EPILEPSY Neuroscience Nursing Orientation Johns Hopkins Epilepsy Center Rebecca E. Fisher RN BSN CNRN Alison Griffiths RN ASN

EPILEPSYEPILEPSY

Neuroscience Nursing OrientationNeuroscience Nursing OrientationJohns Hopkins Epilepsy CenterJohns Hopkins Epilepsy Center

Rebecca E. Fisher RN BSN CNRNRebecca E. Fisher RN BSN CNRNAlison Griffiths RN ASNAlison Griffiths RN ASN

Seizure Disorder DefinitionSeizure Disorder Definition

• SeizureSeizure– A transient disturbance in cerebral A transient disturbance in cerebral

function due to paroxysmal neuronal function due to paroxysmal neuronal dischargesdischarges

– Irritation and excitabilityIrritation and excitability

• EpilepsyEpilepsy– Occurrence of two or more seizuresOccurrence of two or more seizures

PrevalencePrevalence

• Single SeizureSingle Seizure– 10% of the US population10% of the US population

• EpilepsyEpilepsy– 1-2% of the US population by the age of 1-2% of the US population by the age of

20. It reaches 3% by the age of 7520. It reaches 3% by the age of 75– 5 to 8 in 1000, of approximately 1.25 to 5 to 8 in 1000, of approximately 1.25 to

2 million people2 million people

IncidenceIncidence

• Third most common neurological Third most common neurological disorderdisorder– 80% will respond well to treatment80% will respond well to treatment

• Intractable seizures 20-25%Intractable seizures 20-25%

• Febrile seizures in children 2-5%Febrile seizures in children 2-5%

• Close relatives of epilepsy patients Close relatives of epilepsy patients have a threefold increase in incidence.have a threefold increase in incidence.– 5-10% inherited5-10% inherited

EtiologyEtiology

• Primary (idiopathic)Primary (idiopathic)– 50% of all epilepsy50% of all epilepsy

• Secondary (organic)Secondary (organic)– Birth traumaBirth trauma– Head traumaHead trauma– TumorsTumors– InfectionsInfections– BiochemicalBiochemical– CVACVA– Degenerative Degenerative

DiseasesDiseases

TermsTerms

• IctalIctal– The time during a seizureThe time during a seizure

• Post IctalPost Ictal– The time following a seizureThe time following a seizure

• InterictalInterictal– The time between seizuresThe time between seizures

International Classifications of International Classifications of SeizuresSeizures

• Primary Generalized EpilepsyPrimary Generalized Epilepsy– Involves both hemispheres at the start Involves both hemispheres at the start

of the seizure (usually starts deep within of the seizure (usually starts deep within the brain)the brain)

• Partial EpilepsyPartial Epilepsy– Involves a focal area of the brain that Involves a focal area of the brain that

may or may not spreadmay or may not spread

Primary Generalized Primary Generalized SeizuresSeizures• Absence- brief staring spells (3-5 secs)Absence- brief staring spells (3-5 secs)

• Myoclonic- abrupt brief jerking of limbsMyoclonic- abrupt brief jerking of limbs

• Clonic- muscle contraction and Clonic- muscle contraction and relaxingrelaxing

• Tonic- stiffening, extension of limbsTonic- stiffening, extension of limbs

• Atonic- “drop attacks”Atonic- “drop attacks”

Partial EpilepsyPartial Epilepsy

• Simple (consciousness is not impaired)Simple (consciousness is not impaired)– Motor- abnormal movement of arm, leg, hand, Motor- abnormal movement of arm, leg, hand,

and faceand face– Somatosensory or special sensory- epigastric Somatosensory or special sensory- epigastric

feeling, visual symptoms, smell, and auditoryfeeling, visual symptoms, smell, and auditory– Numbness or tingling in limbNumbness or tingling in limb– Autonomic- tachycardia, flushing, and Autonomic- tachycardia, flushing, and

respirationrespiration– Psychic- déjà vu, and fearPsychic- déjà vu, and fear– Aura is a simple partial seizureAura is a simple partial seizure

Partial EpilepsyPartial Epilepsy

• Complex (consciousness is impaired)Complex (consciousness is impaired)– Most common in adult epilepsy populationMost common in adult epilepsy population– May or may not start with simple partial May or may not start with simple partial – May see staring lasting seconds to minutesMay see staring lasting seconds to minutes– May see semipurposeful repetitive May see semipurposeful repetitive

movements (i.e. fumbling, lip smacking, movements (i.e. fumbling, lip smacking, swallowing, vocalizations, and wandering)swallowing, vocalizations, and wandering)

Evolving into Secondary Evolving into Secondary Generalized Seizures Generalized Seizures

• May start as simple, or complex May start as simple, or complex seizure, then progress to tonic-clonic seizure, then progress to tonic-clonic movements.movements.

