On Tuesday July 5^th 2016, Queen Square Private Healthcare welcomed an audience of GPs and charitable organisations to the latest in the Queen Square GP Seminar series.  For this event, we were privileged to have Dr Sanjeev Rajakulendran speak for us on the management of long term epilepsy.  Dr Rajakulendran is a consultant neurologist at the National Hospital for Neurology and Neurosurgery and sees private patients at the Queen Square Private Consulting Rooms.  Along with his neurology colleagues, he runs various epilepsy clinics for NHS and private patients in Queen Square.

The event was opened by Fiona Vicary, the superintendent of the Queen Square Imaging Centre and after a brief welcome, she introduced the key speaker.

Dr Rajakulendran started by giving an overview of chronic epilepsy which would form the basis of his presentation.  He explained that approximately 70% of individuals with epilepsy will be rendered seizure free with the appropriate anti-epileptic medication.  However, the remaining 30% of sufferers (between 100,000 and 125,000 patients in the UK) will continue to experience seizures.  The mortality rate of this group is two to three times that of the general population, owing to the risk from seizure related injury, sudden unexpected death in epilepsy (SUDEP), underlying undiagnosed conditions and suicide.  Reducing the number of patients with uncontrolled seizures is now a priority.  It was explained that the risk of apparent drug resistance is greater in those patients who do not respond to their first appropriate anti-epileptic medication and those who had a high number of seizures prior to diagnosis and treatment i.e. a longer duration of epilepsy.

Dr Rajakulendran then moved on to present a practical approach to chronic epilepsy.

Firstly, he advised that the first question should be is it epilepsy?  The differential diagnosis of seizures is broad and includes:

• Vasovagal syncope
• Cardiac Syncope
• Psychogenic non-epileptic attack / dissociative seizure
• Migraine
• Hypoglycaemia
• Transient Ischaemic Attack
• Panic Attack, and
• Central nervous system inflammation (as in MS)

Sound clinical examination is essential to classify epilepsy and Dr Rajakulendran emphasised the importance of the use of first seizure clinics and neurologist review.  As many as 20% of individuals with apparent chronic epilepsy will in fact be suffering from non-epileptic attacks.

Dr Rajakulendran then focussed on dissociative seizures and psychogenic non-epileptic attacks as a common but under-recognised alternative explanation for chronic seizure.  He explained that patients will often, but not necessarily always have a history of psychiatric illness, and such patients can often present a challenge.  Between 15-18% if suspected seizures are thought to be dissociative in nature and can of course, co-exist with epileptic seizures.

Dr Rajakulendran then outlined some common factors which could be used to distinguish epileptic, from dissociative seizures.  Epileptic seizures are often sudden in onset, whereas dissociative seizures may be more gradual in nature.  The situation in which a seizure presents can also be potentially relevant in dissociative seizures, whereas epileptic events are thought to be random in this respect.  Epileptic seizures are commonly brief compared to dissociative seizures, although are associated with a longer period of recovery. (Post ictal confusion).  Crying and resistance to eye opening are uncommon in epilepsy but sometimes a feature of dissociative seizures, whereas tongue biting is common in epilepsy (particularly the lateral aspect) but rare in dissociative seizures.  Finally, motor activity during epilepsy is often synchronous and rhythmical, whereas dissociative seizures are commonly asynchronous, involving waxing and waning movement, pelvic thrusting and side to side head movement.  Eye witness account and even recordings of such attacks can be most useful for diagnosis, and video-telemetry is regarded to be the gold standard for diagnosis.  Even with explanation, treatment for depression and anxiety if present and cognitive behavioural therapy, prognosis is variable, with 50-70% of patient continuing to have dissociative seizures.

Dr Rajakulendran proceeded to explain the role of a neurologist in a specialist setting such as Queen Square.  Firstly, a neurologist would consider using appropriate investigations.  MRI can be useful for identifying covert structural lesions and PET/SPECT imaging is now increasing in popularity.  Routine and Sleep EEG and Video telemetry (particularly when dissociative seizures are suspected) are all also commonly used diagnostic tools.  A neurologist would then assess treatment options.  With systematic trials of anti-epileptic medications, 10-15% of sufferers may be rendered seizure free and more than 25% may experience significant reduction in seizure occurrence.  These trials are tailored to each patient so that the patient benefits fully from a dedicated treatment plan, coordinated with their named neurologist.  Most importantly, the neurologist will withdraw medications if they are found not be effective.  Surgery is also a valid treatment option, although this should be considered earlier if possible.  Palliative procedures such as vagal nerve stimulation are also common, as well as dietary therapy such as the ketogenic diet.  Access to epilepsy nurse specialists and counselling is also essential.

Dr Rajakulendran then proceeded to discuss various risk factors for patients with chronic epilepsy which should be monitored.  Patients with chronic epilepsy have a 2-3 fold increase in fracture risk due to the observed effects of anti epileptic drugs on bone metabolism.  Therefore, a consideration of bone health is paramount.  Vitamin D levels should be monitored, and supplementation with Vitamin D and Calcium should be considered.  Advice should also be given to the patient regarding lifestyle choices such as diet, alcohol consumption, smoking and exercise.  The use of Sodium Valproate in female patients (particularly those of childbearing age) was also discussed.  The rate of teratogenicity of Sodium Valproate is around 10%, although there is now major concern about its effect on neurodevelopment and in particular, its effect on IQ, language and memory and potential links with autism/ADHD (rates of 30-40%).  Dr Rajakulendran suggested this as red flag to all clinicians, who should question whether female patients should be on valproate and if so, were they aware of the risks and given advice regarding contraception.  Again, the importance of specialist input was emphasised.

Finally, Dr Rajakulendran discussed the potential for the use of medicinal cannabis for the treatment of epilepsy.  He explained that there are anecdotal reports and animal studies which suggest a potential anti-epileptic effect of cannabis, and in particular the cannabidiol compound which does not cause psychoactive effects but has been shown to have anti-seizure effects in animal models.  Randomised trials are needed to assess its effectiveness but the compound may be useful in severe paediatric epilepsy syndromes such as Lennox-Gastaut Syndrome.

To conclude, Dr Rajakulendran urged the audience to resist the view that ‘nothing can be done’ for patients who suffer with chronic seizures.  Care professionals should first question whether the seizures can be attributed to epilepsy and if necessary, refer the patient to a tertiary centre and neurologist with a special interest in epilepsy.  Consideration should be given to co-morbidities which may be exacerbating seizure activity, and special consideration should also be paid to bone health.

Following the presentation, delegates were invited to the Queen Square Private Consulting Rooms where they enjoyed a drinks and canapes reception and the chance to network with their colleague and the evening’s speaker.

The next GP seminar is planned for Tuesday 6^th September 2016 and will be a dedicated session on Headache and Migraine, led by Dr Manjit Matharu.