- I'D LIKE TO WELCOME YOU ALL
	TO OUR SECOND CALL
	
	IN THE "INTRODUCTION TO
	EPILEPSY" AUDIO CALL SERIES.
	
	MY NAME IS SEAN GAMBLE,
	AND I'M WITH THE EMPLOYEE
	EDUCATION SERVICE
	
	OUT OF ST. LOUIS
	
	AND I'M THE PROJECT MANAGER
	FOR THE SERIES.
	
	THIS IS A CALL THAT WILL
	CONTINUE TO OCCUR
	EVERY OTHER MONTH
	
	ON THE FIRST WEDNESDAY
	AT 2 P.M. EASTERN.
	
	OUR NEXT CALL
	WILL BE ON JULY 6
	
	WITH DR. MARTY ZELINSKI,
	
	AND YOU'LL BE SEEING SOME
	INFORMATION COMING OUT
	SOON ON THAT.
	
	OUR LINES ARE MUTED,
	BUT THEY WILL BE OPENED UP
	
	AT THE END
	OF THE PRESENTATION
	
	WHEN WE ARE READY
	FOR QUESTIONS AND ANSWERS
	
	WITH DR. RUTECKI.
	
	PLEASE BE SURE TO COMPLETE
	YOUR EVALUATION TO GET
	CREDIT FOR THIS PROGRAM.
	
	COMPLETE DIRECTIONS
	FOR YOUR EVALUATION
	ARE IN THE BROCHURE
	
	OR ON THE CATALOG.
	
	YOU'LL HAVE 30 DAYS TO SUBMIT
	YOUR EVALUATION FORMS.
	
	DEADLINE DATE IS JUNE 3.
	
	NOW I'D LIKE TO TAKE THE TIME
	TO WELCOME OUR SPEAKER FOR TODAY
	
	DR. PAUL RUTECKI.
	
	DR. RUTECKI, IT'S ALL YOURS.
	
	- OK, THANK YOU.
	
	THIS IS JUST
	THE INTRODUCTORY SLIDE,
	
	BUT I'M GOING TO BE
	TALKING ABOUT EPILEPSY
	AND TRAUMATIC BRAIN INJURY.
	
	AND THE NEXT 5 OBJECTIVES
	I WANT TO COVER--
	
	THE FIRST IS ACTUALLY TO REVIEW
	A LITTLE BIT ABOUT THE EPILEPSY
	CENTERS OF EXCELLENCE
	
	AND THEIR ORGANIZATION
	SO THAT YOU KNOW HOW
	TO REFER TO US.
	
	THEN I WANT TO PRESENT A CASE
	OF POST-TRAUMATIC EPILEPSY.
	
	THEN REVIEW THE EPIDEMIOLOGY
	OF POST-TRAUMATIC EPILEPSY--
	
	EPILEPSY AFTER
	A TRAUMATIC BRAIN INJURY.
	
	AND THEN DISCUSS
	THE THERAPEUTIC EVALUATION
	
	AND ALSO THE EVALUATION
	OF INTRACTABLE EPILEPSY
	
	AND THEN REVIEW SOME
	POTENTIAL RESEARCH STRATEGIES
	
	WE'RE TRYING TO DEVELOP
	WITHIN THE VA.
	
	SO THE NEXT SLIDE JUST IS
	AN INTRODUCTION TO THE VA
	EPILEPSY CENTERS OF EXCELLENCE.
	
	AND THE FOLLOWING SLIDE
	TELLS YOU A LITTLE BIT
	HOW THEY WERE ACTUALLY FOUNDED.
	
	THEY REALLY ARE
	CONGRESSIONAL MANDATES.
	
	THERE'S SECTION 404
	OF PUBLIC LAW 110-387,
	
	AND IF YOU'RE REALLY INTERESTED,
	YOU CAN LOOK THAT UP
	IN THE "CONGRESSIONAL RECORD."
	
	AND IT'S UNDER
	"VETERANS MENTAL HEALTH
	AND OTHER CARE IMPROVEMENTS."
	
	AND IT WAS REALLY SPURRED ON
	BY THE SUPPORT OF JOHN BOOS,
	
	WHO SOME OF YOU MAY KNOW
	USED TO BE THE HEAD OF VA
	NEUROLOGY AT A NATIONAL LEVEL.
	
	AND HE PARTNERED WITH
	
	THE AMERICAN ACADEMY
	OF NEUROLOGY,
	
	THE AMERICAN EPILEPSY SOCIETY,
	THE EPILEPSY FOUNDATION,
	
	AND C.U.R.E. TO SUPPORT THIS
	BILL AND GET THIS BILL WRITTEN.
	
	AND IT REALLY WAS
	LARGELY LEVERAGED
	
	WITH THE RECENT HISTORY
	OF TRAUMATIC BRAIN INJURY
	
	THAT WAS OCCURRING IN OUR
	OPERATION IRAQI FREEDOM,
	
	OPERATION ENDURING
	FREEDOM VETERANS.
	
	AND IT WAS LINKED TO SERVE
	ANY POLYTRAUMA CENTER NEEDS.
	
	AND CONGRESS BASICALLY
	ALLOCATED $6 MILLION
	A YEAR TO 6 CENTERS.
	
	WELL, AT THE TIME THIS WENT
	THROUGH IN THE BILL--
	
	THE NEXT SLIDE SORT OF
	DESCRIBES THE OBJECTIVES--
	
	REALLY WAS TO IMPROVE CARE
	FOR EPILEPSY IN VETERANS,
	
	TO APPROVE AVAILABILITY
	SO THAT ALL VETERANS
	
	WOULD BE ABLE TO BE EVALUATED
	BY AN EPILEPSY CENTER IF NEEDED.
	
	AND THEN THEY GOT TO
	ANTICIPATE THE NEED
	
	FOR POST-TRAUMATIC
	EPILEPSY CARE.
	
	AND I GO TO THE NEXT SLIDE,
	
	AND THIS IS--OUR CURRENT
	CHIEF OF NEUROLOGY,
	
	DR. ROBERT RUFF
	IN CLEVELAND,
	
	KNEW ABOUT THE EXISTING
	EPILEPSY FACILITIES
	WITHIN THE VA.
	
	AND BASICALLY, THIS IS WHAT
	HE SORT OF PUT TOGETHER,
	
	WITH THE RED SITES
	BEING EPILEPSY CENTERS
	
	THAT HAD ALREADY BEEN DOING
	EPILEPSY MONITORING
	AS WELL AS SURGERY,
	
	THE GREEN SITES
	DOING MONITORING,
	
	AND THE BLUE SITES
	BEING POLYTRAUMA SITES.
	
	SO HE DECIDED THE BEST WAY
	TO APPROACH THIS--AND IT'S
	ON THE NEXT SLIDE--
	
	IS TO ORGANIZE THE COUNTRY
	INTO 4 REGIONS:
	
	NORTHEAST, SOUTHEAST,
	SOUTHWEST, AND NORTHWEST,
	
	WITH AT LEAST 3 TO 4
	VA MEDICAL CENTERS IN EACH AREA
	
	THAT WOULD THEN SERVE
	THE WHOLE UNITED STATES,
	
	PARTICULARLY IN TERMS OF
	PROVIDING EPILEPSY
	VIDEO-EEG MONITORING
	
	AND SPECIALIZED
	EPILEPSY CARE.
	
	THE NEXT SLIDE JUST
	GIVES YOU WHAT WE PUT IN
	
	IN OUR APPLICATION
	AS A NORTHWEST CENTER.
	
	AND THAT WAS TO, AGAIN,
	IMPROVE CARE FOR
	VETERANS WITH EPILEPSY
	
	WITH A FOCUS ON
	POST-TRAUMATIC EPILEPSY;
	
	TO LEVERAGE TECHNOLOGIES
	SO THAT WE COULD DO
	TELEMEDICINE AND TELE-EEG;
	
	TO DEVISE AN EDUCATIONAL CORE
	FOR PRESENTATIONS LIKE THIS,
	
	BUT ALSO PRESENTATIONS TO
	VETERANS AND THEIR FAMILIES
	AS WELL AS PROVIDERS;
	
	AND THEN DEVELOP
	A RESEARCH INFRASTRUCTURE.
	
	AND OUR INITIAL THOUGHTS
	WERE REALLY TO TRY TO LOOK
	AT THE EPIDEMIOLOGY
	
	OF POST-TRAUMATIC EPILEPSY
	AND VETERANS WHO'VE HAD
	RECENT TRAUMATIC INJURY
	
	DURING THE CONFLICTS
	THAT HAVE BEEN OCCURRING.
	
	AND THE NEXT SLIDE
	BASICALLY SAYS WHERE WE'RE AT
	AND WHERE WE'RE GOING.
	
	ONE OF THE THINGS
	WE WANT TO DO,
	
	AND I THINK ACROSS THE COUNTRY,
	
	IS IMPLEMENT A REAL NETWORK
	
	AND BE ABLE TO PROVIDE
	ALL VETERANS AND ALSO
	ALL PROVIDERS IN THE VA SYSTEM
	
	TO HELP WITH CARE
	FOR EPILEPSY.
	
	AND THERE IS A WEB PAGE,
	AND I PUT THE ADDRESS
	THERE ON THE SLIDE.
	
	WE REALLY WANT TO IDENTIFY
	PATIENTS WITH EPILEPSY
	AND THEIR NEEDS,
	
	PARTICULAR POST-TRAUMATIC
	EPILEPSY.
	
	AND AS WE'LL HEAR
	MORE ABOUT TODAY,
	
	BUT PROBABLY EVEN MORE SO
	IN THE NEXT CALL,
	
	AND THAT IS MANY PEOPLE
	WITH INTRACTABLE EPILEPSY
	
	ACTUALLY DON'T HAVE EPILEPSY
	AND HAVE PSYCHOGENIC SEIZURES,
	
	BUT TO IDENTIFY
	THEM AS WELL;
	
	AND THEN DEVELOP RESEARCH
	REGARDING POST-TRAUMATIC
	EPILEPSY SURGERY;
	
	AND ANOTHER AREA WE'RE
	WORKING ON IS DEVELOPING
	STANDARDS OF CARE
	
	FOR EPILEPSY CARE IN THE VA.
	
	SO THE NEXT SLIDE, WE'RE GONNA
	GO TO A CASE PRESENTATION.
	
	THIS IS A PATIENT WHO'VE
	WE'VE EVALUATED HERE
	IN THE PAST YEAR.
	
	HE'S 48, LEFT-HANDED,
	AND WAS HIT BY A BASEBALL
	BAT AT AGE 24
	
	WHEN HE WAS IN THE SERVICE
	
	IN SOME SORT OF AN ALTERCATION
	THAT HAD OCCURRED.
	
