Leading The Wave, One of America’s Best Neurologists; Now Serving Florida & Beyond!

By Paul J. Watkins EPILEPSY FREEDOM

FLORIDIAN CENTER OF EXCELLENCE IN COMPREHENSIVE EPILEPSY CARE.

CENTER AT FALCON ADVANCED NEUROLOGY, A

Epilepsy is one of the most common neurological disorders that causes unprovoked, recurrent seizures. A seizure is a sudden rush of abnormal electrical activity in the brain. Anyone can develop epilepsy, but it’s more common in young children and older adults. In adults aged 65 and older, the most common causes for new-onset epilepsy are ischemic stroke, neurodegenerative conditions such as dementia, tumors, and trauma. Nearly 25% of newonset epilepsy occurs in the elderly.

With an average prevalence of 1%, sixty-five million people around the world have epilepsy.Three million four hundred thousand of those people are in the United States, and about 224,000 of them are in Florida. In addition, one in 26 people in the United States will develop epilepsy at some point in their lifetime. One-third of epilepsy patients live with uncontrolled seizures despite taking seizure medications. Six out of ten people with epilepsy have been unable to identify the cause of it. There are two main types of epilepsy: generalized epilepsy, which may affect the whole brain at the same time, and focal (or partial) seizures, which originate in one part of the brain and may spread to nearby areas, or even the entire brain.

If a seizure doesn’t affect consciousness, it’s called “focal aware,” previously known as “simple partial seizure.” If a seizure affects consciousness, it’s called “focal unaware,” previously known as “complex partial seizure.” Seizures can either be convulsive or non-convulsive, and at times, especially in critically ill ICU patients, seizures may be happening inside the brain without any obvious outward signs except altered mental status or comatose state. These are called “subclinical seizures.” Most seizures last one to two minutes, but sometimes, they may go on for several minutes. One episode of seizure or a cluster of seizures lasting more than five minutes without the patient returning to baseline is a life-threatening condition called “status epilepticus.”

Epilepsy causes people to have repeated seizures, but not everyone who has a seizure has epilepsy. Low blood glucose or sodium level, alcohol withdrawal, illicit drugs, infections, certain medications, or fever (especially in children) can also cause seizures. Other problems, such as anxiety, conversion disorder/psychogenic non-epileptic seizures (PNES), or fainting spells, can cause events that look like seizures. As a result, patients are sometimes subjected to unnecessary medications and procedures. Therefore, accurate and timely diagnosis and treatment are of paramount importance.

STATE-OF-THE-ART CARE

Since 2007, Epilepsy Freedom Center at Falcon Advanced Neurology in Orlando has been providing leading-edge diagnosis and treatment of all types of epilepsy and sleep disorders.

“Epilepsy can be due to a variety of reasons across the age spectrum, starting from newborn babies to elderly adults,” says Falcon Epilepsy Freedom Center’s medical director and neurologist-in-chief Jaivir S. Rathore, MD, FAES. “DocJ,” as he’s known, is triple board certified in neurology, epilepsy, and clinical neurophysiology.

He’s among the select few neurologists in the entire state of Florida to have received the prestigious Fellow of the American Epilepsy Society (FAES) designation in 2021 for his distinguished career and more than a decade of clinical, research, and leadership contribution to the field of epilepsy and neurology. Dr. Rathore is a Member of the American Academy of Neurology (AAN) and the Continuing Medical Education (CME) Committee for the American Epilepsy Society (AES), a Former Vice-Chairman of the Clinical Fellows Council, and Chief Fellow of the prestigious Johns Hopkins Hospital in Baltimore, Maryland, which has been ranked the number one hospital for neurology and the most number one ranked hospital in the United States by U.S. News & World Report.

Symptoms Of Epilepsy

Seizures may present in a variety of ways, some of which may be difficult to recognize, especially for patients or their families, and in some cases, even for healthcare providers other than trained epilepsy specialist neurologists. Most physicians know seizures as generalized tonic-clonic, often called “grand mal seizures,” in which a person has shaking, eye-rolling, foaming at the mouth, tongue biting, bowel/bladder incontinence, falling, and becoming unconscious. Many times, though, epilepsy can have subtle presentations, including abnormal taste or smell, déjà vu sensation; abnormal visual or auditory phenomenon, including hallucinations; headaches, altered mental status like staring spells or loss of consciousness episodes, “roller coaster” feeling, gastric rising sensations, palpitations, nausea; and decline in cognitive abilities, including memory deficits. Another possible presentation is outof-context smiling or laughing (gelastic seizures) or crying (dacrystic seizures).

Sometimes, seizures can cause an intense sense of impending doom or fear, which may be labeled as “psychiatric conditions” or “panic attacks” and may cause several years of delay in diagnosis and appropriate treatment. Seizures can cause labile mood, more commonly depression, anxiety, acute psychosis, and suicidal ideations. “My paper in Harvard journal ‘Epilepsy & Behavior,’ grant funded by the National Institutes of Health (NIH), on depression screening using PHQ-9 as a screening tool is one of the most commonly used tests worldwide,” informs Dr. Rathore. The paper can be found at: https://pubmed.ncbi.nlm.nih.gov/25064739/.

“Epilepsy can worsen a variety of other medical conditions. In patients with or without cardiac arrhythmias, it increases the risk of sudden death due to cardiac arrest in 1% of cases. This phenomenon is called ‘Sudden Unexpected Death in Epilepsy,’ or ‘SUDEP,’ the risk of which is higher in convulsive seizures and seizures that originate from sleep stages,” states Dr. Rathore, an Alumnus Fellow of the Cleveland Clinic Epilepsy Center. Find more information about the Center at The Charles Shor Epilepsy Center | Cleveland Clinic.

Diagnosis And Treatment

Diagnosis of epilepsy starts with a comprehensive history taking and meticulous neurological examination by an experienced neurologist, followed by a brain wave test (video EEG) and a brain MRI with epilepsy protocol. In addition, the neurologist may order lab work to rule out an electrolyte disturbance, metabolic cause, infection, or drug abuse as the cause. In some pediatric cases, the neurologist may order a genetic panel as well. There’s a series of other imaging studies that can be done if a patient needs exact localization of the seizure focus if surgery is planned (which may include FDG-PET, Ictal SPECT, fMRI, or magnetoencephalogram (MEG) and neuropsychological evaluation). For more accurate localization of seizure focus and functional brain mapping before surgery, stereotactic intracranial electrode placement for SEEG or sub-dural grid electrodes for electrocorticography/ECoG can be done. Dr. Rathore collaborates with functional neurosurgery at some of the leading tertiary care hospitals for surgical care of his patients.

“Robotic SEEG started in North America at the Cleveland Clinic in Ohio in 2010,” shares Dr. Rathore, “and I was one of the first fellows to learn that revolutionary technique during my fellowship with the world-renowned first neurosurgeon to do it, Dr. Jorge González-Martínez.”

There are more than 30 antiepileptic medications available to control seizures in nearly two-thirds of patients. Special precautions need to be taken in selecting the medications, especially in pregnant patients due to the risk of fetal abnormalities (teratogenicity) of certain medications like valproic acid, topiramate, phenytoin, etc. Unfortunately, despite trying multiple medications, nearly 36% of patients continue to have recurrent seizures, either due to not being able to take these medications because of side effects or due to the medications being ineffective in controlling the seizures. In such patients, neuromodulation, diet therapy (such as ketogenic or Modified Atkins Diet), or surgery are options.

Successful Outcomes

The majority of patients do very well on medications, and most of them can be seizure free, are at lower risk of sudden death, and enjoy a significantly improved quality of life.

Per literature, the reported rates of excellent surgical outcome for non-lesional partial epilepsy range from 41% to 65% for the temporal lobe, 37% for mixed mesial temporal and neocortical sites, and 29% to 56% for extratemporal epilepsy. In the lesional group, seizure freedom rates were significantly better when patients underwent surgery early in the course of the disease.

