- ALL RIGHT. WE CAN GO
AND GET STARTED.

I WOULD LIKE TO WELCOME YOU ALL
TO OUR FIRST CALL

OF THE FISCAL YEAR
IN THE 2013 EPILEPSY PATIENT

AUDIO CALL SERIES.

MY NAME IS SEAN GAMBLE
AND I AM WITH

THE EMPLOYEE EDUCATION
SERVICES OF ST. LOUIS,

AND I'M THE PROJECT
MANAGER FOR THE SERIES.

OUR LINES ARE MUTED
AND WILL BE OPENED UP

AT THE END OF THE PRESENTATION
WHEN WE ARE READY FOR QUESTIONS.

PLEASE LIMIT YOUR QUESTIONS
TO ENSURE EVERYONE HAS A CHANCE

TO ASK ANY THAT THEY MAY HAVE.

PLEASE BE SURE TO COMPLETE
YOUR EVALUATION.

YOU GET CREDIT FOR THIS PROGRAM.

COMPLETE INSTRUCTIONS ARE
FOUND IN THE BROCHURE

OR ON THE CATALOG AT CMS.

YOUR DEADLINE TO FINISH
THESE IS DECEMBER 20th.

NOW LET ME WELCOME
OUR SPEAKER FOR TODAY,

DR. CHRISTOPHER RANSOM.
DR. RANSOM, IT'S ALL YOURS.

- OK, THANK YOU, SEAN.

SO, AS SEAN MENTIONED,
I'M CHRIS RANSOM.

I'M AN EPILEPTOLOGIST
AT THE VA-PUGET SOUND,

PART OF THE EPILEPSY CENTER
OF EXCELLENCE HERE.

AND THE TOPIC I'M GOING
TO DISCUSS TODAY IS

EPILEPSY AND SEIZURES,
WHICH IS KIND OF A BASIC SET

OF INFORMATION I WANT
TO SHARE WITH PEOPLE.

MANY OF THE AUDIENCE ARE
FAMILIAR WITH THE TOPICS

I'M GOING TO SPEAK ABOUT, BUT I
THINK IT'S IMPORTANT TO ALWAYS

REFRESH OURSELVES ABOUT REALLY
SOME REAL BASIC CONCEPTS

ABOUT EPILEPSY AND SEIZURES
BECAUSE EVERY ONCE IN A WHILE,

YOU KNOW, I SEE PATIENTS THAT
SAY, "WELL, YOU SAID EPILEPSY.

WHAT DOES THAT MEAN?"
SO I THINK IT IS CRUCIAL

THAT EVERYONE UNDERSTANDS
WHAT THEIR POSITIONS ARE

WHEN TALKING ABOUT--
WHEN THEY'RE REFERRING

TO EPILEPTIC SEIZURES
AND EPILEPSY.

AND SO I'M GOING TO ORGANIZE
MY TALK REALLY ALONG THE LINES

OF THE OUTCOME OBJECTIVES, WHICH
WERE LISTED ON THE BROCHURE.

SO, WHAT IS A SEIZURE?

THIS IS A DEFINITION THAT WAS
PUT FORTH BY HUGHLINGS JACKSON

IN 1870; ALWAYS AMAZES ME.

HUGHLINGS JACKSON WAS A REAL
PIONEER OF BRITISH NEUROLOGY,

AND HE MADE THIS DEFINITION
BEFORE HE EVEN KNEW

ABOUT ELECTRICAL ACTIVITY
IN THE BRAIN.

AND HIS DEFINITION IS THAT
A SEIZURE IS "AN OCCASIONAL,

"AN EXCESSIVE, AND
A DISORDERLY DISCHARGE

OF CEREBRAL NERVOUS
TISSUE UPON MUSCLE."

WE'VE LEARNED A TREMENDOUS
AMOUNT ABOUT THE BRAIN

AND EPILEPTIC SEIZURES,
BUT WE CAN HARDLY IMPROVE

ON THAT DEFINITION.

BUT TO REFINE THIS,
AN EPILEPTIC SEIZURE RESULTS

FROM AN ABNORMALLY SYNCHRONIZED

AND HIGH-FREQUENCY FIRING
OF NEURONS IN THE BRAIN,

OR NERVE CELLS, THAT RESULTS
IN ABNORMAL BEHAVIOR

OR EXPERIENCE OF THE INDIVIDUAL.

SO THIS IS AN ELECTRICAL EVENT.

THE BRAIN IS AN ELECTRICAL
DEVICE, AND WHEN THIS

ELECTRICITY DEVELOPS
A HIGHER AMPLITUDE

OR ABNORMAL PATTERN,
IT PRODUCES THE SIGNS

AND SYMPTOMS OF A SEIZURE.

AND DIFFERENT PARTS OF OUR BRAIN
DO DIFFERENT FUNCTIONS,

SO THE EXPERIENCES OF
AN INDIVIDUAL AND THE SYMPTOMS

THAT ARE SEEN DURING
THE SEIZURE ALL RELATE

TO WHICH PART
OF THE BRAIN IS AFFECTED.

FOR EXAMPLE, SEIZURES
THAT INVOLVE THE FRONTAL LOBE,

WHICH IS AN AREA THAT IS
INVOLVED WITH MOVEMENT,

OFTEN SHOW DRAMATIC MOVEMENTS
OF THE LIMBS AND WHAT WE CALL

MOTOR ACTIVITY, WHEREAS SEIZURES
THAT INVOLVE THE TEMPORAL LOBE

OFTEN DON'T PRODUCE A LOT
OF PROMINENT MOVEMENT,

BUT INVOLVE EXPERIENCES
THAT THE INDIVIDUAL WILL FEEL,

SUCH AS A DEJA VU.

