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The Allegheny General Hospital (AGH) Comprehensive Epilepsy Program was established in 1987 by James Valeriano, MD, of the Department of Neurology and has become one of the largest such services in the tri-state area of Pennsylvania, Ohio and West Virginia. The Comprehensive Epilepsy Program is a member of the National Association of Epilepsy Centers and designated a Level 4 Epilepsy Center. We specialize in diagnosing epilepsy along with both medical and surgical treatment in adolescents and adults.
Medical management in the form of antiepileptic drugs (AEDs) are used for initial treatment. Our program has participated in numerous investigational clinical drug trials over the last two decades, which provides an opportunity for patients to try an investigational drug before it is FDA approved if they have failed approved AEDs. Surgical treatment is available, which includes: temporal lobectomies, cortical resections, corpus callosotomies, and implantation of the vagal nerve stimulator. Surgical placement of depth electrodes and grid electrodes are utilized for localization if needed.
- James P. Valeriano, MD
Director, Comprehensive Epilepsy Program
- Kevin M. Kelly, MD
Director, Neuroscience Research ASRI
- Jack Wilberger, MD
Chairman, Department of Neurosurgery
- Carol Schramke, PhD
Over 2,000 EEGs per year are performed at the Allegheny General Hospital EEG Laboratory. The laboratory is equipped with 4 Nicolet Alliance recording machines (portable capable), 3 digital video-monitoring workstations (one in the Main lab, one each in the outpatient offices of Drs. Valeriano and Kelly), and 3 BMSI 6000 portable video-EEG machines for the adult and pediatric inpatient floors, ICUs, and emergency department rooms. Three adult inpatient rooms and one pediatric inpatient room are hard-wired for video EEG monitoring.
This type of EEG allows prolonged (24-72 hour) outpatient EEG. The patient is setup with an EEG electrode array and wears it at home for one to three days. This is used in evaluation of seizures, of seizures versus non-epileptiform events, and at times as part of the surgical evaluation of epilepsy.
This type of study is done as an inpatient and is used for two main purposes: determining whether patient's events are epileptic in nature or may be caused by other physiologic or psychologic processes; and in pre-surgical evaluation of epilepsy patients. Video/EEG monitoring can be performed with routine surface electrodes as is done with routine EEGs performed in the lab or can be performed with more specialized electrodes. These include sphenoidal electrodes, which are inserted through the skin and into the sphenoid sinuses. More invasive electrode placements are also available including depth electrodes, which are placed through the skull and into the brain substance and also subdural grid electrodes, which are placed on the brain surface.
These latter two procedures are not always necessary to perform in order to provide surgical treatment of epilepsy, but have been performed extensively at Allegheny General Hospital and are available if necessary.
MRI & CT
Allegheny General Hospital has 3 MRI scanners and 4 CT scanners, which proved state of the art imaging capabilities to detect potentially epileptiform lesions.
Single Photon Emission Tomography (SPECT), Positron Emission Tomography (PET) PET and SPECT scanning are physiological imaging techniques utilizing brain uptake of radioisotopes based on cerebral blood flow and brain metabolism. They are valuable in trying to define abnormal metabolic brain areas that could signal the focus of epileptogenic brain tissue.
Patients with epilepsy frequenctly complain of problems with memory and cognition. Neuropsychological evaluations, conducted by Dr. Schramke, are used to identify cognitive strengths and weaknesses and these results are used to counsel patients regarding strategies to cope with and compensate for their limitations. In addition, this type of evaluation can be useful in identifying other factors, such as a medication side effects and problems with depression and anxiety that may be contributing to patient complaints. Neuropsychological evaluations are also a routine part of pre-surgical evaluations and these data are used to obtain information useful in verifying a patient's lesion location, appropriateness for surgery, and risk for a loss of function following surgery.
Non-epileptic seizure-like events versus psychogenic seizures
It is well documented that a substantial percentage of patients who present to an epilepsy clinic actually have seizure-like episodes, which are not secondary to epilepsy. Patients who are thought to possibly have non-epileptic seizure-like events are evaluated through a multidisciplinary team approach. Video/EEG monitoring, the most reliable way of distinguishing between epilepsy and this disorder, is available at Allegheny General Hospital. Patients are typically admitted for between 48 and 72 hours. During that time arrangements can be made for evaluations with a psychiatrist and a psychologist. Panic disorder and other anxiety disorders, conversion disorder, and mood disorders may all cause or contribute to patients being incorrectly diagnosed with seizure disorder. Patients with epilepsy may also experience events that are caused by psychological factors rather than epileptic events (i.e., have both epileptic seizures and non-epileptic events). Through the use of video/EEG monitoring, diagnostic interviews, and psychological testing the accuracy of diagnosis is maximized. Patients are provided with feedback regarding the results of this evaluation and referred for appropriate treatment following these evaluations.