	HE WAS HOSPITALIZED
	AND IN A COMA FOR A WEEK
	
	AND HAD A LEFT FRONTAL
	HEMORRHAGE EVACUATED.
	
	HE DID MAKE A SLOW
	BUT NEARLY COMPLETE RECOVERY.
	
	AND THEN ONE YEAR
	AFTER THE INJURY,
	
	HE HAD HIS FIRST GENERALIZED
	TONIC-CLONIC SEIZURE.
	
	GO TO THE NEXT SLIDE.
	
	HE WAS TREATED, THEN,
	SUBSEQUENTLY WITH PHENYTOIN
	AND THEN CARBAMAZEPINE
	
	AND FOR 20 YEARS WAS STATED
	TO HAVE GOOD SEIZURE CONTROL,
	
	HAVING 2 OR 3
	SEIZURES PER YEAR.
	
	HE DID HAVE AN EPISODE
	OF STATUS EPILEPTICUS
	IN THE 1990s.
	
	UNFORTUNATELY, HE IS HOMELESS
	
	AND HAS HAD A PROBLEM
	WITH ALCOHOLISM.
	
	HE ACTUALLY WAS SENT TO US
	BY A VA THAT HELPS VETERANS
	WHO ARE HOMELESS
	
	AS WELL AS THOSE WHO HAVE
	PROBLEMS WITH ALCOHOL.
	
	AND HE HAD BEEN SOBER
	FOR A NUMBER OF MONTHS
	
	AND CONTINUED TO HAVE
	SEIZURES THAT PRIMARILY
	OCCURRED AT NIGHT.
	
	GO TO THE NEXT SLIDE.
	
	AND SO OVER THE PAST 2 YEARS,
	HE'S BEEN HAVING 2 TO 3 SEIZURES
	A WEEK, MOSTLY DURING SLEEP,
	
	DESCRIBED AS GENERALIZED
	TONIC-CLONIC IN CHARACTER.
	
	THERE'S NO AURA. HE OFTEN
	WAKES UP SORE OR WITH
	A BITTEN TONGUE.
	
	HE TRIED SOME OTHER
	ANTI-EPILEPTIC DRUGS,
	
	INCLUDING TOPIRAMATE
	AND VALPROATE.
	
	WHEN WE SAW HIM, HE WAS ON
	GABAPENTIN, A MODERATE DOSE OF
	600 MILLIGRAMS, 3 TIMES A DAY,
	
	AND LEVETIRACETAM 1,500
	MILLIGRAMS, TWICE A DAY.
	
	SO WE ADMITTED HIM FOR
	A VIDEO-EEG MONITORING STUDY.
	
	GO TO THE NEXT SLIDE.
	
	AT THAT TIME, OTHER FACTORS
	IN HIS HISTORY
	
	WERE HYPERTENSION
	AND HYPERLIPIDEMIA.
	
	HIS EXAM WAS
	PRETTY UNREMARKABLE.
	
	HE HAD 1/3 MEMORY IN 5 MINUTES.
	
	HE HAD A LITTLE BIT OF
	RIGHT UPPER EXTREMITY DRIFT.
	
	SO VERY MILD WEAKNESS THERE.
	
	HIS ROUTINE EEG SHOWED
	LEFT FRONTOTEMPORAL SLOWING
	IN THE THETA RANGE
	
	WITH INTERMITTENT SPIKE OR
	SHARP WAVES EMANATING FROM F7,
	
	WHICH IS THE FRONTOTEMPORAL
	ELECTRODE.
	
	AND HIS MRI--WE'LL
	LOOK AT IN A SECOND--
	
	SHOWED LEFT FRONTOTEMPORAL
	ENCEPHALOMALACIA,
	
	A LEFT TEMPORAL
	ARACHNOID CYST,
	
	AND THEN SOME MICROVASCULAR
	CHANGES IN HIS WHITE MATTER.
	
	SO THE NEXT SLIDE SHOWS
	A SAGITTAL SECTION OF HIS BRAIN,
	
	AND YOU CAN SEE THERE'S
	A FRONTAL LESION ABOVE THE EYE
	
	AS WELL AS A TEMPORAL LESION
	JUST TO THE RIGHT,
	
	JUST POSTERIOR TO THE ORBIT.
	
	AND IT'S A RATHER
	COMPLICATED LESION.
	
	ON THE NEXT SLIDE,
	YOU CAN SEE IT
	IN A CORONAL VIEW,
	
	AND IT IS CLEARLY
	INFERIOR ORBITAL FRONTAL
	
	WITH SOME WHITE MATTER CHANGES.
	
	AND THE NEXT SLIDE SHOWS
	A MORE POSTERIOR VIEW,
	
	WHERE YOU SEE THIS TEMPORAL
	ARACHNOID CYST THERE.
	
	IT'S UNCLEAR WHETHER IT
	ACTUALLY COMMUNICATES WITH
	THE LATERAL VENTRICLE OR NOT.
	
	THE NEXT SLIDE IS JUST
	A T2 CORONAL FLARE
	OF THE HIPPOCAMPAL REGIONS.
	
	AND I'M SHOWING THAT BECAUSE,
	AS YOU'LL HEAR LATER,
	
	FOR SOME CASES OF
	SURGICAL TREATMENT OF
	POST-TRAUMATIC EPILEPSY,
	
	HIPPOCAMPAL SCLEROSIS
	MAY ACTUALLY BE A FINDING
	
	THAT PORTENDS
	A GOOD SURGICAL OUTCOME.
	
	BUT HE DID NOT SEEM TO HAVE THAT
	ON THIS T2 FLARE STUDY.
	
	THE NEXT SLIDE DESCRIBES THIS
	VIDEO-EEG MONITORING STUDY.
	
	DURING THIS STUDY,
	HE HAD 3 PARTIAL SEIZURES
	
	OF LEFT FRONTOTEMPORAL
	ORIGIN AND THEN
	SECONDARILY GENERALIZED.
	
	THEY ALL BEGAN IN SLEEP,
	AND, INTERESTINGLY,
	
	THEY BEGAN WITH WHAT APPEARED
	TO BE A BRIEF APNEIC SPELL.
	
	IT DID APPEAR DURING
	HIS STUDY THAT WE
	UNCOVERED HIS SLEEP APNEA
	
	WHICH HAD NOT BEEN DIAGNOSED.
	
	I'LL MENTION THAT SUBSEQUENTLY
	HE DID REFER BACK TO HIS CENTER
	
	TO GET IN A FORMAL
	SLEEP STUDY AND DID
	HAVE SLEEP APNEA
	
	AND WAS TREATED FOR THAT.
	
	HIS SEIZURES CONSISTED OF
	OPENING HIS EYES AND STARING,
	
	THEN HAVING
	ORAL-BUCCAL AUTOMATISMS,
	
	AND THEN SOME RHYTHMIC
	RIGHT-HAND MOVEMENTS
	
	WITH A SECONDARY GENERALIZED
	SEIZURE DEVELOPING.
	
	AND THE NEXT FEW SLIDES
	SHOW HIS EEG DURING
	ONE OF HIS SEIZURES.
	
	SO THIS NEXT SLIDE
	SHOWS ITS ONSET.
	
	AND IF YOU LOOK AT THE
	SECOND CHANNEL FROM THE TOP,
	
	THERE IS THIS RHYTHMIC
	HIGH-THETA, LOW-ALPHA FREQUENCY
	ACTIVITY IN F1 AND F71
	
	THAT CONTINUES AND THEN STARTS
	GETTING CONTAMINATED WITH
	SOME MUSCLE [INDISTINCT].
	
	GO TO THE NEXT SLIDE.
	
	IT CONTINUES WITH MAYBE A LITTLE
	MORE WIDESPREAD RHYTHMIC SLOWING
	
	INTO LEFT FRONTAL REGIONS.
	
	AND THEN THE NEXT SLIDE
	SHOWS IT AS SORT OF
	ORGANIZING A LITTLE MORE
	
	INTO THE LEFT
	FRONTOTEMPORAL REGION
	
	WITH SOME FASTER
	FREQUENCIES SUPERIMPOSED.
	
	AND AT THIS TIME,
	HE'S HAVING LIP SMACKING.
	
	AND THEN THE NEXT SLIDE
	IS WHERE HE BEGINS THEN
	
	TO HAVING SOME RIGHT
	FOCAL MOTOR ACTIVITY
	
	AND SOME BRIEF TONIC POSTURING
	
	THAT GOES ON TO
	A FULL-BLOWN GENERALIZED
	TONIC-CLONIC SEIZURE,
	
	DURING WHICH THE BACKGROUND
	EEG ACTIVITY IS BASICALLY
	UNINTERPRETABLE.
	
	SO IT DOES LOOK LIKE
	THEY'RE STARTING FROM
	HIS LEFT FRONTOTEMPORAL REGION,
	
	NOT SURPRISINGLY THE AREA
	WHERE WE SAW THE MASSIVE--
	
	OR RATHER LARGE AREA
	OF ENCEPHALOMALACIA.
	
	WE'LL GO TO THE NEXT SLIDE.
	
	SO WHAT WE DID WAS WE DID
	
	GET HIM EVALUATED FOR
	OBSTRUCTIVE SLEEP APNEA.
	
	HE'S BEEN TREATED WITH BIPAP.
	
	WE DID INSTITUTE
	A TRIAL OF LAMOTRIGINE,
	
	WHICH UNFORTUNATELY
	HAS NOT CLEARLY
	CONTROLLED HIS SEIZURES.
	
	SO HE DOES APPEAR
	TO BE CLEARLY INTRACTABLE,
	
	AND WE ARE PLANNING TO
	EVALUATE HIM FOR POSSIBLE
	SURGICAL TREATMENT,
	
	AND THE PROCESS, WE'LL NEED
	TO DO INVASIVE EEG MONITORING
	
	AND ALSO GET A FORMAL
	NEUROPSYCHIATRIC EVALUATION
	
	TO GET A BETTER IDEA OF HIS
	BASELINE COGNITIVE FUNCTION.
	
	ONE INTERESTING THING
	ABOUT HIM IS HIS INJURY
	IS ON THE LEFT SIDE.
	
	HE IS LEFT-HANDED.
	
	QUITE FRANKLY, I DON'T REMEMBER
	WHETHER THERE WAS A FAMILY
	HISTORY OF LEFT-HANDEDNESS,
	
	BUT ONE THING THAT
	WOULD BE IMPORTANT
	TO SORT OUT WITH HIM
	
	WITH FURTHER EVALUATION
	
	WOULD BE WHICH SIDE
	IS LANGUAGE-DOMINANT.
	
	I SUSPECT IT'S THE LEFT, BUT
	WE WOULD NEED TO FIND THAT OUT.
	
	IT WOULD BE SOMETHING
	THAT WOULD POTENTIALLY LIMIT
	
	THE SURGICAL RECEPTION
	THAT COULD BE DONE.
	
	AND LASTLY, I'LL MENTION
	A CONCERN ABOUT SUDEP.
	
	SUDEP REFERS TO SUDDEN
	UNEXPECTED DEATH IN
	EPILEPSY PATIENTS.
	
	IT IS A REAL PROBLEM,
	AND A GENTLEMAN LIKE THIS
	
	HAS ROUGHLY A 15- TO 20-TIME
	GREATER RISK OF DYING
	
	COMPARED TO
	AN AGE-MATCHED CONTROL.
	
	THE RISK FACTORS FOR SUDEP
	INCLUDE HAVING GENERALIZED
	TONIC-CLONIC SEIZURES,
	
	EVEN THOUGH THEY MAY
	BE SECONDARILY GENERALIZED;
	
	LIVING ALONE;
	
	AND AS WE'VE LEARNED
	MORE ABOUT SUDEP,
	
	IT OFTEN OCCURS DURING SLEEP.
	
	AND A COUPLE OF UNFORTUNATE
	CASES WHERE PEOPLE
	HAVE BEEN MONITORED
	
	AND IT WAS NOT RECOGNIZED
	THAT THEY HAD A SEIZURE,
	
	THEY'VE HAD VIDEO-EEG
	RECORDINGS OF BASICALLY
	SUFFOCATION WITHIN A PILLOW.
	
	SO THIS GENTLEMAN CLEARLY
	IS SET UP FOR THAT,
	
	AND IT'S A CONCERN.
	
	SO WANTED TO DISCUSS
	A LITTLE BIT--AND THIS IS
	ON THE NEXT SLIDE--
	
	OF WHAT IS THE
	PROBABILITY OF DEVELOPING
	EPILEPSY IN THAT INJURY
	
	AFTER A HEAD TRAUMA
	IN A CIVILIAN POPULATION.
	
	AND THIS SLIDE IS FROM
	AN EPIDEMIOLOGIC STUDY
	FROM THE MAYO CLINIC,
	
	AN ANNEGERS STUDY,
	
	AND IT SHOWS 4 CURVES.
	
	THE MOST LOWEST ONE IS JUST
	THE POPULATION IN GENERAL.
	
	AND YOU SEE THERE IS A LOW
	PROBABILITY OF DEVELOPING
	EPILEPSY OVER YEARS
	
	WITH NO BRAIN INJURY.
	
	YOU CAN'T QUITE SEE IT,
	BUT IT'S THE LITTLE STARS.
	
	SO PEOPLE DO DEVELOP
	EPILEPSY IN THEIR LIFETIME.
	
	INCIDENCE OF EPILEPSY
	IS PROBABLY ABOUT 3.5%.
	
	SO IN AN ADULT POPULATION,
	IF YOU FOLLOWED THEM,
	
	PEOPLE WILL DEVELOP EPILEPSY
	FOR WHATEVER REASON.
	
	THE LINE JUST ABOVE IT IS FOR
	MINOR OR MILD HEAD TRAUMA.
	
	AND THIS WOULD BE DEFINED AS
	A LOSS OF CONSCIOUSNESS
	
	OF LESS THAN 30 MINUTES.
	
	THE RISK RATIO
	FOR THAT IS 1.5,
	
	MEANING THAT COMPARED TO
	THE GENERAL POPULATION,
	
	THERE'S A SLIGHT INCREASE
	OF 1.5 GREATER CHANCE
	OF DEVELOPING EPILEPSY
	
	AFTER A MINOR HEAD TRAUMA.
	
	THE NEXT LINE IS FOR
	MODERATE HEAD TRAUMA.
	
	AND THIS IS A LOSS
	OF CONSCIOUSNESS OF
	GREATER THAN A HALF-HOUR,
	
	BUT LESS THAN 24 HOURS,
	OR A SKULL FRACTURE.
	
	AND THEN THE RISK RATIO
	IN THIS CASE IS 2.9.
	
	AND SO IT IS SIGNIFICANT,
	AND 4% TO 5% OF PEOPLE
	WILL DEVELOP EPILEPSY.
	
	THE OTHER THING TO NOTE
	IN THIS IS THAT THIS MAY
	TAKE UP TO 30 YEARS TO PRESENT.
	
	SO IT CAN BE QUITE DELAYED.
	
	AND THEN THE TOP LINE
	IS SORT OF WHAT OUR PATIENT HAD.
	
	LOSS OF CONSCIOUSNESS
	OF GREATER THAN 24 HOURS
	
	WITH A SUBDURAL OR CONTUSION.
	
	AND THEN YOUR RISK RATIO
	GETS UP TO 17 TIMES COMPARED
	TO THE GENERAL POPULATION.
	
	AND NOTE AGAIN THAT PEOPLE,
	EVEN AFTER 15 YEARS
	FOLLOWING THE INJURY,
	
	MAY DEVELOP EPILEPSY.
	
	SO THINGS CAN BE QUITE DELAYED.
	
	BUT THESE ARE THE PEOPLE
	WHO ARE AT RISK.
	
	AND THAT'S GONNA BE
	IMPORTANT TO LOOK AT
	IN TERMS OF OUR VETERANS
	
	WHO ARE COMING BACK WITH
	VARIOUS TYPES OF
	TRAUMATIC BRAIN INJURY.
	
	SO THE NEXT SLIDE REVIEWS
	WHAT WE KNOW ABOUT
	TRAUMATIC BRAIN INJURY
	
	AND POTENTIAL POST-TRAUMATIC
	EPILEPSY IN THE MILITARY.
	
	WE DO KNOW THAT THERE'S
	BEEN A LITTLE OVER
	1.6 MILLION SOLDIERS
	
	SERVING IN AFGHANISTAN OR IRAQ.
	
	WHEN THESE SOLDIERS ARE
	SCREENED, AT LEAST
	MOST RECENTLY,
	
	ABOUT 20% OF THEM
	SCREEN POSITIVELY FOR
	TRAUMATIC BRAIN INJURY.
	
	SO THAT'S OVER
	300,000 PATIENTS.
	
	OF THAT, DEPENDING
	ON HOW SEVERE IT IS,
	
	MOST OF THEM DO TURN OUT TO HAVE
	MILD TRAUMATIC BRAIN INJURY.
	
	BUT THOSE WHO HAVE MODERATE
	OR SEVERE TRAUMATIC BRAIN INJURY
	
	HAVE SIGNIFICANT RISK
	FOR EPILEPSY,
	
	SOMEWHERE IN THE BALLPARK
	OF 15% TO 34%
	FOR MODERATE TO SEVERE.
	
	AND THEN THOSE PATIENTS,
	BASED ON OUR EXPERIENCE
	WITH VIETNAM VETERANS,
	
	MAY HAVE AS HIGH AS A 53% RISK
	OF DEVELOPING EPILEPSY FOLLOWING
	A PENETRATING SKULL INJURY.
	
	SO THIS WAS THE RATIONALE
	FOR MAKING SURE WE HAD
	EPILEPSY CARE IN THE VA.
	
	AND SO WE EXPECT TO SEE PATIENTS
	WITH POST-TRAUMATIC EPILEPSY.
	
	CERTAINLY, I HAVE,
	AND I'M SURE SOME OF YOU HAVE.
	
	AND THEY HAVE TENDED,
	IN MY EXPERIENCE,
	
	TO BE IN THE CONTEXT
	OF MODERATE TO SEVERE
	TRAUMATIC BRAIN INJURY.
	
	THE NEXT SLIDE JUST SUMMARIZES
	SOME OF THE TRAUMATIC BRAIN
	INJURY SCREENING,
	
	AND ACTUALLY THAT NUMBER
	HAS GROWN SO THAT BETWEEN
	APRIL 2007 AND 2010,
	
	THERE WERE 445,000
	VETERANS SCREENED.
	
	ABOUT 20% SCREENED POSITIVELY,
	
	AND THEN THOSE WHO
	SCREENED POSITIVELY
	WERE EVALUATED FURTHER,
	
	AND 35,000 RECEIVED A TRAUMATIC
	BRAIN INJURY CODE--ICD9 CODES.
	
	AND THAT WOULD BE ANYWHERE FROM
	SIMPLE CONCUSSION
	TO A POST-CONCUSSIVE SYNDROME
	
	TO A VARIETY
	OF VARIOUS DIAGNOSES.
	
	AND THE MOST COMMON CAUSE FOR
	A TRAUMATIC BRAIN INJURY
	IN THIS GROUP OF VETERANS
	
	WAS IMPROVISED
	EXPLOSIVE DEVICES,
	
	WHICH IS A BLAST INJURY,
	
	AND IS REALLY A NEW
	TYPE OF INJURY FOR
	THE VETERAN POPULATION.
	
	SO WE DON'T REALLY KNOW
	THE SEQUELAE OF THIS.
	
	THIS MAY NOT BE THE SAME AS
	A MORE SIMPLE CONCUSSION.
	
	SO WE DON'T KNOW.
	
	THE NEXT SLIDE TALKS ABOUT
	ANOTHER SOURCE OF DATA,
	
	WHICH IS REALLY
	QUITE INTERESTING.
	
	IT'S THE DEFENSE AND VETERANS
	BRAIN INJURY CENTER, OR DVBIC.
	
	IT'S A GREAT WEB SITE TO LOOK AT
	AND IT'S LISTED ON THIS SLIDE.
	
	AND THEY KEEP TRACK OF
	TRAUMATIC BRAIN INJURY
	BASED ON DoD RECORDS.
	
	AND OVER A LITTLE MORE THAN
	A DECADE OF THIS CENTURY,
	
	THERE HAVE BEEN OVER 200,000
	PEOPLE IN THE MILITARY
	
	WHO'VE HAD TRAUMATIC
	BRAIN INJURY,
	
	AND THIS IS WHATEVER
	HAPPENS DURING THE MILITARY.
	
	SO IT MAY BE A CAR ACCIDENT.
	
	IT MAY BE TRAUMA THAT
	WAS IN THE CONTEXT OF COMBAT.
	
	THE NEXT SLIDE IS
	A HARD SLIDE TO READ,
	
	BUT IT JUST BASICALLY
	TELLS YOU HOW DVBIC,
	AND THE VA IN GENERAL,
	
	HAS BEEN LOOKING AT
	TRAUMATIC BRAIN INJURY.
	
	AND SO IT'S EITHER A MILD
	TRAUMATIC BRAIN INJURY,
	
	WHICH WOULD BE WHAT WE WOULD
	CALL A CONCUSSION,
	
	AND IT CONSISTS OF
	A CONFUSED STATE,
	
	WHICH LASTS LESS THAN 24 HOURS,
	
	OR A LOSS OF CONSCIOUSNESS
	UP TO 30 MINUTES.
	
	AND THEY ALSO HAVE MEMORY
	PROBLEMS FOR 24 HOURS OR LESS.
	
	THERE'S NO
	STRUCTURAL ABNORMALITY
	ON BRAIN HEMORRHAGING.
	
	MODERATE TRAUMATIC BRAIN
	INJURY IS MORE SEVERE,
	
	SO THERE'S A CONFUSED
	OR DISORIENTED STATE
	THAT LASTS MORE THAN 24 HOURS,
	
	A LOSS OF CONSCIOUSNESS
	OF MORE THAN 30 MINUTES
	
	BUT LESS THAN 24 HOURS,
	
	AND THEN MEMORY LOSS
	OR PROBLEMS FROM
	24 HOURS TO 7 DAYS,
	
	AND THERE MAY OR MAY
	NOT BE STRUCTURAL
	ABNORMALITIES ON IMAGING.
	
	SEVERE TRAUMATIC BRAIN INJURY
	INCLUDES A CONFUSED
	OR DISORIENTED STATE
	
	FOR MORE THAN 24 HOURS,
	LOSS OF CONSCIOUSNESS
	FOR MORE THAN 24 HOURS,
	
	MEMORY LOSS FOR MORE
	THAN 7 DAYS,
	
	AND THEN STRUCTURAL
	BRAIN IMAGING YIELDING
	NORMAL OR ABNORMAL RESULTS.
	
	AND THEN LASTLY--AND THIS IS
	LARGELY FOR MILITARY PURPOSES;
	
	IT REALLY COMES FROM OUR
	UNDERSTANDING OF POST-TRAUMATIC
	EPILEPSY IN VIETNAM VETERANS--
	
	IS PENETRATING
	TRAUMATIC BRAIN INJURY,
	
	WHERE THERE'S
	AN OPEN-HEAD INJURY,
	
	WHERE THERE'S BEEN PENETRATION
	OF THE DURA BY EITHER A MISSILE
	
	OR BY A DEPRESSED
	SKULL FRACTURE,
	
	AND USUALLY IT COULD BE A HIGH-
	OR A LOW-VELOCITY INJURY.
	
	AND THIS SUBGROUP OF PEOPLE
	AND THIS TYPE OF
	TRAUMATIC BRAIN INJURY
	
	ARE PROBABLY AT
	THE GREATEST RISK
	FOR DEVELOPING EPILEPSY.
	
	AND THE NEXT SLIDE JUST SHOWS
	WHAT DVBIC DEMONSTRATES
	
	IN TERMS OF THEIR MONITORING
	OF TRAUMATIC BRAIN INJURY
	
	IN DEFENSE MILITARY...
	
	SOME ARE VETERANS.
	SOME ARE STILL ACTIVE.
	
	AND YOU CAN SEE THE VAST
	MAJORITY ARE MILD.
	
	SO OVER 3/4 OF THE TRAUMATIC
	BRAIN INJURIES ARE MILD,
	
	AND PRESUMABLY THEY'RE
	GONNA BE SIMILAR TO
	THE MILD TRAUMATIC BRAIN INJURY
	
	DESCRIBED IN ANNEGERS' STUDY
	IN A CIVILIAN POPULATION.
	
	WE DON'T KNOW THAT FOR SURE,
	
	AND WE DON'T KNOW HOW MANY OF
	THESE MILD TRAUMATIC BRAIN
	INJURIES ARE ACTUALLY MULTIPLES,
	
	WHICH COULD BE A GREATER RISK.
	
	BUT THERE IS ROUGHLY
	ABOUT 25% OR SLIGHTLY LESS
	WHO'VE HAD EITHER MODERATE--
	
	34,000 PEOPLE--WHO'VE HAD
	A MODERATE INJURY,
	
	WHO ARE PROBABLY AT AT LEAST
	A 5% TO 10% RISK OF
	DEVELOPING EPILEPSY.
	
	AND THEN A SMALLER
	SEVERE PENETRATING,
	
	WHERE YOU'RE PROBABLY MORE
	INTO THE 25% TO 50% CHANCE
	OF DEVELOPING EPILEPSY.
	
	AND AGAIN, THAT MAY OCCUR
	OVER A PERIOD OF MANY YEARS.
	
	THE NEXT SLIDE SHOWS
	WHAT WE KNOW FROM VIETNAM VETS.
	
	AND IT'S SORT OF INTERESTING.
	
	THIS IS A COHORT OF VETERANS
	
	WHO HAD PENETRATING HEAD INJURY
	IN THE VIETNAM CONFLICT.
	
	THEY'VE BEEN FOLLOWED BY
	A GROUP THAT AT ONE TIME,
	AND STILL IS,
	
	BASICALLY HEADED OUT OF NIH
	AND NATIONAL INSTITUTE OF
	NEUROLOGIC DISEASES.
	
	AND THE FIRST COHORT
	OF PATIENTS WHICH,
	AS IT'S SHOWN HERE,
	
	WAS A SMALLER COHORT
	OF ABOUT 500 PATIENTS,
	
	AND A LITTLE OVER HALF OF THEM
	WITH PENETRATING HEAD TRAUMA
	DEVELOPED EPILEPSY.
	
	THIS LATER STUDY LOOKED
	AT A BIGGER COHORT
	OF PATIENTS, OVER 1,000,
	
	WHO WERE FOUND FOR HEAD TRAUMA
	AND PENETRATING HEAD TRAUMA.
	
	AND YOU CAN SEE THAT 5 YEARS
	FOLLOWING THE INJURY,
	
	ALMOST 1/3
	HAD DEVELOPED EPILEPSY.
	
	BUT OVER THE NEXT 10 YEARS,
	
	THAT WENT UP BY ANOTHER
	ROUGHLY 20%--OR NOT QUITE 20%,
	BUT UP TO A PERCENTAGE
	
	THAT CONTINUED TO GROW
	MANY YEARS AFTER THAT.
	
	SO BETWEEN--AFTER 15 YEARS
	OF THE INJURY,
	
	THERE STILL WERE 12% OF VETERANS
	WHO DEVELOPED EPILEPSY.
	
	AND THAT'S A CONCERN BECAUSE
	IT MAY NOT BE EASY TO
	RECOGNIZE THEIR EPILEPSY
	
	IF YOU'RE NOT
	THINKING ABOUT IT
	
	AND IF THE PATIENTS DON'T
	HAVE FRANK, GENERALIZED
	TONIC-CLONIC SEIZURES.
	
	THE NEXT SLIDE TALKS ABOUT
	THE DIFFICULTY SOMETIMES
	
	IN DIAGNOSING
	POST-TRAUMATIC EPILEPSY.
	
	IT IS PRETTY EASY WHEN THERE'S
	CLEAR, CONVULSIVE SEIZURES.
	
	BUT AS YOU KNOW, THERE ARE
	A LOT OF OTHER SEIZURES
	WHICH ARE NOT CONVULSIVE.
	
	THEY'RE NOT CONVULSIVE.
	THEY'RE COMPLEX PARTIAL
	IN CHARACTER
	
	OR FOCAL IN CHARACTER,
	WITH OR WITHOUT
	IMPAIRMENT OF THINKING.
	
	AND THEY CAN BE VERY
	DIFFICULT TO SORT OUT,
	
	PARTICULARLY WITHIN
	THE CONTEXT OF OTHER TRAUMATIC
	BRAIN INJURY CO-MORBIDITIES,
	
	SUCH AS PROBLEMS WITH ATTENTION
	WHEN THERE'S BEEN
	FRONTAL LOBE LESIONS.
	
	SLEEP PROBLEMS, WHICH MAY
	OCCUR AFTER TRAUMA
	
	OR MAY ALSO BE RELATED TO
	POST-TRAUMATIC STRESS DISORDER.
	
	POST-TRAUMATIC STRESS DISORDER
	CERTAINLY OCCURS IN A RELATIVELY
	HIGH PERCENTAGE OF PATIENTS
	
	WHO'VE HAD TRAUMATIC
	BRAIN INJURY.
	
	AND THEN ALSO GENERALIZED
	ANXIETY DISORDER.
	
	THE NEXT SLIDE IS AN INTERESTING
	STUDY THAT WAS PUBLISHED
	IN "NATURE NEUROSCIENCE"
	
	BY KOENIGS THAT ACTUALLY
	LOOKED AT THIS COHORT
	OF VIETNAM VETERANS
	
	WHO HAD PENETRATING
	SKULL BRAIN INJURY,
	
	AND THEY DID
	AN INTERESTING THING.
	
	WHAT THEY DID IS THEY DETERMINED
	
	WHETHER THEY HAD POST-TRAUMATIC
	STRESS DISORDER OR NOT,
	
	AND THEN THEY LOOKED AT
	WHERE THE BRAIN LESIONS WERE.
	
	AND BASICALLY FOR EVERY PATIENT
	WHO HAD A BRAIN LESION
	
	WHO DID NOT HAVE POST-TRAUMATIC
	STRESS, THEY WOULD RATE IT -1.
	
	FOR EVERY VETERAN WHO HAD
	A BRAIN LESION IN AN AREA
	
	THAT DID DEVELOP POST-
	TRAUMATIC STRESS DISORDER,
	THEY RATED IT +1.
	
	SO THIS SCALE OF THESE BRAINS
	SHOW -23 AS THE DARKEST BLUE.
	
	SO THAT MEANS THERE WERE 23
	VETERANS WHO HAD LESIONS
	IN THESE AREAS
	
	THAT DID NOT DEVELOP
	POST-TRAUMATIC STRESS DISORDER.
	
	SO IT'S SORT OF INTERESTING.
	
	THERE ARE CERTAIN TYPES
	OF INJURIES FROM
	TRAUMATIC BRAIN INJURIES
	
	WHERE THE LESIONS PROTECT
	SOMEONE FROM POST-TRAUMATIC
	STRESS DISORDER.
	
	IN THIS GROUP FELT THAT THIS
	WAS THE SUBSTRATE FOR
	POST-TRAUMATIC STRESS DISORDER.
	
	AND AS YOU CAN SEE, IT'S
	THE MEDIAL FRONTAL REGIONS.
	
	SEE IT ON THE TWO SAGITTAL
	SECTIONS IN THE TOP
	
	AND THEN THE VERY ANTERIOR
	FRONTAL REGIONS, AS YOU CAN SEE,
	
	AND CORONAL SECTIONS,
	
	AND THEN AS YOU
	MOVE POSTERIORLY,
	
	THE AMYGDALA AND ANTERIOR
	TEMPORAL LOBE.
	
	SO IN SOME WAYS, OUR VETERAN
	HAS SIMILAR LESIONS,
	
	AND HE DOES NOT HAVE
	POST-TRAUMATIC STRESS DISORDER,
	
	A CASE THAT I PRESENTED,
	
	AND IN FACT, HE'S RATHER
	INDIFFERENT NOW.
	
	HE DIDN'T HAVE A COMBAT INJURY,
	
	WHICH MAYBE WOULD
	MORE LOAD HIM UP FOR
	
	POST-TRAUMATIC STRESS,
	
	BUT ANY SORT OF AN ASSAULT CAN
	
	LEAD TO POST-TRAUMATIC
	STRESS DISORDER,
	
	AND CERTAIN LESIONS WILL SEEM
	TO PROTECT AGAINST THAT.
	
	SO PRESUMABLY, POST-TRAUMATIC
	STRESS DISORDER
	
	IS LARGELY MEDIATED BY
	ENDURING DYSFUNCTION
	
	IN THE AMYGDALA,
	ANTERIOR TEMPORAL LOBE,
	
	AND MEDIAL
	FRONTAL LOBE CORTICES.
	
	SO SOMETHING INTERESTING
	THAT CAME OUT OF THAT.
	
	WHAT WE DON'T KNOW IN SHANGHAI,
	
	THE PERSON WHO WROTE THIS PAPER,
	I ASKED HIM AND HE DIDN'T KNOW
	
	WHETHER THESE PATIENTS WERE--
	WHO HAD THIS TYPE OF LESION
	
	WERE MORE LIKELY TO HAVE
	POST-TRAUMATIC EPILEPSY.
	
	THE NEXT SLIDE IS ANOTHER,
	I THINK, INTERESTING PAPER
	
	THAT WAS BY DIAZ-ARRASITA,
	
	AND IT HAS RESULTS
	IN A NUMBER OF PATIENTS
	
	WHO WERE EVALUATED WITH
	VIDEO-EEG MONITORING
	
	WHO WERE FELT TO HAVE
	POST-TRAUMATIC EPILEPSY.
	
	SO THERE WERE 125 PATIENTS.
	NON-DIAGNOSTIC STUDIES OCCURRED
	
	IN 18% OF THE PATIENTS
	AND THAT MEANS BASICALLY
	
	THEY WERE MONITORED.
	
	NO EVENTS OCCURRED
	TO SAY WHETHER
	THE PATIENT HAD EPILEPSY.
	
	IN 1/3 OF THE PATIENTS, THERE
	WAS NON-EPILEPTIC SEIZURES.
	
	OK? AND THESE
	WERE MOSTLY PSYCHOGENIC
	NON-EPILEPTIC SEIZURES.
	
	SO PEOPLE WITH HEAD TRAUMA
	OFTEN HAVE THIS PHENOTYPE,
	
	AND TO WHAT EXTENT IT OVERLAPS
	WITH POST-TRAUMATIC
	STRESS DISORDER
	
	AND ANXIETY DISORDERS,
	I THINK DR. ZELINSKI
	
	WILL TALK ABOUT MORE
	IN THE NEXT CALL.
	
	OF THESE PATIENTS, 65% DID HAVE
	CLEAR POST-TRAUMATIC EPILEPSY.
	
	THERE WERE A FEW THAT SEEMED
	TO HAVE GENERALIZED ONSET,
	
	SO MAYBE THEY HAD A PRIMARY
	GENERALIZED EPILEPSY
	
	AND JUST HAPPENED TO ALSO HAVE
	A HISTORY OF TRAUMA.
	
	BUT FAR MORE COMMONLY,
	91% OF THE PEOPLE WITH EPILEPSY
	
	DID HAVE A FOCAL ONSET
	AS OUR PATIENT,
	
	AND IT WAS USUALLY
	FRONTAL OR TEMPORAL,
	
	AND UNLESS FREQUENTLY,
	OCCIPITAL OR PARIETAL,
	
	ON ONSET.
	
	THE NEXT SLIDE WILL TALK ABOUT
	
	WHAT WE KNOW ABOUT
	POST-TRAUMATIC EPILEPSY,
	
	AND UNFORTUNATELY,
	WE DON'T KNOW VERY MUCH.
	
	WE HAVE NO
	EVIDENCE-BASED GUIDELINES.
	
	THERE HAVE BEEN NO CLINICAL
	TRIALS TO COMPARE
	
	ANTI-EPILEPTIC DRUGS.
	
	IT'S REALLY UNCLEAR WHETHER
	[INDISTINCT] SURGERY
	
	HAS A ROLE FOR
	POST-TRAUMATIC EPILEPSY
	
	WHEN IT'S REFRACTORY.
	
	WE HAVE NO TREATMENT TO PREVENT
	POST-TRAUMATIC EPILEPSY.
	
	THESE ARE ALL AREAS
	WE NEED TO RESEARCH.
	
	AND THEN SOMETHING THAT
	I'M LEARNING MORE ABOUT
	
	IS THAT TRAUMATIC BRAIN INJURY
	
	IS ASSOCIATED WITH
	PROGRESSIVE CHANGES,
	
	INCLUDING PROGRESSIVE ATROPHY,
	
	BUT ALSO THE POTENTIAL FOR
	DEVELOPING LATE-ONSET EPILEPSY
	
	AS WELL AS PROGRESSIVE
	WORSENING OF EPILEPSY.
	
	THE NEXT SLIDE
	JUST REVIEWS ONE PAPER,
	
	ONE OF THE FEW PAPERS THAT
	REALLY ADDRESSES SURGERY
	
	WITHIN THE CONTEXT OF PEOPLE WHO
	HAVE POST-TRAUMATIC EPILEPSY,
	
	AND THIS WAS FROM
	THE YALE GROUP.
	
	THEY DID FIND
	A SUBSET OF PATIENTS,
	
	PARTICULARLY IF THE TRAUMA
	WAS BEFORE THE AGE OF 5,
	
	THAT WERE ASSOCIATED WITH
	HIPPOCAMPAL SCLEROSIS.
	
	AND THAT'S WHY I TALK ABOUT THAT
	IN TERMS OF THE MRI SCAN
	
	ON THIS GENTLEMAN, WHO DID NOT
	HAVE HIPPOCAMPAL SCLEROSIS.
	
	WHAT THEY DID FIND
	IS IN THIS GROUP,
	
	THERE WERE 25 PATIENTS
	THAT THEY EVALUATED.
	
	17 OF THESE PATIENTS
	APPEARED TO HAVE
	
	MEDIAL TEMPORAL-LOBE ONSET
	OF THEIR SEIZURES.
	
	ANOTHER 8 HAD
	NEOCORTICAL ONSET.
	
	21 OF THESE PATIENTS
	WERE TREATED SURGICALLY
	
	AND 9 OF THEM
	BECAME SEIZURE-FREE,
	
	WHICH ISN'T THAT GREAT.
	
	CERTAINLY NOT AS GOOD AS
	MORE STRAIGHTFORWARD
	
	ANTERIOR TEMPORAL[INDISTINCT]
	ASSOCIATED WITH
	
	HIPPOCAMPAL SCLEROSIS.
	
	AND IN THE PEOPLE WHO
	DID HAVE A GOOD OUTCOME
	
	WHO WERE SEIZURE-FREE,
	
	THEY TENDED TO HAVE
	HIPPOCAMPAL SCLEROSIS
	
	AND AN EARLY HISTORY
	OF HEAD TRAUMA,
	
	OR THEY HAD
	FOCAL CORTICAL ABNORMALITIES
	
	WITH [INDISTINCT] STAINING
	OF THE CORTEX.
	
	AND I MAY ADD
	THAT THERE HAVE BEEN
	
	EXPERIMENTAL MODELS OF EPILEPSY
	USING IRON OR HEMOSIDERIN
	
	THAT SEEM TO CREATE
	A [INDISTINCT] OR A FOCUS
	
	OF EPILEPTIC SEIZURES.
	
	THE NEXT SLIDE SHOWS A CLASSIC
	STUDY BY NANCY TEMKIN
	
	REGARDING WHETHER WE CAN
	PREVENT POST-TRAUMATIC EPILEPSY,
	
	AND IN THIS GROUP, THESE WERE
	ALL CIVILIAN INJURIES
	
	IN THE SEATTLE REGION
	THAT WENT TO A REFERRAL HOSPITAL
	
	THAT DEALT WITH
	TRAUMATIC BRAIN INJURY.
	
	ALL PATIENTS WHO HAD SOME
	MODERATE TO SEVERE INJURY
	
	WERE RANDOMIZED TO TREAT THEM
	WITH PHENYTOIN OR PLACEBO
	
	FROM THE GET-GO.
	
	AND YOU CAN SEE THE TOP GRAPH
	SHOWS THE FIRST WEEK,
	
	AND IN THAT
	FIRST WEEK, PHENYTOIN
	
	DECREASED THE NUMBER
	OF PATIENTS WITH SEIZURES.
	
	SO FAR FEWER PATIENTS
	DEVELOP SEIZURES
	
	WHEN THEY WERE TREATED WITH
	PHENYTOIN FOR THE FIRST WEEK
	
	COMPARED TO PLACEBO.
	
	BUT UNFORTUNATELY,
	THE BOTTOM GRAPH
	
	SHOWS THAT THIS
	DIDN'T CLOSE OVER TIME,
	
	AND IN FACT,
	IT'S NOT SIGNIFICANT.
	
	MORE PATIENTS TREATED
	WITH PHENYTOIN
	
	DEVELOPED EPILEPSY TWO YEARS
	FOLLOWING THE INJURY
	
	THAN THOSE TREATED WITH PLACEBO.
	
	AND AGAIN, YOU CAN SEE
	THE PLACEBO RATE WAS ABOUT 20%.
	
	THE PHENYTOIN WAS
	SOMEWHERE ABOUT 27%.
	
	AND ACTUALLY, THE PATIENTS
	TREATED WITH PHENYTOIN
	
	TENDED TO HAVE
	A MORE DELAYED REHAB,
	
	SO IT ACTUALLY PROBABLY WAS
	A DETRIMENT FOR THESE PATIENTS.
	
	THE NEXT SLIDE BASICALLY
	MENTIONS ANOTHER STUDY
	
	THAT ALSO WAS DONE
	BY NANCY TEMKIN
	
	WHERE SODIUM VALPROATE
	OR DEPAKOTE WAS USED,
	
	AND THAT DID NOT PREVENT
	THE DEVELOPMENT OF EPILEPSY
	
	FOLLOWING TRAUMATIC
	BRAIN INJURY,
	
	AND IN FACT THERE WAS A HIGHER
	MORTALITY RATE EARLY ON
	
	IN THE PATIENTS RANDOMIZED
	THROUGH DEPAKOTE.
	
	SO THE BOTTOM LINE IS OUR
	CURRENT ANTI-EPILEPTIC DRUGS
	
	ARE NOT ANTI-EPILEPTIC TONIC.
	
