Lance Fogan's Blog

If your seizure control is notsatisfactory, and if you and your doctor are trying different antiepilepticdrugs (AED), be aware that some side-effects can be more common with certainAEDs and less with others. Your choice could be beneficial for you. This topicwas reviewed by Mary Beth Nierengarten in the November 21, 2024, issue ofNeurology Today page 9. Older adults with epilepsy are much more likely toexperience new cardiovascular events, including strokes, transient ischemicevents (TIA) and heart attacks if they take the enzyme-inducing antiepileptic drugs.1

Enzyme-inducing antiepilepticdrugs (EIAEDs) are a class of medications used to manage seizures. They havethe effect of increasing the activity of certain liver enzymes, primarily thecytochrome P450 (CYP450) family. How Enzyme Induction Works:

•    EIAEDs, theenzyme-inducing drugs, stimulate the production of CYP450 enzymes in the liver.

•    These enzymesare responsible for metabolizing (breaking down) many drugs and othersubstances in the body. Carbamazepine (Tegretol), Phenytoin (Dilantin),Phenobarbital (Luminal)and Primidone (Mysoline) are the classicalenzyme-inducing antiseizure drugs (ASDs). Non-enzyme-inducing ASDs includeLevetiracetam (Keppra), Lamotrigine (Lamictal), Lacosamide (Vimpat). The EIAEDswere used in a third of those with the increased risk and this Canadian study (reference1) highlights the risk of long-term use of these medications for epilepsy.Co-morbidities with other medical diseases, especially cardiovascular risks,should be considered when choosing among 25 commonly used AEDs.

Those patients studied ranged inage from 62 to 85. Most were white. males and females of comparable numbers.None in the study had had a previous reported stroke, transient ischemic attack(TIA) or heart attack but the study showed 24.6% of the enzyme-inducing ASMswere then associated with new-onset cardiovascular events. Consider thesefindings, if possible, with your doctor when choosing your first-line therapy,avoiding Tegretol, Dilantin, Phenobarbital, and Primidone. If you havecardiovascular symptoms and risks, consider an EIAED as Levetiracetam (Keppra),Lamotrigine (Lamictal) or Lacosamide (Vimpat). Other common AED adverseeffects, e.g. balance and cognition problems, should also be discussed withyour physician.

We need to take a comprehensiveapproach for long-term outcomes for patients with epilepsy as most patientswith epilepsy will be on these medications for decades or life-long.

1.    Li J, Shlobin NA, Thijs RD, et al.Antiseizure medications and cardiovascular events in older people withepilepsy. JAMA Neurol 2024; Epub 2024 Sept 30.

Lance Fogan, M.D., is Clinical Professor of Neurology at theDavid Geffen School of Medicine at UCLA. His hard-hitting emotional family medicaldrama, “DINGS, is told from a mother’s point of view. “DINGS” is his firstnovel. Aside from acclamation on internet bookstore sites, U.S. Report ofBooks, and the Hollywood Book Review, DINGS has been advertised in recent NewYork Times Book Reviews, the Los Angeles Times Calendar section and PublishersWeekly. DINGS teaches epilepsy and is now available in eBook, audiobook, softand hard cover editions.

  and is now available in eBook, audiobook, soft and hard cover editions.

Enzyme-inducing antiepileptic drugs (EIAEDs) are a class ofmedications used to manage seizures that also have the effect of increasing theactivity of certain liver enzymes, primarily the cytochrome P450 (CYP450)family

.

How Enzyme Induction Works:

•          EIAEDsstimulate the production of CYP450 enzymes in the liver.

•          Theseenzymes are responsible for metabolizing (breaking down) many drugs and othersubstances in the body/

Carbamazepine (Tegretol), Phenytoin (Dilantin),Phenobarbital (Luminal),and Primidone (Mysoline) are the classicalenzyme-inducing antiseizure drugs (ASDs). Non-enzyme-inducing ASDs includeLevetiracetam (Keppra), Lamotrigine (Lamictal),Lacosamide (Vimpat).

