t affect any of the important functions of the brain.

Doctors usually recommend that surgery patients stay on anti-seizure medications for at least two years after the operation, though the number of medications and doses are often reduced during this time. Some people may have to continue with medication indefinitely to retain seizure control, or may prefer to stay on medication to minimize the risk of having the seizures return.

For more information and to view short videos of doctors talking about these treatments and people talking about their experiences, go to www.EpilepsyFoundation.org/Beyond.

RNS® System

The RNS® System, designed for the treatment of medically refractory partial epilepsy, includes implantable and external products.

Implantable components include the RNS neurostimulator as well as depth leads and cortical strip leads. The RNS neurostimulator is a programmable, battery powered, microprocessor-controlled device that delivers a short train of electrical pulses to the brain through implanted leads. In treating epilepsy, the RNS neurostimulator is designed to detect abnormal electrical activity in the brain and respond by delivering electrical stimulation to normalize brain activity before the patient experiences seizure symptoms. The neurostimulator is implanted in the cranium and connected to one or two leads that are implanted near the patient’s seizure focus.

External products include the programmer, a laptop computer with proprietary software that has a wand and telemetry interface enabling communication with an implanted RNS neurostimulator. Physicians use the programmer to non-invasively program the detection and stimulation parameters of an implanted device. Additional features of the programmer include the ability to view the patient’s brain electrical activity (electrocorticogram or ECoG) in real-time and the ability to upload the patient’s ECoGs that have been stored in the RNS neurostimulator.

Credit: NeuroPace, Inc. www.neuropace.com/product/overview.html