In appropriate cases, laser interstitial thermotherapy (LiTT) may be an option for people whose epilepsy is caused by a visible abnormality in one area of the brain. Some patients who either do not want surgery or are not surgery candidates may be offered neuromodulation (brain stimulation, or a so-called “seizure pacemaker”) with responsive neurostimulation (RNS® Therapy). RNS uses an implanted device to help prevent seizures before they begin or abort them in the early stages, similar to how a pacemaker detects and treats abnormal heart rhythms. Other neuromodulation devices include deep brain stimulation (DBS) and/or vagus nerve stimulation (VNS). Dr. Rathore did a neurostimulation “J. Kiffin Penry” mini-fellowship at the Wake Forest University School of Medicine in Winston-Salem, NC. Dr. Rathore did the first ever case of RNS in Lakeland, FL area in May 2021.

SEIZURE SAFETY PRECAUTIONS & PREVENTIONS

“It’s very important that patients with uncontrolled seizures have a detailed discussion with their neurologist about safety precautions,” says Dr. Rathore.

“Another important aspect is that of seizure trigger identification and its avoidance for seizure prevention,” adds Dr. Rathore. “Many patients may have their personal seizure trigger factors, such as peri-menstrual ‘catamenial’ seizures, but for most, the common ones are missing antiseizure medications for any reason (forgetting it or not being compliant), sleep deprivation, excess stress, sunlight or flickering light exposure in photosensitive epilepsies; certain medications, such as bupropion, tramadol, stimulants, and some antibiotics, such as penicillin, fluoroquinolones, cephalosporins, carbapenems, etc. All epilepsy patients with frequent seizures and/or generalized tonic-clonic seizures must discuss ‘seizure rescue’ medication options with their neurologist. These have evolved from inconvenient, and at times embarrassing, rectal diazepam of years ago to today’s diazepam or midazolam nasal sprays, which are convenient, quick to administer, faster acting, and very effective. These rescue medications can play a vital role in preventing a serious seizure episode or shorten the duration of a seizure and hence can be lifesaving and, in many cases, can avert an ER visit or hospitalization.”

Resource For Patients And The Community

Epilepsy Freedom Center at Falcon Advanced Neurology in Orlando, FL provides comprehensive epilepsy care, encompassing medications, surgery, and neuromodulation. “We also offer the ‘Epilepsy Monitoring Unit’ (EMU) diagnostic aspect of epilepsy at Falcon Advanced Neurology,” Dr. Rathore informs. “It’s the oldest and one of only two private independent diagnostic facilities with EMU in the entire state of Florida. Usually, EMU is found only in the large tertiary care hospitals, and the waiting period to get an appointment at such a facility is several months. This waiting period is a major cause for care deficit and, unfortunately, it sometimes causes ER visits for seizure patients.

“We also collaborate with various clinical trials, and we offer clinical trial participation to our patients across various neurological conditions. Also, we’re a research center for our patients,” says Dr. Rathore.

The Epilepsy Foundation of America is the largest epilepsy organization in the country, and Dr. Rathore is the co-chairman of the Florida chapter. He leads educational sessions for various school districts in Central Florida on seizure first aid and offers free consultations for patients who are underinsured or have no insurance or ability to pay. In addition, Dr. Rathore has co-sponsored and led Walk to END EPILEPSY®. The Epilepsy Foundation of America honored Dr. Rathore in 2021 with its prestigious Volunteer Appreciation Award and the American College of Physicians (ACP) also honored Dr. Rathore as one of the Young Achievers at its annual meeting in Orlando in 2014. “The Doctor Is In” on NBC Bloom TV featured Dr. Rathore in October 2019 to raise awareness about epilepsy.

The Florida chapter’s advocacy group works with the state legislature in the capital city of Tallahassee to bring about several changes to help patients. Most recently, the state of Florida passed House Bill 173 into law on March 25, 2022, thereby protecting children and teens living with epilepsies in the state.

“The most rewarding part of my co-chairmanship is reaching out to patients statewide, increasing the awareness of epilepsy, finding out the challenges that patients are facing, and identifying what we can do to help them, as well as the family members and the schools,” says Dr. Rathore, who is a Member of the Reviewer’s Panel for Neurology®, The Official Journal of the American Academy of Neurology.