SOMETIMES PEOPLE EXPERIENCE
AN EPIGASTRIC RISING SENSATION

LIKE BEING ON
A ROLLER COASTER.

SOMETIMES THEY PRODUCE JUST
A BLAND LOSS OF AWARENESS

AND RESPONSIVENESS.

LIKEWISE, THE OCCIPITAL LOBE,
WHICH IS INVOLVED IN VISION,

SEIZURES THAT BEGIN THERE
OFTEN PRODUCE VISUAL SYMPTOMS:

EITHER FLASHING LIGHTS OR PEOPLE
LOSE PART OF THEIR VISUAL FIELD.

SOMETIMES PEOPLE DESCRIBE
JUST SEEING BLOBS OF COLOR

AND ELEMENTARY SHAPES,
AND THESE ARE ALL PRODUCED--

ALL THE SYMPTOMS
I MENTIONED ARE PRODUCED

BY THIS ABNORMALLY SYNCHRONIZED
AND HIGH-FREQUENCY FIRING

OF NEURONS IN THE BRAIN.

SO A SINGLE SEIZURE IS COMMON.

IT'S ESTIMATED THAT UP
TO 10% TO 15% OF INDIVIDUALS

WILL HAVE A SEIZURE
AT SOME TIME DURING THEIR LIFE.

AND I SAY "A SEIZURE"
BECAUSE MOST OF THESE ARE

WHAT WE CALL PROVOKED SEIZURES.

THEY ARE DUE TO AN ACUTE
AND REVERSIBLE PROBLEM

SUCH AS A SYSTEMIC ILLNESS.

COMMON CAUSES OF PROVOKED
SEIZURES ARE HYPOGLYCEMIA.

PROFOUNDLY LOW DROPS
IN BLOOD SUGAR

HAVE THE ABILITY
TO PRODUCE SEIZURES.

OCCASIONALLY WE SEE
PROVOKED SEIZURES DUE

TO ALCOHOL OR DRUG INTOXICATION
OR WITHDRAWAL, AND I THINK

THAT'S A KEY PHRASE, THAT THESE
ARE PROVOKED SEIZURES.

THEY ARE CAUSED BY A SPECIFIC
CAUSE THAT'S REVERSIBLE,

AND THAT'S IN CONTRAST
TO THE CONDITION OF EPILEPSY.

EPILEPSY IS A DISORDER
IN WHICH THERE IS A TENDENCY

TO HAVE RECURRENT,
UNPROVOKED SEIZURES.

SO THESE ARE SEIZURES
THAT OCCUR WITHOUT WARNING

AND WITHOUT ANY IMMEDIATELY
IDENTIFIABLE CAUSE.

IN CONTRAST TO THE 10%
TO 15% OF PEOPLE

THAT WILL HAVE A SEIZURE
DURING THEIR LIFETIME,

A PROVOKED SEIZURE,
EPILEPSY AFFECTS

ABOUT 1% OF THE GENERAL
POPULATION.

AND 1% IS A SMALL NUMBER,
BUT THIS AMOUNTS TO

A VERY LARGE INCIDENCE
OF EPILEPSY, A PREVALENCE.

SO IT'S ESTIMATED THAT,
YOU KNOW, SO THIS IS

A COMMON CHRONIC
MEDICAL CONDITION,

ONE OF THE MORE COMMON
DISORDERS IN NEUROLOGY.

IT'S ESTIMATED THAT
ABOUT 50 MILLION PEOPLE

WORLDWIDE HAVE EPILEPSY,

AND 2.4 MILLION NEW CASES
ARE DIAGNOSED EACH YEAR.

FORTUNATELY, MOST PEOPLE SHOULD
HAVE THEIR SEIZURES CONTROLLED

WITH MEDICATION AND ARE ABLE
TO LIVE VERY NORMAL LIVES

AND CONTINUE THEIR ACTIVITIES.

SO HOW DO WE DISTINGUISH
BETWEEN PROVOKED SEIZURES

AND UNPROVOKED SEIZURES
IN EPILEPSY?

SO ONE IS JUST THE CHARACTER
OF THE SEIZURES, WHAT IS SEEN.

ANYONE WHO HAS A FAMILY MEMBER
OR FRIEND WITH EPILEPSY,

IT'S--THESE ARE--
IF YOU SEE A SEIZURE,

THESE ARE OBVIOUSLY
DISTURBING EVENTS,

BUT I ENCOURAGE EVERYONE TO TRY
TO BE A GOOD OBSERVER

BECAUSE DOCTORS THAT ARE
EVALUATING PEOPLE WITH SEIZURES

AND EPILEPSY WERE OFTEN RELYING
SOLELY ON THE DESCRIPTION

PROVIDED TO US OF
WHAT PEOPLE SEE.

SO I DO ENCOURAGE EVERYONE
TO TRY AS BEST AS THEY MAY

TO OBSERVE WHAT'S HAPPENING
AND CATALOG AND REMEMBER THIS

BECAUSE THIS IS INVALUABLE
INFORMATION TO PHYSICIANS

THAT ARE TREATING SEIZURES.

SO USUALLY SEIZURES
ARE STEREOTYPED.

THAT MEANS THAT THEY ARE
VERY SIMILAR ONE TO THE NEXT,

AND IN THE HOSPITAL, IF WE WERE
ABLE TO RECORD SEIZURES

WITH VIDEO EEG MONITORING,

YOU SEE THAT IF WE RECORD
SEVERAL SEIZURES,

THEY'RE NEARLY IDENTICAL
ONE TO THE OTHER,

SO THEY'RE USUALLY
HIGHLY STEREOTYPED.

SEIZURES ARE
ALSO TYPICALLY BRIEF,

LASTING BETWEEN 10 SECONDS
TO TWO MINUTES.

