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Diagnosis, Treatments & Support

The Epilepsy Program at The Alan and Barbara Mirken Department of Neurology offers all the latest expertise, technology and multidisciplinary approaches to diagnose and treat epilepsy, as well as provides support to you and your family.

How We Diagnose Epilepsy
When you first arrive at the epilepsy program, an epileptologist (a neurologist with special training in treating epilepsy) will lead the team to accurately diagnose and further understand the kind of seizures you experience and what kind of epilepsy you have. These conclusions will inform what kind of treatment you will begin. Diagnostic approaches and tests include:

Basic Evaluation
A physical examination will be conducted and a comprehensive personal and family history taken. Close friends or family may be asked to report their observations of your seizures. Blood work may also be taken to rule out other conditions that may be causing your seizures.

Imaging Tests
Several imaging tests may be used to both rule out other conditions that may be causing your seizures and to further explore if there are brain abnormalities like a tumor that may be triggering your epilepsy. Imaging technology includes Computed Tomography Scan or CT scan (pronounced sometimes as "cat"). This is an X-ray procedure enhanced by a computer, which results in a three-dimensional view of the brain.

We also have Magnetic Resonance Imaging (MRI), which uses a magnetic field and radio waves to produce highly accurate, computer-enhanced, cross-section images of the brain. Beth Israel's epilepsy program uses the new 3-tesla MRI, which increases the magnetic strength of the standard MRI and is able to better detect more subtle brain abnormalities.

Positron Emission Tomography (PET) scans and Single Photon Emission Computed Tomography (SPECT) scans are tests that use tracers injected into the body to view the brain's metabolism and function. These tests complement the MRI scan. The MRI scan provides neuroanatomical information; the PET and SPECT scans provide more information about brain function.

Electroencephalogram (EEG)
The standard outpatient EEG records and measures 30 minutes of your brain's electrical activity. About half of the patients with epilepsy will show the conclusive diagnostic abnormalities in a single EEG. When conducted in a larger series (typically three), the EEGs will catch the conclusive abnormalities in nearly 90% of the patients with epilepsy.

If, after a thorough outpatient evaluation (and with other possible seizure-causing conditions being ruled out), diagnosis is still unclear, video EEG monitoring can be conducted. Patients are admitted overnight to the epilepsy program's dedicated monitoring unit at Mount Sinai Beth Israel. The 24-hour EEG monitoring can often spot the subtle abnormalities that the standard EEG does not always find.

Neuropsychological Testing and Brain Mapping
Often used as a pre-surgical evaluation, the epilepsy team has several ways to map the brain so as to better understand what parts of the brain are being affected by epilepsy, so that important functions like language or memory are not compromised during surgery. First the epilepsy team carefully and safely anaesthetizes various parts of the brain, while keeping the patient conscious. Then, using either EEG technology or MRI technology, as well as interviewing the patient, the epilepsy team's epileptologist and neuropsychologist (along with appropriate test technologists) pinpoint the affected areas in the brain.

How We Treat Epilepsy
While many cases of epilepsy cannot be cured, they can be managed effectively with medication, electrical stimulation and sometimes surgery. Treatment considerations include:

Medications
The first line in the control of epilepsy is medication. Many tried and true medications have been in use for decades and are still available, but newer generations of drugs are offering many patients better quality of life with good seizure control and less side effects in the short- and long-term. Beth Israel's epilepsy team has years of experience in matching the right drug to the right person and to the right seizure history, helping the patient navigate the early trial period when side effects and seizures are noted and dosage and types of medications are tailored. Nearly 75% of people with epilepsy will find a satisfactory outcome with medications.

Vagus Nerve Stimulator (VNS)
This electrical simulator device can be implanted under the chest muscle (similar to a heart pacemaker) with the wire tunneled under the skin and ending in the neck under the vagas nerve. The epilepsy experts program the stimulator to give a series of intermittent and ongoing stimulations to the nerve at various strengths and frequencies.

It is not entirely clear how the VNS works, but scientists speculate that the device scrambles or blocks some of the abnormal electrical discharges in the brain. While the VNS works on an automatic, preprogrammed cycle, it also has the ability to be activated when a magnet is swept over the device from the outside of the body, allowing patients to self-activate it. For those who can sense a seizure is about to start, the VNS can be useful in stopping the process. For patients who cannot sense an impending seizure, it can be useful for family and companions to shorten the seizure, which leads to faster recovery. The magnet also provides an easy and non-invasive way for the epilepsy team to both test and fine-tune the VNS's programming.

Surgery
Some people with epilepsy have seizures caused by brain tumors, vascular malformations in the brain, or developmental brain abnormalities. If these abnormalities can be found, mapped and identified through the epilepsy program's sophisticated imaging technology, these people are possible candidates for surgical removal of the offending brain formations. Other people can be good surgical candidates, too, not because of obvious brain malformations, but because rigorous diagnostic tests have determined that their seizures are localized to a focused area of the brain and can be surgically treated. A thorough pre-surgical screening is done on all candidates to evaluate whether surgery can be done without compromising normal brain function. We work closely with the neurosurgery team at Mount Sinai Roosevelt, led by Dr. Robert R. Goodman, to determine which patients would benefit from surgical treatment.When appropriate and successful, such surgeries are, in effect, a cure.

Alternative Treatments
The epilepsy team stays abreast of the latest thinking in treatment including the potential of complementary medicine. Patients who are interested in such alternative approaches are encouraged to bring up discussions with the team during their evaluation.

Epilepsy and Other Conditions
Epilepsy can both complicate other conditions or other conditions can cause barriers to the use of certain epilepsy medications and treatments. The epilepsy team is well experienced in managing both epilepsy and other conditions (called co-morbidities) including: high cholesterol, osteoporosis, pregnancy, diabetes, and mood and anxiety disorders, among many others. This expertise is especially essential when treating older adults with epilepsy, as many older adults often cope with several chronic conditions. Searching for, diagnosing and analyzing co-morbidities is an important part of Beth Israel's epilepsy program's comprehensive evaluation.

How We Support You and Your Family
While Beth Israel's epilepsy program is built on a foundation of state-of-the-art clinical excellence and research, it is infused, too, with a spirit of compassion, support and patient education. From evaluation and diagnosis, to prognosis and treatment, to careful and ongoing monitoring and management, the patient and his or her family are carefully taught how to live with epilepsy and what to expect.

Patient education is provided in individual sessions and through an ongoing series of patient education seminars, including some conducted in Spanish.

Emotional and practical support is further provided via our access and referral to counseling, social services and support groups.

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