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

A multi-center study in NeurologyToday September 19, 2024; volume 24; issue 18; page 9 entailed results ofclinical investigations in 37 tertiary epilepsy centers in the United States,Australia and Europe. The goal was to advise clinicians and patients as to themost effective antiepilepsy (AED) drugs with the BEST TOLERATED SIDE-EFFECTS.Keppra, Lamictal, Tegretol and Trileptal are all available as generics and are widelyused. More drug side effects may result in patients stopping their meds despitetheir effectiveness.

From 2012 to 2020 two hundredtwenty-five adults were studied. Of the participants 132 were takinglevetiracetam (Keppra), 55 taking lamotrigine (Lamictal), 19 carbamazepine(Tegretol) and 19 oxcarbazepine (Trileptal). There were no significantdifferences in total Adverse Event Profiles (AEP) screening for depression andanxiety among the 4 drugs. Those on Keppra were three times more likely to havefeelings of AGGRESSION but almost half of these experienced feelings ofUNSTEADINESS compared with Lamictal. Discontinuation rates were 42.1% each for Tegretoland for Trileptal, 34.8% for Keppra and 16.4% for Lamictal. Keppra had thehighest discontinuation rate because of adverse events alone——18%—and Lamictalusers had the lowest discontinuation rate—5%. Across medications femalepatients were more likely to report FATIGUE, DOUBLE VISION OR HEADACHE.

An anecdotal conversationoccurred among 10 epileptologist neurologists. The question arose, “If youdeveloped epilepsy what drug would you want to be on?” The unanimous answer wasLamictal. This study should lead to greater awareness of possible mental healthconsequences of using Keppra. Doctors should not be afraid to change drugs ifKeppra users begin to feel anxious or depressed. This study is not yetgeneralizable for consideration to other forms of epilepsy or to epilepsy drugsnot included in this study.

Epilepsy patients are more likelyto have ANXIETY AND DEPRESSION. It is not known whether mental health treatmentimproves epilepsy seizure control. Psychiatric conditions are common inepilepsy patients even before epilepsy is diagnosed. Keppra can make patientsFEEL EDGY, ANGRY or MEAN rather than they describing themselves feelingaggressive or in a “Keppra rage.” Spouses and family may notice thesepersonality traits before the patients themselves do. Neurologists must beaware of these mental affects of these AEDs.

AED side effects can affect drugcompliance and seizure control. One need not hold to the initial AED choicesince other drugs may be more effective in seizure control with fewer emotionalside effects. Keppra was found to be the most frequently prescribed drug asemergency room non-neurologists often choose Keppra when someone is admittedwith their first seizure. Prompt AED change when indicated can be very positivein the overall life of an epilepsy patient.

Lance Fogan, M.D. is Clinical Professor of Neurology at theDavid Geffen School of Medicine at UCLA. His hard-hitting emotional familymedical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his firstnovel. Aside from acclamation on internet bookstore sites, U.S. Report ofBooks, and the Hollywood Book Review, DINGS has been advertised in recent NewYork Times Book Reviews, the Los Angeles Times Calendar section and PublishersWeekly. DINGS teaches epilepsy and is now available in eBook, audiobook, softand hard cover editions.

            Weall should understand that an epilepsy diagnosis need not lead our patients togive up hope for a successful life. This patient’s experience confirms that.Half of all the three million Americans with epilepsy exhibit complete ornearly complete control of their seizures. An epilepsy diagnosis does not necessarilyrestrict your life. Afterall, Chief Justice John Roberts of the United StatesSupreme Court has epilepsy.

My novel, DINGS, includesreassurance of this by the fictitious neurologist in my book to the mother of hernewly diagnosed third grader who was failing school due to unrecognized non-convulsiveepileptic blank-out seizures.

In the October/November2024 issue of Brain&Life, Mary Bolster wrote of a courageous man (page38). Tyler Rogers climbed the tallest mountain in the world, the 29,029 feettall Mount Everest, despite his history of epilepsy. He graduated from highschool in 2013. As a team wrestler he had experienced a severe concussion. Twoweeks later he had his first grand mal seizure. Realization ensued that he hadbeen experiencing auras and sporadic numbness and other symptoms without lossof consciousness. He had never complained of these phenomena until hisconvulsion. His antiseizure medications (ASMs) did not prevent repeatconvulsions and their side effects were unpleasant.

On a subsequent airplane flight,he had a 9-minute generalized seizure. Monitoring with brain-implanted-electrodesthen revealed that he had a lesion in his right temporal lobe. A laser ablationwas utilized to remove the lesion. He had no seizures for the next 18 monthsuntil breakthrough seizures occurred. Another laser ablation was then performed.

Laser ablation is a surgicalprocedure but a less invasive surgery. It uses targeted laser technology todeliver heat to ablate, or destroy, cells responsible for causing seizures. Itis generally considered as another treatment when anti-seizure medications havebeen ineffective in controlling a patient’s seizure frequency. This was thesituation in Tyler’s case. Laser ablation can be particularly promising whenlesions believed to be causing seizures are located deep in the brain, where amore invasive surgical approach would be too high-risk.

Tyler reported that henoticed an immediate improvement in his word recall and cognition. Seizure-freefor the subsequent 18 months until seizures reappeared. He had another laserablation.

A friend who had summittedEverest counseled Tyler that he could do it, too. Months of intensive trainingfor his climb ensued. He advised his sherpa guides on the climb and hisclimbing teammates what to do if he had a convulsion. He didn’t. In March,2023, he successfully reached the summit of Everest. Months later focal simpleseizure recurred with no loss of consciousness. He’s had no more seizures withclose neurological follow-up.

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in recent New York Times Book Reviews, the Los Angeles TimesCalendar section and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.

SusanFitzgerald summarized this study in the January 2, 2025, issue of NeurologyToday. Transcranial Magnetic Stimulation (TMS) is a non-invasive neurotherapeuticprocedure using magnetic fields from coils placed over the head to stimulatespecific areas of the brain. Safe and painless, it has been used for chronicpain, migraine and various mental health conditions as depression, obsessive=compulsivedisorder, etc. TMS is being investigated for other conditions includingmovement disorders, neuropathic pain and stroke.

AChinese study of patients aged 18-65 diagnosed with drug-resistant epilepsy(DRE) found that sessions of continuous transcranial magnetic stimulation (TMS)targeting the cerebellum (in the back of the brain, hitherto not usuallybelieved to play a major role in epileptic seizures but has been considered forseveral decades) may reduce seizure frequency in patients whose anticonvulsantmedications fail to control their seizures. Thirty-eight patients wererandomized to receive active stimulation followed by sham stimulation. Thefrequency positive responder-rate increased by 24% compared with shamstimulation. Some patients became seizure-free during the entire two months ofthe study. The exact mechanism how these results were achieved, and which typeof epilepsy are more likely to benefit, are unknown.1

Ofthe 38 studied patients, 31 had focal epilepsy, one had generalized epilepsyand six had uncertain onset. Each patient had a total of 10 TMS sessions. Thesham patients then switched to the active TMS arm of the study. Both sides ofthe cerebellum (the dentate nucleus) were targeted but are there other nearbystructures affected? Participants studied had a 34% reduction in seizuresfollowing active treatment and 23% reduction in seizures following shamtreatments. Adverse reactions included headache, tinnitus (ringing in the ears)and dizziness. All these problems resolve within days.

Oneconsideration in interpretating the result is that “blinding” the study populationis problematical as actual stimulation feels nothing like the sham stimulation.

Large-sample,multicenter, randomized controlled trials are needed to further validate theefficacy but if further research confirms the efficacy and safety of TMS, it’san easy and inexpensive treatment. A new treatment option for poorly controlledepilepsy that doesn’t involve surgery or more medications should appeal topatients.

I describe anotherresearch to control epilepsy that can give hope to our patients that they arenot alone.