SEIZURES THAT LAST LONGER
THAN TWO MINUTES

ARE VERY UNCOMMON.

THE BEHAVIORS THAT PEOPLE
EXHIBIT DURING

EPILEPTIC SEIZURES
ARE OFTEN REPETITIVE.

SOMETIMES PEOPLE HAVE
PURPOSEFUL HAND MOVEMENTS

THAT WE TERM AUTOMATISM.

OCCASIONALLY PEOPLE WILL HAVE
FLEXION OF A SINGLE LIMB

OR TURN THEIR HEAD
ONE WAY OR THE OTHER,

AND THOSE ARE FEATURES
THAT ARE IMPORTANT

FOR PHYSICIANS TO UNDERSTAND.

SEIZURES ALSO HAVE
AN EVOLUTION AND EITHER HAVE

A CRESCENDO TO
PRE-CRESCENDO PATTERN.

SO THE BEGINNING OF THE SEIZURE
OFTEN LOOKS VERY DIFFERENT

IN TERMS OF WHAT
AN INDIVIDUAL'S EXPERIENCING

OR WHAT THEIR BEHAVIOR LOOKS
LIKE THAT'S DIFFERENT

THAN IT IS AT THE END
OF THE SEIZURE.

SO WE EXPECT
TO BE SOME EVOLUTION

OF THE BEHAVIORING CENTER DURING
THE COURSE OF THE SEIZURE.

THE OTHER FEATURE
OF EPILEPTIC SEIZURE IS

THAT THEY OCCUR RANDOMLY
AND UNEXPECTEDLY, WHICH IS

OBVIOUSLY ONE OF THE MOST
CHALLENGING, DISABLING,

AND ANXIETY-PROVOKING
FEATURES OF THE ILLNESS.

ALTHOUGH THESE ARE SOME THINGS
THAT WE EXPECT TO SEE

OF EPILEPTIC SEIZURES,
THERE ARE MANY EXCEPTIONS,

SO OFTEN MAKING THE DIAGNOSIS
OF SEIZURES AND EPILEPSY

ON CLINICAL GROUNDS ALONE
IS PRACTICALLY IMPOSSIBLE

AND WE'LL NEED TO DO
ADDITIONAL EVALUATION.

AND SO THE THINGS THAT WE THINK
ABOUT--THEY CAN LOOK

ALL THE WORLD LIKE
AN EPILEPTIC SEIZURE;

THERE ARE SEVERAL
DIFFERENT CONDITIONS.

ONE OF THE MOST COMMON IS
SYNCOPE, OR SIMPLY FAINTING,

AND, YOU KNOW, THIS CAUSES
SOMEONE TO PASS OUT AND THEN

FALL TO THE GROUND,
AND OCCASIONALLY THERE CAN BE

SOME MOVEMENTS ASSOCIATED
WITH THIS PASSING OUT

THAT CAN EASILY BE
CONFUSED FOR A SEIZURE.

SYNCOPE COMMONLY IS DUE
TO DROPS IN BLOOD PRESSURE,

SUCH AS EVEN STANDING UP
TOO QUICKLY AFTER BEING SEATED

FOR A WHILE, OR CARDIAC
DYSRHYTHMIA--

THE ABNORMAL HEART
RHYTHMS--AND OTHER CAUSES.

AND THEN--SO THAT'S ONE
OF THE BIG THINGS

THAT PHYSICIANS ARE ALWAYS
TRYING TO DISTINGUISH BETWEEN,

ARE SEIZURES AND SYNCOPE.

THESE TWO THINGS HAVE VERY
DIFFERENT TREATMENTS.

TRANSIENT ISCHEMIC ATTACKS,
OR SMALL STROKES,

CAN OFTEN MIMIC AS A SEIZURE AND
CAN BE CONFUSED FOR A SEIZURE.

I MENTIONED SOME METABOLIC
DISORDERS SUCH AS HYPOGLYCEMIA,

WHICH CAN PRODUCE SYMPTOMS
THAT LOOK LIKE A SEIZURE.

SOME TYPES OF MIGRAINE HEADACHES
CAN CAUSE SYMPTOMS

THAT WILL BE MISTAKEN
FOR A SEIZURE.

THERE'S ALSO SOME MORE RARE
TYPES OF SLEEP DISORDERS

AND MOVEMENT DISORDERS
THAT ARE FREQUENTLY MISTAKEN

FOR SEIZURES, AND THESE ARE
THINGS THAT PHYSICIANS TRY

TO DISTINGUISH BEFORE
DECIDING ON A THERAPY.

LASTLY, I'LL JUST MENTION
THAT...PSYCHIATRIC CAUSES

AND CHANGES IN BEHAVIOR ARE
VERY COMMON, AND WE TERM THIS

CONVERSION DISORDER,
AND THESE CAN PRODUCE

WHAT WE CALL PSYCHOGENIC
NON-EPILEPTIC SEIZURES.

AND THIS IS ONE OF
THE CONDITIONS THAT IS

FREQUENTLY DIAGNOSED
IN VIDEO EEG-MONITORING

AND IT'S ABOUT--WORLDWIDE,
ABOUT HALF THE CASES SUBMITTED

TO VIDEO EEG-MONITORING UNITS
END UP BEING DIAGNOSED

WITH PSYCHOGENIC
NON-EPILEPTIC SEIZURES

AND NOT EPILEPTIC SEIZURES.

AND THAT'S A REALLY
IMPORTANT THING TO DETERMINE

BECAUSE FREQUENTLY
PEOPLE ARE TREATED

WITH ANTI-EPILEPTIC DRUGS, UP TO
2 OR 3 DIFFERENT MEDICATIONS,

THAT ARE NOT HELPING
STOP THE EVENT.

