Melanie Cole (Host): Well, many epilepsy patients can be effectively treated with medication or surgery. Those treatments aren’t always an option for all patients. My guest is Dr. Nathan Fountain. He is a board-certified neurologist and neurophysiologist who serves as director of UVA Health Systems F.E. Dreifuss Comprehensive Epilepsy Program. Welcome to the show, Dr. Fountain. Tell us what is epilepsy and how does it affect patients.

Dr. Nathan Fountain (Guest): Thank you. Epilepsy is a common condition that we should talk about very specifically because it often has a stigma associated with it or some preconceived notions, so talking about what it is, is definitely the place to start and epilepsy is really any condition that causes seizures. Seizures are an electrical storm of the brain and the kind of seizure that most people think about is what used to be called a grand mal seizure, we now call a generalized tonic clonic seizure and in this case, the electrical storm of the brain grabs the whole brain at once. The patients typically stiffen and fall to the ground and jerk all over. It’s very dramatic to see fortunately for the patients having it, they are usually unconscious, so they don't experience anything necessarily unpleasant during the seizure, but is very dramatic and because it's so dramatic, people are often scared by that, may be appropriate so because it is something that can be pretty scary and intimidating to see, but in fact, the electrical storm that affects the brain most often doesn't affect the whole brain, but instead just affects one small part and that kind of seizure that comes out or is manifest depends on which part of the brain is affected, so for example, if just a small part of the brain that controls the left hand is what having the electrical storm then in that case it will just cause left hand jerking and people will otherwise be perfectly aware of what's going on. They are perfectly conscious, hey look my hand is jerking that’s what my seizure is. If instead the seizure or electrical storm affects just the vision part of the brain for instance then it could just be spots or dots or have other kinds of things in the vision. The most common spot that seizures occur is in the temporal lobe and the temporal lobe controls consciousness and awareness of memory, so in this case, this kind of seizure typically called a complex partial seizure has patients just stop and stare. They are kind of zoned out or staring off into space for just a few moments and they don’t do anything else, they return to normal and that’s actually is the most common kind of seizure. The seizure itself can affect individuals in many very specific ways that only just for a few moments because their characteristic of it is that people who are otherwise perfectly fine had a seizure that starts all of a sudden, goes on for a minute or two and then the seizure stops and people return to normal. A bigger problem for epilepsy is what happens in between seizures because people might be so scared by the seizures that they are afraid of the person which is of course entirely inappropriate. Epilepsy is not a psychiatric disease and most people who have epilepsy are otherwise perfectly fine than having seizure, so it affects patients both by having seizures but also in other ways in between.

Melanie: Dr. Fountain, I understand that with the different types, will come different types of treatment, but what do you generally do as a standard treatment option and how do you decide which work for what patients?

Dr. Fountain: Certainly, the place to start is with medication. There are number of medications. In the past about 15 years, there have been about 15 new medications approved and that means we have almost 20 medications to choose from. Which medication we choose depends on which kind of seizure occurs, but also other characteristics that people might have. The things that might need to be treated in addition to the seizures or particularly side effects with medications that you might avoid, so some seizure medications for an instance cause weight loss, so if you are overweight, you might actually like that medication, but if you're particularly skinny then that's not going to work for you. Some medications will treat migraine headache in addition to seizures, so if you have migraine headaches then that particular medication might be a great option. Older medicines if we go back 15 or 20 years, today they cause things like sleepiness and drowsiness. They could affect the liver and the blood work, so older medications required a lot of blood work and tend to be a little bit more fickle. So, we try to avoid those and choose newer medication. Fortunately, about half of patients with epilepsy will respond to the first medication we try. In other words, someone comes in with new onset seizure, they have just had one or two seizures that seems to be result of epilepsy and we start the medication and they don’t have any more seizures as long as they are taking the medication. So that works for about half of people. It’s about another quarter of people that we have to try number of different medications and after trying a number of medications then they are well-controlled. So, their seizures are well-controlled on their medication, but for about 25 or 30% of people despite our best efforts, they continue to have seizures.

Melanie: So now tell us about the new treatment option UVA is offering for epilepsy treatment.

Dr. Fountain: There are a number of new treatments, of course besides the standard medication, the new medication, then there are research medications. We always have ongoing trials, but sort of a new breakthrough or a new way to approach epilepsy is through devices. There has been a device that has been around for quite a while, but doesn't actually stimulate the brain, but instead stimulates the different part of the body. It stimulates the nerves in the neck and that’s the standard therapy that has been around a while. The new treatment today at UVA and other places that have been involved in this research project is sort of a Star Wars like device in which electrode wire that can monitor the seizure are placed onto the brain where the seizures come from and a small computer chip is implanted in the skull and it monitors the brainwave activity and when it detects a seizure coming from the area the seizures arrive, then it provides a little zap, a little electrical stimulation to that part of the brain to stop the seizure. It also can provide at the other time and by stimulating the place where the seizures arrives in the brain, it can prevent them from occurring, so the reason this is so novel is because it's responsive neurostimulation. In response to seizure occurring, this little electrical stimulation can prevent it and the reason that it is such a nice thing for people with epilepsy is because as I mentioned before, the medications often cause problems with drowsiness or sleepiness or other things like that, but this new device doesn't have any of those problem. Of course, it does require surgery to have it implanted and the device is new, so we are not really sure how long it will last, but it seems that the battery life for most people will probably be at least a year and hopefully in the future, it will be rechargeable.

Melanie: Dr. Fountain, which patients might benefit from this?

Dr. Fountain: It’s really most appropriate for patients who are not controlled with medication because the great advantage to medications is that if someone is having seizures, it starts them on a medication, if that seizures go away, it's great, if the seizures come back and they don’t tolerate the medications, you can stop the medication and then they are off the medication and have no after affects from it, but for devices, once they are implanted, the intention is to keep it there even if it's not beneficial because the risk of removing is probably greater than the risk of leaving it there and that means that you really have a strong inclination to implanted to begin with, so the people who are most appropriate are people with epilepsy who haven’t responded to medications, so what that means as I mentioned before, it's appropriate for about 25 to 30% of people with epilepsy.

Melanie: Now why should patients with epilepsy choose UVA for their care?

Dr. Fountain: Oh, it is certainly a leader in epilepsy care. The Comprehensive Epilepsy Program at UVA was one of the first three comprehensive epilepsy centers in the world that was started by a grant from NIH, the National Institutes for Health that designs comprehensive care for epilepsy and really we have been a leader since then, the faculties are internationally renowned. We have many accolades. We do a lot of research, but for most people what I think they appreciate is individual care. Our comprehensive care is aimed at treating each individual depending on the specific problem that they are having. We have nurse case managers or case coordinators in our clinic who are able to coordinate all the care. We tend to service the medical home for people with epilepsy, so we don't provide primary care. If somebody has a cold or an infection, a common medical problem, we would send them to their primary care doctor, but because often epilepsy determines many other aspects of their lives then their care coordinator can help decide what needs to be done for that. I would say that it were certainly the largest epilepsy center in a mini state radius, but beyond that, it’s the individual care that we provide for people that I think separates us from other epilepsy program.

Melanie: That's very exciting. Thank you so much Dr. Nathan Fountain. You are listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening.