How a Level 4 Epilepsy Center Offers New Paths to Seizure Control.

For people living with epilepsy, seizures are more than just a medical event. They can impact the ability to drive, think clearly, work, or live independently. The goal of seizure control is getting back to your life.

Almost 3 million adults, and nearly half a million children, in the U.S. live with epilepsy, a disorder in which the dysregulated flow of brain electricity results in seizures. These sudden, temporary changes in brain function can range from momentary lapses of attention to convulsions.

Most people with epilepsy can control their condition with medications. Yet for about 30% of people—about 1 million people in the U.S.—medication isn’t enough. This is called drug-resistant (refractory) epilepsy, and it requires advanced expertise to help patients get better control of their seizures and improve their quality of life.

What is a Level 4 Comprehensive Epilepsy Center?

MedStar Georgetown University Hospital is home to a National Association of Epilepsy Centers (NAEC) Level 4 designation—the highest possible level of care. 

This recognition means we provide a comprehensive set of services for patients, from the most advanced diagnostic mapping to complex neurosurgery. One of the key parts of our program is how we work together. 

In our regular surgical conferences, we gather expert neurologists, neurosurgeons, radiologists, and neuropsychologists to review and discuss the best treatment path for each patient. Working together means we’re in constant communication, and each patient’s individual recommendations are backed by our collective experience.

Foundation in observation: The Epilepsy Monitoring Unit.

Seizures are unpredictable and individualized. There are many different kinds of seizures, and they can start in different areas of the brain. To understand where they start and how they progress, it’s helpful to be able to “watch” a seizure in real time in a safe, controlled environment—the epilepsy monitoring unit (EMU).

In the EMU, specially trained neurologists, nurses, and technicians use continuous video EEG monitoring while patients stay in private rooms with around-the-clock nursing care. This method enables us to sync up the physical symptoms of a seizure with the electrical activity in the brain. Recording over an extended period gives us a more complete picture of brain activity before, during, and after a seizure.

This information helps the neurologist better understand the type of seizure and identify the precise area in the brain where seizures start. This valuable information helps us decide upon and deliver the most effective treatment. 

Precision mapping and treatment options.

Once we’ve captured images of a seizure in action, we use advanced tools to build a 3D map of the brain. These tools can include:

• High-resolution MRI to identify physical scarring or tumors.

• PET scans to learn how the brain uses sugar for energy. Areas of decreased sugar consumption can indicate the source of a seizure.

• Functional MRI to measure small changes in blood flow that happen with brain activity.

When we’re unable to pinpoint precisely where in the brain seizures are produced, we can opt for a Phase II study to conduct intracranial monitoring. During this specialized surgery, we place electrodes directly in or on the brain to identify the source.

Surgical resection: The gold standard.

MedStar Health offers some of the most sophisticated surgical techniques to treat epilepsy. When we’re able to find a clear source (or focus) that’s causing seizures, the most effective treatment is surgical resection to remove that small portion of the brain. 

Surgical options include:

• Temporal lobe resection: Removes all or part of the temporal lobe, where many seizures can start.

• Extratemporal cortical resection: Removal of brain tissue in other areas where seizures begin.

• Lesion resection: Removal of lesions that cause seizure activity, such as tumors. 

• Corpus callosal section: Restricts seizure activity to one half of the brain by disrupting the nerve pathways that connect its hemispheres.

Neuromodulation: Pacemaker for the brain.

When seizures start in more than one place in the brain, or when the focus area is too important to remove, we consider neuromodulation. These smart devices act like pacemakers for the brain, helping to regulate electrical activity and control seizures.

These devices include:

• Responsive neurostimulation (RNS): Implanted in the skull to monitor the brain 24/7. When it detects the very beginning of a seizure, the device delivers a small electrical pulse to stop it from spreading.

• Deep brain stimulation (DBS): Provides continuous electrical stimulation to a part of the brain called the thalamus. This helps lower the brain’s overall irritability, reducing the frequency of seizures.

• Vagus nerve stimulation (VNS): Placed in the neck to send pulses of electricity to the brain through the vagus nerve. This helps patients control seizures about as well as an additional medication.

In our research, we’re always looking for ways to make treatment safer and more effective. This includes exploring the use of stem cells to improve the brain’s ability to stop seizures. We’re also excited to explore innovative solutions for wireless monitoring so patients can go about their daily lives while we keep an eye on seizure activity.  

Related: Read "Deep Brain Stimulation for Movement Disorders: Improved Quality of Life, Less Medication."

Dietary considerations.

It’s not clear why, but ketosis and the ketogenic diet can help control seizures when medication fails – especially in children. This method maintains a low calorie count by making fat the primary dietary component. The ketogenic diet causes the body to remain in ketosis, a fat-burning mode, for long periods.

Next steps in seizure control.

The idea of having brain surgery can be scary. Being evaluated by our team doesn’t mean you’ve committed to surgery. First, we work to understand what’s happening in your brain. We’ll only recommend surgery if we’re confident it’s your best option to achieve seizure control.

We encourage all our patients and their families to connect with advocacy groups such as the Epilepsy Foundation. Our teams are active in these programs and find their virtual and in-person support groups, outings, and educational activities helpful and empowering.

Many patients with epilepsy may have been told for years their options are limited, or “nothing can be done.” At our Level 4 Comprehensive Epilepsy Center, we find there are often many options that can help our patients find a new path to seizure control and a better quality of life.