SO IT'S REALLY CRUCIAL
TO DISTINGUISH BETWEEN

THESE TWO TYPES OF THINGS AND
ESTABLISH APPROPRIATE THERAPIES.

SO HOW DO WE DIAGNOSE EPILEPSY
OR SEIZURES IN EPILEPSY?

SO THERE'S ALWAYS--
WE ALWAYS START

WITH A GOOD HISTORY
AND PHYSICAL.

THAT'S WHAT I WAS STRESSING
ABOUT, BEING OBSERVERS

ABOUT WHAT HAPPENS
DURING A SEIZURE

BECAUSE WE RELY HEAVILY
UPON THESE DESCRIPTIONS.

SO A GOOD HISTORY AND PHYSICAL,
AND WE ALSO EXPLORE

RISK FACTORS FOR EPILEPTIC
SEIZURES IN THE HISTORY,

WHICH I'LL COMMENT ON BRIEFLY.

TYPICALLY, PEOPLE HAVE A KIND
OF A GENERAL MEDICAL EVALUATION,

WHICH WOULD INCLUDE,
IN ADDITION TO A PHYSICAL EXAM,

SOME BASIC BLOOD WORK.

WE OFTEN SCREEN FOR...FOR DRUGS
AND OTHER TOXIC SUBSTANCES

WHICH HAVE THE CAPACITY
TO PRODUCE SYMPTOMS

THAT WOULD LOOK LIKE
A SEIZURE.

BUT THE MAINSTAYS
OF DIAGNOSING SEIZURES

AND EPILEPSY INVOLVES
AN ELECTROENCEPHALOGRAM,

OR AN EEG, TO INTERPRET
BRAIN WAVE PATTERNS.

THESE ELECTRICAL BRAIN WAVES
HAVE A CHARACTERISTIC

FREQUENCY AND APPEARANCE.

AND IN MANY TYPES
OF EPILEPSY, WE CAN SEE

ABNORMAL ELECTRICAL PATTERNS
ACROSS THE ENTIRE BRAIN

OR EVEN OVER A SPECIFIC
AREA OF THE BRAIN.

AND I MENTIONED THOSE TWO
DIFFERENT FINDINGS

WE MAY FIND ON THE EEG
IN PEOPLE WITH EPILEPSY

BECAUSE THOSE LEAD TO DIAGNOSIS
OF THE TYPE OF EPILEPSY

AND THE TYPE
OF SEIZURE SOMEONE HAS.

SO SOMETIMES THE EEG PATTERNS
ARE...APPEARING BILATERALLY,

ON BOTH SIDES OF THE BRAIN
AT THE SAME TIME,

AND SOMETIMES THEY CAN BE
LOCALIZED OR SPECIFIC AREAS

OF THE BRAIN, AND I'LL SPEAK
MORE ABOUT THOSE IN A MOMENT.

THE SECOND CRUCIAL ELEMENT
TO EVALUATION OF SEIZURES

AND EPILEPSY IS SOME TYPE
OF NEURO-IMAGING TEST,

PREFERABLY MRI.

AND THIS GIVES US DETAILED
STRUCTURAL INFORMATION

ABOUT THE BRAIN,
WHICH WILL HELP US IDENTIFY

THE RISK FOR RECURRENCE
OF THE SEIZURES.

IF SOMEONE PRESENTS WITH
A FIRST SEIZURE AND RECEIVES--

THEY HAVE A NORMAL EEG
AND A NORMAL MRI,

LARGE STUDIES TELL US THAT
THE RISK OF SEIZURE RECURRENCE

IS PROBABLY IN THE RANGE
OF 20% TO 30%.

SO IN THAT SITUATION...

OCCASIONALLY PEOPLE DON'T START
ANTI-EPILEPTIC MEDICATIONS

RIGHT AWAY, BUT IT DEFINITELY
DEPENDS ON THE SITUATION,

WHAT SOMEONE DOES FOR EMPLOYMENT
AND THE PATIENT'S WISHES.

MOST PHYSICIANS REALLY MAKE
THIS DECISION THE PATIENT'S

AND FEEL IT'S THEIR JOB
TO PROVIDE AS MUCH INFORMATION

AND THEN COME UP WITH A PLAN
TOGETHER THAT'S APPROPRIATE.

THAT'S NOT ALWAYS THE CASE;
SOMETIMES PHYSICIANS

WILL HAVE VERY STRONG
RECOMMENDATIONS ABOUT

WHETHER OR NOT SOMEONE NEEDS
TO BEGIN MEDICATIONS.

MRI, IF IT'S NOT NORMAL,
CAN HELP US PREDICT...

BOTH THE RISK OF RECURRENCE AND
ALSO HELPS US TO FIND THE TYPE

OF SEIZURE AND EPILEPSY
AN INDIVIDUAL HAS EXPERIENCED.

FOR EXAMPLE...IN ELDERLY PEOPLE,

PEOPLE THAT ARE OLDER IN LIFE,

STROKES AND BRAIN TUMORS ARE
AN IMPORTANT CAUSE OF SEIZURES.

AND IF WE WERE TO MAKE
THOSE FINDINGS ON AN EEG,

THAT WOULD DEFINITELY
SUPPORT THE DIAGNOSIS

OF SEIZURES AND EPILEPSY AND
ALMOST ALWAYS WOULD LEAD TO

THE RECOMMENDATION OF BEGINNING
AN ANTI-EPILEPTIC MEDICATION.

AT THIS POINT, IF WE DON'T
HAVE A CLEAR ANSWER

ABOUT WHETHER
OR NOT THE SYMPTOMS THAT

THE INDIVIDUAL IS EXPERIENCING
ARE DUE TO EPILEPTIC SEIZURES,

ADDITIONAL TESTS ARE
USUALLY RECOMMENDED.