Psychogenic SeizuresPsychogenic Seizures

• Seizures that originate from an Seizures that originate from an emotional disorder rather than emotional disorder rather than paroxysmal neuronal discharges.paroxysmal neuronal discharges.

• EEG will be normalEEG will be normal

• Patients can have a mixture of Patients can have a mixture of Epilepsy and Psychogenic seizure Epilepsy and Psychogenic seizure activity.activity.

Possible clinical signsPossible clinical signs

• Asymmetrical or thrashing of limbs, Asymmetrical or thrashing of limbs, pelvic thrusting, side to side head pelvic thrusting, side to side head movement, gradual onset, multiple movement, gradual onset, multiple manifestations, prolong duration, manifestations, prolong duration, purposeful activity, initiation or purposeful activity, initiation or termination by suggestion, lack of termination by suggestion, lack of amnesia, little postictal period.amnesia, little postictal period.

TreatmentTreatment

• Varies depending on psychiatric Varies depending on psychiatric diagnosisdiagnosis– AntidepressantsAntidepressants– PsychotherapyPsychotherapy– Relaxation techniquesRelaxation techniques

First Aid Generalized First Aid Generalized SeizuresSeizures• Help to lying position with something soft Help to lying position with something soft

under the headunder the head• Position to side if possiblePosition to side if possible• Remove glasses and loosen tight clothingRemove glasses and loosen tight clothing• Clear area of sharp or hard objectsClear area of sharp or hard objects• Do not restrain of force anything in the Do not restrain of force anything in the

mouthmouth• Suction airway only if necessarySuction airway only if necessary• Time event, check vitals and neuro status, Time event, check vitals and neuro status,

examine for injuries, monitor until return to examine for injuries, monitor until return to baselinebaseline

First Aid Complex Partial First Aid Complex Partial SeizuresSeizures

• Stay with patient and ensure safetyStay with patient and ensure safety

• Clear area of sharp and hard objectsClear area of sharp and hard objects

• Do not restrainDo not restrain

• Monitor patient until return to Monitor patient until return to baselinebaseline

Notification of MDNotification of MD

• New onset of seizuresNew onset of seizures

• Change in seizure type and Change in seizure type and frequency or durationfrequency or duration

• Seizure > 5 minutesSeizure > 5 minutes

• Failure to return to baselineFailure to return to baseline

Status EpilepticusStatus Epilepticus

• A seizure that persists for a sufficient A seizure that persists for a sufficient period of time ( 10 minutes) or is period of time ( 10 minutes) or is repeated frequently so that recovery repeated frequently so that recovery between attacks does not occur. between attacks does not occur. Diagnosis for status is at 30 minutes.Diagnosis for status is at 30 minutes.

• Patients in status may appear Patients in status may appear consciousconscious

ComplicationsComplications

• ShockShock

• HypoxiaHypoxia

• ICPICP

• AcidosisAcidosis

• FeverFever

• ArrythmiaArrythmia

• HemorrhageHemorrhage

• Neuronal DeathNeuronal Death

EtiologyEtiology

• Anticonvulsant withdrawalAnticonvulsant withdrawal• Acute metabolic disturbances Acute metabolic disturbances

(hypoglycemia, hyponatremia, (hypoglycemia, hyponatremia, hypocalcemia)hypocalcemia)

• CVACVA• CNS infectionCNS infection• CNS traumaCNS trauma• TumorsTumors

Treatment Treatment

• AnticonvulsantAnticonvulsant– Start with Start with Benzodiazepines Benzodiazepines – Diazepam Diazepam (Valium): 0.25mg/kg up to 20mg IV. (Valium): 0.25mg/kg up to 20mg IV.

Give slowly 1-2mg/minGive slowly 1-2mg/min– **May also give rectally (Diastat-rectal gel)**May also give rectally (Diastat-rectal gel)– Lorazepam Lorazepam (Ativan) 0.05mg/kg up to 10mg IV. (Ativan) 0.05mg/kg up to 10mg IV.

Give slowly 2mg/min (this is the preferred Give slowly 2mg/min (this is the preferred medication because it lasts longer than the medication because it lasts longer than the Valium in the body)Valium in the body)

– Midazolam Midazolam 5-10mg, well absorbed IM5-10mg, well absorbed IM

Long-acting AEDLong-acting AED

• Phenytoin Phenytoin (Dilantin): 18-20mg/kg IV(Dilantin): 18-20mg/kg IV– Do not give faster than 50mg/kgDo not give faster than 50mg/kg– Use only with normal salineUse only with normal saline– Monitor vital signs carefullyMonitor vital signs carefully– Avoid IV infiltration (purple glove Avoid IV infiltration (purple glove

syndrome)syndrome)– Different institutions have different Different institutions have different

guidelines concerning the administration guidelines concerning the administration of this drugof this drug

