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Comprehensive Epilepsy Program at the University of Michigan

2 | Comprehensive Epilepsy Program at the University of Michigan

Highly Specialized Clinical Care The University of Michigan Comprehensive Epilepsy Program offers the advantage of a large and comprehensive academic center, bringing together many experts across medical disciplines with a national reputation for excellence in patient care, treatment and research. We offer hope to patients and their families through complete and expert care of epilepsy, even for the most complex cases. The team consists of highly skilled specialists who evaluate, diagnose and treat the full spectrum of epilepsy and seizure disorders through holistic clinical care, surgery, new drug trials, vagus nerve stimulation, and the latest imaging techniques.

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Our board-certified adult and pediatric neurologists, neurosurgeons, speech language pathologists, neuropsychologists, neuroradiologists, clinical nurse specialists and social workers meet on a weekly basis to discuss patients being evaluated in the Comprehensive Epilepsy Program, and to develop optimal treatment plans.

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The Comprehensive Epilepsy Program evaluates more than 3,000 patients every year with state-of-the-art brain imaging and diagnostic tools that help pinpoint the location and cause of seizures, and determine the best course of treatment for each individual. We assess more than 750 patients annually in our 24-hour epilepsymonitoring unit staffed by specially trained EEG technologists and nurses. Epilepsy Fellows and neurology faculty with expertise in epilepsy are available around the clock to read studies in real time. Our team has extensive experience performing and interpreting the following diagnostic techniques: • S  PECT imaging of blood flow in the brain, done by injecting a special tracer as soon as the seizure starts to help identify the most active part of the brain at seizure onset • P  ET imaging to identify brain areas involved in seizures

functional MRI (fMR)I to define areas of the brain that are involved in language, motor and other tasks • E  EG with video for all recordings, immediate access to an epileptologist with expertise in interpreting EEG recordings, and quantitative EEG available on every tracing • Inpatient language, memory and behavioral testing during events  lectrocoticography in the operating • E room or before surgery, looking directly at the brain for function and electrical discharges  agnetoencephalography (MEG) in • M selected cases to help us develop a better understanding about where seizures are starting Patients experiencing neuropsychological problems or difficulties with work or school performance may be referred to our Neuropsychology Program for neuropsychological testing, clinical evaluation or therapy.

 RI to evaluate for subtle changes • M in brain architecture as well as

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“The University of Michigan offers a person who has epilepsy unique services in terms of imaging, neuropsychology, speech language pathology, social work support, and the expertise of epileptologists and the neurosurgeons at a large academic center.” Simon Glynn, MD Assistant Professor, U-M Department of Neurology

The Comprehensive Epilepsy Program is designated a Level 4 referral center by the National Association of Epilepsy Centers. This designation is reserved for those centers that provide the highest level of medical and surgical diagnostic and treatment options for epilepsy patients.

A Life Transformed: Epilepsy Surgery Offers Hope Epilepsy surgery can be very helpful for some patients with medically refractory epilepsy. Despite this, only about one or two out of 100 people who may be eligible for neurosurgical treatment of epilepsy are ever referred for evaluation for surgery, and usually only after they have seizures that have not responded to medicines over decades. One of those people was Paul Skripnik, a 29-year-old musician and composer whose epilepsy prevented him from driving and attending music school. After many years spent unsuccessfully trying to control his seizures with various medications, Paul came to the specialists at the University of Michigan Comprehensive Epilepsy Program to see if he might be a candidate for surgical intervention. After extensive testing and imaging, our team implanted intracranial grids to confirm the exact source of Paul’s seizures in his parietal lobe and define a safe area to resect without placing his manual dexterity and higher brain function at risk.

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In January 2013, after living 16 months seizure-free, Paul and his musician friends celebrated by performing at “Seize the Day,” a benefit concert that raised funds for the Epilepsy Foundation of Michigan. Most of the music was written and composed by Paul since his operation. Most recently, Paul produced another benefit concert and participated in a panel discussion during U-M Investing in Abilities Week in October. “Living without seizures is a dream for all who experience epilepsy. Now it is a reality,” he says. “My thinking skills, memory, and faculty for music have improved steadily since the operation. I am overjoyed to be rid of that part of my brain. My life was not only saved, but changed for the better.”

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Surgical Treatment of Epilepsy While most patients’ seizures can be adequately controlled with antiepileptic medicines, around 30 percent are resistant to such therapy and may benefit from surgical removal of the epileptic focus. In cases of medically refractory epilepsy, surgery often provides a cure for the seizures. The Comprehensive Epilepsy Program has extensive experience and a national reputation for excellence in epilepsy surgery, performing 70 to 100 procedures per year. Potential candidates for this surgery are carefully evaluated in our weekly conference.

