Advanced Treatment and Management

Our epilepsy team knows how challenging life can be when you’re having frequent seizures. Our program brings specialists and other professionals together to manage even the most difficult-to-treat epilepsy cases.

What is Epilepsy?

Epilepsy is a neurological disorder characterized by seizures. Short bursts of intense electrical energy in the brain cause seizures. When these bursts occur in one part of the brain, it’s called a partial seizure. When they happen throughout the brain, it’s called a generalized seizure. The most severe seizure is a grand mal seizure, which can lead to loss of consciousness, and even death.

Seizure symptoms can include:

  • Brief blackout followed by a period of confusion
  • Changes in behavior, such as picking at one's clothing
  • Drooling or frothing at the mouth
  • Eye movements
  • Grunting and snorting
  • Loss of bladder or bowel control
  • Mood changes, such as sudden anger, unexplainable fear, panic, joy or laughter
  • Shaking of the entire body
  • Sudden falling
  • Tasting a bitter or metallic flavor
  • Teeth clenching
  • Temporary stop in breathing
  • Uncontrollable muscle spasms with twitching and jerking limbs (myoclonus)

Hard-To-Manage Epilepsy

Sometimes epilepsy doesn’t respond to treatment prescribed by your primary care doctor or general neurologist. When epilepsy is hard to treat, it’s often called intractable epilepsy. It can also be called refractory, uncontrolled or drug-resistant epilepsy.

If you have intractable epilepsy, you may live in fear of the next seizure. After all, you don’t know when it will strike or what you will be doing when it does. Our goal is to control your seizures effectively so you can do the things you want to do and live as fully as possible.

If your seizures have not been brought under control after three months of care by a primary care provider (such as a family physician or pediatrician), it’s time to seek specialized care. Your primary care doctor can refer you to a neurologist or to an epilepsy center. If you are already seeing a general neurologist, and your seizures have not been brought under control after 12 months, you should request a referral to a specialized epilepsy center with an epileptologist.

Experts in Care

The team at Penn State Health’s Level 4 Epilepsy Center includes epileptologists and other specialists who are trained and experienced in treating intractable (hard-to-treat) epilepsy. They’ll work together and with you to create a treatment plan tailored to your needs and goals.

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Why Choose Penn State Health

The Penn State Health Epilepsy Center is designated a Level 4 Center by the National Association of Epilepsy Centers (NAEC). Level 4 is the highest designation of epilepsy centers. Level 4 centers offer the most complex forms of diagnostic evaluations and treatment options, including intensive neurodiagnostic monitoring and extensive medical, neuropsychological and psychosocial treatment. Level 4 centers also offer complete evaluations for epilepsy surgery.

It’s a multidisciplinary program, bringing specialists from different fields together using a team approach. This team includes a wide range of professionals, including:

  • Adult and pediatric epileptologists (neurologists with specialty training in epilepsy)
  • Epilepsy surgery-trained neurosurgeons
  • Electroencephalogram (EEG) technologists
  • Neuroradiologists
  • Nuclear medicine radiologists
  • Psychiatrists
  • Clinical neuropsychologists
  • Neuroscience nurses
  • Dietitians

Our care is tailored just for you. The team works together and with you to make decisions based on your needs and goals. We’ll create a treatment plan designed just for you. We can confirm your diagnosis, and using advanced technology, determine where the seizures are coming from. Using this information, we can recommend a course of treatment that may include medication, dietary therapy or a range of surgical options. We’ll make sure you know what to expect from your treatment plan, and we’ll monitor your progress to ensure your epilepsy is well-managed and that seizures are brought under control.

At Penn State Health, you may have an opportunity to access new medications or treatments by participating in a clinical trial. Our epilepsy team will let you know if we think you could benefit from participation, and we’ll let you know what to expect so you can make an educated decision. Your participation allows you to access the latest promising treatments, it also contributes to new knowledge and its real-world application.

Find out more about clinical trials at Penn State Health.

A Complete Epilepsy Diagnosis and Treatment Program

There are many epilepsy syndromes, and the Penn State Level 4 Epilepsy Center treats them all. Regardless of what is causing your seizures, we can create a treatment program that can help you achieve the best possible outcomes - and possibly even a seizure-free life.

