A Comprehensive Approach to Epilepsy Care: The Minnesota Epilepsy Group Model

By Jenna Haines
Wednesday, August 28, 2019

Minnesota Epilepsy Group’s expansive team of providers specializes in diagnosing and treating epilepsy and other seizure-related conditions.

Recognized as both the largest epilepsy program in the Midwest and a level 4 epilepsy center in the Twin Cities, Minnesota Epilepsy Group provides state-of-the-art diagnosis and treatment services for patients of all ages with epilepsy and seizure-related conditions. These services are facilitated by Minnesota Epilepsy Group’s diverse team of epilepsy specialists, many of whom have been recognized internationally for their work in advancing epilepsy care.

These specialists include both adult and pediatric epileptologists (neurologists specializing in epilepsy), neurosurgeons who specialize in epilepsy, neuropsychologists, neuroradiologists, psychologists, electroencephalogram (EEG) technologists, nurses who specialize in epilepsy, clinical pharmacists, social workers, child life specialists, and occupational, physical and speech therapists.

“Having a comprehensive team of providers allows us to be thorough in our evaluations,” says James White, MD, an epileptologist at Minnesota Epilepsy Group. “We can ensure that we have true experts covering all aspects of care, including patients’ diet, psychosocial well-being and cognitive function. While reducing seizure activity is the major focus of what we do, the big picture is centered around improving patients’ quality of life.”

Extensive Diagnostic Evaluations

In addition to offering patients access to a number of clinical trials and some of the most advanced treatment options for seizures, including medications, surgery and alternative therapies, such as nutritional counseling and medical cannabis, Minnesota Epilepsy Group works with patients on both an inpatient and outpatient basis to ensure they receive a complete and accurate diagnosis.

Outpatient evaluations most often take place at one of the group’s two clinics in St. Paul and Edina. Here, patients can work with epileptologists, neuropsychologists, psychologists and social workers to help clarify their seizure type, adjust medications, improve side effect profiles, address any psychosocial concerns and collaboratively tackle other, everyday issues, such as problems with school, work or finances.

Inpatient evaluations are provided on both an emergency and elective basis and take place at one of Minnesota Epilepsy Group’s partnering hospitals.

Emergency admissions include patients who present with frequent seizure activity, status epilepticus (seizures lasting longer than five minutes in duration), symptoms of confusion or who have lapsed into a coma. In emergency cases, the primary goal is to stop patients’ seizure activity as quickly as possible to prevent long-term neurologic deficits. If a patient displays clear signs of a seizure, such as bodily convulsions, he or she is quickly treated with seizure medications.

However, according to Dr. White, a high percentage of patients experience seizures without convulsions. Instead, they may be in a confused state or stare off into the distance. These patients undergo continuous video-EEG monitoring — often for 24 to 48 hours — to help the epileptologists determine if they are having seizures, where the seizures are coming from and how best to move forward.

“Our ability to offer 24/7 video-EEG monitoring allows us to detect seizure activity with a better degree of certainty than a short EEG,” Dr. White says. “At many hospitals, many EEGs last only half an hour. We know that you miss a high percentage of seizures in critically ill patients, however, if you do not conduct longer monitoring sessions.”

Minnesota Epilepsy Group also offers inpatient, continuous video-EEG monitoring services and other diagnostic tests. Diagnostics include PET and MRI scans, magnetic source imaging (MSI), and neuropsychological and psychology evaluations, for patients electively seeking to determine whether they are experiencing epilepsy-related seizures or nonepileptic events, clarify their seizure type or obtain presurgical evaluation.

Presurgical evaluations are administered to patients with intractable epilepsy, meaning that the patient’s seizures are drug-resistant and cannot be controlled after completing a full course of two or more seizure medications. The data obtained during presurgical evaluation is then presented by each patient’s lead epileptologist at one of Minnesota Epilepsy Group’s weekly surgical conferences, a meeting involving approximately 20 providers of varying specialties.

Diagnostic Surgery

If a patient is determined to be a potential candidate for surgery, a new surgical, diagnostic tool can be utilized to help further localize the source of their seizures and verify that it is not in a functionally important area of the brain, such as an area related to speech or motor skills. This tool, known as stereotactic EEG (SEEG), was introduced to Minnesota Epilepsy Group by Nitin Agarwal, MD, a pediatric epileptologist at Minnesota Epilepsy Group.

“During an SEEG, we are able to insert small, filament-like electrodes deep into specific, predetermined brain areas,” Dr. Agarwal says. “This allows us to gather information on those areas of the brain. Children typically tolerate this tool better because there is no craniotomy involved. Instead, small holes are drilled into the skull, and the electrodes are passed through those holes.”

SEEG provides a 3D model of the brain and allows specialists to better understand the source of the seizures and how they propagate through the brain to cause symptoms. In turn, this procedure gives a second chance of healing to many patients who otherwise have not been considered to be good surgical candidates.

