Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today is Dr. Robert McInnis. He's an Assistant Professor of Clinical Neurology at Weill Cornell Medical College-Cornell University. And he's here today to tell us about the latest treatments for seizures and epilepsy. Dr. McInnis, thank you so much for joining us today. I'd like you to start by telling us about epilepsy. What age is it most prevalent? Tell us a little bit about this condition.

Robert McInnis, MD: Sure. Thank you for having me, Melanie. Happy to join you. Epilepsy is a condition that is defined by having a trait to have seizures that are spontaneous and unprovoked. Seizures are an electrical disturbance of normal brain activity that are caused by some population of brain cells that become hyperexcitable, and then seemingly at random will cause this hypersynchronous activity that spreads through the brain and can lead to a whole bunch of different symptoms. Those seizures, I would say, are the defining feature of having epilepsy. There are other symptoms that come with epilepsy usually, and our patients who have epilepsy often have a number of other symptoms that are often cognitive in nature, like related to memory or psychiatric symptoms like issues with depression or anxiety. I like to think of epilepsy as not just seizures, but some other symptoms too that require support.

You asked when epilepsy develops, and I would say epilepsy can emerge really at any age through the lifespan. But when you look at the lifespan, there are kind of two peaks. One is really in neonates, or newborns can develop seizures for a variety of different reasons, usually related to a stressful birth, either strokes or deprivation of oxygen that might happen during the birth process, and those babies will develop epilepsy as a result.

But that risk plateaus and doesn't peak again really until later in life after age 50. People can develop an epilepsy for a number of reasons that are acquired in nature. Specifically things like brain tumors, strokes, head trauma can all result in epilepsy, and that's why the risk sort of accrues over time and with age. But in truth, really anyone at any age can develop epilepsy, and I see people come to my clinic really at all ages.

Melanie Cole, MS: Dr. McInnis, how do you diagnose it and speak about those seizures? Is that a criteria by which you diagnose this, by how many they've had, or do you start treatment after one? Because parents certainly want to know and anyone older that's developed these seizures.

Robert McInnis, MD: Yeah. When I meet patients who are having seizures, seizures don't always equate epilepsy if there's been a single seizure. And in the circumstance of having a single seizure, we usually use additional tests to determine whether the risk of having future seizures is high. We use brain MRI and electroencephalogram. So, the EEG can, in the circumstance, of a single seizure help predict whether someone might go on to have future seizures. So, that's a particular circumstance where tests really can help make a prediction. If either is abnormal or shows an epileptiform abnormality, we can make a prediction that the risk of seizures is high, and we're actually allowed to make a diagnosis of epilepsy in that circumstance.

But I'd say in the most common scenario when I see patients, they've had numerous events by the time I meet them. And the question is whether those events are definitively seizures or not. And so, the main goal when I meet these patients is to take a detailed history from the patient, but also from loved ones that have seen the events to determine whether I think those events are seizures. And seizures don't always have to be convulsive in nature. There can be events that are non-convulsive that involves staring, unresponsiveness. But then even on the more mild side, patients may have what we call focal aware seizures that are a perceptual disturbance that they experience repeatedly. Often that might involve deja vu or intense fear and sometimes these events get mislabeled or misdiagnosed as panic attacks. So when I meet patients, it's my goal to determine whether the repetitive events sound consistent with seizures. And if I'm not sure, then sometimes I bring patients into the hospital for prolonged electroencephalographic monitoring, so EEG testing, where we use that in addition to video to capture events of concern and that can be a gold standard of diagnosis in these situations where I'm uncertain about the diagnosis.

Melanie Cole, MS: Well, I'd like to talk about some of the treatments, both surgical and non-surgical. But I'd like you to touch on diet and its role in epilepsy, because that's been in the news a lot lately. Can you speak a little bit about that before we get into some of the other interventions?

Robert McInnis, MD: Sure. Yeah, diet is a topic that comes up a lot when I meet patients. It's been well understood to potentially treat epilepsy for a while now. We have one diet in particular that's been heavily studied, which is called the ketogenic diet. I guess I'll step back first and say that I think about diet really as an adjunctive treatment for people that have epilepsy and usually medications are the first thing we use to try and control seizures. For those patients in whom the seizures are not controlled with medications alone, things like diet are important to consider. And the ketogenic diet is a specific diet that involves restricting carbohydrates and focusing instead on getting fuel from fats and less on protein, but protein is allowed as well. And by doing this, basically, the body doesn't use glucose for fuel. It will begin to use ketones. And what we find is that in patients who are able to sustain the ketogenic diet, that their seizures can, in some circumstances, be reduced by up to 50%. And for those that have frequent seizures, that can be a very meaningful reduction in their seizure frequency.

The drawbacks of the diet is that it can be difficult to sustain and really, the effectiveness requires that you sustain the diet indefinitely to get the benefits of it. But good news is that we have some other diets like the modified Atkins diet, which is very similar to the ketogenic diet, but is not as strict in terms of the limiting carbohydrates. It emphasizes fat and reduces carbohydrates, but might be easier for some patients to implement. And we have some data that it actually is helpful. So, diet, I think, is very reasonable and should be considered in our patients whose medications are not working to fully control their seizures.

