EPILEPSY TREATMENT IN GERMANY – Prof Dr med Christian Erich Elger
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Prof. Dr. med. Christian Erich Elger is an outstanding neurologist and epilepsy specialist who has received various prestigious awards for his contributions to science and medicine. Among his achievements, it is worth noting that he received the Max Planck Award, which is granted for outstanding scientific achievements in the field of medicine and research. This award highlights the significance of the professor's scientific papers and innovative research in the field of epilepsy.
Prof. Elger has also been treating epilepsy in adults and children for more than 40 years, focusing on the quality of life of patients. He has drug treatment regimens, innovative minimally invasive procedures, and collaboration with experienced neurosurgeons in his arsenal. The professor's achievements and recognition from the medical community make him an attractive choice for patients seeking expert assistance in the treatment of epilepsy.
Prof. Elger sees patients at the Beta Clinic Bonn. He is the Head Physician of the Department of Adult and Pediatric Neurology, Epileptology. In the interview with the professor, he tells us about the features of the diagnosis and treatment of epilepsy in adults and children and innovations in this area.
Hello, Prof. Elger! Thank you very much for agreeing to the interview. We are very happy to meet you! Could you please tell us about yourself?
My name is Christian Elger. I am a neurologist. I have also completed a habilitation in physiology. I have practiced experimental medicine for a long time, after which I received my professorship in epileptology at the University Hospital Bonn, where I took the post of Head Physician of the Department of Epileptology. At that time, it was the only medical facility in Bonn specializing in epilepsy treatment. I am an honorary doctor here. During my work in the hospital, I have gained tremendous experience, which I am happy to share with my colleagues.
I opened a private clinic in Bonn. We provide the same medical services here as at the University Hospital Bonn, and even more.
In our clinic, decisions are made very quickly. In the university hospital, you have to submit application after application, after which they are considered by authorized commissions, which takes a great deal of time. And two years later, you receive a refusal on your application and submit a new one again to get new equipment… This is a very exhausting process. And in your private clinic, it is up to you to decide everything on your own, so you can buy equipment and use it for the intended purpose.
Prof. Elger, could you please tell us how many foreign patients visit you for treatment every year?
We have made such calculations, and I can say that at least 500 patients from abroad come to us for treatment every year. These are people from all over the post-Soviet space, especially from the Caucasus region up to Kazakhstan. This is a large number of states, including Azerbaijan and other countries in this region. There used to be a lot of patients from Russia, but due to the military aggression in Ukraine and sanctions, Russians do not come so often now.
We also provide treatment to patients from Ukraine. Due to military aggression in this country, we provide medical care to Ukrainians free of charge. I also communicate with my colleagues and patients via Zoom because not everyone has the opportunity to come to Germany.
Prof. Elger, why do you think so many patients come to you for help?
If a doctor is highly specialized, and my focus is epileptology, it goes without saying that he has the necessary knowledge and professional skills to provide high-quality treatment. I am known all over the world. I am the winner of all the existing awards and prizes in the field of epileptology. And what is more, I also have many publications on this topic.
I believe that my patients also like my good attitude towards them. I am sure that this factor plays an important role in medical care. My education and clinical experience allow me to explain to people the features of their disease and the upcoming treatment in simple terms. It seems to me that this also helps patients in the process of deciding whether to start the recommended therapy.
How many years have you been treating epilepsy?
I can say that I am no longer a young man. I am, however, a wise and experienced person, and I have been treating epilepsy for over 40 years.
Prof. Elger, what is the most common cause of epilepsy in children?
It is impossible to name the exact cause. For example, if you ask, "What is the cause of pain?" then this question will not have a definite answer either. In fact, epilepsy has several manifestations, the first of which is a seizure. Such seizures often look scary to others, even to experienced people.
When epilepsy is diagnosed in children, it always has genetic causes. At the moment, doctors do not know all the causes of seizures, but as epilepsy research proceeds, more and more of them are being identified. For example, epilepsy can be caused by birth injuries, bleeding during childbirth, or even a stroke in the fetus associated with underdevelopment of the blood vessels.