	THEY DO NOT PREVENT
	THE DEVELOPMENT OF EPILEPSY.
	
	THE NEXT SLIDE IS GONNA
	SHIFT GEARS SLIGHTLY
	
	AND AT LEAST TALK ABOUT
	WHAT I HOPE
	
	THE EPILEPSY CENTERS
	OF EXCELLENCE
	
	AND THE VA SYSTEM AS WELL
	
	WILL BE ABLE TO DO IN TERMS OF
	USING OUR VETERANS
	
	FOR UNDERSTANDING
	THE DEVELOPMENT
	
	OF POST-TRAUMATIC EPILEPSY
	AFTER TRAUMATIC BRAIN INJURY.
	
	AND THIS IS SOMETHING
	WE'RE HOPING TO DEVELOP.
	
	WE HAVE A LITTLE BIT OF SEED
	MONEY TO START PLANNING THIS,
	
	AND THE IDEAS ARE
	ON THE NEXT SLIDE
	
	TO ACTUALLY DEVELOP A DATABASE
	
	THAT WILL ALLOW US TO RESEARCH
	AND IDENTIFY RISK FACTORS
	
	FOR POST-TRAUMATIC EPILEPSY
	FOLLOWING A SEVERE, MODERATE,
	
	AND MILD TBI.
	
	IT'LL BE INTERESTING TO SEE
	WHETHER THE BLAST TYPE OF INJURY
	
	THAT IS OCCURRING NOW,
	THAT MAY CAUSE A MILD
	TRAUMATIC BRAIN INJURY,
	
	WILL IN ANY WAY PREDISPOSE
	TO LATER EPILEPSY.
	
	WE JUST DON'T KNOW
	
	THE OTHER QUESTION IS,
	AND IT'S CERTAINLY WITHIN
	
	THE CONTEXT OF SPORTS
	BUT ALSO IN TERMS OF
	
	MILITARY PERSONNEL WHO HAVE HAD
	
	MULTIPLE MILD TRAUMATIC
	BRAIN INJURIES.
	
	WILL THAT BE A WAY
	OR BE A RISK FACTOR
	
	FOR LATER DEVELOPING
	EITHER DEMENTIA,
	
	WHICH PROBABLY IT IS,
	BUT, YOU KNOW,
	
	POST-TRAUMATIC EPILEPSY
	THAT MAY BE MASKED
	
	AND FELT TO BE RELATED TO AGING.
	
	SO IT WOULD BE INTERESTING,
	OR WILL BE INTERESTING TO SEE
	
	WHAT HAPPENS TO THESE VETERANS
	AS THEY AGE.
	
	RIGHT NOW IN THE VA SYSTEM,
	
	THERE IS A TRAUMATIC BRAIN
	INJURY SCREENING DATABASE.
	
	BASICALLY THE PATIENTS
	WHO HAVE SCREENED POSITIVE,
	
	THAT DATABASE IS
	BASICALLY CONTROLLED
	
	BY THE REHABILITATION SERVICES
	HERE IN THE VA.
	
	AND SO WE ARE GOING TO BE
	PARTNERING WITH THEM
	
	TO HAVE SORT OF
	A SUBORDINATE DATABASE
	
	OF THOSE VETERANS WHO DO DEVELOP
	POST-TRAUMATIC EPILEPSY.
	
	AND WE WILL SEE
	HOW THAT DEVELOPS.
	
	THE OTHER THING IS TO UNDERSTAND
	
	THAT THE VA IS NOT
	WHERE ALL THE PEOPLE
	
	WHO DEVELOP A TRAUMATIC
	BRAIN INJURY END UP.
	
	A LOT DO NOT COME TO
	THE VA FOR THEIR CARE.
	
	AND THEN WE NEED
	TO ALSO CONSIDER
	
	THE DATABASE THAT
	[INDISTINCT] HAS
	
	IN TERMS OF THEIR JOINT THEATER
	TRAUMA REGISTRY.
	
	THE OTHER THINGS
	WE WERE TRYING TO DO
	
	IS JUST--AND IT'S
	ON THE NEXT SLIDE--
	
	DEVELOP A PLAN TO DETERMINE
	WHAT WE SHOULD CONTAIN
	
	IN A REGISTRY FOR VETERANS
	OF POST-TRAUMATIC EPILEPSY,
	
	AND THEN WE HOPEFULLY
	ARRIVE AT A CONSENSUS
	
	REGARDING TOOLS OR
	SCREENING MEASURES
	
	THAT CAN BE USED, PARTICULARLY
	WITHIN THE CONTEXT
	
	OF PEOPLE WHO HAVE A HIGH RISK
	FOR DEVELOPING EPILEPSY,
	
	AS SORT OF AN ANNUAL SCREEN.
	
	CERTAINLY PATIENTS WITH
	SEVERE OR PENETRATING
	TRAUMATIC BRAIN INJURY
	
	SHOULD BE LOOKED AT CAREFULLY
	AND QUESTIONED CAREFULLY
	
	WHETHER OR NOT THEY ARE
	DEVELOPING SUBTLE SEIZURES
	
	THAT MAY NOT BE OBVIOUS,
	
	AND PERHAPS EARLIER TREATMENT
	MAY BE BETTER
	
	IN TERMS OF A LONG-TERM OUTCOME,
	IN TERMS OF SEIZURE CONTROL.
	
	THE NEXT SLIDE IS
	SORT OF A REVIEW
	
	OF WHAT WE'VE
	ALREADY TALKED ABOUT--
	
	THE LARGE NUMBER OF VETERANS WHO
	HAVE HAD TRAUMATIC BRAIN INJURY
	
	IN THE DIFFERENT DATABASES,
	
	AND I'M GOING TO THE NEXT SLIDE
	
	TO GIVE YOU AN IDEA OF
	WHAT WE'RE THINKING OF
	
	IN TERMS OF
	INCLUDING A REGISTRY,
	
	AND THAT WOULD BE CERTAINLY
	A CLINICAL OR SEIZURE DIAGNOSIS,
	
	DEFINITELY WHAT MEDICATIONS
	VETERANS ARE ON
	
	AND HOW THE OUTCOMES ARE.
	
	WHETHER THERE IS A MEDICINE
	OR AN ANTI-EPILEPTIC DRUG
	
	THAT SEEMS TO WORK BETTER
	IN POST-TRAUMATIC EPILEPSY.
	
	TO LOOK AT THE MRI-EEG FINDINGS
	AND OBVIOUSLY CO-MORBIDITIES.
	
	WE'D BE ALSO VERY INTERESTED
	IN SO-CALLED FALSE POSITIVES
	
	OF THE DIAGNOSIS OF EPILEPSY,
	
	SO THIS WOULD BE PEOPLE
	WHO HAVE--WHO HAD SEIZURES
	
	BUT WHEN THEY'RE
	ACTUALLY MONITORED,
	
	HAVE NON-EPILEPTIC SEIZURES.
	
	AND THE NEXT SLIDE, AGAIN,
	SORT OF POINTS OUT
	
	THAT WE PROBABLY NEED
	TO LOOK CAREFULLY
	
	AT THE VETERANS
	WHO ARE AT HIGH RISK
	
	FOR DEVELOPING
	POST-TRAUMATIC EPILEPSY
	
	AND THEN TRY TO IDENTIFY,
	IN THIS CASE, FALSE NEGATIVES,
	
	PEOPLE WHO HAVE
	FUNNY SENSATIONS OR FEELINGS
	
	THAT MAY BE SEIZURES
	AND AREN'T PICKED UP
	
	AND TO RAISE THAT
	INDEX OF SUSPICION
	
	IN PEOPLE WHO ARE AT HIGH RISK
	FOR EPILEPSY.
	
	THIS ALSO WOULD BE
	A GROUP OF PATIENTS
	
	WE COULD STUDY FOR LATE
	PROPHYLAXIA-TYPE THERAPIES
	
	TO SEE IF WE COULD PREVENT THE
	DEVELOPMENT IN THESE VETERANS,
	
	PARTICULARLY WITHIN THE CONTEXT
	OF EPILEPSY
	
	DEVELOPING MANY YEARS
	AFTER THE INJURY.
	
	AND THAT WOULD BE IN
	THE NEXT SLIDE OUTLINE--
	
	TO DEVELOP A TOOL OR TOOLS
	
	TO REALLY IDENTIFY
	POST-TRAUMATIC EPILEPSY EARLY
	
	RATHER THAN LATER,
	
	AND AGAIN, THIS IS BASED UPON
	THE VIETNAM STUDY
	
	WHERE 12% OF THE PEOPLE
	WITH POST-TRAUMATIC EPILEPSY
	
	DEVELOPED MORE THAN 15 YEARS
	AFTER THEIR TRAUMA.
	
	AND THEN THE LAST SLIDE
	ARE THE TAKE-HOME MESSAGES.
	
	THE FIRST THING IS
	THAT THE MORE SEVERE
	THE TRAUMATIC BRAIN INJURY,
	
	THE MORE LIKELY SOMEONE IS
	TO DEVELOP EPILEPSY
	
	AND RIGHT NOW,
	MILD TRAUMATIC BRAIN INJURY,
	SIMPLE CONCUSSIONS,
	
	DO NOT SEEM TO BE A MAJOR RISK
	FOR POST-TRAUMATIC EPILEPSY.
	
	THE SECOND MAIN POINT
	IS WE DO NOT HAVE
	
	A PROPHYLACTIC TREATMENT
	FOR POST-TRAUMATIC EPILEPSY.
	
	SO PEOPLE WHO HAVE HAD
	A SIGNIFICANT BRAIN INJURY,
	
	WE DO NOT HAVE ANY RATIONALES
	TO PUT THEM ON
	
	ANTI-EPILEPTIC DRUGS
	
	PRIOR TO THEM
	DEVELOPING EPILEPSY.
	
	THEY DON'T SEEM TO WORK.
	
	THE NEXT POINT IS THAT WE NEED
	TO EVALUATE PATIENTS
	
	WITH [INDISTINCT] EPILEPSY,
	PARTLY BECAUSE
	
	POST-TRAUMATIC STRESS DISORDER
	AND POST-TRAUMATIC EPILEPSY
	
	CAN COEXIST OR THEY MAY
	MIMIC EACH OTHER,
	
	AND WE REALLY NEED TO
	[INDISTINCT] DIAGNOSIS
	
	AND THAT OFTEN REQUIRES
	VIDEO-EEG MONITORING,
	
	AND VIDEO-EEG MONITORING
	CAN BE [INDISTINCT]
	
	CENTERS OF EXCELLENCE,
	AND SO THOSE OF YOU
	
	WHO ARE NOT AT A CENTER THAT
	PROVIDES VIDEO-EEG MONITORING,
	
	YOU CAN CERTAINLY GO
	TO THE VA EPILEPSY
	
	CENTERS OF EXCELLENCE WEB SITE
	GIVEN EARLIER IN THE TALK
	
	AND FIND OUT WHERE
	YOU MAY BE ABLE
	
	TO REFER YOUR PATIENTS.
	