Melanie Cole, MS: Well, speak for just a minute about the medications and what they're intended to do.

Robert McInnis, MD: Yeah, great question. Medications are, again, the mainstay of treatment for people that have epilepsy. We call them anti-seizure medications because we've sort of convened as a group to rename them anti-seizure medications instead of anti-epileptic medications because we know that they're effective in stopping seizures, but they're not effective at removing the trait to having seizures. And so, the goal in using anti seizure medications is to reduce the excitability of the brain and its propensity to have spontaneous seizures. So whenever we start medications, anti-seizure medications, our goal is to reduce the seizure frequency and ideally achieve a state of having no seizures. And in tandem with that, our goal is always to protect the person who is starting these medications against the side effects of them. And our main strategy is to go up slowly on any dose of a medication such that we find the dose that works to control seizures, but minimizes any side effects that might come out.

Melanie Cole, MS: Well, thank you for that explanation. And now, for patients that are refractory, whose medications, you've done the adjuvant diet, maybe they've tried. And ketogenic is a difficult one to stick with. But like you said, it has been shown to help. So if all of these things have not been working and the person is still suffering from seizures, what's next?

Robert McInnis, MD: Excellent question. I think the good news is that two-thirds of patients who develop epilepsy are going to get their seizures under control with medications or diet or a combination of the two. For those that don't have complete control of their seizures and whose seizures remain disabling, we begin to think about surgery once patients have tried two medications, we found that those two medications have been ineffective. Surgery is a important treatment intervention for those patients, though it needs to be tailored to the type of epilepsy that the patient has.

One major type of epilepsy is called focal epilepsy. And in those patients with focal epilepsy, their seizures start in a certain part of the brain and the electrical activity spreads from a certain focus. And in these patients, some of them may be amenable to having the part of the brain that is causing the seizures to be removed. It could be removed in a subset of patients, if this location isn't important for essential functions. Sort of a detailed evaluation is required to determine who is a candidate for that. But in those that are eligible, it can be very effective, if not curative, for epilepsy.

For other patients whose seizures are focal, but are in an area where the brain cannot be removed, there are other devices that we might implant either in the body or in the brain to quiet down seizures. There's also another subset of epilepsy called generalized epilepsy, where the brain engages in abnormal electrical activity almost on both sides at the same time. So, the whole brain gets engaged at the same time in those seizures. And we do have devices for them as well. So, devices are a potential option for patients with generalized epilepsy as well.

Melanie Cole, MS: It's pretty cool how many tools you have in your toolbox to help people that do have seizures or have diagnosed the condition of epilepsy. What I'd like to know, Dr. McInnis, is if you are with a loved one, or even if you see someone on the street, and we used to hear about different things you were supposed to do, but that's changed. If you see someone having a seizure, is that a 911 call? What are we supposed to do?

Robert McInnis, MD: Yeah. If you see someone having a seizure, it is important to, I think, first just stay with that person. And we usually advise loved ones of our patients who have epilepsy to begin timing the seizure. Because the duration of the seizure, the longer it goes, the more likely it's going to continue without stopping and that's an emergency. Fortunately, most seizures stop in under really a minute or two. But if a seizure persists for greater than certainly five minutes, then that's an emergency. And medical providers need to come emergently to help basically attend to that person and bring them to a hospital. But for the other patients, you know, the majority of whom fortunately the seizure will stop on their own, it's important to give first aid really to anyone.

For anyone that has a seizure, and the majority, I think we can be reassured will stop eventually seizing, but will need some care while they're having a seizure. I think the main things to be attentive to are the position of the patient or the person having the seizure. We think it's safer for a person to be on their side rather than on their back. Certainly prone is a bad position to have a seizure in, because people could choke either on their saliva or if they vomit during a seizure. So, putting them on their side is important. And removing really anything around the person that could be harmful. So if, you know, there's sharp objects around the person or a hard coffee table, I advise their loved ones to move objects out of the way that could be harmful while the patient is not in control of their body. And then, I think calling 911 if you don't know the person certainly. And if there's any dangerous aspect of the situation where the patient is or the person is, calling 911 is important to get extra help.

Melanie Cole, MS: Great advice, Dr. McInnis. And do you have any final thoughts which you'd like patients to take from this episode about seizures and epilepsy and what you'd really like them to know and exciting things in your field?

Robert McInnis, MD: Great question. Yeah, I think I became an epilepsy doctor, because I think epilepsy is a condition that we can be very optimistic, has excellent treatment options, has a lot of new technologies that are available to help diagnose patients and come up with a really tailored treatment plan that I think can bring people back to having a normal daily function and return to quality of life. I think that having onset of new seizures can be a very scary thing for people and their families. But I think that there is a lot of reason to be hopeful that treatments will be effective. And those people in whom medications are not effective, there are new options coming down the pipeline and new ways to use the treatments we already have to better control seizures and bring people back to normal function.

Melanie Cole, MS: It's about quality of life, isn't it, doctor? And thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, Pandora, and Google Podcasts. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole. Thanks so much for joining us today.

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