Implanted intracranial electrodes

6 | Comprehensive Epilepsy Program at the University of Michigan

Treatment plans are tailored to meet the needs of individual patients, taking into consideration the social, psychological and physical factors unique to them. Our Program provides a comprehensive range of surgical options for our epilepsy patients, ranging from minimally invasive neurostimulation therapies to direct brain electrical recordings, to brain resections of various types. Some of the more common procedures performed are:

Vagus Nerve Stimulation Stimulation of the vagus nerve in the neck can provide a significant reduction in the number and severity of seizures in selected patients. We have vast experience with both adult and pediatric patients in this therapy and currently have implanted nearly 500 patients with these devices. The best candidates are typically patients whose epilepsy is determined to be generalized epilepsy not originating from a specific area (focal point) of the brain or originating from a focal point that cannot be determined, or that is coming from a focal point that is not safe to remove.

Grids and Depth Electrodes Our neurosurgeons may place electrodes over the brain surface (grids) or depth electrodes to allow us to precisely determine what area of the brain seizures are originating from and if it is safe to remove that area. Intracranial electrodes provide extremely sensitive information on the electrical activity of the neurons, and can reveal the onset of a seizure far in advance of its appearance on scalp EEG. When used in the appropriate situations, grids and depth electrodes are powerful tools that can pinpoint the source of a patient’s seizures.

Temporal Lobectomy Many patients with epilepsy have seizures that originate from the temporal lobe. The temporal lobectomy is therefore one of the most common epilepsy surgery procedures. Temporal lobectomy often results in a cure or significant improvement offering a cure in nearly 70 percent of patients with temporal lobe epilepsy. In patients whose temporal lobe seizures originate near areas that control language, we offer modified temporal lobe resections that preserve these language areas, without compromising the seizure-free outcome.

Other Cortical Resection Another surgical option to stop seizures is a specialized cortical resection procedure in which epileptic tissue caused by congenital anomalies, scar from brain injury or brain tumors is removed. This procedure can be performed in any lobe of the brain. Such procedures are usually done in conjunction with grid electrode recordings, since the seizure-onset zone in these situations is complex and frequently larger than the scar or congenital abnormality at its center.

Awake Brain Surgery In certain patients, the seizure-onset zone can be located in and around brain regions that are important in motor or language function. Since the safety of removing such brain areas is of paramount importance, information on the exact location of these areas in relation to the seizure onset zone must be obtained. We can obtain such information using grid electrodes, or on occasion offer our patients surgery to remove the abnormal brain area under local anesthetic and a twilight anesthetic. Our surgical team has significant expertise in awake brain surgery, allowing our patients the option of operations on brain areas in close proximity to motor or language functions, with a much lower risk.

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“We have a very broad and deep group of physicians and staff with tremendous experience and expertise. They are all here to do one thing: offer safe and effective surgeries for patients with epilepsy.� Oren Sagher, MD Professor, U-M Department of Neurosurgery

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Epilepsy Research At the University of Michigan Comprehensive Epilepsy Program, our team is at the forefront of epilepsy research, participating in diverse epilepsy research efforts ranging from individual clinical projects to nationally funded clinical and basic science trials. We seek to improve our understanding of disease mechanisms and genetic influences, develop better drug therapies, and discover new treatment options for all adult and pediatric patients with seizure disorders. Ongoing efforts include projects cofunded by NIH/NINDS, Citizens United for Research in Epilepsy (CURE), the Dravet Syndrome Foundation,

the American Epilepsy Society, the Pediatric Epilepsy Research Foundation, the Centers for Disease Control and Prevention, and the Center for Organogenesis at U-M, as well as industry-sponsored studies. Our faculty is currently examining animal models containing adult neural stem cells with epileptic markers. This innovative replicating of stem cells will help us understand the role of neural stem cells in epilepsy, and ultimately improve treatment for our patients. Our team also participated in authoring a recently published study in the Annals of Neurology that revealed new information about a possible cause of

LEFT: The process of taking a patient skin biopsy

to brain cells for studying epilepsy mechanisms. RIGHT: Stained resected hippocampal tissue

from an epilepsy patient surgical procedure.

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Dravet syndrome using neurons from stem cells that were created from skin cells of children with the disease. These new findings underline the potential for these new techniques to help our understanding of epilepsy in our patients. Another study is focused on understanding mechanisms underlying the basic physiological generators of epileptic seizures through sophisticated EEG recordings and computational models, and then translating this information into novel device therapies that will stop seizures.

Epilepsy affects approximately 2.2 million Americans— of whom more than 300,000 are children under the age of 15—and is the fourth most common neurological disorder in the U.S., according to the Epilepsy Foundation.

