Epilepsy Awareness Month
Interviewed by Rasa Fournier
Wednesday - November 10, 2010
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Dr. Alan Stein
Director of epilepsy and neurophysiology at Queen’s Medical Center
Where did you receive your schooling/training?
I went to college at the University of Wisconsin and to medical school at Johns Hopkins University School of Medicine. I stayed there to do my residency in neurology, and then I went to the Barrow Neurological Institute in Phoenix, Ariz., for a two-year fellowship in epilepsy. I came to Hawaii in 1998 and started my private practice in 1999 focusing on epilepsy, and after about four years, Queen’s decided it wanted to develop an epilepsy program, so I moved over from private practice to Queen’s in 2002.
How long have you been practicing?
I graduated medical school in 1991 and I’ve been doing purely neurology since then. Since 1998 when I finished my epilepsy training, I’ve been practicing neurology with a focus in epilepsy.
What is epilepsy?
Epilepsy is a condition of recurrent seizures. Think of a seizure as a symptom. It can be from anything as severe as a brain tumor or stroke to something as mild as having too high of a fever or having metabolized your sodium level or glucose level out of control. There are millions of different causes of epilepsy. Some of the conditions are genetic; some are acquired - they came about later in life because of an injury, stroke or brain tumor.
About half of the time we never figure out what is causing the seizures or the epilepsy, but we’re trying to make progress through research and improved tools for doing MRI scans of the brain and other tests to look for causes.
How do you treat epilepsy, and are there any recent advancements?
The mainstay of treatment is with medications. There are close to 20 medicines on the market these days, which is a dramatic increase from 20 years ago, when there were only four or five medications available.
Unfortunately, the percentage of patients who can be completely controlled with medications hasn’t really changed. What has changed is that the side-effects are different and better. There are fewer drug interactions and fewer problems with some of the newer medicines.
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Approximately two-thirds of people with epilepsy are easily controlled with medications. Then there are about a third of patients, who despite having tried numerous medications and combinations of medications, their seizures cannot be completely or adequately controlled. For those patients, there are other treatment options that are often, but not always, successful. Options include brain surgery, which is something that we do here at Queen’s. There’s an electronic device called the Vegus Nerve Stimulator, which is kind of like a pacemaker that gets attached to one of the nerves in the neck that connects to the brain. We don’t really know how that stops seizures, but about a third of people who use that have improvement in their seizures. Then there are some new electronic devices that are being evaluated for epilepsy by the FDA, and those are called deep brain stimulators.
What does electrical stimulation do for the seizure?
We don’t really know. The hope is that it does stop the seizure. In terms of the outward manifestations of the seizure, it appears to help. A seizure is like an electrical storm inside the brain. It may be that even though the electrical storm continues, if you can stop it from spreading and involving larger and larger areas of the brain, that might improve the patient’s number of seizures or how bad the seizures are. The FDA is not looking just at whether it specifically stops the seizures, but if it can limit them and make them not as severe or prolonged.
How does surgery help?
For people who have seizures that come from a single spot in the brain, presumably it’s an area that’s damaged because of previous scar tissue or stroke or injury. If all the seizures come from one spot and if that one spot can be identified, and if the spot is safe to remove without causing major problems - like trouble with talking or paralysis - then the surgeon removes the area and some of the surrounding brain tissue, and we cross our fingers and hope that stops the seizures.
Can someone who has seizures live a relatively normal life?
John Roberts, chief justice of the United States Supreme Court, by definition, has epilepsy because he has had two seizures. There are lots of people who have had epilepsy that is well-controlled, and they have completely normal lives. Alot of my patients who have epilepsy, even though they aren’t terribly well-controlled, are able to have quite normal lives - work jobs, have families, have kids. What they’re not allowed to do is drive a car. If you have a seizure, you’re not allowed to drive a car for six months in the state of Hawaii. Seizures are very difficult to predict, but statistically, you say, well, if someone hasn’t had a seizure in six months, the odds of them having a seizure at any given moment is very low. People who have pretty well-controlled seizures have a lower risk of having car accidents than people with diabetes, heart problems and mental illness, but we let all of those people drive.
People with epilepsy have increased risks of having injuries if they were to have a seizure, but in general those risks are manageable. There are obvious risks with doing things like surfing, water sports, even being in a bathtub or hot tub alone, or doing construction with dangerous power tools, or being up on unprotected heights.
What do we do if we see someone having a seizure?
Mostly you don’t do anything. You don’t want to put something in somebody’s mouth. It’s true that they might bite their tongue, but they’re not going to swallow their tongue. Even if they bite their tongue, it will heal. But if you put something in their mouth then it breaks off, or they break a tooth and it gets caught in their throat, they might actually choke on it, and that’s not something that will heal. If they’re lying on a hard surface, you can get something soft to put under their head. You want to be near them to make sure that they don’t get into trouble.
Most seizures last for approximately two minutes or less. Afterwards, people are often very confused and disoriented. Talk to them in reassuring tones; don’t try to hold them down. If it’s someone who you know has a history of epilepsy, there’s no reason to call an ambulance. If you have no idea about the person, it’s reasonable to call an ambulance.
After a first-ever seizure, you definitely ought to go to the emergency room just to be sure there’s no major problem causing it. Once you’ve been checked out, if in the future you were to have seizures, it’s not something that I would recommend going to the emergency room for, but you do want to follow up with your physician.
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