transmitter NEURO A PUBLICATION OF SANTA BARBARA NEUROSCIENCE INSTITUTE AT COTTAGE HEALTH FALL 2018 Differentiating Between Psychogenic Non-Epileptic and Epileptic Seizures PAGE 4 Cottage Children’s Medical Center Concussion Clinic: An Individualized Approach to Care PAGE 8 A Look at Amyotrophic Lateral Sclerosis PAGE 6 NEUROtransmitter • FALL 2018 Table of Contents 4 Differentiating Between Psychogenic Non-Epileptic and Epileptic Seizures BY MICHAEL GIBBS, MD 6 Amyotrophic Lateral Sclerosis: A Look at This Motor Neuron Degenerative Disease Making Recent Headlines BY KAREN DaSILVA, MD 8 Cottage Children’s Medical Center Concussion Clinic: An Individualized Approach to Care BY REBECCA PIFER, MSN, BSN, and PENNY MORGAN OVERGAARD, PHD, RN 11 Saving the Brain: The 11TH Annual Neuroscience Symposium of The Central Coast, Program Details Thomas H. Jones, MD About Santa Barbara Cottage Hospital and Cottage Health Executive Medical Editor The not-for-profit Cottage Health is the parent organization of Santa Barbara Cottage Philip R. Delio, MD Medical Editor, Neurology Hospital (and its associated Cottage Children’s Medical Center and Cottage Rehabili- Sean Snodgress, MD tation Hospital), Santa Ynez Valley Cottage Hospital and Goleta Valley Cottage Hospital. Medical Editor, Neuroradiology Traci Rodriguez The Santa Barbara Neuroscience Institute at Cottage Health is a physician-led initiative Executive Editor established to focus on medical conditions over the full cycle of care. The Institute Gary D. Milgram, MBA, RN Administrative Editor aims to deliver the highest value to the patient by incorporating best prac tices, Gary Hopkins applying resources judiciously, and measuring and reporting outcomes relentlessly. Managing Editor Albert Chiang+Deja Hsu Art Directors Maria Zate Advisory Editor To be added to the mailing list, please contact Traci Rodriguez at [email protected]. 2 NEUROtransmitter Fall 2018 Dear Colleagues, i want to take this opportunity to draw your attention to Director of Epilepsy Surgery and Professor of Neurosurgery- the interesting articles in this edition of NEUROtransmitter Psychiatry and Biobehavioral Sciences at the Semel Institute highlighting some of the exceptional work being done by our for Neuroscience and Human Behavior at the University of colleagues here in Santa Barbara, but also to invite you to California Los Angeles, and Dr. Jeff Victoroff, Associate attend our 11th annual Saving the Brain Conference, which Professor of Neurology and Psychiatry at the Keck School of takes place on Nov. 2. Medicine at the University of Southern California. Dr. Fried, This issue of the magazine includes an in-depth discussion whose research and clinical work is dedicated to the treatment by Dr. Michael Gibbs, a neurologist with subspecialty of intractable seizure disorders and epilepsy, will speak on “The training in the diagnosis and management of epilepsy, on Changing Landscape of Epilepsy Surgery.” Dr. Victoroff, an differentiating between psychogenic non-epileptic and internationally known expert in traumatic brain injury, will epileptic seizures. Dr. Karen DaSilva, a neurologist and speak on “Concussive Brain Injury: The Revolution.” expert in neuromuscular diseases, presents an update on Closer to home, Dr. Ty Vernon, a clinical psychologist and current diagnostic techniques and available treatments for autism expert who serves as Director of the Koegel Autism ALS. In their article, Rebecca Pifer, Center at the University of California MSN, BSN, and Penny Morgan Santa Barbara, will talk about “Early Overgaard, PHD, RN, from Social Development in Autism.” the Cottage Children’s Medical Also sharing their expertise Center Concussion Clinic, provide and experience at this year’s a timely look at the services – conference are my colleagues Dr. including preventive education, John Park, neurosurgeon and evaluation, diagnosis and specialized Medical Director of the Brain and management of concussion – Spinal Program at Santa Barbara provided by the clinic to young Neuroscience Institute at Cottage athletes in our community. Health, Dr. Robert Taylor, If you haven’t already done so, neuro-interventionalist/vascular I encourage you to register for this neurologist at the Stroke and year’s Saving the Brain neuroscience THOMAS H. JONES, MD Neurovascular Center of Central symposium, which once again features California and Medical Director nationally recognized guest speakers of Neurocritical Care at Cottage as well as local experts from Santa Barbara Cottage Hospital. Health, Dr. Rohit Sharma, a surgical intensivist/acute Our objective this year – and every year – is to provide care physician and Associate Director of Trauma Services conference attendees with a glimpse into the latest advances in at Cottage