Caitlin Whyte (Host): This is Community Connect: presented by Tampa General Hospital. I'm your host, Caitlin Whyte. And joining me today is Dr. Selim Benbadis, the Professor and Director of the Comprehensive Epilepsy Program and EEG Lab at the University of South Florida and Tampa General Hospital. Alongside him, we have Dr. Yarema Bezchlibnyk, an Associate Professor and Director of Stereotactic and Functional Neurosurgery. Today, we explore the fascinating world of epilepsy management and treatment. I'll start with you, Dr. Benbadis. What are the latest advancements in diagnosing and treating epilepsy?

Dr. Selim Benbadis: There are a lot of advances on both sides, on the diagnosing and the treating. On the diagnostic side, I would say the way we do EEG, electroencephalography, the brainwave recording can be done in the normal outside way, if you will, putting electrodes on the head. But as Dr. Bezchlibnyk will, I'm sure, detail, we also can put electrodes inside the brain without being terribly invasive as we were 20 years ago to better define the zone where the seizures are coming from.

EEG is also improved in terms of duration. We can do prolonged EEG, ambulatory EEG, and these things were not available 10 years ago, and many of them are still in the research phase. So, that's one side of the diagnosis. The other side of the diagnosis is video recordings, which has become much more widespread. First of all, everybody has a cell phone and can take videos, which we find very useful for diagnosis. And then,, from a diagnostic point of view, the third part that has improved is imaging, and specifically the more sophisticated MRI images that allow us to see the brain in more detail.

 So for treatment, there are three categories of treatment. One is seizure medications, and there is always new medication being studied and released on the market. And they help because they're different. They have different mechanisms of action, different side effect profiles. So, the more choices we have, the better to help more patients. So, there are always new medications. And generally, they're better than the old ones, mostly in terms of adverse events and drug-drug interactions.

Progress in surgery, I will let Dr. Bezchlibnyk elaborate on that. But we have better ways, less invasive way of resecting epileptic tissues and trying to cure epilepsy. And lastly, neuromodulation, which 20 years ago only had one modality, which was vagus nerve stimulator, in the last five years or so, we have added two others, namely deep brain stimulation and the NeuroPace system, which is the responsive neurostimulation. So, we have three ways of doing neuromodulation without resecting or ablating tissues. And so, all of those give patients more choices, more options, depending on every situation. And every situation is different.

Host: How do lifestyle changes such as diet or sleep influence epilepsy management, Doctor?

Dr. Selim Benbadis: They do influence. They don't give you a cure, but they certainly limit exacerbation. So yes, good sleep hygiene, regular sleep schedules, not using alcohol too much. In moderation, oftentimes in patients with controlled epilepsy, it's okay to have a leisurely drink here and there. But yes, avoiding triggers, especially sleep hygiene and, of course, compliance with medications, which is a big problem.

Host: And how can patients and caregivers recognize early signs of epilepsy in children or adults?

Dr. Selim Benbadis: By observing seizures, which are brief episodes of abnormal behavior, which can be very dramatic, like a whole body convulsion, so-called grand mal seizure, everybody will notice that that's not subtle. But what they can do to help us when patients have seizures that are more subtle, less obvious than a full-blown convulsion episodes that might be seizures, loss of awareness, strange behaviors and they're short-lived, seizures are typically a couple of minutes and then the patient gradually goes back to normal. So, those brief paroxysmal episode of abnormal behaviors, what's very useful for us is a good description by the witnesses. An extension of that is cell phone videos. When patients have a seizure or seizure-like events, we love to see videos of them. It really helps us to determine are these really epileptic seizures? If they are not, what are they? And if they are, what kind are they? Where are they coming from? It's very helpful for us to see videos to make a better diagnosis.

Remember, epilepsy is also often misdiagnosed, so not everything that shakes or triggers or brief abnormal behavior is a seizure. There are other things that can resemble seizures and are not seizures. So, for us to see them is very useful.

Host: Now Dr. Bezchlibnyk, what types of epilepsy surgeries are available? And how do you determine the best option for a patient?

Dr. Yarema Bezchlibnyk: Well, as Dr. Benbadis pointed out, there are many options for surgical intervention in patients with epilepsy. The reason why we consider them is because although there are many medications, again, as Dr. Benbadis pointed out, unfortunately, roughly a third or so of patients who have seizures will not respond over time to medications. And so, those patients will need something else other than medications to get them seizure-free. And we know that poorly controlled seizures can lead to an increase in morbidity and even mortality.

And so, thankfully, there have been advances in all this. And so, Dr. Benbadis already pointed out that even when we consider not resecting or removing abnormal brain tissue, which triggers seizures, there are now three devices that allow us to help seizures get under control, and that's the vagus nerve stimulator, the deep brain stimulation system, and the responsive neurostimulation system, or that's the NeuroPace.

