Localization in epilepsy-making the diagnosis

In this post I shall explain in simple terms how a diagnosis of epilepsy is made by neurologists. First to get a few terms clarified:

The terms “Seizure disorder” and “Epilepsy” are frequently used interchangeably. They both mean the same. The person who is diagnosed with “epilepsy” or “seizure disorder” has a condition which makes him/her prone to having multiple seizures in his lifetime. Another way to put this is a follows. If you are diagnosed with epilepsy, it means that more than likely you shall suffer seizures in your lifetime if you do not take anticonvulsant therapy (anti seizure medication).

Remember any of us can suffer a seizure but it does not mean we have epilepsy. Let me explain with the aid of an example. Think of a person who suffers a seizure because he drank too much or consumed an illicit drug such as cocaine. Now this person has certainly suffered a convulsion/seizure but he does not necessarily have epilepsy. This person has suffered a seizure provoked by an illicit drug. If this person does not consume excess alcohol again/ avoids illicit drug; he may never suffer another seizure in his lifetime. Contrast this with a patient who has epilepsy. The person who has epilepsy is predisposed to having seizures in his lifetime (he/she has an inherent predisposition to seizures-at times this inherent predisposition is due to genetic causes. Other times it may be on account of other causes such as a brain tumor, a vascular (blood vessel) malformation in the brain, a cyst in the brain, due to prior head trauma/injury, due to an old history of meningitis or encephalitis).

So how is the diagnosis of epilepsy made by neurologists. Well when a patient presents to us with a history of seizure; we first attempt to collaborate the history with additional history from the family (preferably someone who may have witnessed the convulsion). This is important because it helps us to distinguish a seizure from seizure mimics such as fall with loss of consciousness, fainting and other causes of confused behavior with or without loss of consciousness. So first and foremost the diagnosis of epilepsy is made based on a good history. As I sometimes tell my patients, I do not want to “miss” a diagnosis of epilepsy (as seizures are associated with falls, injury and sometimes can cause sudden death). At the same time, I do not want to “over-diagnose” someone with epilepsy (as patients usually have to take anticonvulsant drugs for a long time and these drugs do have side-effects). Herein lies the importance and value of good history taking.

Next come the tests which help to “confirm” the diagnosis of epilepsy. Two tests are commonly carried out. A MRI of the brain is usually carried out to rule out “secondary” causes of epilepsy such as brain tumor, cyst, vascular malformation of the brain, look for “scars” of prior head injury or infections. The second test which is carried out is an electroencephalogram (also called a EEG). This test is carried out to look at the brain waves and identify where in the brain (right Vs left side of brain, which part of the brain) is the “misfiring” coming from. The above two tests in conjunction with history help to confirm the diagnosis of epilepsy.

Nitin K Sethi, MD

Concussions and the risk of post-traumatic epilepsy

Concussions and the risk of post-traumatic epilepsy


A concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Immediately following a concussion, an athlete is usually advised physical and cognitive rest till post-concussion symptoms abate. The athlete then enters a stepwise return to play protocol. Premature return to play risks a second concussion, second impact syndrome, exacerbation and persistence of post-concussive symptoms.


Sports and Epilepsy

Sport is important not only in normal healthy populations, but also in persons with medical illness, physical or mental disabilities. Active participation in sports is beneficial physically and psychologically. The main concern in sports for persons with epilepsy is safety.


Why are people with epilepsy restricted from some sports?


Rationale is that the occurrence of an untimely seizure during certain sporting event has the potential for causing substantial injury and bodily harm both to the patient with epilepsy as well as fellow athletes and even spectators.


Example: if a person with epilepsy has a generalized convulsion or a complex partial seizure while skydiving: he shall not be able to deploy his parachute and a fatal accident can occur.


:a person with epilepsy taking part in an automobile racing event suffers a seizure while making a bend at speeds in excess of 100mph


:a person with epilepsy suffers a seizure while taking part in a swimming meet.