Clinical areas of epilepsy research include quality of life issues such as sleep, depression and comorbidities of epileptic patients, as well as clinical genetic studies to determine if these tests may predict the response of individual patients to anti-epileptic medications, and registries for infants and young children with new-onset epilepsy. Our program is the only site in the state of Michigan to participate in the Epilepsy Phenome/Genome Project, an international consortium of 27 clinical centers in the U.S., Canada and Australia funded by the National Institute of Neurological Disorders and Stroke. The goal of this study is to learn more about the genetic basis of epilepsy to further improve the clinical care of patients who live with this disease. [www.epgp.org]

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Pediatric Patient Care The Comprehensive Epilepsy Program includes a dedicated pediatric team that diagnoses and treats children experiencing all types of seizures. About 1,500 pediatric patients are seen by our specialists every year. All of the services and testing described for adult patients are also available for children, in a child- and family-friendly setting staffed by professionals with expertise in pediatrics. Our state-of-theart pediatric EEG facility provides EEGs for children of all ages, including routine EEG studies, short-term outpatient and ambulatory EEG monitoring. We also provide inpatient video-EEG monitoring in order to characterize events and seizures, and for epilepsy surgery evaluations. Additionally, we offer state-of-the-art video-EEG for critically ill newborns and children in the C.S. Mott Children’s Hospital intensive care units. Children experiencing neuropsychological problems or difficulties with school performance may be referred for neuropsychological testing, clinical evaluation or therapy.

About 70 percent of children can control their seizures with one medication. Our Pediatric Treatment-Resistant Epilepsy team provides evaluation and treatment for children whose medications do not adequately control their seizures. For these young patients, we offer a range of other treatment options, including ketogenic diet management, vagus nerve stimulation and epilepsy surgery. Our multidisciplinary team includes pediatric epileptologists, general child neurologists, pediatric neurosurgeons, ketogenic dieticians, nurses, social workers, and epilepsy care coordinators. Our pediatric epileptologists are involved in research to study seizures in newborns, outcomes of pediatric epilepsy treatments on the genetics and epidemiology of neonatal seizures and early-childhood epilepsy, and transition programs for teens and their parents, as they prepare for life as an adult with epilepsy.

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Our Faculty Adult Faculty

Our dedicated team of adult, pediatric and multidisciplinary faculty is passionate about caring for patients with epilepsy. Our goal is to restore quality of life and to help people live seizure-free. We are dedicated to understanding all aspects of epilepsy, improving clinical care and uncovering the best possible treatment options through research.

Simon Glynn, MD Assistant Professor, Department of Neurology

Oren Sagher, MD Professor, Department of Neurosurgery

Temenusha Mihaylova, MD, PhD Assistant Professor, Department of Neurology

Linda Selwa, MD Co-Director, Comprehensive Epilepsy Program Professor, Department of Neurology

Daneila Minecan, MD Associate Professor, Department of Neurology

William Stacey, MD, PhD Assistant Professor, Department of Neurology

Jack Parent, MD Co-Director, Comprehensive Epilepsy Program Professor, Department of Neurology

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Pediatric Faculty

Hugh Garton, MD Associate Professor, Department of Neurosurgery

Sucheta Joshi, MD, MS Associate Professor, Pediatrics

Renée Shellhaas, MD, MS Assistant Professor, Pediatrics

If you would like to consult with a member of the Comprehensive Epilepsy Program or refer a patient, please contact M-LINE 24 hours a day, seven days a week.

M-LINE (800) 962-3555 COMPREHENSIVE EPILEPSY PROGRAM

UofMHealth.org/epilepsy Rani Singh, MD Assistant Professor, Pediatrics

Regents of the University of Michigan Mark J. Bernstein, Julia Donovan Darlow, Laurence B. Deitch, Shauna Ryder Diggs, Denise Ilitch, Andrea Fischer Newman, Andrew C. Richner, Katherine E. White, Mary Sue Coleman, ex officio. © 2013, The Regents of the University of Michigan.

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“Our goal is to make patients with difficult epilepsy seizure-free — people who have jobs and children and can drive and be independent, no different than anyone else.” Oren Sagher, MD | Professor, U-M Department of Neurosurgery

Adult Comprehensive Epilepsy Program Taubman Medical Center 1500 E. Medical Center Drive Ann Arbor, MI 48109

Pediatric Epilepsy Program C.S. Mott Children’s Hospital 1540 E. Medical Center Drive Ann Arbor, MI 48109

M-LINE (800) 962-3555 | UofMHealth.org/neurosciences


University of Michigan Comprehensive Epilepsy Program