The goal, however, for most surgeries that when we evaluate patients is to get patients seizure-free. That's our goal. And most of the time, we accomplish that goal best by removing or ablating the part of the brain that is abnormal, because seizures are abnormal electrical activity, and they come from cells in the brain that are misfiring, the behaving abnormally.

The analogy that I use in my clinic is that you've got a classroom full of kids. And somewhere in this classroom, there's a bad actor who keeps cajoling everybody else in the class to throw their books up in the air. And over time, if this person is allowed to persist in that classroom, then the whole classroom is going to stop paying attention and stop learning.

And so, together with my epilepsy colleagues, including Dr. Benbadis and his team, we can talk about each patient individually. We can figure out where their seizures are coming from. And then, we can try and tailor a surgery to that patient's specific seizures and their specific goals, including neuromodulation or potentially ablating or removing the part of the brain that's abnormal.

Host: And what exciting developments in epilepsy surgery are on the horizon in your opinion?

Dr. Yarema Bezchlibnyk: As Dr. Benbadis pointed out, one of the things that we are focused on is being as precise with our surgical interventions as possible so that we can do a minimal surgical procedure. The goal is to get patient seizure-free, and the best way to accomplish that is to find that specific part of the brain that's acting abnormally, and then remove that part of the brain. We're now able to do that in less and less invasive manner, including through the use of laser fibers where we use the laser to heat up a very small part of the brain tissue that's abnormal in an MRI machine so that we can control how that's being done. Or potentially, we can even pass a little bit of electricity down through the leads that we use to find these abnormal areas so that we can burn an even smaller part of the brain out, and that's done with the patient awake in the room right after we finish localizing those seizures. So, the goal there is to be as minimally invasive and as maximally protective to the rest of the brain as possible while still getting patients seizure-free.

Host: How long does it typically take for patients to notice changes in seizure frequency or severity?

Dr. Yarema Bezchlibnyk: So if we're talking about the most powerful surgeries that we have, that is finding and then removing the abnormal part of the brain, those are results are immediate. Sometimes patients will have a couple of breakthrough seizures because they've had a surgical procedure of some sort, but we expect otherwise for that patient to be seizure-free from almost the moment that we do the surgery.

There are a couple of other interventions, the neuromodulation devices that Dr. Benbadis has pointed out, those are going to take a bit more time for the patient to see a benefit from that intervention. And that could be up to three to six months before we see a significant improvement in seizure frequency or severity. But for the most powerful surgeries that we have, it's an immediate improvement.

Host: Well, my last question is for both of you. I'll stick with you, Dr. Bezchlibnyk. Do you see personalized medicine playing a larger role in surgical decision-making?

Dr. Yarema Bezchlibnyk: I think both of us can answer that because that is precisely what we do. I, together with Dr. Benbadis and his team, you know, we talk about every patient together at our epilepsy conference, which happens basically every week. We talk about their specific experience of epilepsy, we talk about all of the different ways that we have used to try and localize their seizures and confirm that the specific experience of the person's seizures. And then, we personalize our recommendation to that patient that we present at conference.

I then will speak to the patient in clinic, as will Dr. Benbadis and his team, and we'll lay out some options to the patient. And it's ultimately the patient's choice to kind of think through our options and talk with us about our recommendations so that we can come up with something that's going to work for them and their family.

Host: Thank you. And your thoughts, Dr. Benbadis.

Dr. Selim Benbadis: Yeah, I completely agree. A, it's a teamwork and every epilepsy center will tell you the same thing. But as Dr. Bezchlibnyk said, it's a very individual decision. Each patient is different. There are so many factors: the type of seizures, where they're coming from, the imaging, the brainwave pattern, the patient preferences, because some procedures are more invasive, and some are more benign.

So, it's always a very individual risk-benefit analysis. For every single patient, it's different. And that's why we meet and discuss each patient individually as a group, neurologists, neurosurgeon, neuroradiology, neuropsychology. And it's really a wholesome and very individualized decision.

Dr. Yarema Bezchlibnyk: Yeah. I wanted to make one more point in all this, and that is that ultimately it's the patient's decision as to how to proceed. And it's our role as the team that's taking care of them to provide them with options and to educate them on the possibilities. So if there are patients out there that really don't know or think that they want to go through with a surgery, again, a lot of the options that we have aren't specifically surgeries. Dr. Benbadis knows a lot more about medications because this is what he specializes in and there are very different surgical modalities out there. So, not every surgery is, you know, what people might be thinking about. And so, I would encourage people to talk about a referral to an epilepsy program if they have persistent seizures.

Host: Thank you so much for sharing your thoughts and for taking the time to be on the show. That has been Dr. Selim Benbadis and Dr. Yarema Bezchlibnyk. For more information, please visit tgh.org. And if you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect: presented by TGH on your favorite podcast platform. I'm Caitlin Whyte. And this is Community Connect: presented by TGH. Thanks for listening.