Neurology
Room 1500 • Phone: 419.383.3760 • utmc.webmaster@utoledo.edu
Epilepsy Program
The Epilepsy Program provides comprehensive care for adults and children with epilepsy. As a Level 4 Epilepsy Center, we have expertise in diagnosis and management of all forms of epilepsy, and can provide advanced treatments using both medical and surgical approaches.
The Epilepsy Program is directed by Dr. Imran Ali, a board-certified neurologist with fellowship training and board certification in Epilepsy and Clinical Neurophysiology. Our staff includes Associate Director, Dr. John Greenfield, a board-certified epileptologist with fellowship training in EEG and epilepsy, a neuropsychologist, a neuroradiologist and a neurosurgeon, all with special expertise in epilepsy. The Comprehensive Epilepsy Center is supported by a state-of-the-art EEG laboratory that is the only accredited Neurophysiology Laboratory in Northwest Ohio. Comprehensive surgical evaluation as well as investigational drug therapies are available for patients with intractable epilepsy.
Adult and Pediatric Epilepsy Clinic:
Patients (age 12 and above) are usually evaluated initially in our epilepsy clinic, where a thorough history and neurological examination are performed and prior medical records are reviewed. Urgent appointments are available by request. If imaging studies of the brain have been performed in other hospitals, we request that the studies themselves (not just the reports) be brought to the first clinic visit.
Clinical Neurophysiology Laboratory:
The Clinical Neurophysiology Laboratory, located on the 5th floor of The University of Toledo Medical Center, is the only fully-accredited Neurophysiology Lab in northwest Ohio. We perform over 1000 digital EEG studies yearly on inpatients and outpatients of all ages. Long-Term Monitoring for Epilepsy (LTME) is performed with video and digital EEG recording systems hard-wired to more nearby patient rooms and the Intensive Care Unit. Portable EEG monitoring studies can be performed on critically ill patients throughout the Hospital. The Lab also performs visual, somatosensory and brainstem auditory evoked-potential studies on outpatients and inpatients.
Long Term Monitoring for Epilepsy:
For patients with medically intractable seizures, evaluation and treatment depends upon accurate diagnosis of the seizure type. In many cases, this requires Long-Term Monitoring for Epilepsy, in which the patient is admitted to the hospital for 24-hour-a-day monitoring so that seizures can be captured on videotape and EEG recording. Monitoring is performed to diagnose seizure type or to localize seizure onset within the brain for possible epilepsy surgery. Electrodes are placed on the patient’s head, as in a standard EEG, and behavior is recorded by closed circuit camera onto videotape. Additional wire electrodes are sometimes inserted above the jaw near the ear by the neurologist; these electrodes provide better information about temporal lobe seizures than scalp electrodes alone. Antiepileptic drugs are generally reduced or tapered off before or during the admission, which can last from one to several days.
A family member or someone who has witnessed the seizure activity should plan to accompany the patient; this person can trigger a seizure alarm and indicate whether a typical seizure type has been recorded. It is difficult to predict how many seizures may be required; many factors are involved including the number of seizure types, their origin in the brain, and how clearly they can be recorded without interference by movement or other problems. Medications are usually restarted on the day or evening prior to discharge. The epilepsy neurologist will keep the patient and family informed of the progress at least daily during the hospital stay.
Investigational Drug Programs:
For some patients with epilepsy, conventional antiepileptic drugs may be ineffective or poorly tolerated, and epilepsy surgery may not be possible. Investigational drug programs provide access to medications that have been shown to be safe and effective against seizures in smaller trials, but need broader patient exposure before they can be approved by the Food and Drug Administration. These studies are initiated after Institutional Review Board approval. Advantages of investigational drugs include access to new medications that may be more effective than currently approved drugs, frequent follow-up visits and careful monitoring of drug effects, usually at no cost to the patient. These programs provide another option for patients with difficult-to-control seizures.
Epilepsy Surgery:
When seizures cannot be controlled by antiepileptic drugs, epilepsy surgery may be possible for some patients. If the seizures originate from a diseased area of brain (due to a tumor, a blood vessel abnormality or other problems) this area can sometimes be surgically removed, curing or dramatically reducing the number of seizures. This procedure works best when it involves the temporal lobe, a brain region that can be removed without causing neurological deficits. Before epilepsy surgery can be considered, the patient must undergo long term monitoring for epilepsy (LTME, see above) to diagnose and localize their seizures. In some cases, a neurosurgeon places intracranial wire electrodes within the brain ("depth electrodes") or grid electrodes on the brain surface to localize an epileptic brain region for surgery.
If the seizures can be localized, a number of other tests are performed, including a special brain MRI to determine whether a brain lesion is present, neuropsychological and language testing, and visual field testing, among others. A Wada test, in which half of the brain is put to sleep with a short-acting anesthetic, is often performed to localize language in the brain and ensure that the patient can undergo surgery without developing memory problems. After this extensive work-up is completed, the entire epilepsy program team reviews all of the information and decides whether surgery is appropriate.
Vagus Nerve Stimulator:
A Vagus Nerve Stimulator is a small pacemaker-like device that is implanted by a neurosurgeon under the skin near the collarbone, which electrically stimulates the vagus nerve in the neck. Stimulation of this nerve, which connects to a number of important brain regions, can reduce the frequency of seizures in more than half of patients who have the device implanted, even those who have not been controlled by multiple medications. The device runs on its own battery for up to ten years, and is then surgically replaced.
The neurologist can program the device to deliver different patterns of stimulation to maximize seizure control and minimize side effects, which can include hoarseness when the device is active or mild neck pain. Patients can also give extra stimuli by holding a magnet over the device when they sense a seizure coming on; sometimes this may abort a seizure before it happens. The device can now be used in adolescents, and has shown some efficacy in patients with multiple seizure types and mental retardation (the Lennox-Gastaut syndrome).