:a person with epilepsy suffers a seizure while bicycling


:a person with epilepsy suffers a seizure while horseback riding


:a person with epilepsy suffers a seizure while skiing down a steep hill


:even things more mundane such as having a seizure while running on a treadmill, while playing tennis, while jogging outside have the potential to cause bodily harm to the patient and others.



Why are people with epilepsy restricted from some sports?


Rationale is that repeated injury to the head (concussions) during some sports could potentially exacerbate seizures.

Example: a person with epilepsy who is indulging in contact sports such as boxing, karate, kick-boxing, muay thai boxing, American football, ice-hockey, wrestling, judo


But are these restrictions and fears actually based on scientific evidence or are they unfounded? Which sports are safe and which are not? Could indulgence in some sports make seizures potentially worse Vs. could some sports actually be beneficial for people with epilepsy (physically and psychologically)? Can vigorous physical exercise provoke seizures?



Exercise and seizures


One reason that people with epilepsy have been traditionally restricted from certain sports is the fear both in the patient and the treating physician that exercise especially aerobic exercise may exacerbate seizures. Some studies have shown an increase in interictal discharges during or after exercise. Most frequently these patients have generalized epilepsies. At least some frontal lobe and temporal lobe seizures are clearly precipitated or at times solely occur during exercise suggests that these are a form of reflex epilepsies. A number of physiologic mechanism by which seizures may be provoked by exercise have been postulated. These include hyperventilation with resultant hypocarbia and alkalosis induced by exercise. Another possible mechanism which is postulated to cause exercise induced seizures is hypoglycemia. This usually causes seizures after exercise in diabetic patients. Other mechanisms which have been postulated for exercise triggered seizures include the physical and psychological stress of competitive sports and potential changes in anti-epileptic drug metabolism. Exercise is a complex behavior and involves not such the motor system and the motor cortex but also involves other domains such as attention, concentration, vigilance and presumably some limbic networks which mediate motivation, aggression and competitiveness. Hence it is possible that patients who have temporal or frontal lobe epilepsy may on rare occasions have seizures triggered by exercise.


There is some limited evidence that exercise may in fact be protective and have physical, physiological and psychological benefits in patients with epilepsy. Electroencephalographic studies have shown that inter-ictal epileptiform discharges either remain unchanged or may decrease during exercise so there is some hint that exercise may actually raise the seizure threshold. Regular exercise also influences neuronal and hippocampal plasticity by upregulation of neurotropic factors. There is further evidence to suggest that regular physical exercise can improve the quality of life, reduce anxiety and depression and improve seizure control in patients with chronic epilepsy.









What sports are off limits for people with epilepsy?


No sport is completely off limit for a patient with epilepsy. Key though is proper supervision to reduce the potential for injury. There are some sports such as skydiving, automobile racing, swimming in the open seas and horseback riding which should be avoided by patients with epilepsy. Other sports can be enjoyed by patients with epilepsy but one should remember that they all have the potential to result in bodily harm if seizures occur when the patient is not supervised or if he is not wearing protective head and body gear.



Concussion and seizures (post traumatic epilepsy): what is the link?


The link between concussion (closed head trauma) and seizures has been and continues to be closely looked at. The fear of concussions (minor head trauma) making seizures worse is the prime reason why people with epilepsy are discouraged from some sports such as tackle football, ice-hockey, boxing, mixed martial arts and wrestling. The human skull is quite resilient and the closed head trauma has to be significant for it to result in seizures. Usually a concussion which results in prolonged loss of consciousness (some authors say more than 30 minutes) is graded as a significant head trauma. Minor bumps and bruises to the head do not cause seizures, do not increase the risk of future seizures and more importantly do not make chronic epilepsy worse. Seizures may occur immediately following a severe closed head trauma. Immediate post traumatic seizures by definition occur within 24 hours of the injury. They have also been referred to as impact seizures. Early post traumatic epilepsy refers to seizures which occur about a week to 6 months after the injury. Seizures may occur as far out at 2 to 5 years after head trauma (late post traumatic epilepsy). Factors which increase the risk of post traumatic seizures/ epilepsy include severity of trauma, prolonged loss of consciousness (more than 24 hours), penetrating head injury, intra or extraaxial hemorrhage, depressed skull fracture and early post traumatic seizures.

