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Then and Now: VA Innovates in Epilepsy Treatment and Evaluation

by U.S. Medicine

November 10, 2014

By Annette M. Boyle

ALBUQUERQUE – The VA has played a critical role in advancing epilepsy research since 1969, when the first VA unit to study epilepsy — and the first comprehensive epilepsy program in the country — opened in West Haven, CT.

Researchers at the VA and Yale University were the first to combine video recordings of seizures and electrographic changes recorded by polygraph. The technique was so new that the researchers had to purchase the video equipment from a detective agency because no medical equipment vendors supplied video equipment, according to the Yale Comprehensive Epilepsy Center.

“It’s important to realize that the VA has been at the forefront of epilepsy evaluation and treatment,” said Glenn Graham, MD, PhD, deputy national director of neurology for the VA and associate professor of neurology, radiology and neurosciences at the University of New Mexico School of Medicine. “Over the past 50 years, the VA has pioneered epilepsy advances including intensive monitoring, antiepileptic drug monitoring and epilepsy surgery, among many other advances.”

Susan Hayes, EEG Technician at the Durham, NC, VA Medical Center, sets an unidentified  patient up for an EEG. This  is one of the procedures used at the VA Southeast Epilepsy Center of Excellence to diagnose epilepsy. VA Photo.

Susan Hayes, EEG Technician at the Durham, NC, VA Medical Center, sets an unidentified patient up for an EEG. This is one of the procedures used at the VA Southeast Epilepsy Center of Excellence to diagnose epilepsy. VA Photo.

In 1964, researchers primarily understood epilepsy based on clinical phenomenology obtained by patient history, he said. Bulky, early EEGs used polygraph equipment to capture epileptic seizures, and researchers recognized the obvious structural lesions caused by trauma and tumors. An understanding of the relationship between temporal lobe epilepsy and hippocampal sclerosis was in its early stages, as was an awareness that surgery might help some patients with epilepsy.

In 1972, the VA officially designated the West Haven program and another at the Durham, NC, VA as epilepsy centers. During the next few years, new VA epilepsy centers opened in Dallas; Madison, WI; Minneapolis, Seattle and Los Angeles.

The centers conducted landmark research in the use of medications to treat epilepsy. Few drugs treated epilepsy in the mid-1960s, and those that did, chiefly phenytoin and phenobarbital, had serious side effects.

In 1968, carbamazepine gained Food and Drug Administration (FDA) approval, and many others followed in the next two decades. From the mid-1970s through the early 1990s, the VA/Yale center coordinated the clinical studies of antiepileptic drugs with colleagues in VA medical centers across the United States. These multicenter cooperative studies evolved into the largest controlled trials ever for epilepsy, according to the Yale Comprehensive Epilepsy Center.

“For many reasons, the VA Epilepsy Centers involuted about 20 years later,” in the early 1990s, said Graham. While the VA stepped back from epilepsy research for about 15 years, major developments in the field changed how researchers understood and physicians treated seizures and epilepsy.

Initially, “epilepsy was diagnosed with routine EEG and without good brain imaging, so diagnosis was largely clinical and often incorrect,” Graham told U.S. Medicine. “The advent of sophisticated brain-imaging methods, such as MRI, have allowed clear imaging of the brain to establish causes for seizures and epilepsy. Long-term video-EEG in epilepsy-monitoring units is now an established standard for care that allows seizure disorders and syndromes to be correctly diagnosed, which leads to better outcomes and treatment for patients.”

In the years after the closure of the initial VA epilepsy centers, researchers made significant strides in identifying genes involved in epilepsy and gained a much better understanding of the cellular mechanisms of seizure generation. Advances in brain neurochemistry also improved care for epilepsy during this time.

In 2008, the VA founded the Epilepsy Centers of Excellence, 16 sites organized into four regions that work together to provide the best possible care to veterans with epilepsy. Once again, the VA is “doing groundbreaking work studying the incidence, prevalence and treatment of post-traumatic epilepsy in veterans of recent conflicts and of psychogenic non-epileptic seizures (PNES),” Graham said.

The VA first recognized PNES during the late 1960s, and growing awareness of the prevalence of the condition among veterans has led to a focus on PNES at the reestablished Centers of Excellence. The VA has developed and piloted effective treatments for these frequently misdiagnosed and improperly treated seizures, including the use of cognitive behavior therapy, resulting in cures for many veterans, according to Graham.

More than 20 antiepileptic drugs are now available, with less toxicity and fewer side effects than their predecessors. Still, approximately 30% of patients do not fully respond to medication. “These patients now undergo video-EEG monitoring to define their type of epilepsy and to rule out PNES or other conditions that may mimic epilepsy,” Graham noted. Many of these patients have focal epilepsy that may be treated with surgical resection, pioneered at the original Yale/VA center, while others are candidates for new therapies that stimulate either the vagus nerve or the brain directly.

The teams that treat veterans with epilepsy today have not only more tools, but also a much broader view of the impact of epilepsy and seizures on patients. During the 1960s and 1970s, the VA offered neither psychological interventions to epileptic patients suffering from depression and anxiety nor help with psychosocial problems such as employment and driving. In contrast, at the current Epilepsy Centers of Excellence “treatment of psychological and social complications of epilepsy and seizures are a key aspect of effective therapy,” Graham said.

Continued advances can be expected as imaging technologies steadily improve, giving ever-clearer visibility into the structural, electrical and other factors that contribute to and characterize epilepsy. The VA’s commitment to funding research into epilepsy and the dedication of the many clinicians in the Centers of Excellence and elsewhere in the VA who continue to develop and participate in large cooperative studies promise to provide definitive answers about the effectiveness of various treatments over time for the benefit of veterans and other patients with epilepsy and other seizure disorders.

During the past five decades, the VA also made significant strides in increasing understanding of other neurological disorders including Parkinson’s disease and Alzheimer’s disease. In 2001, the VA established the Parkinson’s Disease Research, Education and Clinical Center network, which supports Centers of Excellence in Portland/Seattle, San Francisco, Los Angeles, Houston, Richmond and Philadelphia. These six centers are conducting national studies on surgical interventions, deep brain stimulation, drug therapies, gait and falling issues, non-motor fluctuations, olfactory function and mental health issues associated with Parkinson’s.

As the number of veterans with Alzheimer’s disease and other forms of dementia continues to increase, the VA also has risen to the challenge of developing better methods of diagnosis and treatment. Current research in this area includes blood tests for dementia risk and evaluation of medications that may slow brain degeneration…


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