Epilepsy 101

Mohamad Z. Koubeissi, MD, explains the advancements in epilepsy diagnosis and successful treatment, including medications and surgical options. Dr. Koubeissi also discusses the difference between focal and generalized seizures, potential triggers, and the impact an epilepsy diagnosis may have on an individual's career, relationships, lifestyle and/or cognition.
Epilepsy 101
Featured Speaker:
Mohamad Z. Koubeissi, MD, FAAN, FANA
Mohamad Z.Koubeissi, MD is board-certified in Neurology, Clinical Neurophysiology, and Epilepsy.  He is an Associate Professor of Neurology and the Director of the Epilepsy Center at The George Washington University School of Medicine & Health Sciences and a member of the medical staff at The George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates.

Learn more about Mohamad Z.Koubeissi, MD
Epilepsy 101

Dr. Mike Smith (Host): Welcome to GW Healthcast. I'm Dr. Mike Smith. Our topic today is “Epilepsy 101: What Newly Diagnosed Patients Need to Know”. My guest is Dr. Mohamad Koubeissi. He is a member of the medical staff and Director of the Epilepsy Center at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Koubeissi, welcome to the show.

Dr. Mohamad Koubeissi (Guest): Glad to be here. Thank you.

Dr. Mike: So, why don't we go ahead and first start and talk about what does the latest research show and what might be some of the causes of epilepsy?

Dr. Koubeissi: Epilepsy, by definition, is the propensity or the susceptibility to have spontaneous seizures that are unprovoked, okay? So, a single seizure may occur in up to 10% of the population. One of every ten people that we know may experience a seizure in their lifetime but the susceptibility to have recurrent, unprovoked seizures is what constitutes epilepsy, which is 1% of the population. Seizures, in general, can be either generalized or focal, if we want to broadly categorize them. Focal seizures start in one area of the brain and then spread like, for example, they can start in the area that is responsible for movement and spread to other areas that are responsibility for cognition and awareness, or they can start in the area that is important for vision or hearing, etc. Generalized seizures, they appear to involve widely distributed networks in both sides of the brain at the same time. What seizures are, is just abnormal synchronized electric discharges that affects a big neuronal population, meaning, big numbers of cells in the brain. So, anything that disrupts the brain, potentially may produce seizures. Examples are numerous, obviously. Trauma can cause seizures. Blood itself is very irritating to the brain cells and may cause them to fire abnormally which is a seizure. Abnormal blood vessels, stroke, a brain tumor, abscess, other kinds of infection like meningitis, encephalitis--anything that irritates the outer layer of the brain, which is the cerebral cortex--can cause seizures. But, still, despite all this knowledge, there is still almost half of the patients of epilepsy, we do not know of any specific cause for their seizures.

Dr. Mike: Okay. So, in some of those . . . So, what that latest research is finding, then, in some people, sounds like they're born with it, the nerve highways--how one brain cell connects to another and makes these neural or brain cell connections, in some people--it's not quite organized or structured the way it should be and that might be a cause of epilepsy in some people. Is that correct in saying that?

Dr. Koubeissi: This is correct. To explain further, this abnormal connectivity between brain cells may occur only in a small region of the brain and that's enough to produce abnormal electrical activity which, in turn, spreads like fire in the woods to involve other brain regions resulting in the clinical manifestation of the seizure. But, the description about abnormal connectivity between brain cells is an accurate one.

Dr. Mike: How do we actually . . . So, going back to the definition of epilepsy, what's the formal definition of it? It's not just one seizure because that might happen throughout somebody's life once or twice, but what's the real, true definition of epilepsy?

Dr. Koubeissi: The definition of epilepsy has slightly changed over time. Strictly speaking, like you mentioned, seizure is an abnormal electrical discharge or electrical activity in the brain, but epilepsy refers for recurrent, unprovoked seizures. The practical definition that clinicians used is two or more unprovoked seizures that are more than 24 hours apart.

Dr. Mike: How do we treat the seizure disorders or the epilepsy? What's the current treatment regimen in most cases?

Dr. Koubeissi: In the last two decades, there has been a plethora of newer generation anti-seizure medications. In the 20th century, for the majority of the 20th century, the world had only two and later three medications to treat seizures. Now we have close to 26 or 27, so we are in good shape in terms of anti-seizure medications these days. When you diagnose a patient with epilepsy, someone who has had two or more unprovoked seizures, then you start with prescribing an anti-seizure medication. Anti-seizure medications can reliably and continuously control seizures in up to two-thirds of all newly-diagnosed patients with epilepsy, which is good. The remaining one-third, we call them medically intractable, or pharmico-resistant. These are the ones who continue to have seizures just by treatment with one medication. What you normally do in such individuals whose seizures are not fully controlled by medications is you try to add another drug, switch to a different drug regimen, or, if they prove to be completely not responding to two or more medications at good trials, you may need to evaluate them for possible epilepsy surgery. That means if you can tell with accuracy where the seizure focus is, you want to test is it safe to remove it surgically. In certain individuals, epilepsy surgery can promise up to 80% chances of seizure freedom when continued medical therapy would not offer more than 5% chance of seizure freedom down the road.

Dr. Mike: So, in your experience, in treating patients with epilepsy, Dr. Koubeissi, what kind of effect does the diagnosis have, the disease itself have on people, and even the treatment? You know, in terms of like their career, cognition, relationships, what have you experienced?

Dr. Koubeissi: We have seen the whole spectrum. A lot of people are alarmed but, shortly thereafter, reassured that their kinds of seizures are the ones that tend to respond to medications successfully and that seizures, if controlled, should not affect their life at the social, or psychological, or cognitive levels, and they tend accept the diagnosis and be adherent with their anti-seizure medications and follow-up on time. A lot of them have a fine time with . . . do not have a major difficulty accepting the diagnosis. On the other hand, there are a lot of other people who continue to adhere to stigma-related to epilepsy. The moment they hear the word 'epilepsy' they think perhaps spirits or craziness, or something that is completely untreatable, and it takes time to educate these individuals that this is not the case. So, in some individuals in big cities with good public transportation systems, if you tell them that they need to refrain from driving until a feasible period of time elapses with no seizures while on treatment, be it three months or six months or twelve months, depending on where you live, they get completely stressed out because their lifestyle may necessitate driving on a regular basis. Others, they say fine, we can use the public transportation, we can wait a year with no driving, and they accept it kind of without a big deal. So, we see the whole spectrum in terms of the impact of the diagnosis and what it entails on the patients.

Dr. Mike: Okay. In summary, then, Dr. Koubeissi, is there something you would like people to know about epilepsy?

Dr. Koubeissi: I would like people to know that epilepsy is very, very common. It affects one of every hundred people that we know and epilepsy is completely treatable in two-thirds of people, and even in the remaining third, we continue to increase the utilization of epilepsy surgery and electrical stimulation, and even diet therapies in order to minimize the impact of epilepsy on people's lives. I would people to know that epilepsy does not prevent people from being creative and leaders and there are major figures in history who had epilepsy, including some great authors and artists like Theodor Dostoyevsky, possibly Vincent Van Gogh, the great painter also had it, Great Alexander had epileptic fits as well, among numerous, numerous others. So, it does not prevent you from being creative, and in the majority of cases, it should not impact your life severely.

Dr. Mike: Okay. That was very nice summary, Dr. Koubeissi, I like the way you said that, and I want to thank you for the work that you're doing and also thank you for coming on this show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Koubeissi or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. This is Dr. Michael Smith. Thanks for listening.