Follow up with Follow up with long-acting long-acting AEDsAEDs

• Fosphenytoin Fosphenytoin (Cerebyx): prodrug of (Cerebyx): prodrug of phenytoinphenytoin– Water soluble (does not contain propylene Water soluble (does not contain propylene

glycol) fewer IV site and cardiac complicationsglycol) fewer IV site and cardiac complications– Dispensed in phenytoin equivalents (1 PE of Dispensed in phenytoin equivalents (1 PE of

fosphenytoin=1 mg of Dilantin) fosphenytoin=1 mg of Dilantin) – Loading dose 18-20 PE/kgLoading dose 18-20 PE/kg– Max rate is 150 PE/min IV with cardiac and BP Max rate is 150 PE/min IV with cardiac and BP

monitoringmonitoring– May be given IM (large volumes i.e. 20ccs split May be given IM (large volumes i.e. 20ccs split

in two IM sites) in two IM sites)


• Fosphenytoin continuedFosphenytoin continued– Side effects- same as phenytoin Side effects- same as phenytoin

(hypotension, cardiac arrthymias, rash, (hypotension, cardiac arrthymias, rash, dizziness, and itching groin)dizziness, and itching groin)

– Each institution has specific guidelines Each institution has specific guidelines concerning administration of this drugconcerning administration of this drug


• Phenobarbital:Phenobarbital: 10-20mg/kg 10-20mg/kg– Do not give faster than 50-100mg/min.Do not give faster than 50-100mg/min.– Caution following BZD (increase risk of Caution following BZD (increase risk of

respiratory depression and hypotension)respiratory depression and hypotension)

Depacon (Valproate Sodium Depacon (Valproate Sodium Injection)Injection)• For use in Myoclonic Status and when For use in Myoclonic Status and when

unable to take po Valproic Acidunable to take po Valproic Acid• Dispensed in Valproic Acid equalents Dispensed in Valproic Acid equalents

(500mg po = 500mg IV)(500mg po = 500mg IV)• Administer over 60 minutesAdminister over 60 minutes• In 50ccs (Normal Saline, LR, or D5W)In 50ccs (Normal Saline, LR, or D5W)• No more than 20mg/minuteNo more than 20mg/minute• Give the same frequency as poGive the same frequency as po• Some institutions has a policy and Some institutions has a policy and

procedure concerning administration procedure concerning administration

Side effects of DepaconSide effects of Depacon

• Not like po-wt gain and hair lossNot like po-wt gain and hair loss

• SomnolenceSomnolence

• DizzinessDizziness

• ParesthesiaParesthesia

• NauseaNausea

• H/AH/A

• Pain at injection sitePain at injection site

Other TreatmentsOther Treatments

• Petobarbital coma, Petobarbital coma, propofolpropofol

• Supportive CareSupportive Care– AirwayAirway– ProtectionProtection– Lab tests (CBC, BMP, Lab tests (CBC, BMP,

ABGs, AED levels)ABGs, AED levels)– FluidsFluids– VS, EKGVS, EKG– Drug TherapyDrug Therapy– Investigate CauseInvestigate Cause

Other optionsOther options

• KeppraKeppra– IV option coming in the near futureIV option coming in the near future

Diagnostic StudiesDiagnostic Studies

• HistoryHistory• Physical ExamPhysical Exam• Blood workBlood work• Epilepsy Protocol MRI-Epilepsy Protocol MRI-

structural changesstructural changes• 3Tesla MRI3Tesla MRI• fMRI- language functionfMRI- language function• CTCT• Epilepsy monitoring Epilepsy monitoring

unitunit• EEG (don’t seizure on EEG (don’t seizure on

demand)demand)

• PET-metabolism changesPET-metabolism changes• WADA-side of language WADA-side of language

and memory dominanceand memory dominance• Neuropsych/Cognitive Neuropsych/Cognitive

functioning testingfunctioning testing• MRS-biochemicalMRS-biochemical• SPECT-perfusion SPECT-perfusion

changes changes • MEG-localization of MEG-localization of

interictal epileptiform interictal epileptiform activity with focal activity with focal seizures used with MRI seizures used with MRI and EEGand EEG

TreatmentTreatment

• Anticonvulsant TherapyAnticonvulsant Therapy

• Ketogenic Diet/Atkins DietKetogenic Diet/Atkins Diet

• Vagus Nerve StimulatorVagus Nerve Stimulator

• SurgerySurgery

Potential Efficacy of AEDsPotential Efficacy of AEDs

• CarbamazepineCarbamazepine– Simple ComplexSimple Complex– Complex PartialComplex Partial– Tonic ClonicTonic Clonic

• PhenytoinPhenytoin– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic ClonicTonic Clonic

Potential Efficacy continuedPotential Efficacy continued

• ValproateValproate– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic– AtonicAtonic– MyoclonicMyoclonic– Atypical AbsenceAtypical Absence– Absence Absence