“As epilepsy is a worldwide disease, I also provide global econsultations, worldwide webinars, and in-person educational lectures at some of the leading medical centers in the US, India, and multiple other countries,” says Dr. Rathore.

The epileptologist is passionate about his work and taking care of his patients. This is evident in his #1 national ranking among all neurologists in web-based, pooled patient reviews on Healthgrades, U.S. News & World Report, and WebMD’s Preferred Provider for 2022. Dr. Rathore was also included in “The America’s Best” neurologist in 2020-2022, as well as being designated the best-rated neurologist in Orlando, FL: https://threebestrated.com/neurologists-in-orlando-fl

Full Range Of Neurological Services

Although a substantial portion of Dr. Rathore’s practice is devoted to caring for epilepsy patients, he offers the full spectrum of neurology services at Falcon Advanced Neurology in Orlando, FL, as well as at two additional clinics in The Villages area of Central Florida in collaboration with TriCounty

Health, LLC. [see Services sidebar]

“I feel a great sense of responsibility to care for my elderly patients, especially those with seizure disorder, given one of my practice areas is The Villages, Florida, which is the largest retirement community in the world, and me being the only boardcertified adult epileptologist in this large catchment area of central to north Florida, in between big cities like Orlando, Tampa, Gainesville, and Jacksonville,” says Dr. Rathore.

“I’m the regional medical director for the southeast US – including Florida – for one of the largest home video EEG companies, called NeuLine Health. We provide home video EEG services across twenty-three states so these patients are not deprived of this testing only because they cannot go to centers or hospitals due to mobility or transportation issues,” says Dr. Rathore.

“Human brain is an enigma containing around 86 billion interconnected neurons, which makes it one of the most complex objects in the universe, which fascinates me,” says the epileptologist. This interest guided him through his medical studies. “I ended up doing an epilepsy research fellowship at Cleveland Clinic for two years and then I did a two-year epilepsy clinical fellowship at Johns Hopkins Medicine. It’s a great honor and privilege to work for the Epilepsy Foundation of America at that level, do research, serve the patients, and offer them the latest, cutting-edge technology in the field of epilepsy. I believe it’s the calling of my life, and I am truly grateful to my family, teachers/ mentors, and friends who have helped me reach this stage of my career.”

DR. RATHORE WELCOMES REFERRALS FROM ALL HEALTHCARE PROVIDERS.

Continued on page 8

For more information about Falcon Advanced Neurology & Epilepsy Freedom Center, located at 6000 Metrowest Blvd., Suite 104-105, in Orlando, Florida, 32835, please call (407) 365-3033, or visit www.fsneuro.com. Dr. Rathore has collaborated with TriCounty Health to provide neurology clinic services in The Villages area at 17190 SE 109th Terrace Rd., Summerfield, FL 34491, and at 3990 E. FL-44 in Wildwood, FL 34785 (Suite 4056 in Freedom Plaza). Please call (352) 268-0003 to reach either clinic, or visit www.tricountyhealthllc.com for more information.

SERVICES AVAILABLE AT FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER INCLUDE, BUT ARE NOT LIMITED TO:

Routine and long-term monitoring video EEG (inpatient and at home)

Stroke/TIA

Dizzy spells/syncope

Various headache syndromes (including chronic migraines) and BOTOX® therapy

Concussion/traumatic brain injury (TBI)

Movement disorders, including Parkinson’s Disease, Tardive dyskinesia, Dystonia etc.

Speech/language disorders

Sleep disorders

Memory and dementia disorders, such as Alzheimer’s Disease

Multiple sclerosis and its diagnosis with lumbar puncture for CSF analysis

Neuropathy

Sciatica pain

FALCON ADVANCED NEUROLOGY & EPILEPSY FREEDOM CENTER

6000 Metrowest Blvd. • Suite 104-105 Orlando, FL 32835• 407-365-3033 www.fsneuro.com

#JohnsHopkins #ClevelandClinic #Harvard #UIChicago

#NIH #TopDoctor #EpilepsyFoundation

Restless legs syndrome

Spinal cord disorders

Myasthenia gravis (MG) and other autoimmune neurological conditions