Diagnosis and Evaluation

Penn State Health’s skilled and experienced epileptologists (epilepsy specialists) will confirm your diagnosis and evaluate its causes and effects through a detailed history and clinical examination, followed by appropriate tests. Identifying the correct epilepsy syndrome and rapid treatment with the best possible medication can often greatly reduce the number of seizures and their effects on your life.

Initial tests usually include electroencephalography (EEG) and a high-field (3T) magnetic resonance imaging (MRI) scan. You may be admitted to our epilepsy monitoring unit (EMU) for video EEG monitoring.

Our specialists use many other advanced tests to accurately diagnose and evaluate epilepsy. If you may benefit from epilepsy surgery, you’ll need tests to ensure the surgery is performed safely, precisely and effectively.

Our team will talk to you about the tests you’ll need and what to expect. You can also read about the different types of diagnostic tests in our patient information booklet.

Presurgical Testing

Presurgical testing is done in two phases to determine whether you will be a good fit for epileptic surgery. The Phase I evaluation focuses on noninvasive tests. Not all patients will require every test during Phase I. Your epileptologist will determine the necessary and appropriate tests to best fit your needs.

Phase I testing can include:

  • Electroencephalography (EEG). This outpatient test is used to diagnose epilepsy and to determine if epileptic seizures are partial or generalized. It can be as short as 30 minutes or a longer ambulatory study for 24-72 hours where you go home with the electrodes on your scalp.
  • Inpatient video-EEG monitoring. This test is also performed with electrodes attached to the scalp, but you will be admitted to the epilepsy monitoring unit in the hospital for several days to record seizures with both video and EEG.
  • 3-Tesla Magnetic Resonance Imaging (MRI). This test can detect abnormalities that could be the cause of epilepsy.
  • Positron emission tomography (PET). PET scans look at the metabolic activity of the brain and help determine if your brain is functioning normally. PET scans are typically done in an outpatient setting. Our team will also record an EEG during the PET to confirm that you aren’t having a seizure at the time of the scan.
  • Single-photon emission computed tomography (SPECT). This test is performed during seizures and can identify the region of the brain with blood flow increases, determining where the seizure originated.
  • Neuropsychological evaluation, functional MRI. These tests are used to assess cognitive functions, especially language and memory function. The functional MRI also measures blood flow changes in areas of the brain during specific cognitive tasks.
  • Intracarotid amobarbital/methohexital (Wada test). In this test, medication is injected into one carotid artery at a time. The medication can cause a one- to five-minute paralysis of one-half of the brain to allow for testing of the other half. This test is also used to predict postoperative deficits in language and memory function.

After Phase I evaluation, our epilepsy team meets to discuss potential surgical options. The team might determine that more testing is needed. This additional testing is called Phase II evaluation.

Phase II evaluation involves video-EEG monitoring with electrodes that are placed inside the skull, on the surface of the brain or within the brain. Once the electrodes are placed, you will be transferred to the epilepsy monitoring unit for video-EEG monitoring.

The electrode types and implantation options for Phase II testing might include:

  • Subdural electrodes. These are placed directly on the surface of the brain to record the EEG without the interference of skin, fatty tissue, muscle and bone.
  • Depth electrodes. Small wires with electrodes are implanted directly in the brain to record deeper brain activity.
  • Combination of subdural and depth electrodes. You may receive a combination of both subdural and depth electrodes.
  • Stereoelectroencephalography (stereoEEG). Multiple depth electrodes are implanted in a specific pattern to contain the seizure focus.
  • Functional mapping. This usually happens in the epilepsy monitoring unit after enough seizures have been recorded. The team maps out critically important areas of the brain by using brief, painless electrical stimulation through each electrode.

Designated Center of Excellence

The Milton S. Hershey Medical Center offers access to the only academic Level 4 Epilepsy Center in south central Pennsylvania accredited by the National Association of Epilepsy Centers.

The Level 4 designation is granted by the National Association of Epilepsy Centers. Level 4 is the highest accreditation and means we offer the most complex types of epileptic diagnostic evaluations and treatment options, including intensive neurodiagnostic monitoring, as well as more extensive medical, neuropsychological and psychosocial treatment. Our Level 4 center also performs complete evaluations for epilepsy surgery and neurostimulation, including placement of intracranial electrodes and provides a broad range of surgical options.

