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Epilepsy

What is epilepsy?

Epilepsy is a condition of repeated seizures triggered by abnormal changes in the electrical and chemical activity of the brain.

Seizures are also called convulsions, episodes or fits.

What is a seizure?

Seizures come on suddenly. They temporarily change a child’s state of awareness and his physical activity. They also affect the senses, such as smell, vision or sensation.

Different types of seizures cause different sets of symptoms. Possible symptoms during a seizure include:

  • Jerking of the child’s muscles or entire body
  • Changes in attention
  • Changes in behavior
  • Tightening of a muscle group
  • Staring spells with blinking
  • Brief loss of memory
  • Loss of consciousness
  • Violent convulsions
  • Uncontrolled urination
  • Rhythmic mouth movements
  • Confusion and sleepiness after the seizure

Neurologists are doctors who specialize in disorders of the brain and nervous system. Most children with seizures are treated by neurologists.

The type of seizures your child has helps doctors suggest the best course of treatment, which could be medicine, surgery or a combination of the two.

Medicine helps about two out of three children with epilepsy be seizure-free. Read more about neurology at Children’s.

Frequent, uncontrolled seizures that are not helped by medicine can be harmful, interfering with normal development and learning and even permanently damaging a child’s developing brain. Some of the medicines can have side effects in some children that are intolerable and interfere with normal learning and development. If medicine does not control a child’s seizures, his neurologist may refer him for a neurosurgery evaluation.

Who gets epilepsy?

Epilepsy affects 1 percent of the general population, but is more common in children. Five percent of children under 5 years old have epilepsy.

This does not include children who have seizures caused by a high fever. Those are a separate type of seizure called febrile seizures, which can occur only once or reappear another time a child has a fever.

There is no specific cause in more than half of the children who have epileptic seizures. A number of things other than epilepsy or high fever can cause seizures:

  • Brain tumors
  • Head injuries
  • Exposure to toxins or poisons
  • Brain infections
  • Injury to the brain of a developing fetus
  • Genetic abnormalities

What is your experience with epilepsy?

Children’s has a very active and well-respected epilepsy surgery program.

Our Neurosurgery and Neurology departments work together closely. They decide which children with epilepsy are good candidates for surgery.

Children’s is also a part of the University of Washington Epilepsy Surgery Program. We operate on about 40 patients with epilepsy each year, using the most up-to-date technology and science, to find and remove the focus of epilepsy.

In addition, each year, we implant a device called a vagal nerve stimulator in 15 to 20 children to help control their seizures. This device is used when the child is not helped with medication and the seizures would not be helped with surgery on the brain.

How do you evaluate and find a seizure focus before surgery?

Identifying exactly where in the brain a seizure begins is very important. It helps us perform successful epilepsy surgery whenever possible. Researchers at Children’s are working on many ways to identify where seizures start.

Dr. Jeffrey G. Ojemann and his team use both standard and leading-edge techniques.

We have a special unit in our hospital devoted to monitoring children’s brain activity. Using video and EEG equipment, we look for clues to their seizures.

If needed, neurosurgeons surgically place (implant) electrodes on the surface of your child’s brain to record electrical activity. We monitor children this way to help us plan their surgery.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) is a standard procedure that produces high-quality pictures of the inside of the human body. These pictures let your child’s doctor see very detailed chemical and physical information about his brain.

Arrow points to scar tissue where seizures occur.
Arrow points to scar tissue where seizures occur.

Most Children’s hospitals have 1.5 Tesla MRI scanning equipment. Children’s also has the newest 3.0 Tesla MRI scanner which shows fine detail of the brain and may be better to show where seizures are arising.

Sometimes, an MRI scan can identify the part of the brain where seizures start by showing a picture of scar tissue in the brain.

We compare this picture with an electrical recording of a seizure in your child’s brain. If they match, we can consider surgery as a way to help treat her seizures.

Brain tracing shows seizures beginning in one part of the brain (asterisk) and then spreading (double asterisks) to other parts.
Brain tracing shows seizures beginning in one part of the brain (asterisk) and then spreading (double asterisks) to other parts.

Unfortunately, for some children with epilepsy, MRI scans do not show us where in their brains seizures begin.

For these children, we place electrodes on many parts of their brains during surgery to figure out where the seizures start.

These electrodes can be used to identify where seizures come from and also to identify critical parts of the brain — a process called brain mapping.

Other types of brain mapping may also be used, including the Wada test and functional MRI.