	SO WITH THAT, I'LL STOP.
	THANK YOU,
	
	AND I'D ALSO LIKE TO THANK
	THE EES SERVICE
	
	FOR ALLOWING US TO PRESENT
	THIS DATA TO YOU
	
	AND THIS INFORMATION TO YOU.
	
	OK, SEAN.
	
	- THANK YOU, DR. RUTECKI.
	
	I'D LIKE LET EVERYBODY KNOW
	THAT THE LINES ARE
	OPEN NOW FOR QUESTIONS,
	
	SO IF ANYONE HAS ANY QUESTIONS
	FOR THE DOCTOR,
	
	GO AHEAD AND ASK.
	
	- I HAVE A QUESTION
	FROM HOUSTON.
	
	- YEAH. GO AHEAD.
	
	- YES. WHAT EFFECT DOES
	A LEFT TEMPORAL ARACHNOID CYST
	
	HAVE ON HIS BRAIN?
	
	- WELL, THAT'S A GREAT QUESTION.
	THE QUESTION IS
	
	WHAT DOES THE LEFT TEMPORAL
	ARACHNOID CYST
	
	HAVE, OR WHAT EFFECT DOES IT
	HAVE ON HIS BRAIN?
	
	ARACHNOID CYSTS
	ARE RATHER UNUSUAL,
	
	AND THERE ARE OCCASIONS WHERE
	
	THEY CAN ACTUALLY
	CREATE PRESSURE
	
	AND MAY BE ASSOCIATED WITH
	THE DEVELOPMENT OF EPILEPSY,
	
	BUT MOST OF THE SERIOUS
	ARACHNOID CYSTS,
	
	PATIENTS DON'T DEVELOP EPILEPSY.
	
	SO IT HAS TO BE TAKEN WITH
	CONTEXT OF THEIR HISTORY.
	
	FOR HIM, I DON'T KNOW
	IF WE HAVE ANYTHING.
	
	WE HAVE HAD PATIENTS WHO
	HAVE HAD ARACHNOID CYSTS
	
	WHO WE'VE [INDISTINCT]
	AND TRY TO MAKE SURE
	
	THAT THEY DON'T
	DEVELOP PRESSURE,
	
	AND I'M NOT SURE
	I'VE SEEN THAT CLEARLY
	
	BENEFIT [INDISTINCT] CONTROL.
	
	AND WHEN IN THE FEW OCCASIONS
	WHERE WE'VE DONE
	
	RESECTIVE SURGERY IN THE CONTEXT
	OF AN ARACHNOID CYST,
	
	IT'S USUALLY REQUIRED THAT
	ACTUALLY CORTICAL TISSUE
	
	NEEDS TO BE REMOVED TO ACHIEVE
	SEIZURE FREEDOM.
	
	SO I DON'T KNOW, BUT YOU CAN
	GET VERY COMPLICATED INJURIES
	
	WITH--COMPLICATED
	ANATOMIC ABNORMALITIES
	
	WITH TRAUMA, INCLUDING
	ARACHNOID CYSTS LIKE THIS.
	
	BUT I DON'T KNOW.
	IT IS SORT OF AN UNUSUAL
	MRI PICTURE.
	
	- MM-HMM.
	THE AREA.
	YEAH. THANK YOU.
	
	- SURE.
	
	ARE THERE ANY OTHER QUESTIONS?
	
	- I'VE GOT A QUESTION
	FROM CINCINNATI.
	
	YOU WERE MENTIONING
	ABOUT THE DANGER OF,
	
	YOU KNOW, DEATH WITH EPILEPSY
	IN SLEEP.
	
	IS THAT--IF SOMEONE
	HAS EPILEPSY,
	
	NOW, WOULD THEY ALWAYS
	HAVE SEIZURES IN THEIR SLEEP
	
	OR ARE SOME PEOPLE
	MORE SUSCEPTIBLE TO THAT
	
	AND ONLY HAVE IT
	DURING WAKING HOURS, OR
	
	WHAT KIND OF BREAKOUT IS THAT?
	
	- IT'S INTERESTING--THERE'S
	A SUBSET OF PATIENTS,
	
	AGAIN, [INDISTINCT]
	
	- WAIT A MINUTE.
	I'M SORRY.
	I CAN'T HEAR YOU.
	
	- YEAH, I'M SORRY.
	THERE'S A LITTLE BIT
	OF AN ECHO FOR ME.
	
	YOU MAY BE GETTING IT, TOO.
	
	THERE IS A SUBSET OF PATIENTS
	WHO CLEARLY HAVE
	
	THE MAJORITY OF THEIR SEIZURES
	WHEN THEY'RE ASLEEP.
	
	- OH, REALLY?
	- AND THEN SOME OF THOSE
	
	HAVE [INDISTINCT]
	PARTIAL SEIZURES.
	
	AND THOSE DON'T SEEM
	TO CARRY AS MUCH RISK
	
	FOR [INDISTINCT]
	THE MAIN GROUP
	
	THAT HAS A RISK [INDISTINCT]
	
	THOSE WHO HAD
	SECONDARY GENERALIZED
	[INDISTINCT] SEIZURES.
	
	- YEAH.
	- AND THEY OFTEN OCCUR
	
	WHEN THE PATIENT LIVES ALONE.
	
	WE DON'T REALLY KNOW
	WHAT'S HAPPENING,
	
	AND OFTEN IT IS WITHIN SLEEP.
	
	SO THERE IS A GROUP
	OF PEOPLE NOW,
	
	AND THERE HAVE BEEN
	[INDISTINCT] REPORTED CASES
	
	IN VIDEO-EEG
	MONITORING [INDISTINCT]
	
	WHERE SOMEONE'S
	UNFORTUNATELY DIED,
	
	AND THEY'VE BASICALLY BEEN
	IN A PRONE POSITION,
	
	AND [INDISTINCT]
	THEIR RESPIRATION
	
	IS NOT GOOD AT THE END
	OF THEIR SEIZURE
	
	AND THEY DON'T GET ENOUGH
	RESPIRATORY DRIVE
	
	AND THEY END UP SUFFOCATING.
	
	THEY DON'T MOVE THEIR HEAD
	[INDISTINCT]
	
	THAT'S ONE THOUGHT.
	THE OTHER THOUGHT IS,
	
	YOU KNOW, WHETHER
	THERE ARE PATIENTS
	
	WHO CLEARLY HAVE
	[INDISTINCT] SO...
	
	- YEAH.
	- BUT IT IS A CONCERN
	IN THIS GUY,
	
	AND YOU KNOW,
	I COULD SHOW THE VIDEO,
	
	BUT IT IS--
	GENERALIZED CONVULSION
	
	IS VERY SCARY,
	AND LUCKILY, HE WAS,
	
	YOU KNOW, SPEAKING IN
	A [INDISTINCT] POSITION,
	
	BECAUSE HE REALLY CHANGES COLOR
	
	AND HE REALLY DOES GET
	HYPOXIC DURING HIS SEIZURE.
	
	- YEAH.
	- SO IT'S A WHOLE AREA OF STUDY
	
	THAT IS REALLY
	BECOMING IMPORTANT,
	
	AND SOME PEOPLE FEEL THAT
	THERE MAY BE A DECREASE
	
	IN RESPIRATORY DRIVE,
	AND THAT MAY BE
	
	PARTLY MEDIATED BY
	THE RESPIRATORY CENTERS
	
	THAT ARE LARGELY DRIVEN BY
	SEROTONIN, INTERESTINGLY,
	
	AND I BELIEVE THERE IS A TRIAL
	ONGOING OR TALK OF A TRIAL
	
	TO USE SSRI AS SEROTONIN
	UPTAKE INHIBITORS
	
	IN PATIENTS TO PREVENT THAT.
	
	- OH. OK.
	
	YEAH, BECAUSE I THOUGHT MAYBE
	THAT THE SEIZURES
	
	DIDN'T TOUCH THE RESPIRATORY
	CENTERS, BUT THEY DO THEN, HUH?
	
	- YEAH, THEY CAN,
	AND THERE WAS A RECENT ARTICLE
	
	IN "ANNALS OF NEUROLOGY"
	THAT ARGUED THAT WAY.
	
	THERE WAS ALSO A CASE REPORT
	OUT OF THE UNIVERSITY OF CHICAGO
	
	ON EPILEPSY WHERE THEY
	DISCUSSED A PATIENT
	
	WHO, UNFORTUNATELY,
	DIED IN THE HOSPITAL
	
	DURING VIDEO-EEG MONITORING.
	
	WAS NOT ATTENDED TO IN
	A CLOSE ENOUGH FASHION
	
	AND ENDED UP SUFFOCATING
	IN A PILLOW.
	
	- YEAH, BECAUSE I WAS
	WONDERING ON THE FLOOR--
	
	I WORK ON A TELEMETRY UNIT, BUT
	WE DO GET SEIZURE PATIENTS--
	
	IS WHAT WOULD BE YOUR SUGGESTION
	AS TO THE SAFETY?
	
	WHAT SHOULD WE BE--I MEAN,
	WE HAVE THE SEIZURE PADS
	AND EVERYTHING, BUT--
	
	- WELL, THE MAIN THING IS
	IS TO GET IN THERE
	
	AND TURN SOMEBODY OVER
	ON THEIR SIDE
	
	AND MAKE SURE
	THEIR AIRWAY'S OPEN.
	
	NOT STICK SOMETHING
	IN THERE, NECESSARILY,
	
	BUT CLEAR ANY SECRETIONS,
	
	BUT ALSO JUST
	GETTING THEM SO THAT
	
	THEY ARE ABLE TO MAINTAIN
	THEIR AIRWAY.
	
	THE CURRENT THEORY IS THAT
	FOLLOWING A SEIZURE,
	
	THERE MAY JUST BE ENOUGH
	RESPIRATORY DRIVE SUPPRESSION
	
	IN CERTAIN INDIVIDUALS
	
	THAT THEY DON'T--IF WE WERE
	TO FALL ASLEEP
	
	AND OBSTRUCT OUR AIRWAY
	IN A PILLOW,
	
	WE WOULD THEN--
	OUR RESPIRATORY CENTERS
	
	WOULD OVERCOME THAT
	AND WE'D TURN OVER
	
	AND START BREATHING AGAIN.
	