• GabapentinGabapentin– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic

• LamotrigineLamotrigine– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic– AtonicAtonic– MyoclonicMyoclonic– Absence and atypica absenceAbsence and atypica absence


• TopiramateTopiramate– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic– Lennox-GastautLennox-Gastaut– Infantile SpasmsInfantile Spasms– Primary generalizedPrimary generalized

Potential Efficacy ContinuedPotential Efficacy Continued

• TiagabineTiagabine– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic– Infantile SpasmsInfantile Spasms

• LevetiracetamLevetiracetam– Simple PartialSimple Partial– Complex Partial Complex Partial – Tonic-ClonicTonic-Clonic– AbsenceAbsence– MyoclonicMyoclonic


• OxcarbazepineOxcarbazepine– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic

• ZonisamideZonisamide– Simple PartialSimple Partial– Complex PartialComplex Partial– Tonic-ClonicTonic-Clonic– AbsenceAbsence– Infantile spasmsInfantile spasms– MyoclonicMyoclonic


• PregablinPregablin

- Simple partial- Simple partial

- Complex partial- Complex partial

DilantinDilantin

• Capsules 100mg, 30mg Capsules 100mg, 30mg Brand nameBrand name

• Dosing 200-500mgDosing 200-500mg

• Half life 22 hoursHalf life 22 hours

• Blood levels 10-20 (if Blood levels 10-20 (if no side effects MDs no side effects MDs may push the top level)may push the top level)

• High incidence of drug High incidence of drug interaction with all interaction with all other medicationsother medications

• Side effectsSide effects– AtaxiaAtaxia– RashRash– Blood changesBlood changes– OsteomalaciaOsteomalacia– Cosmetic changesCosmetic changes– Dental changesDental changes

Tegretol, Tegretol XR, & Tegretol, Tegretol XR, & CarbatrolCarbatrol

• Tabs 100mg, Tabs 100mg, 200mg, 300mg 200mg, 300mg (Carbatrol), & (Carbatrol), & 400mg (Tegretol XR)400mg (Tegretol XR)

• Dose 400-2000mgDose 400-2000mg

• Half life 10-25 hrsHalf life 10-25 hrs

• Levels 4-12Levels 4-12

• XR & Cabatrol BID XR & Cabatrol BID dosingdosing

• Side effectsSide effects– Weight gainWeight gain– GI upsetGI upset– AtaxiaAtaxia– Blurred visionBlurred vision– Decreased WBCDecreased WBC– HyponatremiaHyponatremia– HepatotoxicityHepatotoxicity

Depakene, Depakote, Depakene, Depakote, &Depakote ER&Depakote ER• Caps 125mg,250mg, Caps 125mg,250mg,

500mg500mg• Dose 500-4000mgDose 500-4000mg• Half life 8-12 hrsHalf life 8-12 hrs• Blood levels 50-150Blood levels 50-150• May be used for May be used for

migraine managementmigraine management• Interacts with LamictalInteracts with Lamictal• First line drug for First line drug for

myoclonic seizures myoclonic seizures (IV)(IV)

• Side effectsSide effects– Weight gainWeight gain– TremorsTremors– Uterine changesUterine changes– SedationSedation– Disturb mensesDisturb menses– Hair lossHair loss– H/AH/A– DizzinessDizziness– Increase ammonia Increase ammonia

levelslevels

PhenobarbitalPhenobarbital

• Tabs 15mg, 30mg, Tabs 15mg, 30mg, 60mg, & 100mg60mg, & 100mg

• Dosing 30mg or Dosing 30mg or 100mg100mg

• Half life 72 hrsHalf life 72 hrs

• Blood levels 15-40Blood levels 15-40

• Side effectsSide effects– SedationSedation– HyperactivityHyperactivity– ConfusionConfusion– Mood changesMood changes

Mysoline (Metabolizes to Mysoline (Metabolizes to Primidone & Phenobarbital)Primidone & Phenobarbital)

• Tabs 250mgTabs 250mg

• Dose 500-1500mgDose 500-1500mg

• Half life PRM 3-Half life PRM 3-12hrs12hrs– PBB 72 hrsPBB 72 hrs

• Levels PRM 6-12Levels PRM 6-12– PBB 15-40PBB 15-40

• Side effectsSide effects– SedationSedation– HyperactivityHyperactivity– Mood changesMood changes

NeurontinNeurontin

• Caps 100mg, 300mg, Caps 100mg, 300mg, & 400mg, Tabs 600mg & 400mg, Tabs 600mg & 800mg& 800mg

• Dose 3600mg (no Dose 3600mg (no research telling how research telling how high to go) high to go)

• Dosing TID or QIDDosing TID or QID• Half life 5-8 hrsHalf life 5-8 hrs• Blood levels-not doneBlood levels-not done• Use in management of Use in management of

migrainesmigraines

• Side effectsSide effects– SedationSedation– AtaxiaAtaxia– DizzinessDizziness

LyricaLyrica

• Capsules 25mg, 50mg, Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg200mg, 225mg, 300mg