Counseling patients


Patients with epilepsy should be encouraged to exercise and take part in sports. My personal feeling is that no sport should be off limits to them with the exception of maybe sky-diving, river rafting and boxing. The goal should be exercising and playing sports safely. Walking, running, cycling and yoga are great exercises which can be indulged in with little to no risks. I advise all my patients with epilepsy (especially those with poorly controlled epilepsy) to wear a Medic Alert bracelet or carry a card in their wallet. This is of immense help were a seizure to occur in the field (as for example when a patient is jogging or cycling and is not in the immediate vicinity of his or her home). Low risk recreational sports such as walking or running usually do not need a one is to one supervision if seizures are well controlled by history. Team sports such as volleyball, basketball, baseball and softball are popular sports which carry a low risk of injury. For cycling I advise my patients to wear a helmet and have their bikes fitted with lights and reflectors. I also advise them to keep off from the busy city streets. “you do not want to have a seizure at the wrong place and at the wrong time”. Swimming is a great way to keep fit and also to meet and make friends. I feel many patients with epilepsy are discouraged from swimming due to an irrational fear of caregivers and physicians of drowning. I advise my patients not to swim alone. Most of the city pools have life guards and a polite request to them to keep a watch out goes a long way in reassuring both the patient and the caregivers. Swimming in the open seas is more risky. I advise my patients to swim close to the beach under the watchful eyes of a life guard. Also having a buddy around helps, preferably someone strong enough to pull the patient out of the water if a seizure was to occur. The option of wearing a life jacket is under utilized.


Final thoughts (a patient’s perspective)


These are the thoughts of a young patient of mine:


“I have always been a very active person and love playing sports such as Tennis, Yoga, Running etc, and I always try to pursue my dreams and not let things get in the way, but being epileptic, it is sometime hard to not worry about things happening. Whenever I play sports I get hot easily (face turns purple) and in the back of my head I find myself always hoping that nothing happens that would cause me to have a seizure. I ran my first half marathon two years ago, and in the back of my head there is always the thought of something happening, so I started to motivate myself by saying “I can do this, you will be fine.” My father taught me when I was younger that I can choose to let it hold me back or make the most of life! Many people consider epilepsy a disability, but I try not to because I don’t let it hold me back.”



Nitin K Sethi, MD, MBBS, FAAN Assistant Professor of Neurology New York-Presbyterian Hospital Weill Cornell Medical Center

Insomnia-what we know and how to treat it

Insomnia-what we know and how to treat it



Nitin K Sethi, MD, MBBS, DNB (Int Med), FAAN





In this blog post I shall address insomnia. Insomnia is a rather common medical problem for which patients consult doctors and sleep physicians. Broadly speaking insomnia can be of two types: sleep onset insomnia (the person finds it hard to fall asleep. Normal sleep latency is usually around 10 to 15 mins. Patients with sleep onset insomnia lie in bed sometimes for hours but sleep eludes them) and sleep maintenance insomnia (normally humans should be able to maintain sleep for 6 to 8 hours, though some of us are short sleepers and others long sleepers. People with sleep maintenance insomnia are unable to maintain sleep waking up multiple times during the night and struggling to fall back asleep again). One of the most common type of insomnia is psychophysiological insomnia and this is what I shall address in detail.