Advanced Surgical Treatments for Seizures

One of the most effective forms of surgeries for treating epilepsy is a resective surgery, such as temporal lobectomy, during which the neurosurgeon removes the area of the brain causing seizures. Resective surgery can potentially eliminate patients’ seizures altogether, but this procedure can be done only in cases where the source is localized and coming from an area of the brain that can be operated on safely.

If the source of seizures is coming from three or four areas of the brain or cannot be resected, patients can undergo neuromodulation, a technique that stimulates the brain over long periods of time — helping reduce both seizure frequency and intensity.

The vagus nerve stimulator (VNS), for example, is a neuromodulation device that can be used on both pediatric and adult patients. It is made up of two components — a battery, which is placed in the chest area, and a wire, which extends from the battery to the vagus nerve. By stimulating the vagus nerve, this device can reduce seizures by up to 60%.

Two newer neuromodulation techniques include responsive neurostimulation (RNS) and deep brain stimulation (DBS). RNS involves the placement of electrodes on the surface of the brain (or in the brain) in locations that the seizures are coming from. In the event of a seizure, this device can sense it and stimulate those predetermined areas of the brain to stop it. This technique is not yet universally approved for children but can be offered on a case-by-case basis with special approvals.

When treating epileptic seizures with DBS, probes are placed deep inside the left and right sides of the brain. The device is generally positioned to target and stimulate the anterior nucleus of the thalamus, which has connections to the cerebral cortex and helps reduce seizures in the long term.

“We recognize that epilepsy is about more than seizures. Children with epilepsy also suffer from learning disorders, such as dyslexia, and mood disorders, such as anxiety and depression, at much higher rates than other children. We pride ourselves in taking care of the whole patient, so we have a dedicated team that is able to treat those specific aspects of epilepsy.”
— Douglas Smith, MD, pediatric epileptologist at Minnesota Epilepsy Group

Pediatric and Geriatric Care

Generally, children and those over the age 60 most commonly develop epilepsy, which is why Minnesota Epilepsy Group employs both pediatric epileptologists and epileptologists with extensive experience in treating older adults. In addition to catering to an increased demand for new evaluations, having these specialists is important because both the causes and effects of epilepsy vary drastically between age groups.

“Pediatric epilepsy and adult epilepsy could be considered completely different diseases,” says Douglas Smith, MD, a pediatric epileptologist at Minnesota Epilepsy Group. “Children, for example, are far more likely to have epilepsy due to genetic causes and are more likely to outgrow their epilepsy. The comorbidities are also very different between children and adults. With pediatric epilepsy, we don’t have to deal nearly as often with issues of driving, pregnancy or certain comorbidities, such as renal failure or diabetes. However, pediatric epilepsy has its own unique challenges and is often associated with a greater sense of urgency.”

This urgency is due to seizures affecting children’s brains at key stages in their growth. If these seizures are not identified and treated early on, they can cause developmental delays that cannot be reversed.

Another priority for pediatric patients is ensuring that they do not fall behind academically, as children with uncontrolled seizures, unaddressed learning disorders or who are on medications that are too sedating often struggle in school.

Older adults account for the second spike in new epilepsy diagnoses due to an increase in incidences that can cause epilepsy, such as falls, brain tumors and strokes. Adults also, however, present unique challenges.

For instance, older adults tend to metabolize seizure medications slower; take more medications, which increases their risk of harmful drug interactions; be more negatively affected by side effect profiles, which can increase their risk of injuries and other ailments; have lower bone density, which can be further reduced by taking certain seizure medications; have other conditions that can mimic epilepsy symptoms; and have anxiety or depression, which can be more prevalent in patients with epilepsy of all ages.

However, by having a comprehensive staff of specialists capable of addressing each of the clinical and psychosocial challenges unique to different age groups, Minnesota Epilepsy Group is able to elevate the quality of care it delivers.

The Importance of High-Level Epilepsy Care

Receiving proper and timely treatment for seizures can help prevent damage to the brain and developmental delays in children. Studies have also found that early treatment can improve patients’ overall quality of life in the long term.

Helping ensure patients receive an accurate diagnosis and effective treatment plan for epilepsy or other seizure-related conditions as quickly as possible is paramount. That is why Minnesota Epilepsy Group encourages providers to refer to a level 4 epilepsy center patients who are suffering from seizures or have seizures related to a genetic disorder, need clarification of their seizures and epilepsy diagnosis, suffer from nonepileptic events, need evaluation for surgical treatments, are looking for alternative therapies like the ketogenic and modified Atkins diets, are in the hospital and confused, or are in a coma and/or struggle with side-effect profiles from epilepsy medications.

“At Minnesota Epilepsy Group, we are able to connect patients to the right resources, people and treatments right from the beginning,” Dr. Agarwal says. “When patients come here, they get more than access to the highest level of care for epilepsy and seizure-related conditions — they gain access to an entire comprehensive care model.”

For more information about Minnesota Epilepsy Group, visit mnepilepsy.org or call 651-241-5290.