• Newest drugNewest drug• Dosage for Epilepsy Dosage for Epilepsy

300-600mg/day300-600mg/day• Dosing BIDDosing BID• Half LifeHalf Life• No blood levelsNo blood levels• Medication is also used Medication is also used

for pain managementfor pain management

• Side effectsSide effects -Double vision-Double vision -Ataxia-Ataxia -Edema-Edema -Weight gain-Weight gain - Dry mouth- Dry mouth - Trouble - Trouble

concentratingconcentrating

BenzodiazepinesBenzodiazepines

• ValiumValium

• AtivanAtivan

• TranxeneTranxene

• KlonopinKlonopin

• Side effectsSide effects– DrowsinessDrowsiness– FatigueFatigue– AtaxiaAtaxia– Slurred speechSlurred speech– DiplopiaDiplopia

LamictalLamictal


• Dosage 300-500mgDosage 300-500mg– If miss a dose may If miss a dose may

double up on next dosedouble up on next dose• Half life 14-103 hrsHalf life 14-103 hrs• Blood levels 4-20Blood levels 4-20• Depakote increases Depakote increases

LamictalLamictal• Needs to be adjusted if Needs to be adjusted if

birth control is addedbirth control is added• May make JME worseMay make JME worse

• Side effectSide effect– Rash (slow titration Rash (slow titration

stops this)stops this)– DepressionDepression– DizzinessDizziness– SomnolenceSomnolence– H/AH/A– Blurred visionBlurred vision– Nausea/vomitingNausea/vomiting

TopamaxTopamax


• Half life 21 hrsHalf life 21 hrs

• Dose 200-400mgDose 200-400mg

• May increase May increase DilantinDilantin

• May decrease May decrease Carbatrol, Carbatrol, Phenobarb, i.e.Phenobarb, i.e.

• Side effectsSide effects– Memory problemsMemory problems– Word finding Word finding

difficulties difficulties – Kidney stonesKidney stones– DizzinessDizziness– AtaxiaAtaxia– SomnolenceSomnolence

TrileptalTrileptal

• Tabs 150mg, 300mg, & Tabs 150mg, 300mg, & 600mg600mg

• Dose 900-2400mgDose 900-2400mg

• Dosage BIDDosage BID

• Developed to improve Developed to improve on Tegretol’s side on Tegretol’s side effects effects

• If Allergic to Tegretol If Allergic to Tegretol 20% chance to become 20% chance to become allergic to Trileptalallergic to Trileptal

• Side effectsSide effects– SomnolenceSomnolence– H/AH/A– DizzinessDizziness– Rash Rash – Weight gainWeight gain– AlopeciaAlopecia– NauseaNausea– HyponatremiaHyponatremia

KeppraKeppra

• Tabs 250mg, Tabs 250mg, 500mg, & 750mg500mg, & 750mg

• Dose 500-4000mgDose 500-4000mg• Dosing BIDDosing BID• Blood levels are Blood levels are

drawn but results drawn but results depend on the pt a depend on the pt a “good” level can “good” level can be from 20s-30sbe from 20s-30s

• Side effectsSide effects– Mood changes (use Mood changes (use

of vitamin B6)of vitamin B6)– Lose of appetiteLose of appetite– Weight loseWeight lose– DiarrheaDiarrhea

ZonegranZonegran

• Caps 25mg, 50mg, Caps 25mg, 50mg, & 100mg& 100mg

• Dose 200-400mg Dose 200-400mg and can be pushed and can be pushed higherhigher

• Dosing BID or DailyDosing BID or Daily• Levels 10-30Levels 10-30

• Side effectsSide effects– This is a This is a SulfaSulfa drug drug – Kidney stonesKidney stones– DrowsinessDrowsiness– Loss of appetiteLoss of appetite– GI disturbanceGI disturbance– ManiaMania– DepressionDepression– DizzinessDizziness– IrritabilityIrritability

Ketogenic DietKetogenic Diet

• High fat, low carbohydrate, limited protein High fat, low carbohydrate, limited protein dietdiet

• Simulates metabolism of a fasting state Simulates metabolism of a fasting state (ketosis)(ketosis)

• Ketosis has an anticonvulsant effectKetosis has an anticonvulsant effect

• Used in young children here at Johns Used in young children here at Johns Hopkins Epilepsy CenterHopkins Epilepsy Center

• Currently Thomas Jefferson has a program Currently Thomas Jefferson has a program for adults for adults

Nursing issuesNursing issues

• Avoid medication preparations Avoid medication preparations containing sugarcontaining sugar

• Need daily sugarless multivitamin Need daily sugarless multivitamin with iron and calciumwith iron and calcium

• Monitor urine ketonesMonitor urine ketones

• Give only allotted noncaloric liquids Give only allotted noncaloric liquids (may have diet decaffeinated soda) (may have diet decaffeinated soda)

Vagus Nerve StimulatorVagus Nerve Stimulator

• Stimulation wires placed around left vagus nerve Stimulation wires placed around left vagus nerve in the neck.in the neck.