1.    WangYY, Ma L, Shi X-J, et al. Cerebellar transcranial magnetic stimulation to treatdrug-resistant epilepsy: A randomized, controlled, crossover clinical trial. Epilepsia2024; Vol 66, Issue 1: p240-252. https://doi.org/10.1111/epi.1816

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in recent New York Times Book Reviews, the Los Angeles TimesCalendar section and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.

   TheSunflower Syndrome was described in a recent BrainAndLife by SusanFitzgerald 1 It is a rare photosensitive type of seizure disorder. Thecommon Petit Mal form of epilepsy is characterized by loss of awareness forseconds, some eyelid fluttering without falling or significant limb jerking norincontinence. Its EEG is characteristically identifiable with the classic“3/second spike-wave complexes”. But unlike petit mal epileptic seizures whichcan be induced by flashing lights or by driving under trees whose branchesintermittently block the sun causing “flashing”, the EEG abnormality insunflower epilepsy occurs simultaneously by bright sun or other light. It doesnot seem to be triggered by the light as the hand waving and EEG abnormalityare simultaneous.2

   Asunflower seizureis a rare stereotypical form of epileptic seizure consisting of eye flutteringwith a hand waving before the eyes as the person irresistibly turns toward thesun or some other bright light accompanied with altered awareness. This turningtoward the sun, like a sunflowers’ heliotropism, is due to the strong desire toface the sun or light while wiping the hands before the eyes. It lasts secondsand can occur up to a hundred times a day. Additionally, generalizedconvulsions often occur. Other neurological disorders usually don’t occur.

   Victimsare made fun of by others in schools because of this strange, uncontrollable misunderstoodbehavior. Diagnosis is commonly delayed because of ignorance that this is a specificform of epilepsy. “He would be outside, facing the sun and waving his hand.”The patient cannot explain what and why he is doing this. People often exhibitthese behaviors a long time before they seek medical evaluation.

   TheEEG shows cerebral hemispheric involvement on both sides similar to the spikeand wave pattern with 3 complexes/second of petit mal epilepsy. It does notappear to be a focal type of epilepsy. The EEG test should include bright lightexposure, a routine part of EEGs. Sunflower epilepsy generally begins inchildhood and mostly in girls. No blood tests are diagnostic. The diagnosis canbe difficult and is based on the clinical seizure features of hand-before eyesand simultaneously attending to the sun.

   Physiciansshould be aware of this syndrome. The first report of SS is likely by H.Gastaut in 1951 who described two children that seemed to seek out the lightand induce seizures by rapidly passing their hands in front of their eyes (HW).

   Treatment:There haven’t been enough trials to evaluate treatment yet. Valproate ishelpful. Wearing dark glasses or blue-tinted lenses or contact lenses, favorshaded rooms

1)Brain and Life. Pages 35-37; December 2024/January 2025

2) Sourbron J, Neishay A, Yancheng L, Thiele EA. Ictal EEG in sunflower syndrome:Provoked or unprovoked seizures? Epilepsy& Behavior Volume113,December 2020, 107470

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in New York Times Book Reviews, the Los Angeles Times Calendarsection and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.

Everyone in the epilepsy world, i.e.patients and the millions who are touched by their epilepsy and those whosupport these people, should salute a new epilepsy-themed musical produced in asmall Los Angeles theater.

Any attempt to raise epilepsyawareness in the public is so welcome. The Hudson Backstage Theatre on SantaMonica Blvd., Hollywood, CA is staging the world premiere of It’s All YourFault, Tyler Price. Ashley Lee reviewed this musical in the November 20,2024, Los Angeles Times. With actors, the musical tells of a family’sexperience supporting their daughter and her epilepsy. Lee describes the workas entertaining, empathetic and educational. This ubiquitous condition affectsone out of every hundred people in America. Leaders in all fields are countedamong them, notably Chief Justice of the Supreme Court John Roberts.