Epilepsy Monitoring Unit (EMU)

In this six-bed inpatient unit for adult and pediatric patients, you’ll receive round-the-clock video-EEG monitoring. Each patient is given a private room with a private bath. This provides information about the ongoing electrical activity in the brain, and records and analyzes seizures. The EMU helps our team make a definite diagnosis and pinpoint the exact location in your brain where the seizures start. You may need to stay in the EMU, for several days, while doctors, nurses and technologists observe from the designated viewing area and monitor the EEG activity. Our team will take the utmost care to ensure your safety and comfort while you are in the EMU.

Accredited EEG Laboratory

The EEG laboratory at Penn State Health is accredited by the EEG Laboratory Accreditation Board of ABRET Neurodiagnostic Credentialing and Accreditation for both routine EEG and long-term monitoring (LTM). This means that it has met strict technical, quality and lab management standards and is recognized as a place where patients receive high-quality diagnostics.

Treatment

Our team will use the information gathered during diagnosis and evaluation to create a treatment plan based on your needs and goals. In many cases, medication can bring seizures under control successfully. However, sometimes surgery is the most effective and appropriate option. We’ll talk to you about your options, what to expect and what you’ll need to do before, during and after treatment.

Medications

Medications are highly effective and completely control seizures in the majority (approximately 70%) of patients. With more than 20 antiseizure medications currently available, and more likely to be available in the near future, there is a good chance one will work for you.

Our adult and pediatric epileptologists have the knowledge and experience needed to select the most appropriate medications for your specific needs. Their decisions about medication are based on:

  • Your age
  • Any additional medical conditions you have
  • Cost of medication
  • Your gender
  • Possible side effects of medicine
  • Potential interactions with your other medications
  • Your type of seizure and epilepsy

If your seizures are poorly controlled with two or more medications, you are said to have drug resistant, refractory or intractable (hard-to-treat) epilepsy. Our team may recommend different antiseizure medications singly or in combination, and we may talk to you about participating in a clinical trial to test a new medicine. We may also recommend surgery, a neurostimulation device or dietary therapy.

Surgery

Epilepsy surgery has a long record of safety and effectiveness, and our team is experienced in all types of surgical treatment, including the latest proven procedures. We’re committed to keeping you safe and as comfortable as possible before, during and after your surgical procedure.

Epilepsy surgery may involve resection, disconnection, stereotactic radiosurgery or implantation of neuromodulation devices.

Surgical Resections

Surgical resection is the removal of abnormal tissue. Types of resection may include:

  • Lesionectomy. A lesion is a brain abnormality that shows up on imaging. Some types of lesions - such as cavernous malformations (blood vessel abnormality) and tumors - are prone to cause seizures. When the pre-operative testing indicates that these lesions are the cause of the epilepsy, they can be removed surgically.
  • Lobectomy. Each hemisphere, or half, of the brain is divided into four main lobes - the frontal, temporal, parietal and occipital. Seizures may arise within any of the lobes. A lobectomy is an operation to remove a lobe of the brain. Removal of one of the temporal lobes - called a temporal lobectomy - is the most common type of epilepsy surgery performed. Other types of lobectomies may rely on more specialized testing and surgery to prove a lack of vital function (such as speech, memory, vision, motor function).
  • Multilobar resection. This involves removal of parts or all of two or more lobes of the brain. It is used for more widespread abnormalities causing seizures if no vital functions are in those regions.
  • Hemispherectomy. The brain is divided into a left and right hemisphere. In rare cases, children may have severe, uncontrollable and devastating seizures that can be associated with weakness on one side of the body. This may occur with a large amount of damage or injury to one of the hemispheres. Surgery to remove or disconnect a hemisphere, a hemispherectomy, may stop the seizures. The two main subtypes of this surgery are anatomic and functional. Anatomic hemispherectomy involves removing the entire half of the brain that is injured and is generating the debilitating seizures. This includes the four lobes of the hemisphere - frontal, temporal, parietal and occipital. Functional hemispherectomy involves separating the abnormal hemisphere from the normal one by disconnecting fibers that communicate between the two. Often, some portions of the abnormal brain are surgically removed to perform this disconnection.
  • Laser thermal ablation. In some cases where the region of seizure onset is limited to a small region, our team uses lasers to perform surgery. Using robotic targeting, surgeons place a laser fiber into the area to be treated. While under anesthesia, you’ll be taken to the MRI scanner to confirm location of the laser and to perform tissue ablation - using laser heat to destroy the abnormal tissue. Our MRI system provides live feedback with thermal heat maps to ensure abnormal areas are being destroyed and other regions protected.