• Subclavicular placement of transformerSubclavicular placement of transformer• Nerve stimulus is typically on for 30 seconds and Nerve stimulus is typically on for 30 seconds and

off for 5 minutes in cycles (like a buzz)off for 5 minutes in cycles (like a buzz)• Need to evaluate over 6 months Need to evaluate over 6 months • Often palliative treatment (add on to current Often palliative treatment (add on to current

medications)medications)• Magnet swiped over the transformer will cause Magnet swiped over the transformer will cause

the buzz to occur longer in order to stop the the buzz to occur longer in order to stop the seizure. seizure.

VNS continuedVNS continued

• Magnet held over the transformer will turn Magnet held over the transformer will turn off the VNS. Once the magnet is removed off the VNS. Once the magnet is removed it will turn back on.it will turn back on.

• We in the Epilepsy Center can turn the We in the Epilepsy Center can turn the generator completely off.generator completely off.

• Status may result from turning off the VNSStatus may result from turning off the VNS• May be around microwaves and cell May be around microwaves and cell

phones, etc.phones, etc.• Cannot be around MRI unless the VNS is Cannot be around MRI unless the VNS is

turned off.turned off.

Epilepsy MonitoringEpilepsy Monitoring

• Performed at large teaching Performed at large teaching hospitalshospitals

• Most Epilepsy patients respond Most Epilepsy patients respond well to medicationwell to medication

• Monitoring and visits to Epilepsy Monitoring and visits to Epilepsy Centers is usually reserved for Centers is usually reserved for those pts whose seizures are those pts whose seizures are unresponsive to medicationunresponsive to medication

Epilepsy MonitoringEpilepsy Monitoring

• Admission for 2-7 days to a special unitAdmission for 2-7 days to a special unit

• Epilepsy medications are reduced before Epilepsy medications are reduced before and during admission (if seizures are and during admission (if seizures are infrequent) infrequent)

• Clinical events (seizures) are recorded and Clinical events (seizures) are recorded and EEG is reviewed and evaluatedEEG is reviewed and evaluated

• Type of Epilepsy is diagnosed and seizure Type of Epilepsy is diagnosed and seizure onset is lateralized and localized (if onset is lateralized and localized (if possible)possible)

Surgical ManagementSurgical Management

• Depth electrodesDepth electrodes• Epidural ElectrodesEpidural Electrodes• Subdural Electrodes (Grid)Subdural Electrodes (Grid)

– Brain mappingBrain mapping

• LobectomyLobectomy– Temporal most common, extratemporal Temporal most common, extratemporal

resectionresection

• Corpus CallosalCorpus Callosal– Atonic or GTCAtonic or GTC

• HemispherectomyHemispherectomy

Epilepsy SurgeryEpilepsy Surgery

• Some patients may Some patients may need to have need to have depths placed. depths placed.


• If not well localized If not well localized pt may need to pt may need to have bilateral have bilateral strips placed to aid strips placed to aid in localizing and in localizing and lateralizing seizure lateralizing seizure onsetonset


• If pt seizure focus If pt seizure focus is in or near an is in or near an area of high area of high function then a function then a subdural grid may subdural grid may be placed to help be placed to help map area of map area of function and aid in function and aid in surgery designsurgery design

Teaching the family and Teaching the family and patientpatient• About their seizuresAbout their seizures• First AidFirst Aid• Medication and ComplianceMedication and Compliance• Diagnostic tests, blood test, surgeryDiagnostic tests, blood test, surgery• Effects on Depression, Memory, Cognitive FunctionEffects on Depression, Memory, Cognitive Function• Disability and WorkDisability and Work• Emotional SupportEmotional Support• Assist in Problem SolvingAssist in Problem Solving• Their State Driving LawsTheir State Driving Laws• Support Groups for all ages and their familiesSupport Groups for all ages and their families

PregnancyPregnancy

• Counseling should be done prior to conception ageCounseling should be done prior to conception age– Birth defects (increase by 1-2% above general Birth defects (increase by 1-2% above general

population)population)

• Counseling on AEDs and contraceptionCounseling on AEDs and contraception– InteractionsInteractions

• AED changes now prior to conceptionAED changes now prior to conception– Seizure control on AEDs with only dosage changes during Seizure control on AEDs with only dosage changes during

pregnancy pregnancy – AEDs with lowest Birth defect informationAEDs with lowest Birth defect information

• Folic Acid daily (may be a higher dose)Folic Acid daily (may be a higher dose)– Neural tube development Neural tube development

• Planned pregnanciesPlanned pregnancies

Once PregnantOnce Pregnant

• High Risk OBHigh Risk OB• Increased number of clinic visits with Epilepsy Increased number of clinic visits with Epilepsy