Health, and Dr. Philip Delio, a neurologist at the field of neuroscience research as they apply to clinical care. Neurology Associates of Santa Barbara and Medical Director I am especially pleased to welcome as our keynote speaker of Stroke Services at Cottage Health. Dr. Greg Albers, The Coyote Foundation Professor of I look forward to seeing you at this year’s conference. You Neurology and Neurological Sciences at Stanford Medical will find more information about the symposium, including Center. In his address – “How the Stroke Stopwatch was how to register, at the back of this issue. Shattered” – Dr. Albers, the principal investigator of the DEFUSE 3 trial, will describe the study’s groundbreaking Sincerely, research that expanded the treatment window for ischemic stroke from six to 24 hours, using specially designed imaging THOMAS H. JONES, MD software that allows physicians to see stroke in real time. Neurosurgeon and Medical Director Our other visiting speakers are Dr. Itzhak Fried, Santa Barbara Neuroscience Institute at Cottage Health Fall 2018 NEUROtransmitter 3 Differentiating Between Psychogenic Non-Epileptic and Epileptic Seizures BY MICHAEL GIBBS, MD sychogenic non-epileptic seizures (PNES) medically unexplained symptom. Seventy-five percent of are a type of non-epileptic seizure and are PNES patients have post-traumatic stress disorder (PTSD), misunderstood by many people outside of the field with 30 percent of those individuals having suffered from of epilepsy. Even among neurologists who do not sexual abuse and 25 percent from physical abuse. PNES is Pspecialize in epilepsy, PNES is commonly misdiagnosed. seen in a significant number of active and former military While abnormal electrical brain activity is always seen with members who have experienced a blast injury of some kind. epileptic seizures, non-epileptic seizures – sometimes referred to as “non-epileptic events” to avoid confusion with the PNES Versus Other Non-Epileptic Seizures term “seizures” – may exhibit many different alterations of Non-epileptic seizures encompass a broad range of seizure- awareness or experience. like events, with their own specific indicators. For example, syncope, with or without convulsion, usually is triggered by a Prevalence of PNES precipitating event, such as a psychological stressor or another The estimated prevalence of PNES is factor such as a history of low blood pressure approximately 33 per 100,000 population, which or lightheadedness on standing. Syncope often makes PNES about as common as multiple involves some body stiffening and can be difficult sclerosis and Parkinson’s disease. PNES patients to distinguish from epileptic seizures. Syncope are predominantly women and the mean age at patients also do not generally show the same post- onset is 31. While PNES is not seen in young ictal confusion and agitation that persons with children, there seems to be no upper age limit to epilepsy experience. the disease. Other non-epileptic seizures may include Forty-six percent of PNES patients have hypoglycemic episodes in which patients exhibit some previously been diagnosed with anxiety or MICHAEL GIBBS, MD stiffening or shaking, breath-holding spells in children, depression, and 57 percent have at least one other cataplexy (a sleep phenomenon), or even a paroxysmal 4 NEUROtransmitter Fall 2018 movement disorder. Complex migraine can also be considered a type of non- FIRST CASE STUDY epileptic seizure. EEG Monitoring Helps PNES, however, is the largest Diagnose Non-Epileptic Seizure in Patient category of non-epileptic seizures. Between 30 and 40 percent of Observed in an EMU, a female ictal cry at onset, with a stop-start patients in the epilepsy monitoring patient having a seizure exhibited quality to it. In epileptic seizures, unit (EMU) at Santa Barbara several signs and symptoms that the individual typically experiences Cottage Hospital receive a diagnosis initially indicated the seizure tonic contraction of their diaphragm of PNES. might be epileptic. She had eye and lets out a single, large ictal cry. opening at onset, consistent with Additionally, the patient had tonic Etiology of PNES an epileptic seizure, and appeared pulling on the left face but clonic PNES is listed in the Diagnostic to have a seizure aura. She also had movements in the right arm, which and Statistical Manual of Mental some clonic jerking, with elbow has no anatomical basis in the brain Disorders-5th Edition as a subtype of a flexion of her right hand, at the since they are different electrical functional neurologic disorder, meaning onset and the movement seemed phenomena and should not be it is an experiential and behavioral to be rhythmic. Asynchronous or occurring at the same time. manifestation of distress that is arrhythmic