What is epilepsy?
Epilepsy, also called seizure disorder, is a neurologic disorder which affects the nervous system. There are many types of seizures, which include:
- Tonic-clonic or convulsive seizures (formerly known as grand mal)
- Absence seizures (formerly known as petit mal)
- Atonic seizures
- Clonic seizures
- Tonic seizures
- Myoclonic seizures
Having a child with epilepsy can be frightening. At Cohen Children's, our team of epileptologists (neurologists with special training in epilepsy), neurosurgeons, nurse practitioners, clinical nurse, social worker, genetic counselor, neuropsychologist and dietitian are here to help you with this difficult diagnosis, in all its challenges. Whether it's dealing with a middle-of-the night breakthrough seizure, help with school accommodations or a complex epilepsy surgery discussion, our caring and compassionate team is here for you and your family.
We use extensive diagnostic methods to determine the nature, type and severity of your child's epilepsy. When looking for brain abnormalities, MRI is the main brain imaging technology used. Our experts utilize our new advanced MRI units to develop a highly detailed picture of the brain. To make a diagnosis, we also use electroencephalogram (EEG), which records electrical activity from the brain. We offer routine and ambulatory EEG services, as well as video ambulatory EEG at our outpatient location. We have excellent video EEG monitoring facilities at Cohen Children’s Medical Center with a brand new dedicated single-room Neuroscience Unit; we also have portable EEG units and hard-wired playrooms, so that your child is not restricted to a room all the time if they're admitted. The chair of our division, Dr Sanjeev Kothare, has unique duel expertise in sleep and epilepsy. An internationally renowned authority in the field, he is the co-director of our Sleep Lab. Here, we offer a combined video EEG and polysomnopgraphy (sleep study) to characterize nocturnal events. (Sleep apnea can worsen seizure control, so we look for this condition closely.)
Once a diagnosis is established, we'll design a unique treatment plan for your child. The standard treatment is medication and/or diet modification. If that doesn't work, using surgical interventions to control or eliminate seizure activity is often considered as a next step. To help with the challenge of operating on young patients, the neurosurgeons at Cohen Children’s are the first on Long Island to use ROSA®, a robotic operating surgical assistant. This innovative technology will make many pediatric neurosurgery procedures less invasive and more precise and safe for kids.
Research at Cohen Children's
We are a designated pediatric sub-site for the HEP2 (Human Epilepsy Project 2) study. The HEP2 study will monitor 200 people with treatment-resistant focal epilepsy over a two-year period. It's designed to better understand the challenges of living with focal seizures that do not respond to medication and determine biomarkers of epilepsy severity and treatment response. In addition, Cohen Children's has several on-going quality improvement studies.
The symptoms of epilepsy vary greatly. The primary symptom of epilepsy is seizures, a sudden surge of disruptive electrical activity in the brain that usually affects how a person feels or acts for a brief amount of time. Some epileptic seizures can be mild and hardly noticed, while others can be completely disabling, as well as dangerous depending on the activity you’re doing when it occurs. Because of disruption to normal brain activity, seizures can affect many different processes controlled by the brain. Symptoms of a seizure may include:
- Blank gaze, staring into space, lip smacking and fumbling movements
- Confusion, temporary loss of time
- Uncontrolled, erratic muscle spasms, jerking of the upper body, arms and legs
- Loss of consciousness or awareness
- Irregular behaviors or confusing emotions
Focal seizures may be caused by:
- Cortical dysplasia (parts of brain that did not form correctly during embryonic state)
- Cavernous malformations
Generalized seizures can be genetic in origin. At Cohen Children's, we have a strong genetics division to help us test appropriately, as well as a genetic counselor within our outpatient office.
How is it diagnosed?
Diagnosis is needed to determine the nature, type and severity of your child's epilepsy, as well as design a treatment plan. Diagnostic methods may include:
- Clinical history and physical examination—An epileptologist gets a clear description of the events, as well as past medical, family and social history. An examination will be performed to assess cognitive, motor and sensory function.
