Western University, Canada - London Ontario

| Thursday October 23, 2014
12:37 AM
Overview of the Epilepsy Program

The Epilepsy Program at London Health Sciences Centre is widely recognized for its highly qualified team of professionals consisting of neurologists, neurosurgeons, nurses, psychologists, EEG technologists neuropathologists, neuroradiologists and neurophysiologists dedicated to the management of epilepsy, particularly epilepsy surgery.

Its centrepiece is the 8-bed, in-patient Epilepsy Monitoring Unit at University Hospital, the largest in Canada. Devoted primarily to investigation of patients for possible epilepsy surgery, the Epilepsy Unit is also used to aid diagnosis of epilepsy and other related conditions, and to evaluate patients for other types of treatment, including trials of antiepileptic medications.

In addition to patient care, the department supports world-class research and teaching. More than 30 neurologists and neurosurgeons have come from numerous countries to learn about the complex epilepsies in our programme. While the majority of patients treated in the Epilepsy Unit are from Ontario, patients from other Canadian provinces and as far away as Holland, Mexico, Spain and Australia come to London Heath Science Centre as a result of its specialized expertise.

Our Mission: To assess, investigate, treat, teach and research the causes of epilepsy.

Our Vision: To improve the lives of people with epilepsy.

About the Epilepsy Program
Clinical Neurological Sciences -

History

In the early 1970s, Dr. Warren Blume, a neurologist and epileptologist, and Dr. John Girvin, a neurosurgeon and neurophysiologist, recognized the need for a specialized epilepsy unit in southwestern Ontario, one of Canada's most heavily populated areas. Dr Girvin carried out the first epilepsy surgery at London Health Sciences Centre (LHSC) in 1974.

In 1977, the Epilepsy Programme was formally established with the generous support of grants from the Academic Development Fund of Western University, the Richard and Jean Ivey Fund, and the London Health Association, owners and operators of LHSC. A multidisciplinary team of health care professionals with expertise in epilepsy gradually took shape.

In 1986, a four-bed inpatient epilepsy unit dedicated to the investigation and monitoring of seizures was opened on the 10th floor of the LHSC University Hospital campus. This increased the efficiency of inpatient evaluation, allowing a greater number of patients to undergo surgery and other treatments for epilepsy.

Over the years a growing need for inpatient evaluation necessitating an expansion of the Epilepsy Monitoring Unit to 8 beds in 1992. The entire unit was streamlined in conjunction with the adjacent EEG department to provide the most efficient service possible.

More recent innovations include installation in 2002 of 8 fully digital state of the art video-telemetry systems developed in collaboration with XLTEK Corporation of Oakville, Ontario for monitoring of complex epilepsies at University Hospital and the opening of a dedicated pediatric epilepsy monitoring bed using the same equipment at Children's Hospital in 2007.

Research

Trainees are encouraged to participate in one of the many research projects going on in the Epilepsy Programme. Those interested in a career in academic epileptology are expected to participate in at least one project during their fellowship training. If you have a specific area of interest, speak to the appropriate faculty member preferably before you start your training, as there may be funding opportunities available. For certain projects, a fellow may be eligible for the 2 year Masters degree programme in Neuroscience.

Teaching

EEG is one of the 2 laboratory tests that you will be authorized to report as a neurologist. Headache, stroke and seizures are the most common disorders presenting to the general adult neurologist while epilepsy is the most common condition managed by paediatric neurologists. Since exposure to complex seizure disorders is limited on the general neurology service, a more focused experience is available in the EEG/Epilepsy Programme as follows:

  • Basic introduction 1-3 month rotation
  • EEG training minimum 1 year
  • Epilepsy/EEG recommended 2 years

EEG Outpatient / Inpatient

The trainee is expected to:

attend daily EEG reading sessions (1400 hours) observe and participate in EEG recordings with technologist from start to finish make use of and contribute to teaching materials attend any formal EEG teaching sessions

Those aiming to take the Canadian EEG Examination can refer to the link: 

http://www.cnsfederation.org/cnsf/cscn/eeg-exams/

* Neurosurgery trainees may have a different emphasis

Epilepsy Outpatient Clinics

Daily with various Epileptologists/ neurosurgeons

Epilepsy Unit

Patients are admitted to the Epilepsy Unit for surgical investigation, for diagnostic workup and occasionally for anti-seizure drug management. The trainee is responsible for some or all patients in the unit. Trainees will also be responsible for offservice epilepsy consultations in the hospital.

Trainees are encouraged to observe electrocorticography and epilepsy surgery procedures in the OR including insertion of subdural/depth electrodes.

Paediatric Epilepsy

All paediatric EEGs are reviewed in the daily reading sessions. Children younger than 15 years are generally not admitted to University Hospital but rather to the monitoring bed at Children's Hospital. Some children are followed as outpatients at University Hospital but trainees wishing additional exposure to paediatric epileptology may elect to do a one or more month rotation at the Children's Hospital.