Psychophysiological insomnia (PPI)-these are people who cannot “shut their brains down at night”. At night when they settle down to sleep, their mind races (they are thinking about various things-work, personal issues and so forth). As a result they cannot sleep and keep looking at the clock. Over time this behavior gets reinforced to the extent that sleep itself becomes an anxiety provoking stimulus. Meaning they are anxious at night. Most of the people who suffer from PPI also suffer from anxiety and depressive disorders.


How to diagnose psychophysiological insomnia-usually a good history is sufficient in helping to diagnose PPI. Do you think a lot when you are lying in bed? Do you find it difficult to shut/power your brain down? Do you feel anxious in your own bed? Do you suffer from anxiety disorder and depression? Are your insomnia problems chronic (lasted more than 6 months)? Were other causes of insomnia ruled out such as insomnia due to medical problems (congestive heart failure, COPD, nocturnal asthma), insomnia due to certain medications and so forth. Your doctor may order a sleep study. The sleep study is done to rule out obstructive sleep apnea as a cause of disturbed sleep. It also helps your doctor get an idea of your sleep architecture (how much time you spent in different stages of sleep-light Vs. deep Vs. REM). Your doctor may also ask you to maintain a sleep diary. This is a record of your sleeping habits for a period of usually 2 weeks and helps the doctor better understand your sleep quality and hygiene.


Treatment of psychophysiological insomnia-treatment of PPI can be extremely challenging for the physician and frustrating for the patient. There is no good treatment but let us talk about what is out there, what helps and what does not.

  1. Cognitive behavioral therapy (CBT-I) for insomnia is probably what works the best. CBT-I is usually administered by a psychologist and involves several sessions spread over weeks. The therapist attempts to figure out what thoughts keep the patient awake at night and addresses them. Instructions to help structure sleep and wake up times is an important component of CBT-I. CBT-I takes time to act but in the long term is probably equally if not more effective and safer for treatment of PPI than sleeping pills (sedative-hypnotic medications).
  2. Sedative-hypnotic medications (sleeping pills)-there are numerous on the market both over the counter (OTC) ones such as Benadryl, Zzz Quil (to name a few) and prescription ones such as Ambien, Lunesta, Sonata, Belsomra, clonazepam, diazepam, Xanax (to name a few). These medications do work and they work by increasing chemicals in brain that promote sleep namely GABA. Belsomra is a new drug which was launched recently. As compared to other drugs, it works by decreasing chemicals in the brain that keep us awake. Sleeping pills have the advantage that they work quickly but they have 2 big problems. Regular/nightly use of sleeping pills makes the patient dependent upon them. The other problem with regular/nightly use is tolerance (example initially 5 mg of Ambien works great but then it stops acting and the patient needs a higher dose of Ambien say 10 mg to achieve sleep).
  3. Sedating anxiolytic-antidepressant medications: examples include Trazodone, Doxepin and amitriptyline. These medications are taking on a nightly basis and the goal is to address PPI by treating the patient’s anxiety disorder. The sedating qualities of these medications initially is useful in helping patient’s fall asleep.
  4. Non-sedating anxiolytic-antidepressants medications: examples include Paxil and Celexa to name a few. Goal here is to treat the patient’s anxiety/depression. Since these are not sedating, they are administered during the day.
  5. Entraining the circadian rhythm: one important thing which is ignored when insomnia is treated is entrainment of the patient’s circadian rhythm. In the hypothalamus of the brain there are a group of brain cells (called suprachiasmatic nucleus) which helps to maintain circadian rhythm (sleep wake cycle). Many patients with insomnia have poorly entrained circadian rhythm with no regular sleep-wake times. They are frequently night owls and so when they get into bed early say around 11 pm, they are unable to fall asleep since the sleep drive is not there (their brain may be geared to fall asleep around 1 pm). So it is important to structure sleep with the establishment of regular sleep wake times. The circadian rhythm is entrained by light and exercise. Patients should be encouraged to expose themselves to sunlight in the morning after waking up. Exercise in the morning is also helpful.
  6. Steps to improve sleep hygiene: Use the bed only for sleeping or sex. Do not carry your work to bed. Do not use laptops, smart phone while in bed. Your brain should associate your bed with sleep and not work. Half an hour before bedtime, room lights should be dimmed. TV, computers and smart phones should be tuned off and one should engage in activities that relax and calm the brain. This may be reading a book, meditating or even watching TV if that relaxes you. A hot shower before bedtime, drinking hot decaffeinated tea or warm milk increases the core body temperature and promotes good sleep. Deep slow breathing exercises are also very helpful (you can find some of these on the Internet).

