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In those patients, we have other types of of treatments. One treatment is diet. In children we often use something called the ketogenic diet where there's a very, very, limited diet with very little carbs. And that has an antiseizure effect. The problem is that in adults, that's a very difficult diet to stick to. Such a limited amount of carbs one, mishap, you know, one muffin or candy bar and the diet is ruined. So, there are other diets though in adults that may be effective. One's called the modified Atkins Diet where it's a limited carb diet, but not as limited as the ketogenic diet. Now the question is, what are the long term ramifications of the modified Atkins died? And we don't know exactly. We know that it causes weight loss and it causes elevation in cholesterol. Kind of the big questions are, does it affect heart disease and stroke risk down the line? The answers, nobody knows that yet.
In those patients, we have other types of of treatments. One treatment is diet. In children we often use something called the ketogenic diet where there's a very, very, limited diet with very little carbs. And that has an antiseizure effect. The problem is that in adults, that's a very difficult diet to stick to. Such a limited amount of carbs one, mishap, you know, one muffin or candy bar and the diet is ruined. So, there are other diets though in adults that may be effective. One's called the modified Atkins Diet where it's a limited carb diet, but not as limited as the ketogenic diet. Now the question is, what are the long term ramifications of the modified Atkins died? And we don't know exactly. We know that it causes weight loss and it causes elevation in cholesterol. Kind of the big questions are, does it affect heart disease and stroke risk down the line? The answers, nobody knows that yet.
And then there are some other types of what we call neuromodulation. These are surgeries to help control seizures but aren't necessarily going to completely stop them, but help control them. And the one that's been around the longest is something called the vagal nerve stimulator. This is a pacemaker device that's implanted under the skin and the pacemaker is, or there's a wire then this run underneath the skin to the neck to a nerve in the neck called the vagus nerve and it sends an impulse to that nerve and then through a black box mechanism, nobody knows exactly how it works. It sends a signal up into the brain that helps control seizures. And on average maybe a 50% reduction in seizure frequency. Some patients more, some patients less. The advantage of the vagal nerve stimulators, it's not another pill, they don't have to remember to take it, and it has an on demand feature, meaning you can take a magnet and actually if you can tell a seizure is coming on, you can swipe the magnet on the device. And what that'll do is that'll cause the device to turn on, which can abbreviate or prevent a seizure. There's another device that's actually an implanted in the skull and an electrode is actually put into the seizure focus itself, and that device will detect a seizure and actually zap the brain and prevent the seizure from occurring. The challenge with that device, it's called the neuropace device, is that you have to be really sure where or fairly certain where the seizures coming from before you can implant it.
Alternative treatments for epilepsy haven't been particularly effective from my experience. One of the things that comes up most frequently, and I would tell you every day, is the question about marijuana and epilepsy. And there have been some anecdotal reports, particularly stuff you've seen on CNN where there've been some pretty amazing responses that have occurred when kids have had marijuana or some marijuana extract that has helped control their seizures. And I would point out from my end, it's very difficult to sort of give any good advice. And the reason is we don't have any trials really conducted in the fashion or with the rigor that we've expected from every other anticonvulsant medication. And so I can tell you, you know, numbers as far as, side effects and interactions with any anticonvulsant, I have no idea with marijuana as to, you know, how much to give, what drug interactions, what other side effects that happen. And I think that one of the traps that people fall into is they don't think of it as a chemical. They think of pills as chemicals, but marijuana somehow is a leaf. It's a green leafy vegetable. It's not a chemical. And that's not right. It is. It's a chemical that has potentially some good effects, but the equally potentially bad effects. And I couldn't tell you anything about, you know, what epilepsy it works for, which ones it doesn't work for. Could it make some worse? Make some better? And the answer is yes to everything and I just don't know. So it's an exciting thing for the future. Is there some really exciting possibilities there? The answer is yes. Would I, you know, can I recommend it to my patients? I can't, cause I don't have any data on it at all.