Functional MRI

A minimum 3 month elective rotation for training in acquiring and analyzing fMRI data, particularly as it pertains to epilepsy, is available under Dr Mirsattari.

ICU Monitoring

In addition to his interests in epilepsy, Dr. Young specializes in neuro-critical care. He coordinates a programme of continuous monitoring of critically ill patients that some trainees may wish to participate in.

The Epilepsy Program Team
Clinical Neurological Sciences -

The epilepsy team includes a number of different health care professionals who will be involved in your assessment. During your investigation, you will be under the care of a neurologist who is a  specialist in epilepsy and his resident staff and fellows.

If you proceed to surgery, it will be performed by a neurosurgeon with special expertise in epilepsy. Others involved in your investigation and care may include technologists, nurses, neuropsychologists, a clinical psychologist, a psychiatrist, and various additional personnel as required. Sometimes the team will visit as a group. At other times they will see you individually.

Neurologists

  • Jorge G. Burneo, MD, MSPH
    Director of EEG/Co-director Epilepsy Programme
    Associate Professor, Department of Clinical Neurological Sciences
    Tel: 519-663-3464
  • Fax: 519-663-33498
  • Seyed M. Mirsattari, MD, PhD, FRCPC
    Assistant Professor, Department of Clinical Neurological Sciences
  • Rick MCLachlan, MD, FRCPC
    Professor, Department of Clinical Neurological Sciences
  • Bryan Young, MD, FRCPC
    Professor, Department of Clinical Neurological Sciences
  • David Diosy, MD, FRCPC
    Clinical Associate Professor, Department of Clinical Neurological Sciences
  • Warren T. Blume, MD, FRCPC
    Emeritus Professor, Department of Clinical Neurological Sciences
    Paediatric Epilepsy
  • Simon Levin, MD, FRCPC
    Associate Professor, Head, Paediatric Neurology UWO
  • Asuri N. Prasad, MB, BS, FRCP(E), FRCPC
    Associate Professor, Paediatric Neurology

Neurosurgeons

  • Andrew Parrent, MD, FRCPC
    Chief Neurosurgery/ Co-director Epilepsy Programme
    Associate Professor, Department of Clinical Neurological Sciences
  • David A. Steven, MD, FRCPC
    Assistant Professor, Department of Clinical Neurological Sciences
  • Sandrine de Ribaupierre, MD, FRCPC
    Assistant Professor, Department of Clinical Neurological Sciences

Psychology

  • Brent Hayman-Abello, PhD. Neuropsychologist
  • Sue Hayman-Abello, PhD. Neuropsychologist
  • Paul Derry, PhD Clinical Psychologist

 

Epilepsy Surgery Information

EEG Telemetry

The main purpose of your admission is for continuous monitoring using a telemetery system to record seizures. This is the best way to identify from which part of the brain your seizures begin. Understanding exactly where seizures begin in the brain is key to determining if surgery is an option. Monitoring is done using electrodes applied to the scalp exactly the same as when an EEG (electroencephalogram which traces electrical impulses in the brain) is done. The wires are attached to a small box that you carry over your shoulder or around your waist. This is connected by a long cable to another box in the wall that will allow you to move freely about in the Unit.

Each of the eight beds in the unit is equipped with a colour video camera, microphone, and a state-of-the-art EEG. Physicians and staff are able to monitor patients 24-hours a day, without interruption to capture seizures and pinpoint their origin in the brain as they happen.

The video equipment has infrared capabilities to view patients sleeping at night, and can provide an opportunity to record and see physically what happens to a patient during a seizure.

The technology also provides for remote monitoring. Patients can leave the Unit for brief periods and walk to other parts of the hospital and still be monitored. However, leaving the Unit is discouraged since video is not obtained and having seizures in other areas of the hospital may be disruptive.

It is not uncommon for patients to have less frequent seizures than at home while they are in hospital. This may require reduction of antiepileptic medication with a resulting increased risk of grand mal seizures. Therefore, it is extremely important that patients follow instructions from nursing staff and EEG technologists about use of the equipment and about leaving the unit.

In about 40% of patients, a seizure focus cannot be found using this method. A small operation is then carried out under general anaesthesia in which subdural electrodes are placed on the surface of the brain through a small hole in the skull. Further telemetry is done for up to 4 weeks using these electrodes. While the electrodes are in place, this may result in headache and nausea for which appropriate medication is given. About one in 25 patients will experience some minor transient infection of bleeding.

Magnetic Resonance Imaging (MRI)

An EEG shows how the brain is functioning; magnetic resonance imaging reveals, in great detail, the structure of the brain. It can show scar tissue, a small tumor or other abnormalities that may be the cause of your seizures. It is painless and involves no radiation but the equipment is noisy. You will be required to lie still for several minutes in a space about 1 metre wide. If being in confined spaces bothers you (claustrophobia), let the nurses know before going for your MRI.