I hope you find this blog posting on sleep and insomnia helpful. Sweet dreams everyone!

Mirror mirror on the wall who is the smartest doctor of them all?

Mirror mirror on the wall who is the smartest doctor of them all?

Nitin K Sethi, MD

New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, U.S.A.

As a resident in training, I quickly came to the realization that some of my attendings were smarter than others. No matter how vexing the clinical problem these were the few who always knew the answers. I would present the history, examination findings and pertinent labs and voila these master clinicians would be able to put the pieces of the puzzle together. If they did not know the answer right away, they always knew where and how to look for it. What organ system to focus on and what tests to order. They stood out in stark contrast to my other attending, all ‘good’ neurologists but who I frequently found ordering multiple and at times random tests struggling to find answers to what plagued the patient. Eccentric with bedside manners that at times bordered on the theatrical, these master clinicians on the other hand made medicine fun and easy. It was as if they could walk into a patient’s room and smell his disease.
I frequently wondered what set these doctors apart from others. It could not be the medical school or the residency program they graduated from. Few were from Ivy League colleges and a seldom few were known outside the corridors of the institution they served in. On the other hand a good number of the ‘good’ doctors made it to the New York’s best doctors list time and time again. Was it their depth of knowledge? Many of the ‘good’ doctors would quote articles and studies with ease but still came up short at the patient’s bedside. It had to be Factor E (excellence factor) coded by the M (master) gene. Only a chosen few had it.

Now when I am on the other side of the fence teaching residents and fellows in training, I still at times wonder whether master clinicians are born de novo (with copious amounts of Factor E) or whether a chosen few good physicians become master physicians and the rest remain good. A lot has been written about improving residency training. The goal is to produce competent physicians at the end of the training process but can good residents be trained to become master clinicians? Is Factor E teachable and transferable? Does training under the wings of these masters automatically ensure transfer of gene M to the trainee? The field of medicine glitters with examples of master clinicians who taught, mentored and inspired their residents and fellows to become master clinicians themselves. A closer look at these attending teacher-resident trainee relationships is worthy of our attention. The patient’s bedside is your laboratory is the central tenant that master clinicians teach their students encouraging them to spend time at the patient’s bedside hearing their stories with rapt attention for a small detail in the patient’s history may very well be the key which unlocks the whole puzzle. Sherlock Holmes the master sleuth once told his prodigy Dr. Watson “you see but you do not observe”. Blessed with astute powers of observation and an analytical mind master clinicians similarly teach their students that the eyes do not see what the mind does not know. James Parkinson, a master clinician in his own right, in his short monograph titled “The Shaking Palsy” described 6 patients in total, three of whom he simply observed walking on the city streets. Much of the description of the longitudinal course of the illness we now know as Parkinson’s disease was derived from his observations of a single case only. Master clinicians report just not their successes but also their failures. Always remembering and learning from their failures constantly striving to become better they inspire trainees to follow in their footsteps. Knowing all too well that medicine never was nor shall ever be an exact science, they encourage their trainees not to hesitate to think out of the box when confronted with a vexing case. “When you have eliminated the impossible, whatever remains, however improbable, must be the truth” another quote attributed to Sherlock Holmes is well worth remembering. Last but not the least these lone stars of neurology teach their trainees the importance of treating patients with respect and dignity reminding them ever so gently that our patients remain our best teachers.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
(William Osler-Canadian physician 1849-1919)