DoctorsDoctors• Communication between OB and Epilepsy MDCommunication between OB and Epilepsy MD• TeamworkTeamwork• Monthly blood levels with already predetermined Monthly blood levels with already predetermined

target blood level(s)target blood level(s)• High level of communication with expected High level of communication with expected

mother. (Teaching)mother. (Teaching)• Pregnancy Registries (Harvard, Lamictal and Pregnancy Registries (Harvard, Lamictal and

Keppra Registries)Keppra Registries)

Epilepsy Research at Epilepsy Research at Johns HopkinsJohns Hopkins

NeuropaceNeuropace

Atkins for AdultsAtkins for Adults

Schwarz SP754Schwarz SP754

ProgesteroneProgesterone

Not all patients are Not all patients are surgical candidatessurgical candidates

For these pts with intractable For these pts with intractable Epilepsy current research Epilepsy current research

offers hopeoffers hope

Neuropace Surgical ImplantNeuropace Surgical Implant

• A small generator A small generator is implanted with is implanted with electrodes going to electrodes going to various seizure various seizure foccifocci

NeuropaceNeuropace

Strip or depth leads are placed(1 or 2 leads)

A cranial defect is created for the device

Each lead can send out an electrical signal to stop seizure activity

NeuropaceNeuropace

• Age 18-65 yearsAge 18-65 years

• 4 seizures per month or more4 seizures per month or more

• Able to localize seizure focusAble to localize seizure focus

• 2 or more Epilepsy meds tried2 or more Epilepsy meds tried

• VNS will have to be turned offVNS will have to be turned off

• Live locally (lots of clinical visits)Live locally (lots of clinical visits)

Atkins trial for AdultsAtkins trial for Adults

• Age 18 years or Age 18 years or olderolder

• 2 or more seizures 2 or more seizures per weekper week

• No heart, kidney, No heart, kidney, cholesterol cholesterol problemsproblems

• No major No major psychiatric psychiatric problemsproblems

• Need to visit Need to visit Johns Hopkins 4 Johns Hopkins 4 times in 6 monthstimes in 6 months

• Not have tried Not have tried Ketogenic or Ketogenic or Atkins diets prior Atkins diets prior to this trial to this trial

AtkinsAtkins

• Pts are placed on a carefully planned Pts are placed on a carefully planned Atkins diet and followed for 6 months Atkins diet and followed for 6 months to evaluated whether their seizure to evaluated whether their seizure frequency is reduced.frequency is reduced.

• All labs, clinic visits and dietitian All labs, clinic visits and dietitian expenses are funded by the studyexpenses are funded by the study

Schwarz Schwarz SP754 SP754

• Medication trialMedication trial

Inclusion/ExclusionInclusion/Exclusion

• Inclusion (see Inclusion (see attached)attached)

• Age 16-70 yearsAge 16-70 years

• Partial onset seizures Partial onset seizures and or complex and or complex partial seizures partial seizures

• Must have had partial Must have had partial onset seizures for at onset seizures for at least 2 yearsleast 2 years

• Exclusion (See Exclusion (See attached)attached)

• Hx of drug and or Hx of drug and or alcohol abusealcohol abuse

• Medical or Medical or psychiatric conditionpsychiatric condition

• Primary generalized Primary generalized seizuresseizures

Benefits Schwarz SP754Benefits Schwarz SP754

• Patients are closely followed and Patients are closely followed and evaluatedevaluated

• All lab and clinic visits are fully All lab and clinic visits are fully funded by the studyfunded by the study

• Helping a new medication to be Helping a new medication to be developeddeveloped

Progesterone Therapy for Progesterone Therapy for Women with EpilepsyWomen with Epilepsy

• Study Hypothesis: Adjunctive cyclic Study Hypothesis: Adjunctive cyclic natural progesterone therapy natural progesterone therapy significantly improves the course of significantly improves the course of epilepsy in women.epilepsy in women.

• Women ages 13-45 with intractable Women ages 13-45 with intractable seizures that occur in relation to seizures that occur in relation to changes in reproductive hormone levels changes in reproductive hormone levels (catamenial epilepsy) despite trials of at (catamenial epilepsy) despite trials of at least two AEDs least two AEDs

InclusionInclusion

• Documentation of focal Documentation of focal paraoxysmal EEG paraoxysmal EEG dischargesdischarges

• 2 seizures/month 2 seizures/month during previous 3 during previous 3 monthsmonths

• Stable optimal AEDs Stable optimal AEDs for 2 monthsfor 2 months

• Nl breast exams and Nl breast exams and PAP smears 9 months PAP smears 9 months prior for all over 21prior for all over 21

• Menstrual cycle Menstrual cycle intervals between 23 intervals between 23 and 35 days during 6 and 35 days during 6 month priormonth prior