Neuropsychology

Extensive testing is carried out to determine whether there are any abnormalities of certain mental functions such as speech and memory. These tests provide information that helps determine whether an operation will interfere with the normal functions of your brain. Sometimes a procedure called an amytal test is required before surgery to further assess memory function. The details of this test will be explained if it is necessary.

You may also be seen by a clinical psychologist who specializes in epilepsy. Stress plays a major role in increasing seizure activity. The psychologist can identify and help with any emotional, family, or social problems which may be bothering you or which develop during your treatment.

What Type of Surgery Will I Have?

Once all the tests are completed, your doctor will explain the results to you and your family. If the investigations show that 1) onset of your seizures is well localized to one part of your brain, 2) other areas of the brain are functioning normally, and 3) the area of seizure origin can safely be removed, your doctor will probably recommend an operation. Surgery is not recommended in 20% of patients.

Most but not all surgery involves removal of one temporal lobe (the part of the brain under the temple) which is a common location of seizure onset. This is called a temporal lobectomy. Other patients will have a frontal lobectomy, occipital lobectomy, or other procedures depending on where the seizures begin. Occasionally, a corpus callosotomy (split brain operation) or vagus nerve stimulation (VNS) is recommended.

No matter which type of surgery is done, you will have all or part of your hair removed (don't worry, it always grows back!) Most surgery is done under local anaesthesia so speech, memory and movement can be monitored during the operation as another safety precaution. This also allows further recording of brain wave activity during the procedure. The neurosurgeon will explain other details of the operation.

What Should I Expect Following Surgery?

You will be transferred to the Neurosurgery Ward on the 7th floor where you will be in a special observation unit for one to two days before being moved to a regular hospital room. You will probably feel unwell after the operation with headache, nausea, and tiredness.

This usually disappears after two to three days and most patients feel well apart from mild fatigue when they are discharged within a week after surgery. Most patients return to full activity including work within one month of surgery. Your medication will probably be reduced before you are discharged but you will remain on at least one antiepileptic drug for up to a year or more after surgery.

How Will the Surgery Affect My Epilepsy?

The best result of surgery is to be seizure free. This occurs in 3 out of 4 patients after temporal lobectomy and is less likely after other types of surgery. Some patients benefit from a reduction in seizures and antiepileptic medication but continue to have occasional attacks. You should be prepared for the possibility that you may not be helped by surgery. About 10% of people fail to gain any improvement at all.

The best result of surgery is to be seizure free. This occurs in 3 out of 4 patients after temporal lobectomy and is less likely after other types of surgery. Some patients benefit from a reduction in seizures and antiepileptic medication but continue to have occasional attacks. You should be prepared for the possibility that you may not be helped by surgery. About 10% of people fail to gain any improvement at all.

In particular, grand mal seizures may not decrease following surgery and in rare individuals may increase in frequency. Although freedom from seizures during the first weeks or months following surgery is encouraging, this does not necessarily predict long-term control. This can be determined more reliably if patients remain seizure free for one to two years.

Conversely, occasional seizures during the early post-operative months can disappear with time. Some patients continue to experience their aura or warning following surgery but this rarely progresses to full seizures.

What Are the Risks of Surgery?

  • The general risk of infection, bleeding or stroke associated with any surgery involving the brain is less than 1% with epilepsy surgery at University Hospital.
  • A visual field defect or blind spot involving both eyes off to the side opposite the operation may occur particularly following temporal lobectomy but most people are unaware of it and it has no effect on day to day seizures.
  • A decrease or worsening of short-term memory can occur following temporal lobe surgery particularly if it is on the left side of the brain. However, some patients feel that their memory is improved.
  • Following operations on the dominant (usually left) hemisphere, difficulty talking can occur for several days to weeks. Rarely, minor word finding difficulty can persist for a year or more.
  • Some people develop transient emotional or psychological problems such as anxiety or depression that may not appear for days to weeks after the operation and may last for several weeks to months before disappearing.
  • You may experience headache, itching or numbness in the area of the incision that should disappear within several days to weeks following the surgery.
  • If you are fortunate enough to obtain complete seizure control from surgery, you may feel that this will solve all of life's problems. Although many people experience a considerable improvement in lifestyle, sometimes there are other longstanding medical, psychological, family or social problems that can surface and actually take on greater significance once seizures have been controlled.
How to Contact the Epilepsy Program

Fax Number:
519-663-3753

We would be happy to answer any questions or simply provide you with more information about our facilities and the services we offer. Please contact us directly with your questions, through our website by sending an email to Cathy Johnson ( ).

Address:
339 Windermere Road
London, Ontario, Canada
N5A 5A5