So then we think, well, Gee, what do we do after medications and so after medications we have a few different options. The first and sort of best option as far as controlling seizures would be epilepsy surgery. That always scares everybody when it comes up. And when I talk about epilepsy surgery, I'm actually talking about removal of part of the brain. And the key there is that we are able to identify where the seizures are coming from and take that part out. Now not all people with epilepsy have focal seizures. So the people who have generalized seizure disorders, we can't do surgery to take out part of their brand because it comes from everywhere. And then in people with focal seizure disorders, a large percentage of those patients, we can't actually nail down exactly the spot. And so how do we nail down the spot where the seizures are coming from? We do a couple of things. One: we do an MRI of the brain and again we're paying very careful attention for any subtle little scar that we can associate with where the seizures coming from. We also do the video EEG monitoring. That's an integral part of nailing down where the focus is. Where's the seizure coming from? Again, the video EEG monitoring is, it's a significant chunk of time where someone is admitted to the hospital, an EEG is put on their head and we want you for a week, sometimes more, sometimes less and we're actually looking to capture seizures. In that situation, we'll often remove medications to provoke seizures a little bit. Recognizing that this is a very supervised situation where if someone were to have a prolonged seizure or too many seizures, we have ways to treat those as well. Surgery is attractive because we know that in someone who's failed three different medications and continues to have seizures, the likelihood of making them seizure free is very low and it can be in the right scenario much, much better with surgery, like 80% in the right kind of cases. And even in the cases where it's not 80% still significantly better than more medication adjustments. A large percentage of patients won't be able to have epilepsy surgery because we won't be able to be certain where the seizure focus is.
There are lots of options for epilepsy treatment. The mainstay of epilepsy treatment is the large number of anticonvulsant medications, again I point out over 20 with more coming up. But if epilepsy medications or anticonvulsants don't work, we have other options including brain surgery, dietary changes, or what we call neuromodulation devices.
There are a lot of studies that we do to help localize or understand someone's seizures. And often we use those though when we're more trying to specifically design a treatment plan for somebody who's not responding like we want. So for instance, a pet scan we use quite a bit, but it's when we're trying to decide if someone's a candidate for epilepsy surgery, we'll do a pet scan. And what we see with a pet scan is we see the metabolism of the brain and how actively the brain is metabolizing glucose usually. And in areas of the brain where the seizures occur or originate from, that area can be hypometabolic. And so again, what would I'm thinking about often in those cases is can I detect exactly where the seizures coming from and define an area that we could potentially remove to stop seizures.
Epilepsy has multiple potential treatments. When we look at patients with seizures and epilepsy, we have a few different modalities of treatment that we can consider. The first is medication and as the first line treatment for epilepsy, I would point out that when we, when we're choosing a drug for somebody and choosing how to treat them, about 60% of patients will respond to medication. And another 30% to 40% will continue to have seizures despite medication treatment. We'll talk about things besides medications next, but I'll focus on medications first. With respect to medications, there are a lot of different choices. We're looking at over 20 different medications for epilepsy and for seizures. I would point out that often we call these antiepileptic drugs. Really at the end of the day, they're anticonvulsants. There's no one drug better than the next. They're all, as far as we can tell, roughly equally effective. And so what we're often doing, as neurologists and epilepsy doctors, is trying to pick the right drug for you. And I have unfortunately no way of knowing that 100%. I have to take the available data, but at the end of the day we're taking a leap of faith as far as how you're going to respond. The other thing that we sort of don't always know the answer to is what's the right dose? And I get a lot of patients who come back sort of unhappy sort of feeling like, oh that doctor keeps throwing pills at me and just one thing after another. And the issue there is I don't know and not only do I know exactly the right drug for you, I'm going to make an educated guess based on a lot of data that I've got. But I also don't know what the right dose is for you. So what we ended up doing is we pick a medication, we start at a relatively low dose and we sort of hope it works. And, you know, it sounds kind of crazy that it's that blinded and we have that little information, but we really don't. Oh, we can get levels of medications, but that doesn't always tell me if you're going to respond. I don't know what level is right for you.
The key with medications is that one, they all have potential side effects. For any medication out there I can line up people on either side to tell you how great it is and how bad it is. And so until you try it, it's hard to tell for sure. And the other key that I point out to all my patients is that generally speaking, the key to starting something new is to go slow. Start with the lowest dose possible and inch up a little bit, get you to a therapeutic dose, and again, I would point out a low therapeutic dose and then we sort of see what happens. If another seizure happens often and we sort of say, okay, if another seizure happens, you are taking the medications you've been on it a reasonable amount of time, well shoot, we need to bump it up a little bit. The data tells us that about 50% of patients respond becoming totally seizure-free after one med. After two meds, we're looking at probably about 60% or close to 60%. After three meds, the likelihood of making someone's seizure-free is below 4%. it's very low.
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