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Published on April 03, 2019

A common and treatable disorderA common and treatable disorder

According to the Epilepsy Foundation, about one in 26 people will develop epilepsy in his or her lifetime. It is the fourth most common neurological disorder and affects 65 million people worldwide. Finding the right treatment can be life-changing for patients and their families.

“There are differences between a seizure and epilepsy,” said neurologist Mathew Pulicken, MD, MHS, of Neurologists of Cape Cod in Hyannis. “Epilepsy, is diagnosed when patients have recurrent seizures, without provoking factors. Everyone has a chance for having seizures, depending on the individual’s seizure threshold. When you have repeated seizures, it means that something is wrong with the electrical activity in your brain.”

Seizures are caused by abnormal electrical discharges from the brain that spread and become out of control. It can lead to whole body convulsions or loss of consciousness or awareness. If the discharges do not spread to involve the whole brain, it can result in smaller episodes with changes in awareness or shaking/twitching affecting one side of the body. Sometimes even episodes of prolonged staring can be a sign of seizure, he said

Every person has a different seizure threshold, Dr. Pulicken explained, and a seizure can be triggered by many things, including changes in electrolytes, use of stimulant drugs, certain medications and excessive alchohol use

When a patient who has experienced seizures comes to see Dr. Pulicken, he spends about an hour examing them and taking a detailed medical history, including:

  • Any complications that may have occurred during their birth and childhood,
  • History of childhood infections or meningitis, or
  • Head trauma or febrile seizures, or other unexplained episodes of loss of consciousness throughout their life.

“We need to figure out if the seizure was a one-time occurrence or if there is possibility of it happening again, and what tests to order and whether medications should be considered,” he said.

Detailed Testing Is Available

If someone comes in after having a seizure, a 25-minute brain wave test, known as an electroencephalogram or EEG, is ordered. If someone has a seizure during the test, or shows evidence of irritability in the regions of the brain, that puts the patient at higher risk for future seizures. This would indicate epilepsy and a diagnosis can be made based on the EEG results.

Sometimes, the short duration of the brain wave monitoring study has its limitations because a person could be having multiple seizures a day and may still have a normal EEG during the time the study is recording the live brain wave activity. A repeat study or longer EEG study can inform the doctor whether there are epileptiform abnormalities, Dr. Pulicken said.

Dr. Pulicken completed his four-year neurology residency at Tufts University in Boston, followed by fellowship in Epilepsy and EEG at Massachusetts General Hospital, and has been a member of the American Epilepsy Society (AES) since 2011. He attends the AES annual meetings, so he can incorporate all of the latest changes and improvements in the treatment of the disease with his patients

In seizure patients, especially when there is concern for possible epilepsy, neurologists use magnetic resonance imaging (MRI) to look for any structural abnormalities which can make the brain irritable. An MRI can show structural changes in the brain, like blood vessel malformations or areas of abnormal development. In the most common type of epilepsy, the temporal lobe epilespy, there could be associated changes in these regions.

Since 2016, neurologists on Cape Cod have offered a longer-term ambulatory EEG for up to 72 hours. Patients come into the office on North Street in Hyannis and have electrodes placed on their scalp. They can then go home and continue with the routine activities, except washing their hair. A videocamera is also given to the patient to record any clinical episodes of concern. The elcetrodes will continue to record the brain waves for the duration.

“There is a huge utility to the three-day testing,” Dr. Pulicken said. “They don’t have to be admitted to the hospital and they are in their home environment and we can see what’s going on in their brain for up to 72 hours.We may also be able to record the episodes of concern on camera.”

Once a diagnosis is established, patients can receive treatment with Dr. Pulicken or another Cape Cod Healthcare neurologist, who is trained in epilepsy diagnosis and management.

Inpatient Assessment Coming Soon

Sometime this year, Neurologists of Cape Cod physicians are hoping to offer continuous EEG recording for inpatients at Cape Cod hospital. The availability of continuous EEG testing means patients would not have to be transferred off-Cape for this test. Critically ill patients have a higher incidence of sub-clinical seizures, which may only be picked up on continuous EEG.

“This would be extremely important for people who are comatose, so we could assess their brain activity and see if seizures are contributing them not waking up,” said Dr. Pulicken. “The unresponsiveness could be caused by seizures. Continuous EEG can also be used with post-cardiac arrest patients, to assess their prognosis, as epileptic activity soon after cardiac arrest is not a good prognostic sign.”

Dr. Pulicken has noticed an increase in seizures in the elderly population in recent years. When someone has a previous history of strokes, or with neurodegenrative diseases like dementia, there is higher risk of seizures, even if the patient has never had one in their whole life.

There are many treatment options for patients, to control or minimize the condition, he said.

“There are now 28 different medicines to treat seizures with different mechanisms of action. For majority of epilepsy patients, with the correct medication and dosage, epilepsy can be a very manageable condition,” he said.