Positron emission tomography (PET) scans

Using a glucose-PET scan, the arrow points to where the seizures are coming from. The area is damaged and, between seizures, uses less energy. During the seizure, it uses more energy.
The arrow points to where the seizures are coming from. The area is damaged and, between seizures, uses less energy. During the seizure, it uses more energy.

Positron emission tomography (PET) scans can show parts of the brain using less energy. Sometimes, this helps us identify the source of seizures.

Glucose positron emission tomography (glucose-PET), currently the only approved PET test, is a way of creating pictures of how the brain works.

With glucose-PET, we combine a glucose (sugar) molecule with a small amount of radiation and inject it into the child’s body.

The molecule becomes a marker that shows up in certain parts of your child’s brain on a PET scan and tells us how the brain uses the marker.

Glucose-PET is helpful in some cases of epilepsy, but sometimes it shows abnormalities that are not related to the epilepsy. For this reason, PET is not used with everyone and is rarely used alone to make a decision about surgery for epilepsy.

Single photon emission computed tomography (SPECT)

Single photon emission computed tomography (SPECT) produces a picture that can show us where a seizure is coming from. We use it to measure tissue changes and gain information about blood flow. This in turn tells us about a seizure’s starting point.

A SPECT involves a few steps:

SPECT scan shows the area where a seizure begins (colored circles).
SPECT scan shows the area where a seizure begins (colored circles).
  • Your child waits at the hospital to have a seizure.
  • When the seizure begins, we inject a medicine that shows where blood flow is increasing in his brain. The result is a picture we call a SPECT scan.
  • We make another SPECT scan when your child is not having a seizure so we can compare the two scans.

This can show us where in the brain the seizures begin. During surgery, we place electrodes on the brain to confirm our findings.

Not everyone needs a SPECT scan. Only seizures that have some warning and come often enough can be studies with SPECT.

There needs to be enough warning for the nurse to inject the medicine early on in the seizure. If the seizure is already over, the SPECT scan will not show where the seizure came from.

Learn more about research on an imaging technique called flumazenil positron emission tomography.

What surgery do you use to treat epilepsy?

Our neurologists and neurosurgeons decide together on the best treatment for each child with epilepsy. We consider several factors to decide if your child is a good candidate for surgery:

  • He has ongoing seizures even though he takes, or has taken, anti-seizure medicine.
  • He has a known, specific area in his brain, called a focus that causes his seizures. Learn more about how we evaluate and find a seizure focus before surgery.
  • The affected tissue in the focus area can be removed safely. Surgery is designed to avoid damage to motor or language function. Some tests like the Wada test and functional MRI Imaging can help determine which side of the brain or where in the brain the function resides.
  • His doctors believe an operation will help his seizures.
  • He has intolerable side effects from his medicine.

If we cannot find a seizure focus, the child may be a candidate for a vagal nerve stimulator.

Temporal lobectomy

Mesial temporal sclerosis (scar of brain tissue has been removed)
Mesial temporal sclerosis (scar of brain tissue has been removed)

A temporal lobectomy is the most common epilepsy operation for adults and teens. We consider this surgery when the patient has a small, non-cancerous (benign), slow-growing tumor in his temporal lobe, or has mesial temporal sclerosis or cortical dysplasia — abnormal brain tissue.

Often, we can surgically remove the affected area and control a child’s seizures. The neurosurgeon removes the entire temporal lobe if necessary. This surgery may cause seizures to stop in 50 to 70 percent of carefully chosen patients. Another 10 to 20 percent of patients may have better, though not total, seizure control.

After the scar and the seizure focus is surgically removed
After the scar and the seizure focus is surgically removed

Resection of epileptic focus (outside the temporal lobe)

In some cases, we can remove (resect) the tissue causing the seizures in the affected area of the brain.

This is possible if your child’s seizure focus is only in a particular area of the brain and the area is not a critical-function area, like speech or movement.

Finding the focus of the seizure in a child’s brain can be very difficult. A number of steps help us do this. The first is usually surgery, to place electrodes on the surface of the child’s brain.

We monitor him for about one week in Children’s video and EEG monitoring unit. The electrodes give us valuable information about the seizure focus. The neurosurgeon and neurologist can then plan to remove the involved area of the brain.

With parts of the electrodes in place, the child’s doctors will do some functional mapping of his brain. The procedure helps doctors locate the functional cortex in the brain and map out or pinpoint the areas that affect the child’s speech and movement.

Sometimes, we can map a teenage patient’s brain during surgery. During this procedure we wake him up and have him participate in the mapping. This procedure is common with adults.

