M.I. Saleh, MD, PhD
Seizures at Moffitt are as common as brain tumors and neoplasm in general. Unfortunately, seizures can be a reflection and a manifestation of multiple etiologies, including the brain tumor itself, the scarring, radiation and chemotherapy, along with the effects of other neoplasm on the brain, liver, kidney, and the disturbance of the metabolic and hemodynamic balance. Adding to all of that is the lifestyle, diet, other medications, sleep pattern and hygiene of the patient.
To better manage and control seizures in general, one needs to have a complete multilevel approach.
The seizure itself could reflect or appear in different presentations and manifestations from a clear generalized tonic-clonic seizure to a simple twitching and jerking to hints of confusion, dizziness, funny feeling, weakness, and/or behavioral variation and mood swings. For that reason, one has to approach the complexity of seizure diagnosis and control in a systematic approach focusing on the following:
- Educating the patient and the family regarding the nature of seizure and its manifestation; the best way to report it, the trigger of the seizure and how to avoid it, along with the discipline of taking medications as scheduled and advised. It is very common for recurrent seizures to be related to medication level variation and withdrawal. With that, it is important for a thorough discussion of the possibility of other factors that could lead to seizures, including sleep deprivation, other medication, polypharmacy with narcotics and pain medication in general.
- Educating the nurses taking care of the patient is important. They need to receive and analyze the information given to them, either on the phone or indirect contact, about the potential of the patient having a seizure, or not, medication side effects and dosing. It is also important to check the level of medication and, of course, alert the treating doctors of the patient's status and need for intervention at any time.
- Involving the other caregivers such as the neurosurgeon or the medical oncologist, pain management, etc., to balance seizure medication with other therapeutic modalities, whether that is chemotherapy and/or pain medication, antibiotics, etc. It is important for a team approach to ensure a patient is almost seizure free.
- Finally, keeping close contact with patients and their families is important in terms of discipline with medication, their lifestyle, diet, exercise, sleep pattern and stress, along with any other factors that may have triggered or could trigger seizures. Simple examples are: sleep deprivation, excessive use of computer, excessive exposure to photic stimulation, and side effects of other medication including painkillers, muscle relaxants or strong antibiotics. In doing that, one would be better able to fairly manage the seizures. The advantage of better controlling and modifying seizures is clear, in terms of time, energy, economy and, of course, quality of daily living.
Having the patient at home with better control of seizures means fewer phone calls and less frequent visits to the emergency room hospital and/or the clinic.
The neuro-oncology team at Moffitt is working toward establishing a more comprehensive approach to the challenge of frequent seizures by having a vigilant, educated team along with needed diagnostic systems, including highly qualified EEG technicians and the needed technology for recording and monitoring the patient. Specific diagnosis of seizures is very important, as the technology is improving and evolving; in addition to the traditional 30 minutes EEG, the possibility of longer periods of monitoring, ambulatory EEGs, and video monitoring, is adding a great benefit to the patient and the caregivers; because one would be able to monitor the patient's brain more in-depth, over a span of 24 to 72 hours, while they sleep, staying in their comfort zone at home or outside shopping, walking, eating, etc. With that, one would be able to monitor the brain activities, seizure pattern, frequency and intensity, as well as define the type of seizure and improve its control at multiple levels.
Overall, a collective approach can be of great benefit to all parties involved. We are hopeful that better knowledge and management of seizures in general will reflect on the quality of daily living of our patients and their families.
A hallmark of what we do is multidisciplinary care in which we try to have specialists relevant to brain cancer available in the same clinic so that patients can have “one-stop shopping” where possible. This isn't just a convenience for patients, though this is very important with the traffic that we have in Florida, but rather it helps physicians communicate and think and challenge each other about what the best approaches might be best for each patient. In addition, new patients are presented at our weekly Tumor Board in which we can look at all the information available, and evaluate this with the neuro radiologist, neuro pathologist, neurosurgeons, medical oncologists, nurses, physician assistants and the entire team to discuss care and render the best decision possible. It is usually only by carefully reviewing patient scans with an expert neuro radiologist in attendance, as well as the pathologist and go over the details of the pathology and any molecular markers that might be relevant that the best decisions are made.