Epilepsy may also be the result of any malformation. Many malformations are detected in children in infancy, namely before birth or immediately after birth. Malformations can often be detected even at the stage of intrauterine development. In addition, there are certain types of epilepsy, the development of which is connected with the genetic causes. It is often benign rolandic epilepsy that is diagnosed in childhood and completely disappears without any treatment after puberty.
But these seizures are very scary for parents.
Are there any chances of recovery after puberty?
This is a rather difficult question. To begin with, there are types of epilepsy, the development of which is connected with the genetic factors. Although at the moment there is no complete information about such forms of the disease, these resolve on their own at a certain age because the gene that triggers the development of epileptic seizures is deactivated. Such patients fully recover from epilepsy once and for all. I had cases in my clinical practice where adults who had epilepsy as children became aircraft commanders.
In addition, approximately 10% of patients suffering from epilepsy can undergo surgery because they have certain brain malformations. The elimination of these malformations usually allows about half of those operated on to get rid of seizures, even without any further drug treatment. It should be borne in mind that these are estimates since there are currently no controlled clinical trials in this area.
What is the most common cause of epilepsy in adults?
Epilepsy in adulthood is almost the same as epilepsy in childhood, since its main manifestation is also a seizure. In this case, age really matters. After the age of 18, the child is already an adult, and if the first seizures occur in adulthood, then the likelihood that this is a genetic form of epilepsy is negligible. In some cases, the cause of epilepsy in adulthood may be brain malformations, but more often than not, the pathology develops because of traumatic brain injuries, injuries during road traffic accidents, etc.
It is worth noting that seizures often develop due to brain tumors. In such cases, a doctor conducts diagnostics and, based on the results, determines that a patient needs to deal with a brain neoplasm but not with epilepsy. At a more mature age, seizures can also occur against the background of a stroke or Alzheimer's disease. Therefore, the causes of epilepsy depend on the patient's age.
What form of epilepsy is considered the most common in adults?
According to the classification, generalized and focal epilepsy are the most common in adults. Speaking in percentage terms, 25% of patients suffer from generalized epilepsy, and 75% of patients have a focal form of the pathology. Generalized epilepsy responds well to drug treatment.
As for the focal form of epilepsy, about 70% of patients have good chances of recovery.
The main problem with focal epilepsy is the selection of candidates for surgical treatment. Surgery is a good treatment option, and deep brain stimulation may be performed as well.
We always give due consideration to the specific type of epilepsy when discussing a clinical case. For example, sometimes a patient has good chances of recovery when undergoing deep brain stimulation, and in more complex clinical cases, it is the surgical procedure that can help completely get rid of epilepsy.
Prof. Elger, are there cases where it is possible to completely recover from epilepsy?
Yes, there are such cases. Two types of epilepsy in childhood can be completely cured. First of all, it is a benign focal epilepsy of childhood. In 90% of cases, children with this type of epilepsy completely get rid of seizures after puberty. The complete disappearance of seizures is also possible in patients with generalized epilepsy. Absence epilepsy in children is a type of generalized epilepsy. I don't know if people in other countries have heard of the children's poem "The History of Hans Stare-in-the-Air"?
This is a poem from the children's book "Shock-Headed Peter" ("Struwwelpeter"), written by a German pediatrician. He described childhood illnesses in short poems with illustrations. In the poem "The History of Hans Stare-in-the-Air", it is about absence epilepsy, which disappears after the onset of puberty. With these two types of epilepsy mentioned above, the complete disappearance of seizures and the rejection of medications are possible.
The chances of recovery thus depend on the type of epilepsy.
Prof. Elger, how have approaches to epilepsy treatment changed recently?
I think that the most important point is the improved quality of medicines, in particular their tolerability and effects on other organs. Some medicines may cause elevated liver enzymes.
Great progress has also been made in epilepsy surgery. Today, not many patients are undergoing surgery, but their number is still increasing.
The first book on the treatment of epilepsy was published back in 1900. About 600 patients with epilepsy are now operated on in Germany every year. The number of patients who could be operated on is at least twice as high. As I said, the operation often gives a chance for a full recovery, so this is extremely important. Improving diagnostic methods also contributes to improving the quality of epilepsy treatment, including surgery.
Innovative methods of nuclear medicine have also now appeared to reduce the epileptogenic focus.
What are the peculiarities of your approach to epilepsy treatment?
I do not want to praise myself, but in my approach to treatment, it is important that the focus be on the patient and not on the treatment process. My typical patients are people with complex forms of epilepsy accompanied by cognitive impairments.
For example, parents may bring to me a 7- or 8-year-old child with physical disabilities. I study his clinical case and see that he is taking four medicines, but at the same time, the frequency of his seizures only increases, and the quality of his life deteriorates sharply. It doesn't matter to this child whether he has three or five seizures a week, even though each of these seizures lasts no more than one minute.
The goal of treatment in such cases is to provide the patient with a high quality of life. At the same time, one should have a clear idea of the upcoming therapeutic measures and their goals. Many of my colleagues focus specifically on seizures, seeking to reduce their number and intensity. They, however, do not assess the child's general health condition and cannot determine the specific goal of treatment. Doctors often carry out treatment without understanding what the patient's health condition will be after the completion of treatment.
The specialist should have in-depth knowledge of the combination of medicines and their dosages. This is the only way to improve the patient's health condition. The patient may have repeated seizures, but his quality of life will still be significantly improved.
Prof. Elger, what new treatment methods do you use in your work?
I have one absolutely innovative technique in my arsenal. This is the latest generation of laser therapy. I also use advanced brain stimulation procedures, but they are not fundamentally different from those that doctors have long known about. Of course, they are more effective, but there are no major changes in the method. Laser therapy, in my opinion, is a real breakthrough in the field of epileptology.
A special probe with a diameter of about two millimeters is inserted into the brain to perform the laser procedure. It is important that this probe does not damage brain structures. All manipulations are carried out under MRI guidance, which ensures their highest accuracy. After having approached the epileptogenic focus, a specialist begins to work with the laser device. The therapeutic effect is achieved by heating tissues up to 50ºC, which leads to protein denaturation and destruction of the epileptogenic focus.
The final stage of the laser procedure is the removal of the probe. The very next day after the laser treatment, the patient can be discharged from the clinic, which is also a huge advantage of this therapy. I believe that this is a revolutionary method of treating epilepsy. The therapeutic procedure is quite expensive but very sparing. This method is very popular in the USA, despite the high cost. Although it doesn't really matter to patients in the USA, as the prices for other types of epilepsy treatment there are almost at the same level. If we talk about Germany, the situation is different.
In our country, such treatment costs two to three times higher than classical treatment methods. However, this type of laser therapy is very sparing and highly effective.
Does the quality of German medicines differ from medicines available in other countries?
Patients with focal epilepsy usually take Carbamazepine. This drug has been on the European market since 1964. If you look at the results of clinical trials of anticonvulsants, Carbamazepine is still the most effective. This drug has side effects, the most severe of which are elevated liver enzymes.
According to research findings, evidence-based medicine has not yet made any fundamental changes in the development of anticonvulsants. However, doctors have the opportunity to combine drugs to achieve the best therapeutic results. For example, patient A will best benefit from drug B, and patient C will best benefit from drug D. So when we consider a specific group of drugs, today there are no fundamental changes, but experienced epileptologists know that the possibility of a successful combination of drugs is a great step forward.
Prof. Elger, how often do patients come to you with an incorrect diagnosis?
In my private clinic, such cases are not very common as compared to those times when I worked at the University Hospital Bonn. Together with colleagues from the university hospital, we calculated that 10-12% of patients seek medical help with an incorrect diagnosis. For example, cardiovascular collapse is often mistaken for epilepsy because a sharp drop in blood pressure and sudden cardiac arrest cause seizures with twitching of certain parts of the body that resemble epileptic ones. In such cases, doctors conduct differential diagnostics and prescribe the necessary treatment.
Patients with psychogenic non-epileptic seizures are another rather complex group of patients in whom an erroneous diagnosis of epilepsy is possible. Luckily, today we can record video on our mobile phones, and it makes our work easier. For example, parents send us videos of their children having seizures. This allows us to make a more accurate diagnosis.
What are the difficulties of diagnosing epilepsy in young children?
Direct recording of epileptiform activity is possible only with the help of EEG monitoring. Typically, video EEG monitoring is used during sleep because during the daytime a child may be too active and capricious. Before putting the child to sleep, a special cap with electrodes is put on his head. In some cases, the patient may be given melatonin tablets.
Melatonin does not pose any danger to the child. This is a natural substance with a hypnotic effect. The doctor can thus assess the electrical activity of the brain. It usually takes much longer to detect epileptiform activity in a child than in an adult.
What, in your opinion, is the key to effective treatment of epilepsy in children?
The problem with the treatment of children is that the responsibility for the child lies on the shoulders of the parents, and the parents are very worried about their child. If the child has a complex form of epilepsy and for quite a long time the parents do not see any significant success in therapy, then many believe that the attending physician has prescribed ineffective medications and stop giving them to the child. Parents may also notice the side effects of anticonvulsants, and sometimes they only think that the child has these side effects.
There are also cases when parents simply throw away the medicines, and the child does not receive any treatment. In my opinion, this may cause fatal consequences, and the child may simply die. When I talk to parents, I explain everything to them in detail and assure them that they can discuss with me any questions they have. I also believe that many doctors make the mistake of prescribing a high dose of this or that drug. There have been many studies showing the drug that helps the patient will be effective at low doses as well.
Very few patients actually feel better when they take a high dose of an anticonvulsant, but there are also side effects to consider. If the doctor can see any improvement in the child's health condition, the dose of the drug may be increased. Possible side effects should, however, always be taken into account. At the same time, it is extremely important to control the EEG monitoring indicators.
The doctor must clearly see if there is any improvement in the child's EEG results when he takes high doses of drugs. The key role is given to strict adherence to the systemic intake of medicines and regimen prescribed by the healthcare professional. When it comes to the treatment of young children, the parents are responsible for this. In addition, young children usually receive drugs in the form of syrup with a high sugar content. I always tell parents in detail about the peculiarities of taking such syrups to prevent damage to the child's teeth.
I do my best to eliminate syrups with a high sugar content from the treatment regimen as soon as possible, but before that, the child needs to be taught to take pills. Tablets can also be taken in high doses by adding them to applesauce.
At some point, many parents are disappointed and stop believing in the success of the treatment. What would you advise them?
You are right. Many parents say that they have already changed 4-5 drugs and that the chances of their child being cured are negligible. In such cases, the probability that the child will get rid of epileptic seizures is no more than 5%, but still, it is 5% and not 0%. My treatment strategy in such cases is to exclude one drug from the treatment regimen.
I strive to convince parents that if the child has a slight increase in the number of epileptic seizures but, at the same time, his health condition improves, then such treatment is most effective for him. I think that parents need a detailed explanation so that they understand the essence of the treatment and can directly participate in it. Some parents seek help from naturopaths, and I also discuss this with them.
What parents think is the best option may be what parents just want to believe, because their attitude towards a child's illness is always more optimistic than it should be. If a naturopath tells you to give up taking medicines and do only what he advises, the life of the child is in danger. There was a case in my practice where treatment with alternative medicine almost cost the patient his life. I reported this situation with the naturopath to the appropriate authorities. He was then sentenced to a year in prison.
What types of surgery can be performed to treat epilepsy?
The most common surgical treatment for epilepsy remains a classic operation. When performing the operation, a surgeon removes an epileptogenic focus. Such treatment is carried out in patients with focal epilepsy. The volume of resection is still a matter of dispute since there have been no reliable clinical trials that would allow the formulation of clear recommendations.
