1）Outpatient Epilepsy Clinic. Promoting cooperation between hospitals and clinics for epilepsy care
As a team of specialists, we have made full efforts to provide the best care to patients suffering from epilepsy or movement disorders. Until recently, epilepsy has been recognized as a childhood-onset disease. However, with the advent of a superaging society, epilepsy that develops in the middle-aged or elderly has become a current problem in Japan. In addition, the number of the hospitals and physicians that can offer the epilepsy care is not adequate. Moreover, it is unclear which department, neurology, neurosurgery, or psychiatry, is in charge for the adult epilepsy service. In order to offer the optimal epilepsy care, it is very important to establish the cooperation model among general physicians and epilepsy specialists for epilepsy care like that in European and North American countries. As a tertiary care institute for epilepsy in Kyoto, we have led cooperation among primary, secondary and tertiary facilities in the Kinki district (esp. in Kyoto-Shiga region) to provide a comprehensive epilepsy service with a dedicated team of neurologists, neurosurgeons, pediatricians and psychiatrists.
In the fiscal year 2014, we saw 1092 outpatients. 103 patients were newly consulted from other hospitals and clinics in the Kinki district. We promoted hospital-clinic cooperation by returning the referral patients to their local clinics and hospitals.
2）Inpatient evaluation and treatment for epilepsy (including video-EEG monitoring)
Since 1991, we have been running the epilepsy monitoring unit (EMU) in the Neurology Ward for evaluation of patients with epilepsy. We now have two dedicated rooms for EMU, equipped with the digital video-EEG system. By capturing seizures with simultaneous video and EEG recording, we can perform
i） An accurate diagnosis of epilepsy: To determine whether the seizure is epileptic or non-epileptic, including movement or psychogenic disorders,
ii） Identification of epileptic focus: To locate the epileptic focus for epilepsy surgery in patients with medically intractable epilepsy.
In the fiscal year 2014, we examined 35 patients in the EMU (subdural/depth electrode implantation: 4, presugical evaluation: 24, evaluation of limbic encephalitis: 6, diagnosis of epilepsy: 11).
In addition, we provide patients with multidisciplinary studies for comprehensive evaluation, such as 3 tesla MRI, routine EEG, FDG-PET/SPECT, MEG and neuropsychological testing. Routine EEGs were performed in 1265 patients (including 906 outpatients) in this fiscal year.
We have established an epilepsy surgery program with close collaboration with the Department of Neurosurgery since 1991. Since the first epilepsy surgery in 1992, we have performed more than 190 epilepsy surgeries, with the majority of patients having seizure freedom or substantial decrease leading to better QOL. We provide each patient with the individually tailored surgery plan by incorporating the findings of the multimodal studies (see below) as well as the Wada test. The patients may proceed to the invasive presurgical evaluation with intracranial electrodes (subdural and/or depth electrodes) when the epileptic focus cannot be precisely localized (such as in cases with non-lesional MRI) or the focus is located at or around the functionally important areas such as motor or language cortices. In such cases, the patients undergo the first surgery for implantation of intracranial electrodes. After electrode implantation, the patients are evaluated for the epileptic focus (by recording seizures) and the functional cortical areas (by incorporating the state-of-art mapping techniques) for 1-2 weeks. Then, the patients undergo the second surgery for resection of the epileptic focus. The patients may undergo the awake brain surgery, where the patients wake up from anesthesia if necessary. Awake surgery has the advantage to evaluate the brain functions such as motor and language during resection and monitor the ‘natural’ epileptic spikes without any influence from anesthetics. In the fiscal 2014, our team performed epilepsy surgery in 14 patients (4 with chronic intracranial electrode implantation) and awake brain surgery about 60 patients (including non-epilepsy cases).
4）Examinations for epilepsy
As the tertiary care epilepsy facility, we provide patients with the state-of-arts studies for the evaluation of epilepsy. As the comprehensive epilepsy program in the national university hospital, we incorporate the leading techniques as clinical research studies (IRB approved) for the optimal presurgical evaluations.
- Electroencephalography (EEG)
- Magnetoencephalography (MEG)
- FDG-PET (18F-fluorodeoxyglucose positron emission tomography) SPECT (Single photon emission computed tomography) including ictal SPECT
- 3 tesla MRI
- functional MRI (fMRI)
- EEG-fMRI (simultaneous EEG and functional MRI recording)
- Neuropsychological testing (WAIS-III, WMS-R, WAB, semantic batteries and Kanji/Kana related tasks)
- invasive EEG monitoring with intracranial electrodes Recently, autoimmune epilepsy is regarded as one of the important cause of epilepsy. Following tests are diagnostic for autoimmune epilepsy.
- Cerebrospinal fluid / serum antibody test
5）Development of novel treatments for epilepsy
i) Interventional Neurophysiology: Recently, neurophysiology has been highlighted for its application to treatment of various neurological diseases. In our hospital, we apply a novel interventional neurophysiology method, neurofeedback treatment, to medically intractable patients in whom epilepsy surgery is not applicable. Patients train themselves to control the brain activity (by adjusting slow EEG potentials) to suppress epileptic seizure activity. Our preliminary study shows a good efficacy as comparable to that for the Vagus Nerve Stimulation.
ii) Promoting the clinical trials for new anti-epileptic drugs.
6）Diagnosis and treatment for movement disorders
It is also our mission to provide the optimal care for patients with movement disorders. We provide precise diagnosis using advanced diagnostic tools for better treatment of movement disorders such as tremor, myoclonus, dystonia and other involuntary movements.
The pathophysiology of movement disorders, however, is not fully understood. We have been investigating their pathophysiology and treatment in close collaboration with the Department of Neurology and Human Brain Research Center (HBRC).
7）Simulation training of brain death determination
Since Organ Transplant Law went into force in 1997, we, in close collaboration with the affiliated departments, have been regularly practicing the course ‘Simulation-based training in brain death determination’. In this course, we simulate the management about how and what to do when the donor is found and until organs are taken. The training is highly practical for those in charge of brain death determination in our hospital.