AND THE MOST IMPORTANT ONE
IS CONTINUOUS AUDIO-VISUAL

EEG-MONITORING, AND SOME OF YOU
MAY BE FAMILIAR WITH THIS

OR HAVE ACTUALLY UNDERGONE
THIS TYPE OF TEST,

BUT IT INVOLVES ADMITTING
AN INDIVIDUAL TO THE HOSPITAL,

WHERE THEY ARE KEPT IN
A SPECIAL ROOM THAT'S EQUIPPED

WITH EEG EQUIPMENT
AND A VIDEO CAMERA.

AND THE GOAL OF THIS IS TO HAVE
AN INDIVIDUAL IN THE HOSPITAL

WITH EEG RECORDINGS BEING MADE
AND VIDEO RECORDING BEING MADE

WHILE THEY SUFFER ONE
OF THEIR SPELLS.

AND IF WE DO THIS, WE ALMOST
ALWAYS CAN MAKE A DIAGNOSIS.

IT'S NOT ALWAYS EPILEPSY,
BUT RECORDING THE VIDEO EEG DATA

DURING A SPELL GIVES US
THE INFORMATION

ABOUT WHETHER THERE'S
ABNORMAL ELECTRICAL PATTERNS

DURING THE EVENT, WHICH WOULD
SIGNIFY AN EPILEPTIC SEIZURE.

IT ALSO ALLOWS US
TO ANALYZE IN DETAIL

THE CLINICAL FEATURES,
THE BEHAVIOR AND SYMPTOMS

THAT HAPPEN DURING THE SEIZURE,

AND THAT'S ALMOST
AS IMPORTANT AS THE EEG.

WE'VE LEARNED A GREAT DEAL
ABOUT WHAT TYPES OF BEHAVIORS

AND SIGNS ARE PRODUCED
BY EPILEPTIC SEIZURES,

SO THAT'S ANOTHER CRUCIAL
ELEMENT TO THE VIDEO EEG STUDY.

IF THIS DOESN'T PROVIDE ANY
ANSWERS, SOMETIMES ADDITIONAL--

EVEN MORE TESTS ARE GOING
TO BE SUGGESTED, SUCH AS

A SLEEP STUDY, BUT MORE--
IT'S DESIGNED

TO BETTER IDENTIFY
DISORDERS IN SLEEP.

SO I'LL JUST MENTION
THAT THE INCIDENCE

OF EPILEPSY VARIES BY AGE.

IT'S HIGHEST--THE GREATEST
NUMBER OF INDIVIDUALS

DEVELOP EPILEPSY
AT VERY YOUNG AGES,

IMMEDIATELY AFTER BIRTH
AND DURING SCHOOL AGE,

BUT THERE'S ALSO
AN INCREASE IN EPILEPSY

AND THE INCIDENCE OF SEIZURES
IN EPILEPSY AS PEOPLE AGE.

AND IT'S BECOME APPARENT
THAT AS PEOPLE AGE, LIKE,

AS I MENTIONED, THE INCIDENCE
OF EPILEPSY INCREASES

AND IT GETS HIGHER
AND HIGHER THROUGHOUT LIFE.

AND THIS IS DUE TO STROKES
AS WELL AS NEURO-DEGENERATIVE

DISEASES SUCH AS ALZHEIMER'S,

WHICH CAN PREDISPOSE PEOPLE
TO SEIZURES AND EPILEPSY.

THE CAUSES OF EPILEPSY
ALSO VARY BY AGE.

SO, IN THE VERY YOUNG,
PERINATAL INJURIES

SUCH AS BIRTH ASPHYXIA,
METABOLIC DEFECTS,

AND CONGENITAL MALFORMATIONS
THAT ARISE FROM ABNORMALITIES

IN DEVELOPMENT SUCH AS
CEREBRAL PALSY--

THOSE ARE THE MOST IMPORTANT
CAUSES OF EPILEPSY.

INFECTION IN THE CNS IS
AN IMPORTANT CAUSE OF EPILEPSY

AS WELL IN THIS AGE GROUP.

AS WE LOOK
AT OLDER INDIVIDUALS,

THE MOST IMPORTANT CAUSES
OF EPILEPSY ARE HEAD TRAUMA,

WHICH IS THE NUMBER-ONE
CAUSE OF EPILEPSY

IN THE AGE GROUP BETWEEN
15 TO 40 YEARS OLD;

AS WELL AS CEREBRAL VASCULAR
DISEASE, OR STROKES;

AND BRAIN TUMORS.

SO OFTEN, WE CAN ASCRIBE
SEIZURES IN EPILEPSY

TO A SPECIFIC IDEOLOGY.

BUT EVEN WITH OUR ADVANCED
NEURO-IMAGING TECHNIQUES

AND AN EVER-INCREASING BATTERY
OF TESTS THAT WE CAN USE,

IN ABOUT HALF THE CASES,
A LITTLE MORE THAN HALF

THE CASES, WE REALLY
DON'T KNOW THE CAUSE.

NO IDENTIFIABLE CAUSE
FOR THE SEIZURES AND EPILEPSY

CAN BE FOUND, AND WE CALL
THAT TYPE OF EPILEPSY

CRYPTOGENIC EPILEPSY.

WE BELIEVE THERE'S A CAUSE,
BUT WE JUST CAN'T

CONVINCINGLY DEMONSTRATE
WHAT THAT IS.

AND I'LL JUST MENTION,
GENETIC FORMS OF EPILEPSY

ARE BECOMING
INCREASINGLY RECOGNIZED.

IN FACT, WE'RE LEARNING MORE
AND MORE ABOUT THESE TYPES--

THIS CAUSE OF EPILEPSY,
AND AS TIME GOES ON,

WE'RE PROBABLY GOING TO HAVE
MORE AND MORE OPPORTUNITY

TO IDENTIFY GENETIC
CAUSES OF EPILEPSY.