This procedure is routinely completed to assess the contribution of each hemisphere to language and memory performance, prior to surgery, and as a part of the comprehensive pre-surgical evaluation. By injecting sodium methohexital (Brevital) into the main artery supplying blood to one half of the brain, and effectively putting one hemisphere to sleep, we are able to measure the contribution of the other hemisphere to memory and language functions. This procedure typically involves first sedating the hemisphere of interest (i.e., the side of the brain that contains the area thought to be generating seizures and the areas that would be removed surgically), testing for memory and language abilities, and then repeating this same procedure with an injection to the alternate hemisphere. These test results are used to determine if patients are at risk for severe memory disturbance following surgery. In addition, these results help us predict which patients are most likely to be seizure free following surgery and therefore provide patients with important information when deciding whether surgery is the appropriate treatment for them. Patients normally are scheduled for this procedure following completion of the video EEG monitoring that is used to identify the suspected seizure focus. Patients can expect to be hospitalized overnight to allow for recovery from the procedure. The procedure itself normally lasts about one hour. A neuroradiologist inserts the catheter and administers the medication. A neurologist is present throughout the procedure and monitors the patient's EEG. Memory and language testing is completed by our neuropsychologist. The medication is administered through a catheter inserted into the femoral artery, which is located in the groin area, and the catheter is ultimately placed in the carotid artery, which provides blood flow to the brain. Patients are shown pictures and objects and are asked to respond to simple questions while sedated and then memory is tested. The results of this procedure are discussed with the patient and the patient's family, as well as the entire epilepsy surgery team, and can help in deciding whether surgery is appropriate for each patient.
The initial evaluation and accurate diagnosis is important in the medical management of epilepsy. In new onset epilepsy, workup for etiology, seizure classification and whether or not the patient does indeed have epilepsy are considerations in treatment. Medical management is initiated with antiepileptic drugs (AED's). Treatment of new onset epilepsy with traditional or newer AED's is based on the individual patient's needs. Choosing the appropriate AED may depend on the patient's age, gender (issues such as pregnancy, birth control pills, etc.), and concomitant medications. Once therapy is initiated, follow-up is required to evaluate the effectiveness of the AED and tolerability. Dose adjustments may be necessary or a switch in the AED may be needed to try to achieve seizure control.
In some patients, seizure control can be difficult. Experimental AED's, currently being evaluated by the FDA, become an option at this point. At our center we have extensive experience in the use of not only all marketed AED's, but also are involved in trials of investigational medications. Experience in these areas is important due to specific efficacies of various AEDs, side effects, and potential drug-drug interactions. Patients who do not respond to medical treatment are considered to have medical refractory epilepsy.
All types of epilepsy surgery have been performed at Allegheny General Hospital since the inception of the Comprehensive Epilepsy Center in 1987 and neurosurgery plays an integral role in the evaluation and management decisions of all potential candidates for epilepsy surgery.
Surgery may be necessary as a component of the work-up to identify the specific location in the brain from which the seizures arise or used as a treatment to remove the affected part of the brain in an attempt to reduce or eliminate seizures. If a specific, treatable seizure focus cannot be identified or the risks of brain surgery are unacceptable, other neurosurgical treatments may be available.
All of the following are performed through the Comprehensive Epilepsy Center:
Using specialized, stereotaxic computer guidance, thin electrode wires are inserted directly into areas of the brain felt likely to be responsible for the seizures. This is used when more standard methods of EEG monitoring are not able to identify the seizure focus.
The surface of the brain is directly monitored using a thin plate of electrodes to attempt to identify a seizure focus. If the focus is felt to be near critical control centers such as speech or movement, the brain can be mapped using the grid so as to specifically identify these centers and decrease the risk of any subsequent surgery to remove the seizure focus.
Removal of a portion of one temporal lobe may be highly successful in controlling or curing epilepsy in appropriate patients with complex partial epilepsy.
Focal Cortical Resections
Abnormal tissue on the surface of the brain, if not directly responsible for critical functions such as speech, may be removed in an attempt to control intractable epilepsy.
The corpus callosum connects the right and left sides of the brain. In the most severe of seizure disorders this connection and be severed in an attempt to prevent the seizures from spreading from one side of the brain to the other.
Vagal Nerve Stimulator
In patients who are not candidates for direct surgical treatment of their epilepsy, the vagal nerve stimulator may provide a chance of seizure reduction.
The AGH Comprehensive Epilepsy Center is actively involved in the evaluation of new surgical treatments including deep brain stimulation and seizure-sensing devices to activate treatments such as vagal nerve stimulation.
Epilepsy Surgery Outcomes
An extensive database is maintained through the Comprehensive Epilepsy Center to comprehensively track the outcomes of patients undergoing surgical treatments. Surgical success rates at AGH compare quite favorably with those reported nationally. For temporal lobectomy, over 70 percent of patients are seizure free (with about 30 percent still requiring some medication), while another 20 percent have a significant reduction in seizure frequency. With vagal nerve stimulators, approximately 50 percent of patients have had a 50 percent reduction in their seizures. Overall less than 2 percent of patients have had any complication from the surgical evaluation or treatment of their epilepsy.
Vagal Nerve Stimulator
Vagal Nerve Stimulator (VNS) was approved in 1997 as adjunctive therapy in reducing the frequency of seizures. VNS therapy delivers stimulation via a device implanted just under the skin in the left chest area. The pacemaker-like device sends mild, intermittent electrical impulses through a lead to the left vagus nerve, which then sends signals to the brain. Each device is programmed for the individual patient, and the patient and caregiver have the ability to initiate or abort stimulation with the use of a hand-held magnet.
Clinical Research Trials
Our program has participated in numerous clinical investigational drug and device trails since 1991. Dr. Valeriano was the investigator in virtually all of the trials along with Drs. Kelly and Wilberger, who were co-investigators in some of these trials. Dr. Wilberger also participated in a clinical trial as the investigator with the vagal nerve stimulator. Our program continues to be actively involved in ongoing research trials involving both investigational and currently marketed AEDs.