The musical was created by the girl’sfather, Ben Decter, an Emmy-winning composer of several TV shows. Ben sharesthat he couldn’t discuss his daughter’s seizures due to anger, sadness andisolation—a familiar story in the epilepsy community upon learning thediagnosis in one’s child. Decter found personal relief when he began to composesongs on his piano. He and his wife appreciated that he could put things intosongs that he couldn’t say out loud. Unburdening oneself from painful feelingsand thoughts, such as the topic in this play, can be accomplished by sharingthem with loved ones and close friends. All people touched in some way byepilepsy appreciate how hard it is to accept the diagnosis of epilepsy. Divorceand separation are quite common.

A friend overheard his songs and puthim in touch with the director, Kristin Hanggi, who took to this material. Theydeveloped it together. A school bully mocks the protagonist’s epilepsy. In partsuch an incident pushed the creators to educate the public about epilepsy viathis musical play. The actors teach the audience how to reassure and to keeppatients safe during a seizure by the actors leading audience members tocall-and-respond gospel-like to safety tips.

Reporter Lee empathizes that Addie,the real-life daughter with epilepsy who inspired the show, celebrates howpeople with epilepsy are seen and to know that they’re not alone. The musicalplay exposes how the diagnosis affects all family members; open communicationis stressed.

UCB, a global pharmaceutical companyinvolved in developing epilepsy medicines, learned of this play. UCB is a majorfinancial sponsor in producing It’s All Your Fault, Tyler Price.

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in New York Times Book Reviews, the Los Angeles Times Calendarsection and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.

Conner shuffled overto a shelf. His lithe, four-foot frame was draped in an over-sized adultpatient gown that floated around his ankles. He wore it open in the frontrather than in the back.

He picked up aplastic, multi-colored model of the brain. He turned it over and sideways, andthen started to pull apart its components. A piece fell onto the thinlycarpeted floor.

“Don’t do that,Conner!” I said sharply.

Sam turned and winkedat him. “Aw, I’m sure that’s what it’s there for, Sandra. He’s okay.”

When the doctorreturned I saw him focus on Conner’s underpants. We exchanged glances and grinsabout the tan-and-olive camouflage motif. Conner had begged for them becausethey were military like his dad. I bought him a dozen.

Sam and I sat besideeach other along one wall. I started to get up. “Would you like me to reversethe gown, Doctor? Conner insisted on tying it in front.”

“No, no. It’s fine.Okay, Conner, let’s see you just walk back and forth, normally.”

“Like this?”

The neurologistnodded. He evaluated Conner’s arm swings, balance and how he walked. “Perfect.Now, walk on your tiptoes. Like this.” Dr. O’Rourke rose onto the balls of hisfeet and demonstrated what he wanted Conner to do.

“Good. Now, walk onyour heels like this.” The doctor rocked back onto his heels as he leanedforward and elevated the toes of his shiny, black shoes to take a few awkwardsteps. Once again, our boy mimicked him. I covered my mouth with both hands toconceal a smirk at their awkward postures.

“Fine! Your legs areequally strong. Now, I want you to walk as if you are on a tightrope. Put onefoot in front of the other and touch the heel in front with the toes on theother foot. Keep the feet real close together.”

Conner took fiveperfect in-line steps.

“You’ve got greatbalance.”

“This is easy, Dr.O’Rourke!” Conner beamed.

The neurologistreturned Conner’s broad, toothy grin. “I knew you’d like this part of ourvisit. Now, hop up and down on your right leg like this.” Dr. O’Rourke put hishands over the side pockets of his white coat to prevent papers and tools frompopping out as he hopped a couple of times. Conner imitated him. “Now switchlegs. Excellent!”

“Okay, now put yourfeet together like this so that they touch ankle to ankle, side by side.” Thedoctor stood with the side of each of his shoes touching the other. “Yes, justlike that! Now, stand like that and don’t move.”

“This is so easy!”Conner exclaimed. Sam smiled at him and then looked at me.

The neurologistnodded. “Now, stay just like that and close your eyes. Don’t move.”

Conner stood ramrodstraight and squeezed his eyelids extra tight in that exaggerated way thatlittle kids do. A few seconds later, the doctor said, “That’s great, Conner.Your balance centers could not be better. Now turn around so I can check yourback.”