Surgical Disconnection

These surgeries involve cutting and dividing fiber bundles that connect portions of the brain. The rationale is to separate the area of the brain generating the seizures from the normal brain.

  • Corpus callosotomy. This is one of the main fiber bundles that connect the two hemispheres. When debilitating generalized seizures or falling-type seizures start on one side of the brain and quickly spread to the other, patients may be candidates for this procedure. A large part of this fiber bundle may be cut. This procedure may not stop seizures, but it can greatly reduce them and improve quality of life.
  • Functional hemispherectomy. This involves separating the abnormal hemisphere from the normal one by disconnecting fibers that communicate between the two.
  • Multiple subpial transections (MST). If seizures arise from an area of the brain that cannot be safely removed, multiple subpial transections can be an option. In this procedure, a small wire is placed into the brain to perform transections at multiple points in a region. This can decrease seizures by disconnecting the cross-communication of neurons.

Stereotactic Radiosurgery

Stereotactic radiosurgery involves the delivery of a focused beam of radiation to a specific target area. Gamma Knife® radiosurgery, one of the most common forms of radiosurgery, uses gamma rays to target the area to be treated. In epilepsy, stereotactic radiosurgery can be used for small, deep-seated lesions that are visible on MRI.

Neurostimulation

Neurostimulation uses special devices to alter the activity of nerves. It’s often used to treat epilepsy that doesn’t respond well to medication. Our specialists are experienced in precisely placing these devices to help reduce seizures.

  • Vagus nerve stimulation. The vagus nerve stimulator (VNS) is a Food and Drug Administration-approved device for the treatment of epilepsy that is not controlled with antiseizure medications. It involves the surgical placement of electrodes around the vagus nerve in the neck and a generator placed below the collar bone in the upper chest region. It’s usually performed as an outpatient procedure. After placement, an epileptologist can program the device to change the intensity, duration and frequency of stimulation. Vagus nerve stimulation rarely cures seizures but may reduce their frequency and severity.
  • Responsive neurostimulation (RNS). The NeuroPace RNS device is a treatment for adults with partial onset seizures, with one or two seizure onset zones not controlled with antiepileptic drugs. Surgery involves placing a neurostimulator in the skull, connecting two electrodes in or around the area deemed the likely onset region for the seizure, placed either on the surface or into the brain. The device records brain waves and is programmed by the epileptologist to detect seizure onset and then deliver an impulse to stop the seizure. Data collected by the neurostimulator can be uploaded with the use of a handheld wand, to a secure web-based application accessed by the epileptologist. Like VNS, RNS improves seizure control but rarely stops seizures from occurring.
  • Deep brain stimulation (DBS). Approved for epilepsy in 2018, DBS delivers intermittent stimulation throughout the day and night to the anterior nucleus of the thalamus (ANT), a small brain structure involved in the spread of an initially localized seizure. Unlike RNS but similar to VNS, the stimulation is not triggered by detection of seizure onset.

Dietary Therapies

Our epilepsy program offers many dietary therapies - including the ketogenic diet and modified Atkins diet - to help patients control seizures. The ketogenic diet is a special high-fat, adequate protein and low carbohydrate diet that is initiated over three to four days in the hospital. The modified Atkins diet is similar to the ketogenic diet, but slightly less restrictive. Both diets have been shown to reduce seizures in about half the patients that are identified to be appropriate candidates. Dietary therapy may be an option for children or others with refractory epilepsy who are not surgical candidates.

Epilepsy Support Group

Living with epilepsy is challenging. Talking to other people and families who are living with epilepsy can help you cope and find ways to support...

Living with epilepsy is challenging. Talking to other people and families who are living with epilepsy can help you cope and find ways to support yourself and each other. That’s why we offer support groups for our epilepsy patients and their families. Penn State Health Milton S. Hershey Medical Center and the Epilepsy Association of Western and Central PA co-sponsor an epilepsy support group every month from 6 to 7:30 p.m. There is no fee to attend. For more information, contact Danielle Lewis at dlewis@eawcp.org or 717-730-6779, x2001.

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