The local area we find as the problem may be a lesion such as a tumor, vascular malformation or abnormal brain tissue. If the child is a good candidate for a resection of the epileptic focus, we operate.

After this operation, 50 to 65 percent of carefully selected patients have a lot less seizures, or are seizure free.

Hemispherectomy/Hemispherotomy

Both terms describe surgeries used to treat seizures caused by an entire side (hemisphere) of the cerebral cortex. An older version of a total hemispherectomy, called a hemispherotomy, removed most of this cerebral tissue.

Many medical centers, including Children’s, now disconnect rather than remove the epileptic tissue causing the child’s seizures. This procedure is also called a functional hemispherectomy.

Operating this way generally leads to fewer complications and shortens surgery. The terms functional hemispherectomy and hemispherotomy describe different versions of the surgery.

The brain has two halves, the right and left hemispheres. Two groups of children are possible candidates for a hemispherectomy or hemispherotomy:

  1. those with multiple seizure foci throughout one hemisphere
  2. those whose seizures spread throughout the entire hemisphere

Examples of diseases that may benefit from this surgery include:

During surgery, we disconnect the affected hemisphere from the other areas of the brain — including the gray matter and white matter in the area — by cutting the electrical nerve pathways.

The goal is to prevent seizure activity from spreading by separating the abnormal, seizure-causing tissues from the rest of the brain. After such an operation, about 70 percent of children may be seizure free and about 20 percent may have fewer seizures.

Neurological function sometimes relocates to the healthy side of the brain both before and after the surgery. In other cases, if important parts of the brain must be cut, a child will experience noticeable changes.

After surgery, a child will often be weak on one side. If surgery was in the right hemisphere, the left side of his body will be weak, and vice versa. The surgery usually involves the motor area of the brain.

Each side of the motor area controls the opposite side of the body. This weakness can be permanent. Therefore, we limit this operation to children who either have severe seizures that greatly limit the quality of their life or are already weak on the affected side because of the underlying brain illness such as a stroke.

Most children need to stay in the hospital after surgery for rehabilitation to help improve or manage this physical weakness.

Corpus callosotomy

The corpus callosum is a bundle of fibers connecting the right and left sides (hemispheres) of the brain. A corpus callosotomy involves cutting this bundle to prevent seizures from spreading from one hemisphere of the child’s brain to the other. Neurosurgeons do this by cutting the front (anterior) two-thirds of the corpus callosum.

This surgery may be indicated for a child with seizures that do not involve a specific area of brain tissue that we can remove. It helps a child who has ‘drop attack’ seizures — the child’s muscles suddenly contract and he bolts to the floor or collapses forward in his chair.

After surgery, the child’s ‘drop attack’ seizures may lesson by up to 70 or 80 percent of patients. Sometimes our neurosurgeons do a second operation to divide the remaining area of the corpus callosum if the child’s seizures aren’t reduced enough by the first surgery.

Vagal nerve stimulator

Some children are not candidates for epilepsy surgery because:

  • Their seizures begin in several brain areas (they have multiple foci)
  • Their seizures spread (generalize) to both sides of the brain
  • After trying several medicines, they still do not have good seizure control

An alternative is the vagus nerve stimulator. The vagus nerve is a cranial nerve and starts in the brainstem. From there it goes down the neck and into the chest.

The vagus nerve stimulator is about the size of a small cookie. It is put in under the skin on your child’s left chest near the armpit.

During surgery, the neurosurgeon puts in (implants) the stimulator and then tunnels its wires under the skin to the left vagus nerve in the neck region.

After the area heals, the neurologist turns on and manages the device. It delivers a small on-and-off current to the vagus nerve to prevent seizures. Parents and their child, if he is old enough, can also activate the device.

If they sense a seizure starting, they can place a small hand-held magnet over the child’s body at the place where stimulator is located. This can prevent the seizure from starting. The vagus nerve stimulator’s battery needs changing every several years.

We don’t know exactly how the stimulation affects a child’s seizures, but about 50 percent of patients with a vagus nerve stimulator reduce their seizures by more than 50 percent. The vagus nerve stimulator is approved for use with patients 12-years-old and older.

Other treatments

Ketogenic diet is very complex. Neurologists sometimes use it to lessen or stop a child’s seizures. In general, it includes eating foods high in fat, low in carbohydrates and protein and limited in liquids. It must always be used under a doctor’s care.

To learn more about how the ketogenic diet works, please talk to your child’s neurologist.