He lifted Conner’sgown and bunched it up around his shoulders. “I don’t see any spinal curvaturesor birthmarks that sometimes accompany degenerative nervous system diseasesthat are associated with epilepsy.”

That was good tohear. All doctors should interact with patients and their families: educate us,for crying out loud! Dr. Choy did that, too.

“Okay, now climb ontothe exam table, young man.” He felt Conner’s wrist pulses and then inspectedConner’s hands and fingernails. “There can be telltale clues of diseases here.”

Then he picked up athin, cloth measuring tape and wrapped it around Conner’s head. “Your headcircumference is fifty-three centimeters.” He looked at a chart and declared,“Normal head size.”

“Oh, that’s good!” Ifelt my heart thump and then, just as suddenly, a sharp gloom settled over me.I had become so distracted by their interactions that for a precious fewmoments I had actually forgotten why we were here.

Conner looked at usand giggled. He seemed to be enjoying himself.

The doctor smiled andbegan to wrap a pediatric-size blood-pressure cuff around Conner’s left upperarm.

“No! That gets tootight!” Conner yanked his arm away.

“This is a veryimportant part of the evaluation, Conner. It’s a small cuff made for children.I don’t think I’ll have to make it tootight, and the pressure will only last for a few seconds. I promise.”

“Let the doctor doit, Conner,” Sam commanded.

Conner cast a soberglance at his father and slowly extended his arm. He grimaced every time Dr.O’Rourke rhythmically squeezed the large black bulb that slowly tightened thecuff around Conner’s arm.

The doctor placed hisstethoscope in his ears: “Seventy-eight over fifty. That’s fine!”

Dr. O’Rourke movedthe stethoscope to the boy’s chest. “No heart murmurs.” Then he moved thestethoscope over both sides of the boy’s neck. “No abnormal ‘whooshing’ sounds here,either. That suggests no blockages in the arteries leading to the brain. Iwouldn’t expect to hear any in a child.”

Conner nodded andlooked into the neurologist’s eyes. Dr. O’Rourke smiled at him.

“I appreciate howyou’re explaining what you’re doing, Dr. O’Rourke. It’s like we’re all inmedical school.” I laughed and gave Sam’s hand a gentle squeeze.

Finally, theneurologist placed the end of the stethoscope on top of Conner’s head andclosed his eyes.

“I’ve never seen adoctor do that before—listen over thetop of the head, I mean. Do you hearsomething up there?”

“I’m just beingthorough, Mr. Golden. If there’s an abnormal blood vessel or increased pressureinside the skull, sometimes we can hear a telltale sound.”

“Well, did you hearanything?” Sam and I exchanged a worried glance.

“No, and that’snormal. I shouldn’t hear anything.”

This examination wasturning out to be quite a performance. My doctor never did any of these things.

He told Conner to liedown on his back. Then, he quickly moved his hands over Conner’s belly as Dr.Choy had done, stopping here and there, pressing softly and moving his handsagain. Conner looked uncomfortable once or twice, then erupted into giggles. “Thattickles!”

“If an abdominalorgan is enlarged, that could be a clue of a neurological-associated disease.Conner is normal.” He pulled out the waistband on Conner’s undershorts and tooka quick look at his privates. “No evidence of a developmental or geneticdisturbance here. Okay, you can go ahead and sit up now, Conner.”

The neurologistwalked over to a shelf and picked up a dark vial. He shook it a couple oftimes, unscrewed the cap and sniffed. He returned to Conner, who was swinginghis dangling legs over the edge of the exam table. Our boy appeared quitecomfortable being the center of attention.

The neurologistgently pressed Conner’s left nostril closed and waved his other hand with theopen vial under his right nostril. “Can you smell this?”

Conner jerked hishead back and contorted his face. “Ahhhh! Nooooo!” He covered his nose andmouth with his hands.

“No, Conner. Youdon’t have to do that,” Dr. O’Rourke reassured him. “This one’s a good smell.Can you tell me what it is?”