GENETIC CAUSES OF EPILEPSY ARE
TYPICALLY SEEN AT YOUNGER AGES,

IN SCHOOL AGE AND TEENAGE
UP TO 20 YEARS OLD.

SO WHEN SOMEONE DEVELOPS
SEIZURES AND EPILEPSY

LATER IN LIFE--SAY,
THEIR 30s, 40s, 50s, 60s--

WE TYPICALLY DON'T THINK
OF GENETIC CAUSES,

BUT, OF COURSE, THAT CAN BE
POSSIBLE IN SOME INSTANCES.

AND AS IT RELATES
TO THE CAUSE OF EPILEPSY,

WE ALWAYS REVIEW SEIZURE RISK
FACTORS, WHICH INCLUDE PROBLEMS

OF DEVELOPMENTAL PROBLEMS, WE
TAKE A DETAILED BIRTH HISTORY,

WHETHER THERE WERE PROBLEMS
DURING THE WOMAN'S PREGNANCY,

WHETHER THERE WAS ANY
COMPLICATIONS DURING DELIVERY.

SEVERAL OF THESE ARE
VERY COMMON,

AND MOST PEOPLE DON'T GO ON
TO DEVELOP EPILEPSY.

NONETHELESS, THAT IS
AN IMPORTANT RISK FACTOR

FOR THE LATER DEVELOPMENT
OF EPILEPSY, PARTICULARLY

IF THE FEBRILE SEIZURE
WAS PROLONGED,

LONGER THAN 30 MINUTES,
OR IF IT HAS WHAT WE CALL

FOCAL FEATURES, SUCH AS IT
STARTED ON ONE SIDE OF THE BODY.

I MENTIONED THAT WE ALWAYS ASK
ABOUT HEAD TRAUMA AND INFECTIONS

THAT INVOLVE THE CENTRAL
NERVOUS SYSTEM,

SUCH AS MENINGITIS
AND ENCEPHALITIS.

LEARNING ABOUT ANY FAMILY
HISTORY OF EPILEPSY IS

ALSO VERY IMPORTANT AND IT'S
SOMETHING THAT IF YOU'RE

SEEING A PHYSICIAN, THE MORE
INFORMATION YOU CAN PROVIDE

ABOUT FAMILY MEMBERS WITH
SEIZURES AND EPILEPSY,

THAT'S VERY HELPFUL TO THE
PHYSICIAN TO DETERMINE

WHETHER OR NOT THIS IS
RELEVANT TO THE FEATURES

IN EPILEPSY
UNDER CONSIDERATION.

SO WHAT TYPES
OF SEIZURES ARE THERE?

WELL, I MENTIONED EARLIER
THAT WE COULD SEE ON AN EEG

ABNORMAL ELECTRICAL ACTIVITIES
THAT DEVELOP SIMULTANEOUSLY

ON BOTH SIDES OF THE BRAIN,
AND WE CALL THOSE

GENERALIZED SEIZURES
OR GENERALIZED ONSET SEIZURES.

THESE CAN COME,
SOME OF THEM, IN TIDES.

THEY CAN CAUSE WHAT WE CALL
MYOCLONUS, SIMPLE JERKING

MOVEMENTS THAT MAYBE NOT EVEN
CAUSE LOSS OF AWARENESS.

SOMETIMES THESE GENERALIZED
SEIZURES CAN SIMPLY CAUSE

BEHAVIORAL ARRESTS,
OR AN INDIVIDUAL WILL STOP

WHAT THEY'RE DOING AND HAVE
A BLANK STARE FOR A FEW MOMENTS

AND THEN RECOVER RAPIDLY
AND COMPLETELY.

THOSE TYPES OF SEIZURES ARE
TERMED ABSENT SEIZURES,

AND WHEN NEUROLOGISTS TALK
ABOUT ABSENCE SEIZURES,

WE'RE REALLY TALKING
ABOUT A SPECIFIC DIAGNOSIS--

ABSENCE EPILEPSY, WHICH IS
A TYPE OF GENERALIZED SEIZURE.

GENERALIZED SEIZURES CAN
ALSO CAUSE GRAND MAL SEIZURES,

OR THE GENERALIZED
TONIC-CLONIC SEIZURES

THAT WILL INVOLVE
MAJOR MOTOR ACTIVITY.

IT CAN CAUSE PEOPLE TO FALL TO
THE GROUND AND SUFFER INJURY,

AND OFTEN ARE ASSOCIATED
WITH TONGUE-BITING

AND LOSS OF URINARY CONTINENCE.

IN CONTRAST TO THOSE
GENERALIZED ONSET SEIZURES,

SEIZURES THAT START
ON BOTH SIDES OF THE BRAIN

AT THE SAME TIME, THERE ARE
ALSO FOCAL SEIZURES,

HISTORICALLY CALLED
PARTIAL ONSET SEIZURES.

AND THE NAME "FOCAL"
APPLIES AS THEY START

IN A SPECIFIC LOCATION
IN THE BRAIN--

SUCH AS THE RIGHT TEMPORAL
LOBE, FOR EXAMPLE--

AND A SEIZURE THAT STARTS
FOCALLY, THEY CAN STAY IN

THAT LOCATION AND SPREAD LOCALLY
AND CAUSE A SET OF SYMPTOMS.

FOCAL SEIZURES
ARE WHAT PRODUCE AURAS,

SO WHEN PEOPLE HAVE AN AURA,
OR A WARNING SYMPTOM

BEFORE THEIR SEIZURE, THAT IS
ACTUALLY THE FOCAL PART

OF THE SEIZURE, WHERE THEY'RE
EXPERIENCING SYMPTOMS RELATED

TO THE SEIZURE DEVELOPING IN
A SPECIFIC PART OF THE BRAIN.