• Sexually active Sexually active women will use barrier women will use barrier and/or spermicidal and/or spermicidal forms of contraceptionforms of contraception

ExclusionExclusion

• Pregnancy, lactationPregnancy, lactation

• Progressive Progressive Neurological disorderNeurological disorder

• Abnl Liver function testAbnl Liver function test

• Major tranquilizer or Major tranquilizer or reproductive hormones reproductive hormones 3 months prior to study3 months prior to study

• Sensitivity to natural Sensitivity to natural progestroneprogestrone

• Unable to document Unable to document seizures or follow seizures or follow protocolprotocol

• Hx of thromboembolic, Hx of thromboembolic, thrombophlebitis thrombophlebitis disorders, CVAdisorders, CVA

• Malignancy of breast, Malignancy of breast, uterus or ovaryuterus or ovary

• Vaginal bleedingVaginal bleeding

If interested in participating If interested in participating in a study in a study

• Call 410-955-4835Call 410-955-4835

• You will then be referred to the You will then be referred to the appropriate officeappropriate office

Bill of Rights for People Bill of Rights for People Living with EpilepsyLiving with Epilepsy

Sponsored by Novartis Sponsored by Novartis Pharmaceuticals CorporationPharmaceuticals Corporation

The goal of the Bill Of Rights is The goal of the Bill Of Rights is to help you:to help you:• Encourage the patient’s involvement in Encourage the patient’s involvement in

managing many aspects of living with their managing many aspects of living with their epilepsy, including making informed choices epilepsy, including making informed choices and activity participating in decisions about and activity participating in decisions about carecare

• Empower them to ask questions and seek Empower them to ask questions and seek answers from their or their loved one’s answers from their or their loved one’s healthcare teamhealthcare team

• Help them access information and support Help them access information and support resourcesresources

• Encourage them to speak up for their or Encourage them to speak up for their or their loved one’s rights and needstheir loved one’s rights and needs

A first-of-its kind initiative A first-of-its kind initiative

• Designed to educate, empower, and Designed to educate, empower, and increase understanding of epilepsy increase understanding of epilepsy

• A guide to managing life with epilepsy that A guide to managing life with epilepsy that was developed by the community for the was developed by the community for the communitycommunity

• It is not a legal document- these rights are It is not a legal document- these rights are aspirational goals that the epilepsy aspirational goals that the epilepsy community is trying to achievecommunity is trying to achieve

• None of the information should be used as None of the information should be used as medical or legal advicemedical or legal advice

Goals of the Bill of RightsGoals of the Bill of Rights

• Goal #1: Educate and empower the Goal #1: Educate and empower the people affected by epilepsypeople affected by epilepsy

• Goal #2: Increase understanding of Goal #2: Increase understanding of epilepsy among the general publicepilepsy among the general public

Includes guidance on topics, Includes guidance on topics, such as:such as:

• Social aspects of living with epilepsySocial aspects of living with epilepsy

• Communicating with your healthcare Communicating with your healthcare teamteam

• Current information on epilepsy and Current information on epilepsy and treatment optionstreatment options

• Rights at schoolRights at school

• Rights in the workplaceRights in the workplace

Enroll in the SHAREEnroll in the SHARE((SSupport, upport, HHope, ope, AAnd nd RResources esources for for EEpilepsy)pilepsy)• Program to receive Bill of Rights Program to receive Bill of Rights

materials and additional information materials and additional information about living with epilepsy from about living with epilepsy from NovartisNovartis

• Complete and mail your business Complete and mail your business reply cardreply card

• Visit Visit www.EpilepsyBillofRights.comwww.EpilepsyBillofRights.com

• Call toll-free 1-877-6ERIGHTSCall toll-free 1-877-6ERIGHTS

http://www.epilepsybillofrights.com/

ResourcesResources

• Epilepsy Foundation of AmericaEpilepsy Foundation of America

1-800-332-10001-800-332-1000

www.epilepsyfoundation.orgwww.epilepsyfoundation.org

• American Epilepsy SocietyAmerican Epilepsy Society

1-860-586-75051-860-586-7505

www.aesnet.orgwww.aesnet.org

• American Association of Neuroscience NursesAmerican Association of Neuroscience Nurses

www.aann.orgwww.aann.org

http://www.epilepsyfoundation.org/

http://www.aesnet.org/

Resources continuedResources continued

• MedicAlert FoundationMedicAlert Foundation

1-888-633-42981-888-633-4298

www.medicalert.orgwww.medicalert.org

• Food and Drug AdministrationFood and Drug Administration

1-888-INFO-FDA1-888-INFO-FDA

www.fda.govwww.fda.gov

http://www.medicalert.org/

http://www.fda.gov/

Documents

EPILEPSY Neuroscience Nursing Orientation Johns Hopkins Epilepsy Center Rebecca E. Fisher RN BSN CNRN Alison Griffiths RN ASN