Cautiously, Connerbent forward and took another sniff. Before he could answer, Dr. O’Rourkerepeated, “Can you smell that?”

“Yes.”

He tested the othernostril.

“It’s good,” Connerpressed. “Is it gum?”

The neurologistturned around and held the vial under my nose. I sniffed. “It smells likesomething, uh…is it, uh, some spice? No. Cloves! It’s cloves.”

“Right! That’s whatit is.” Then he placed it under Sam’s nose.

“Yeah. It smellsgood. You’re right, son. It did smell like chewing gum.”

The neurologistreplaced the cap and placed the vial back on the shelf. Then he picked up ahandheld eye chart. Conner tested twenty-twenty in each eye.

“Good job. Now, keepyour right eye closed and look into my eye.”

The doctor stoodthree feet in front of Conner. Dr. O’Rourke closed his own left eye and pointedto his open right eye. “Keep looking right here in my eye,” he instructed. Theneurologist stretched out both of his hands to the sides. “Look only into myeye, Conner. I want to out find how well you can see out of all of the cornersof your left eye.” Dr. O’Rourke wiggled a finger off to the side and had Connersay “now” when he saw the movement.

After the exam thedoctor explained, “You did great, Conner! The fact that he sees my fingers movewhen they’re off to the sides means that the visual nerve tracts betweenConner’s eyeballs and the visual cortex at the back of his brain are workingwell. All of that function takes up a lot of space in the brain. My visualfield testing suggests that there are no hidden abnormalities where thesepathways are. That’s very important.”

I sat back and shookmy head. My mind churned with his explanation and trying to visualize what hewas talking about. I had never seen a neurologist at work, and I was so proudof Conner’s mature cooperation.

“He’s doing great,Sandra!” Sam whispered.

The neurologistswitched off the overhead lights and lifted a cylindrical instrument off itsperch on the wall behind Conner. “You’re doing very well. Now I am going toshine a light into your eyes so I can check the area where the retina andnerves are. Keep looking straight ahead and try not to move your eyes. Juststare at the X on that wall. Keeplooking at it even if my head gets in the way.”

The doctor aimed abeam of light at Conner’s right pupil and moved within a couple inches from ourson’s face. As Dr. O’Rourke peered through the instrument, he told us he couldsee where the optic nerve entered the back of Conner’s eye and the little veinspulsating around it. Then he examined the other eye. “There’s no sign ofabnormal pressure inside Conner’s head,” he announced and replaced thecylindrical device on its wall holder.

“That’s a relief,” Isighed. Sam and I looked at each other. We chuckled. Conner’s face had aquizzical expression, but he smiled, too.

 hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now  available in eBook, audiobook, soft and hard cover editions.

     Youcan if you are among the 50% of epilepsy patients who are on the “rightanti-convulsant at the right dosage.” You and your neurologist will know thisis the right anti-convulsant for you because your seizures stop while takingyour prescription. It’s trial and error. 1

     Unfortunately,the other patients in the epilepsy population will continue to experienceseizures, some very infrequently and others almost daily. These groups findtheir seizures do not disappear.

     Epilepsysurgery, no matter how drastic this sounds to you, in selected patients is verysafe and can be curative. A pertinent blog on this topic is on this link: https://lancefogan.blogspot.com/2017/12/blog-89-surgical-removal-of-seizure.html In addition, theGAMMA KNIFE offers hope: http://lancefogan.blogspot.com/2024/01/blog-162-gammaknife-is-focused.html?m=1

     Howto lower your risk of more seizures? You have heard this guidance from yourneurologist/physician repeatedly: “Are you taking your medication as directed?”You all know what is important but too often our patients don’t follow ourrecommendations. Especially our youthful patients. Life interferes: “I got sickwith a high fever or I forgot my pills or I traveled and left the pills at homeor I drank too much alcohol or I didn’t sleep and etc.”