IF THEY SPREAD LOCALLY,
THEY CAN THEN CAUSE SOME

OF THESE REPETITIVE MOVEMENTS
THAT WE SPOKE OF EARLIER

THAT CAN CAUSE LOSS OF AWARENESS
AND RESPONSIVENESS,

AND DEPENDING ON
WHAT PART OF THE BRAIN,

THEY COULD CAUSE A WHOLE HOST
OF OTHER SYMPTOMS,

INCLUDING AN INABILITY
OF SPEECH,

MAYBE AN ABNORMAL
POSTURING OF ONE LIMB.

SOMETIMES THERE CAN BE
LIP-SMACKING MOVEMENTS

OR TWITCHING
OF ONE SIDE OF THE FACE,

SO THESE ARE ALL SYMPTOMS
DUE TO FOCAL SEIZURES.

THERE'S BEEN A RECENT CHANGE
IN THE TERMINOLOGY,

BUT I THINK THE TERMS
THAT WERE PREVIOUSLY USED

OF COMPLEX PARTIAL SEIZURE
VERSUS SIMPLE PARTIAL SEIZURE--

AT LEAST WARRANT MENTIONING.

SO THE TERM COMPLEX PARTIAL
SEIZURE IS USED TO DESCRIBE

A FOCAL SEIZURE, A SEIZURE
THAT BEGINS AND STAYS

IN ONE AREA IN THE BRAIN,
BUT WE CALL IT COMPLEX

BECAUSE IT INVOLVES
A LOSS OF AWARENESS

OR AN ALTERATION OF AWARENESS.

AND THAT'S TO BE CONTRASTED WITH
SIMPLE PARTIAL SEIZURES,

AND SIMPLE PARTIAL SEIZURES ARE
REFERRING TO SEIZURES

THAT CAUSE A SYMPTOM IN ONE PART
OF THE BODY, SUCH AS JERKING

OF ONE LIMB OR TWITCHING
OF ONE SIDE OF THE FACE,

BUT THEY DO NOT ALTER AWARENESS
OR CONSCIOUSNESS AT ALL.

SO AN INDIVIDUAL EXPERIENCING
SIMPLE PARTIAL SEIZURE IS GOING

TO BE FULLY CONVERSANT
AND REMEMBER EVERYTHING,

BUT THEY'LL HAVE THIS
SYMPTOM THAT IS DUE TO

AN ABNORMAL PATTERN
OF ELECTRICAL ACTIVITY

IN A SPECIFIC PART OF THE BRAIN.

FOCAL SEIZURES DON'T
ALWAYS SPREAD LOCALLY,

AND THEY CAN SPREAD OUT
AND INVOLVE THE ENTIRE BRAIN,

AND WE CALL THIS A SECONDARILY
GENERALIZED SEIZURE.

AND SO A SEIZURE CAN START
FOCALLY AND THEN SPREAD TO

INVOLVE THE ENTIRE BRAIN AND
CAUSE A GRAND MAL SEIZURE, WHICH

IS ALSO CALLED A GENERALIZED
TONIC-CLONIC SEIZURE.

SO, AGAIN, SEIZURES ARE BROADLY
CLASSIFIED AS FOCAL AT ONSET,

WHICH WOULD BE SIMPLE
PARTIAL SEIZURES,

WHICH WOULD INCLUDE AURAS;
COMPLEX PARTIAL SEIZURES

AND COMPLEX PARTIAL SEIZURES
WITH SECONDARY GENERALIZATION;

OR THEY CAN BE GENERALIZED AT
ONSET, CAUSE GRAND MAL SEIZURES,

THEY COULD CAUSE ABSENCE
SEIZURES, AND OTHER FORMS

OF SEIZURES THAT ARE
PROBABLY LESS COMMON,

SUCH AS MYOCLONIC
AND TONIC SEIZURES.

CLASSIFICATION OF EPILEPSY
IS REALLY AN EXTENSION

OF THE TYPE OF SEIZURE,
SO WE CLASSIFY EPILEPSY

AS EITHER BEING FOCAL
OR GENERALIZED.

IN THE RECENT CLASSIFICATION
SCHEME PUT FORTH BY

THE INTERNATIONAL LEAGUE
AGAINST EPILEPSY,

THERE'S A LOT OF MORE SPECIFIC
SYNDROMES THAT ARE DEFINED.

I'M NOT GOING TO GO
INTO THOSE TODAY,

BUT THEY HAVE THEN PRODUCED

TO RECOGNIZE THE INCREASED
UNDERSTANDING

OF GENETIC CAUSES OF EPILEPSY

AND WHAT THE CAUSE
OF THE EPILEPSY IS.

SO, WHAT TO DO WHEN
AN INDIVIDUAL HAS A SEIZURE?

AS I MENTIONED,
MOST OF THE TIME,

SEIZURES WILL STOP ON THEIR OWN.

SO SEIZURES THAT LAST LONGER
THAN TWO MINUTES ARE

FAIRLY UNUSUAL,
BUT THE MAIN GOAL IS

TO KEEP AN INDIVIDUAL SAFE,
AND RIGHT NOW I'M TALKING

ABOUT GENERALIZED
TONIC-CLONIC SEIZURES.

SO IF SOMEONE HAS A SEIZURE,
AND THE SEIZURE STARTS,

SHOULD TRY TO HELP THEM
AVOID INJURY, LOWER THEM

TO THE GROUND AND,
IF POSSIBLE, ROLL THEM

ONTO THEIR LEFT SIDE.