- Magnetic resonance imaging (MRI)—When looking for brain abnormalities, MRI is the main brain imaging technology. We use 3T MRI scanner with added features like functional MRI and Diffusion Tensor Imaging ( DTI) in some cases.
- Electroencephalogram (EEG)—An EEG records electrical activity from the brain. The EEG shows patterns of normal or abnormal brain electrical activity. EEG helps the physician to classify the seizure, identify the part of the brain where the seizures originate and evaluate the potential risk for future seizures. The EEG is very useful in determining whether to treat the patient with medication and if so, the type of medication to use.
- Positron emission tomography (PET)—The PET procedure injects a small amount of radioactive sugar into a person to allow a radiation-detecting camera to record brain images. The pictures from positron emission tomography show how and where the brain uses energy. Epilepsy can cause changes in the way the brain uses sugar, and a PET scan can help pinpoint a seizure focus.
- Single photon emission computed tomography (SPECT)—The SPECT procedure measures blood flow in the brain. An ictal SPECT scan is a study performed on people with very frequent or predictable epilepsy seizures. “Ictal” means that the scan is performed during a seizure. This test is performed by injecting a radioactive substance immediately after a seizure begins. After the substance travels to the area of the brain where seizures originate, a special camera detects its location in the brain and produces a corresponding image.
- Neuropsychological evaluation—A neuropsychologist conducts a number of tests to understand how well a person performs in different cognitive functions, such as memory, language and attention.
- Intracarotid sodium amobarbital test (Wada test)—Sometimes a Wada test is necessary prior to brain surgery. This test is performed by injecting a drug via a catheter to temporarily put one side of the brain to sleep in order to test the function of the other side that is still awake. This allows a neuropsychologist, working with a neuroradiologist, to test functions of the right and left sides of the brain individually. The Wada test can determine how each side of the brain performs important brain functions like language and memory. This test also helps to determine the safety of undergoing epilepsy brain surgery.
- Intracranial EEG—For individuals with epilepsy that is highly resistant to medications, inpatient intracranial EEG monitoring may be done to pinpoint the location where seizures begin. For this type of EEG, small electrodes are placed under the skull by a neurosurgeon. The electrodes may be used to both record electrical signals from the brain and stimulate the brain to map necessary brain function. A leading-edge innovation in this field is the sEEG or stereo EEG, where small electrodes are placed orthogonally in deeper parts of the brain, letting doctors sample depths of the sulci (folds on the brain surface). A ROSA® robot is now available for the neurosurgeon to place several sEEG leads safely and rapidly.
Types of treatment
The standard treatment for epileptic seizures is medication, prescribed by a neurologist. If a patient does not respond to medicine, we may explore a number of innovative surgical treatment options to control and prevent seizures, including:
- Laser ablation—Doctors insert a laser catheter in the brain and ablate the seizure (used in cases of a small seizure focus).
- Vagus nerve stimulation (VNS)—Designed to prevent seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. These pulses are supplied by a pacemaker-like device that’s placed under the skin on the chest wall and a wire runs from it to the vagus nerve in the neck.
- Corpus callosotomy—Doctors cut the corpus callosum, the band of tissue that connects and transmits messages from one side of the brain to the other.
- Resective epilepsy surgery—The abnormal portion of the brain is removed.
- Hemispherectomy—The damaged half of the brain is removed (common in a disease process called Sturge-Weber).
- Gamma knife radiosurgery (GKS)—Allows precise and complete destruction of chosen target structures containing healthy and/or pathological cells, without causing significant radiation damage to adjacent tissues.
- ROSA®—A robotic operating surgical assistant that provides the following benefits when conducting brain surgery:
- Provides patient with minimally invasive procedure options
- Increases access to the surgical area due to the robotic arm that mimics human arm movements
- Provides precise instrument guidance through the robot arm’s high dexterity
- Reduces operating time due to increased efficiencies, particularly with placement of multiple electrodes for SEEG
- Eliminates need to remove a portion of the skull
We carefully consider the potential risks and the benefits of epilepsy surgery for each patient’s unique case.