     Keepa seizure journal to keep track of seizures. Is there a discernable pattern:not enough sleep, another illness, menstruation, stress, recreational drugs,beginning a new medication from another physician that could have an effect onyour epilepsy?

     Sideeffects can discourage taking your medication regularly. Reporting these sideeffects to your neurologist can help the doctor work with you to adjust dosagesor change the medication to another effective one if the side effects areintolerable.

     Considera pill-dispensing container that will separate the day’s dosages to discourageforgetting or taking more than prescribed any one day. Carry your physician’scontact information with you if you run out of meds.

     Alwayswear a bicycle helmet when bicycling, avoid bright flickering lights if theyprecipitate your seizures as they often do in some people. Do not drive a caruntil your neurologist clears you and consults with the Department of Vehicles.

1)    Richardson G. How Can People with Epilepsy PreventSeizures? BrainandLife,org. June/July 2024. p37.

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in recent New York Times Book Reviews, the Los Angeles TimesCalendar section and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.

Experience in our neurology clinics is that half ofthe epilepsy population in the United States, i.e. more than three millionAmericans (similar percent of the global population afflicted with epilepsy)can control their epilepsy. When the epilepsy is controlled with just theinitial trial of anticonvulsant drugs (ACD) the long term prognosis for thatperson’s epilepsy is very good. We physicians start treatment with a commonlyused ACD that from experience has shown effectiveness at the commonly used dosage.Side-effects such as drowsiness and laboratory tests of liver function, bloodcounts, etc. hopefully won’t be significant and the patient will adapt to thetreatment quickly.

Edward Faught, MD, wrote on the reality and the hopein treatment.1 As our patients are no doubt familiar, thecourse of epilepsy is variable. Experience shows that not achieving goodcontrol averages one-third of the epilepsy population, despite multipledifferent ACD treatments at various dosages. Identifying the presence orabsence of brain lesions can still lead us astray as some patients do welldespite significant abnormalities on scans. Younger age at onset, abnormal EEGsand very frequent seizures can adversely affect the prognosis.

According to the International League AgainstEpilepsy, drug resistant epilepsy is suggested when 2 ACDs appropriate fortheir type of epilepsy, as judged by your experienced neurologist, at tolerateddosages fail, then a third drug probably will also fail to control allseizures, too (10%).2 However, other studies suggesthope. Schiller and Najjar noted that even after 2 to 5 ACDs had failed anotherdrug could possibly produce seizure control. That was found in 16% of thosepatients deemed therapeutic failures.3

Keep in mind that a highly successful treatment thatcan cure epilepsy is brain surgery. In highly selected patients studied to ruleout adverse side effects that would result from surgery, these procedures aresafe. Post surgery life can be normal. Refer to my previous surgery-relatedblogs #155 (Successful surgery with robot assistant:  https://lancefogan.blogspot.com/2017/12/blog-89-surgical-removal-of-seizure.html), # 145 (Epilepsy patient passes driving test after brainsurgery for poorly controlled epilepsy https://lancefogan.blogspot.com/2022/08/blog-145-epilepsy-patient-passes.html), #121 (…Epilepsy surgery issafe.  https://lancefogan.blogspot.com/2020/08/blog-121-if-your-seizures-arent.html).

Inconclusion we should keep in mind that there is always hope in epilepsytherapy.          

1.    FaughtE. Balancing reality with hope in epilepsy therapy. Neurology 2018;91:p989-990.

2.    KwanP, Arzimanoglou A, Berg AT, et.al. Definition of Drug-Resistant Epilepsy Epilepsia2010; 51: 1069-1077.

3.    SchillerY, Najjar Y. Quantifying the response to antiepileptic drugs: effect of pasttreatment history. Neurology 2008; 70: 54-65.

hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view.“DINGS” is his first novel. Aside from acclamation on internet bookstoresites, U.S. Report of Books, and the Hollywood Book Review, DINGS has beenadvertised in recent New York Times Book Reviews, the Los Angeles TimesCalendar section and Publishers Weekly. DINGS teaches epilepsy and is now available ineBook, audiobook, soft and hard cover editions.