WHEN YOU ROLL INDIVIDUALS
ONTO THEIR SIDES TO REDUCE

THE RISK OF ASPIRATION,
OR SWALLOWING SALIVA--

HAVING SALIVA FALL INTO
THE LUNGS, WHICH CAN CAUSE

A WHOLE OTHER HOST OF PROBLEMS.

DURING A SEIZURE, INDIVIDUALS
ARE NOT SWALLOWING

AND MANAGING THEIR
ORAL SECRETIONS NORMALLY,

SO THERE'S A RISK
OF THIS HAPPENING,

WHAT YOU CALL ASPIRATION.

AND, AGAIN, MOST SEIZURES
STOP ON THEIR OWN.

IF SOMEONE HAS--AN INDIVIDUAL--
A SINGLE SEIZURE,

IT'S A TYPICAL SEIZURE FOR THEM
THAT LASTS A COUPLE MINUTES

AND THEN STOPS AND RESOLVES,
IT'S ALWAYS ADVISABLE

TO CALL THE INDIVIDUAL'S
NEUROLOGIST

AND DESCRIBE THIS TO THEM.

BUT THERE'S NOT
NECESSARILY A NEED TO GO

TO THE EMERGENCY DEPARTMENT.

SOME OF YOU MAY HAVE
EXPERIENCED TRIPS

TO THE EMERGENCY DEPARTMENT
AND, YOU KNOW, THESE ARE

TIME-CONSUMING, EXPENSIVE TRIPS

THAT OFTEN DON'T
PRODUCE MUCH BENEFIT.

AND I SAY THAT BECAUSE--THE E.R.
PHYSICIANS ARE EXCELLENT

AT TREATING A SEIZURE THAT'S
HAPPENING IN FRONT OF THEM,

BUT FOR TREATING EPILEPSY,
THEY MAY NOT DO A WHOLE LOT.

AND LIKE I SAY,
IF THE SEIZURE'S OVER

AND YOU GO TO THE EMERGENCY
DEPARTMENT, AN INDIVIDUAL'S

FEELING WELL, NOT HAVING
ANY SYMPTOMS, AND THEY MAY DO

SOME BLOOD WORK AND
OBSERVE FOR A LITTLE BIT,

BUT THEY MAY NOT EVEN RECOMMEND
ANY CHANGE IN THERAPY

AND JUST SIMPLY SUGGEST
THAT YOU FOLLOW UP

WITH YOUR NEUROLOGIST.

I NEVER TELL MY PATIENTS NOT TO
GO TO THE EMERGENCY DEPARTMENT

IF THEY'RE AFRAID OR SOMETHING
IS REALLY CONCERNING,

BUT I THINK IT'S IMPORTANT TO
EMPOWER PEOPLE NOT TO DO THAT,

THAT IT'S NOT
ALWAYS NECESSARY,

THAT IT'S OK IF A SEIZURE
HAPPENS AND STOPS.

THERE'S NOT A HUGE NEED TO GO
TO THE EMERGENCY DEPARTMENT.

THAT'S NOT ALWAYS THE CASE,
THOUGH, AND PARTICULARLY

FOR SEIZURES THAT LAST
LONGER THAN 5 MINUTES,

OR IF AN INDIVIDUAL HAS TWO
OR MORE SEIZURES IN A ROW

WITHOUT COMPLETELY RECOVERING
IN BETWEEN THE EVENTS,

THOSE ARE SITUATIONS WHERE
IT IS ALWAYS APPROPRIATE

TO SEEK MEDICAL ATTENTION,
PARTICULARLY IF A SEIZURE

IS CONTINUING
LONGER THAN 5 MINUTES.

THAT'S SORT OF THE
OPERATIONAL DEFINITION

OF STATUS EPILEPTICUS,
WHICH IS A SEIZURE

THAT IS NOT STOPPING ON ITS OWN.

AND THAT'S A MEDICAL EMERGENCY,
AND SO IF A SEIZURE LASTS LONGER

THAN 5 MINUTES AND IT'S NOT
STOPPING, IT'S ALWAYS INDICATED

TO CALL THE PARAMEDICS
OR GET THE PATIENT

TO BE SEEN BY A DOCTOR.

AND I THINK AT THIS POINT, I'VE
COVERED MOST OF THE ITEMS

I'VE WANTED TO DISCUSS,
AND IT WOULD BE APPROPRIATE

TO OPEN UP TO QUESTIONS
SO I CAN MAYBE DESCRIBE SOME

OF THE THINGS I MENTIONED
IN GREATER DETAIL

OR ADDRESS OTHER QUESTIONS
PEOPLE HAVE.

- I'M GOING TO OPEN UP
FOR QUESTIONING.

HOLD ON A SECOND.

- SURE.

- ALL RIGHT, DOCTOR.

THE LINES SHOULD BE
OPEN FOR QUESTIONS.

- OK. TERRIFIC.

- DOES ANYBODY HAVE
ANY QUESTIONS?

- I'LL BE HAPPY TO ANSWER ANY
QUESTIONS IF ANYONE HAS THEM.

- ALL RIGHT, SIR.

I DON'T THINK THERE'S
ANY QUESTIONS.

- DID ANYONE ELSE LOG IN, EVEN?

- YEAH, THERE WAS
OTHER PEOPLE ON THE CALL.

I DON'T HAVE
THE FINAL NUMBERS YET.

- OK. WELL,
THAT'S DISAPPOINTING,

BUT I HOPE IT WASN'T TOO BORING
AND TOO BASIC FOR THEM,

BUT--HA HA HA!
THAT'S ALL RIGHT, I GUESS.

- IT WAS VERY GOOD, SIR.

- OK, THANK YOU.
- THANK YOU.

- THANK YOU, DR. RANSOM.

- OK, YOU'RE
VERY WELCOME. BYE-BYE.

- BYE-BYE.