For Referring Providers

One major goal of the Epilepsy Program is to establish cooperative working relationships with referring physicians while at the same time helping to keep their knowledge of epilepsy current.

Cooperation between the Epilepsy Program and referring physicians is particularly important with epilepsy surgery patients because of the complexity of post-operative management. Patients whose seizures are eliminated by surgery can have severe problems adjusting to a life without epilepsy due to the lack of coping skills, pre-existing psychological difficulties, and the shock of a sudden, dramatic change in their lives. Post-operative psychosocial problems can overshadow any benefit derived from the surgery. Only by working closely with referring physicians and community resources can such tragedies be avoided.

Localization and surgical failures need to be re-evaluated periodically in order to determine the cause of the failure. Furthermore, advances in technology often produce new findings that can lead to improved understanding of difficult cases.

While some patients remain under the care of the Epilepsy Program, others return to the care of their neurologist or PCP.

For more information, please contact Dr. Vijay Thadani or Dr. Barbara Jobst directly.

Consultation evaluation

Any pediatric or adult patient with epilepsy can be referred to the Epilepsy Program for consultation. Patients will be seen in the outpatient clinic, and written reports, opinions and recommendations will be provided to the referring physician.

Diagnostic evaluation

Approximately 20 percent of patients referred to epilepsy centers are found not to have epilepsy, or have epilepsy plus other paroxysmal non-epileptic conditions. Other conditions include cardiac arrhythmias, or vasoreactive syncope and atypical drug reactions, but by far the most common nonepileptic disorders are psychogenetic attacks or pseudoseizures.

Differentiation between epileptic and nonepileptic disorders can be extremely difficult. The issue can usually be resolved by careful evaluation to include inpatient monitoring aimed at recording habitual attacks. Patients referred for diagnostic evaluation would first be seen in the outpatient clinic. Impressions and plans would be discussed with the referring physician and, if indicated, inpatient monitoring and further evaluation would be scheduled. Upon completion of the evaluation, written reports of findings and recommendations will be forwarded to the referring physician.

Presurgical evaluation

One of the more exciting developments in the practice of neurology and neurosurgery during the past 20 years has been the expansion of surgical options for patients with medically intractable epilepsy. This has been brought about by the development of specialized epilepsy monitoring units, improved neurosurgical techniques, incredible developments in diagnostic imaging, and the creation of modern computerized multichannel monitoring equipment.

Despite the expansion in specialized programs offering modern epilepsy surgery, an NIH consensus panel recently determined that, while epilepsy surgery was very beneficial in carefully selected patients, it was a grossly underused procedure throughout the world, for several reasons:

• Lack of available facilities in many locations
• Expense in terms of time, money, and personnel
• Underappreciation of the potential for enormous benefit at relatively low risk
• Unfamiliarity of practitioners with the various surgical options available

The presurgical evaluation carries certain risks. The intracarotid amytal procedure has the risks associated with carotid angiography. In relatively young patients, these risks are small. The risk associated with depth electrodes, such as intracerebral hemorrhage and infection, is approximately 3 percent.

Other key points

• A full range of diagnostic and therapeutic options for patients with medically refractory epilepsy are available at the Dartmouth-Hitchcock Medical Center.
• While there are no specific age limitations, the emphasis will be on the younger patient. If a patient can have seizures eliminated early in life and join the mainstream of society and the workforce, the expense involved in epilepsy surgery will be amortized many times over.
• Results of surgery, in terms of seizure control, will vary depending on the type of surgery and its goals.

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