My opinion is that the smaller the volume of resection, the better. But that's easier said than done, and in practice, surgeons have to resort to quite extensive resections. The second most common operation for epilepsy treatment is a hemispherectomy. The surgical procedure involves the partial or complete removal of one of the two brain hemispheres. These surgical interventions facilitate the reduction of the frequency and severity of seizures.
Another option for surgical treatment is a corpus callosotomy. This is an operation to dissect the corpus callosum. Such interventions are usually indicated for patients with severe seizures. A corpus callosotomy is a traumatic intervention, so the patient should weigh everything carefully before deciding on this treatment.
Who may be a candidate for surgery?
During video EEG monitoring, many electrodes are attached to the patient's head, and special equipment records the electrical activity of various parts of the brain. Based on the diagnostic results, the doctor determines the localization of epileptogenic foci and their impact on the patient's health condition. Severe forms of epilepsy are relatively rare, with about 5,000 cases across the European Union.
Thus, about 7% of patients with epilepsy do not have any structural abnormalities, which is also confirmed by a microscopic examination of the brain. Up to 93% of patients do have brain malformations. Surgical treatment may therefore be indicated for them. Severe brain malformations are easy to detect using imaging techniques, but minor malformations are almost impossible to detect. Therefore, in my opinion, even in those 7% of complex cases of epilepsy, brain malformations exist, but at the moment we do not have powerful enough equipment to detect them.
We usually conduct a scan on a 3 Tesla MRI machine. The duration of the procedure is about an hour. The images are then analyzed, including with the help of high-precision computer programs. This allows doctors to identify even minor brain malformations. Having full information on hand, doctors can perform an operation and remove a brain malformation. I believe that it is the attention to the smallest details that largely determines treatment success.
I am sure that someday we will be able to examine patients on a 7 Tesla MRI scanner, but it is very expensive. I don't even know exactly how much it costs. The use of a 4.5 Tesla MRI scanner is a very real prospect. The higher the magnetic field strength, the better the image quality. We use state-of-the-art equipment, and the accuracy of the images is already approaching the submillimeter range.
That's just the way it is. We offer people with epilepsy the highest quality of diagnostics available today, which allows us to prescribe optimal treatment.
Prof. Elger, are there any unique treatments used in Germany that are not available elsewhere in the world?
That's actually quite a difficult question. Among the innovative techniques, as I said before, is laser therapy. Only two hospitals in Germany offer this type of treatment. These are my small private practice and the University Hospital Marburg. We and the university hospital perform approximately the same number of procedures. Several other hospitals have already purchased this advanced laser system and are training physicians to perform this type of treatment. So in the coming years, laser therapy will certainly become more common.
It is not very easy to start practicing this type of treatment at the hospital because laser therapy requires the joint work of a radiologist, an anesthesiologist, a neurosurgeon, and a neurologist. My clinic has such a team, and we are doing a great job. Laser therapy is carried out under MRI guidance, so the device cannot be used to examine other patients for 4-5 hours. It is also necessary to perform high-quality anesthesia, and this is not an easy task. So it is laser therapy that is absolutely revolutionary in epilepsy treatment. At the same time, the cost of the procedure at our clinic is about 70,000 euros.
Compared to prices in the United States, such treatment costs about $140,000 in Chicago. And I'm not sure that doctors in this country can guarantee a better result. It is possible that the results could be even worse. There are probably no other fundamentally new methods of treating epilepsy. A new method of brain stimulation is now also being used, in which electrodes are implanted not in the brain but under the scalp.
This new brain stimulation procedure is a relatively simple intervention. It is, however, quite expensive. And the point is not so much the price as the fact that only 33 such procedures have been performed, so it is difficult to assess treatment outcomes in the long term. This is a very small number of cases to draw serious conclusions about the effectiveness of the treatment.
Prof. Elger, thank you for the informative interview!
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