Epileptology
Inpatient diagnosis and treatment of epilepsy
Epileptology is one of the focal points of treatment provided by the Neurological University Clinic of RKU - Universitäts- und Rehabilitationsklinken Ulm. The offering of diagnostics and therapy for inpatients covers routine EEG and NMR diagnostics with a programme specifically adapted to epileptological issues, the possibility of 24h EEG sampling without extra video documentation (mobile long-term EEG), and video EEG monitoring for pre-surgical diagnostics of epilepsy and differential diagnostics of unclear paroxysmal events. Furthermore, differential diagnostics is supplemented by polygraphic tilt table testing for distinguishing cardiovascular orthostatic dysregulations. Inpatients also profit from difficult changes in medication which could not be provided for outpatients.
Contact for special questions:
PD Dr. H. Lerche
Senior Physician
RKU - Neurological Clinic of Ulm University
Fax: 0731 177-1202
Email: Holger.Lerche@uni-ulm.de
Dr. Y. Weber
Email: yvonne.weber@uni-ulm.de
For appointments for starting to change medication or for general diagnostics, please contact the accepting senior physician available on the phone of the RKU's reception (0731 177-0).
To start video EEG monitoring or long-term EEG including tilt table diagnostics, please contact the video EEG diagnostics unit:
Ms S. Boschka
Phone: 0731 177-1230
Email: eeg.monitoring@rku.de
Pre-surgical diagnostics of epilepsy and surgical epilepsy treatment
In cases of epilepsy which are found difficult to treat and where prevention of attacks fails although all options of medication treatment have been tried (resistance to therapy defines as a lack of response to two sufficiently dosed standard antiepileptics, see below), therapists should consider surgery as an alternative treatment. This requires the epilepsy to be of the "focal epilepsy" type and attacks to originate from a defined cerebral region. So-called generalised epilepsies, i.e. epilepsies where both cerebral hemispheres are involved in an attack right from the start, cannot be treated surgically. In these cases, attacks cannot be prevented by surgical means. Whether or not there is a surgery option requires great efforts of preliminary examination to judge the individual case.
Requisite "basic examinations" include:
- long-term video EEG monitoring
- dedicated nuclear magnetic resonance imaging (NMRI) of the brain exceeding normal NMRI and focussed on the type of epilepsy
- a neuropsychological examination
The results of these examinations may suggest further supplementary examinations before a therapeutic approach can be suggested. This kind of pre-surgical diagnostics aims at identifying the cerebral region that is responsible for "dysfunction: epileptic attack" and at assessing the risks of surgery.
In the vast majority of cases, side-effects and complications of drug treatment subside when the problematic medication is no longer applied complications and "side-effects" of surgery cannot normally be made undone at a larger scaler. Clinical centres practising surgical treatment of epilepsy therefore agree to classify surgery as a secondary type of treatment. Only if extensive drug treatment fails to sufficiently control the epilectic attacks do medical professionals talk of "drug resistance" which is a prerequisite of surgical treatment of epilepsy. A current minimum definition of "drug resistance" reads as follows: A patient is drug-resistant if at least two single agent therapies of first-choice antiepilectics and a combined therapy of these two antiepileptics fail to prevent attacks or if they have intolerable side-effects.
Since epilectic attacks may be a symptom of progressing cerebral diseases (e.g. of brain tumours) which, for this very reason, demand surgery, the first occurrence of epileptic attacks should be answered with careful examinations to discover this kind of disease and to start appropriate treatment.
In cases where an existing epilepsy has been going on for longer and medication has failed to sufficiently control it, the outpatient epilepsy ward will recommend that their patients suffering from a focal type of epilepsy have pre-surgical basic diagnostic tests done. It should be noted that the decision to take these greater diagnostic efforts does not "automatically" include a decision for surgery. Patients can still personally decide for or against such treatment when, and only when, the possibilities of surgery plus their anticipated rate of success or risk can be assessed.
Ulm Epilepsy Centre provides pre-surgical diagnostics through the RKU's Neurology Clinic and actual surgery through the Neurosurgical Clinic of the district hospital in Günzburg. Patients will visit the outpatient epilepsy ward for advice on the indication of pre-surgical diagnostics.
Long-term video EEG monitoring
Pre-surgical epilepsy diagnostics requires long-term video EEG monitoring in order to understand the relation between clinically observed attacks and the electric currents through the brain shown on the EEG plot which helps to find the cerebral region of origin of attacks.
Moreover, long-term examinations often help to decide whether certain "attacks" are really indicative of epilepsy (differential diagnostics). Having "attacks" with or without a reduced state of consciousness and various other symptoms do not necessarily mean that this is "epilepsy". Just going by reported attack incidents, it is sometimes difficult to say whether these were epileptic attacks or not.
In such cases and if attacks are sufficiently frequent, therapists should consider long-term video EEG monitoring which, however, is performed on inpatients only. It involves several days of ongoing video monitoring while sampling data for EEG curve plots taken by electrodes of a special material (collodium) which are attached to the scalp. At the end of the examination period (up to one week depending of the frequency of attacks), the electrodes are removed. This method of examination allows both, an exact analysis of video recordings for the different symptoms of attacks and to plot accompanying EEG changes. Furthermore, EEG curves can be analysed in between attacks either when the patient is awake or asleep. In case electrodes on the scalp (so-called extracranial electrodes) fail to reliably locate the origin of attacks, a second step may consist of implanting electrodes directly in the brain (so-called intracranial electrodes) which will then be used to try and find the exact cerebral region where the attacks originate from.
Many types of epilepsy rarely produce EEG changes indicative of epilepsy. As a rule, EEG plots recorded in normal neurological practice take a snapshot of patients being awake and, sometimes, of patients at a stage of fatigue. Diagnostic possibilities are expanded by collecting EEG data after so-called "sleep deprivation". But even under these circumstances do many patients find it difficult to fall asleep and achieve deeper stages of sleep. Long-term monitoring manages to also record deep-sleep phases which allow more accurate statements about EEG changes in between attacks.