	BUT THAT DOESN'T SEEM TO WORK
	AS WELL IN A [INDISTINCT]
	
	SO IT'S A SCARY THING,
	AND IT'S--
	
	[INDISTINCT] ANOTHER TALK,
	[INDISTINCT] LARGE DISCUSSION,
	
	OR BIG DISCUSSION ON HOW
	YOU SHOULD TELL PATIENTS
	ABOUT THIS,
	
	AND THERE IS A FEELING THAT
	PATIENTS SHOULD BE,
	
	CERTAINLY HIGH-RISK PATIENTS,
	
	THE POSSIBILITY SHOULD
	BE DISCUSSED WITH THEM,
	
	AND AT THE SAME TIME,
	YOU ALMOST NEED TO HAVE
	
	APPROPRIATE COUNSELING IF YOU'RE
	GONNA TELL SOMEBODY THAT.
	
	- YEAH. WHAT WE DO IS
	THE SEIZURE PILLOWS,
	
	WHICH DO KIND OF PREVENT THEM
	
	FROM TURNING OVER ON THEIR
	PRONE, SO THAT WORKS.
	
	- YEAH. GOOD.
	
	- THANK YOU.
	- SURE.
	
	ANY OTHER QUESTIONS?
	
	- I HAVE ONE.
	THIS IS KIRSTEN
	OUT OF LITTLE ROCK.
	
	I WAS JUST WONDERING IF YOU KNEW
	
	APPROXIMATELY THE SIZE
	OF THAT ARACHNOID CYST.
	
	- THE SIZE OF THAT
	ARACHNOID CYST?
	
	- UH-HUH.
	
	- HOO BOY.
	I'D HAVE TO GO MEASURE.
	
	IT LOOKS TO ME
	LIKE IT PROBABLY IS--
	
	IT'S PROBABLY AT LEAST TWO TO 3
	CENTIMETERS IN DIAMETER,
	
	MAYBE A LITTLE BIGGER.
	
	- OK...
	- IT ALMOST LOOKS LIKE IT'S A--
	
	YOU KNOW, WHAT WE WOULD SEE
	FOLLOWING A TEMPORAL LOBECTOMY.
	
	AND WE'VE HAD ONE PATIENT HERE
	
	WHO UNDERWENT
	A TEMPORAL LOBECTOMY
	
	AND DEVELOPED AN ARACHNOID CYST
	FOLLOWING THE RESECTION,
	
	AND HAD A SECOND PROCEDURE DONE
	TO FENESTRATE IT,
	
	AND--BECAUSE THEIR
	SEIZURES CAME BACK,
	
	AND THAT STOPPED THEIR
	SEIZURES AGAIN,
	
	SO IT MAY BE SOMETHING TO DO,
	
	BUT THAT'S--THEY'RE RATHER
	UNUSUAL AND RARE,
	
	AND THERE ARE NOT MANY REPORTS
	OF ARACHNOID
	CYST-INDUCED SEIZURES
	
	CLEARLY BEING CURED, IF YOU
	WILL, JUST BY FENESTRATION.
	
	- OK. THANK YOU.
	- SURE.
	
	ANY OTHER QUESTIONS?
	
	- HI. THIS IS
	TIM FREDERICK FROM ST. LOUIS.
	
	- SURE.
	- PAUL, HOW YOU BEEN?
	
	- GOOD. HOW ARE YOU?
	- GREAT. GREAT.
	
	- DOING FINE.
	- GOOD.
	
	- A SIMPLE QUESTION FOR YOU.
	
	WE HAVE SOMEBODY
	DOWN HERE IN ST. LOUIS
	
	TO BE MONITORING.
	
	WOULD THEY COME UP YOUR WAY OR--
	
	- [INDISTINCT] BUT THEY COULD GO
	WHEREVER YOU WANT TO REFER TO,
	
	BUT WE WOULD BE HAPPY TO--
	
	WE'VE MONITORED PATIENTS
	FROM ST. LOUIS.
	
	- OK.
	- ON THE--AND THIS
	IS SOMETHING--
	
	I DON'T KNOW IF RYAN'S
	ON THE CALL, BUT I'LL
	MENTION IT ANYHOW.
	
	HE'S OUR NATIONAL DIRECTOR.
	
	BUT WE DO HAVE--AND I DON'T KNOW
	
	WHETHER WE HAVE IT
	SET UP IN ST. LOUIS--
	
	A CONSOLE THAT'S AVAILABLE
	THROUGH CPRS
	
	AT A NUMBER OF HOSPITALS.
	
	AND AT ANY RATE, IF YOU TALK
	TO OUR CONTACT PERSON
	
	THAT'S LISTED ON THE WEB SITE,
	
	SHE CAN TELL YOU THE BEST WAY
	TO REFER A PATIENT.
	
	AND THAT'S LIKEWISE
	FOR ALL THE CENTERS.
	
	ON THE WEB SITE, THERE ARE
	CONTACTS--PERSONNEL
	
	THAT YOU--IF YOU WANTED TO REFER
	SOMEONE TO, YOU COULD DO SO.
	
	- MM-HMM.
	- MM-HMM.
	
	- WE GENERALLY HAVE
	A SLIGHT REVIEW.
	
	WE HAVE A FEW THINGS WE WANT
	BEFORE SOMEONE COMES.
	
	WE WANT TO KNOW WHAT
	YOU'RE REALLY LOOKING FOR
	
	AND WHY YOU WANT
	TO DO THIS MONITORING.
	
	WE ALSO ASK THAT
	YOU GET AN MRI SCAN,
	
	BECAUSE ANYBODY WITH
	REFRACTORY EPILEPSY,
	
	OR IF YOU'RE NOT SURE
	OF THE DIAGNOSIS,
	
	YOU BETTER KNOW WHAT SORT OF
	STRUCTURAL BRAIN ABNORMALITIES
	
	THERE MAY OR MAY NOT BE.
	
	SO WE USUALLY REQUIRE
	THOSE TWO THINGS.
	
	AND THEN SORT OF GO FROM THERE.
	
	- MM-HMM.
	- [INDISTINCT]
	
	- PAUL, JUST TO CLARIFY,
	YOU MENTIONED ON THE WEB SITE,
	
	YOU'RE TALKING ABOUT THE CENTERS
	OF EXCELLENCY WEB SITE
	
	OR YOUR SITE THERE IN MADISON?
	
	- NO, IT'S ALL--SO THERE'S--
	ACTUALLY, IT IS
	
	ON ONE OF THESE SLIDES.
	
	RIGHT AT THE BEGINNING,
	THERE IS A WEB SITE
	
	THAT LISTS ALL THE EPILEPSY
	CENTERS OF EXCELLENCE
	
	[INDISTINCT] THE VA.
	
	IT IS ON THE...NINTH SLIDE,
	
	SO IT IS WWW.EPILEPSY.VA.GOV/
	ECOE.ASP.
	
	- MM-HMM.
	- AND ACTUALLY, I THINK--
	
	THIS INTERNET STUFF'S
	REALLY SORT OF AMAZING.
	
	I KNOW THAT--
	I'M USING A PDF FILE.
	
	WHEN I CLICK ON IT,
	IT TAKES ME RIGHT THERE.
	
	SO WHEN YOU DO THAT,
	AND I JUST DID IT,
	
	THERE'S A REGIONAL MAP,
	AND THEN IT HAS ALL THE SITES.
	
	IT HAS A LIST OF HOSPITALS
	AND A PHONE CONTACT.
	
	- MM-HMM.
	
	- THEORETICALLY, MISSOURI
	IS IN THE BLUE,
	
	WHICH IS THE SOUTHWEST, BUT
	
	PRACTICALLY, THIS IS ONE OF THE
	PROBLEMS WITH THIS ORGANIZATION,
	
	THIS PARTICULAR THING,
	SO REALLY,
	
	WE DON'T RESTRICT REFERRALS
	TO ONE CENTER OR ANOTHER.
	
	SO IF YOU LOOK
	WHEN YOU CLICK ON IT,
	
	THERE'S THIS MAP WITH ALL OF
	THE STATES IN DIFFERENT COLORS.
	
	AND THE GREEN STATES
	ARE THE NORTHWEST.
	
	MISSOURI IS A BLUE STATE.
	THIS SOUNDS LIKE
	A POLITICAL THING,
	
	BUT REALLY, WHATEVER
	IS THE CLOSEST
	
	AND OBVIOUSLY ST. LOUIS
	IS A LOT CLOSER TO US
	
	THAN, LET'S SAY, TO HOUSTON
	OR, YOU KNOW...
	
	- RIGHT. AND CERTAINLY
	CULTURALLY, IT'S A LOT CLOSER.
	
	- YEAH, AND SO THAT'S
	ANOTHER THING THAT COMES UP.
	
	SO THE DIVISIONS OF THIS
	WERE MORE TO JUST CREATE
	AN ORGANIZATION,
	
	AND SO WHAT WE'VE DONE,
	AND WHAT MOST OF
	THE PLACES HAVE DONE,
	
	IS THERE ARE SORT OF HISTORICAL
	THINGS THAT HAVE DEVELOPED
	
	IN TERMS OF REFERRAL PATTERNS.
	
	SO FOR INSTANCE, WE GET PATIENTS
	FROM KANSAS CITY ALL THE TIME.
	
	- MM-HMM.
	- AND IT'S JUST
	SORT OF HISTORICAL.
	
	- SURE, SURE, OK.
	- SO WE WON'T BE
	STEPPING ON TOES.
	
	- NO STEPPING ON TOES.
	AND I--YOU KNOW,
	
	I THINK THE POINT IS, IS THAT
	THERE ARE PLACES
	
	WHO ARE WILLING TO DO THIS WORK,
	AND IT'S BUILT INTO THE SYSTEM,
	
	AND IT IS COMMISSIONED, SO--
	
	- GOOD. GOOD.
	ALL RIGHTY. WELL.
	
	VERY NICE PRESENTATION.
	GLAD I TUNED IN WITH YOU.
	
	- GREAT. [INDISTINCT] YOU.
	
	- THANK YOU.
	
	- ANYBODY ELSE?
	
	YEAH, RYAN, IF YOU'RE
	ON THE PHONE,
	
	I WAS JUST GONNA MENTION,
	WE PROBABLY SHOULD GET
	
	A CONSULT DIRECTION FOR
	REFERRALS ON THIS WEB PAGE,
	
	BUT [INDISTINCT] BUT ANYHOW.
	
	ANYTHING ELSE?
	
	WELL, I'M GONNA TAKE OFF
	BECAUSE SOMEONE'S PAGING ME.
	
	- ALL RIGHT.
	WE'LL END THE CALL.
	
	I WANT TO THANK EVERYBODY
	FOR JOINING US TODAY.
	
	- GREAT. THANK YOU TO YOU AGAIN.
	THANKS, PAUL.
	
	- THANK YOU.