Chapter: Diseases of The Brain and Nervous System(A Health Education Guide): Epilepsy

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Refractory Epilepsy

When the main antiepileptic drugs (AED) have been tried according to the guidelines - (including polytherapy) in optimum dose and for adequate time period and still if seizures cannot be controlled, the diagnosis of refractory seizures can be made. Before doing so we need to confirm certain things.

Refractory Epilepsy :

When the main antiepileptic drugs (AED) have been tried according to the guidelines - (including polytherapy) in optimum dose and for adequate time period and still if seizures cannot be controlled, the diagnosis of refractory seizures can be made. Before doing so we need to confirm certain things.

i.               Confirm diagnosis - Is it Epilepsy? Syncope, Hysterical Fits, Hypoglycemic Spells etc. should be ruled out. The type of Epilepsy or any underlying cause should be evaluated.

ii.               Review treatment - Whether an appropriate drug has been given in appropriate dose. Sometimes an inappropriate drug may worsen seizures (eg. Carbamazepine aggravates myoclonic Epilepsy).

iii.               Assess whether the drug combination is right. Blood level of drugs need to be periodically checked. Finish EEG, CT Scan of the Brain, MRI of the Brain to look for any additional cause of refractoriness.

iv.               Check for patient compliance. Is the patient taking the drugs regularly? Is he on drugs for any other disease? Is there any brain tumor, birth defect etc. If needed, patient should undergo special investigations like video EEG, depth electrode EEG, SI’ECT, MRI.

 

If all these issues have been looked into and the relevant problems addressed, most of the seizures can be controlled.However, if despite having tried two different. drugs as mono therapy ( for at least 6 months each) and at least one (or two) combination therapy, patient has one/two fits every month for two years, then the patient is said to have refractory epilepsy. About 15 to 22% of all the patients of epilepsy, are thus having refractory epilepsy. However the diagnosis needs to be individualized taking into consideration the patient’s age and his physical and mental condition and his social and financial background. For such patients the following steps can be taken.

i.               New drugs can be tried as add-ons to the.conventional drugs. Occasionally new drugs -can be instituted as first line of treatment.

ii.               Surgery :When drugs fail to control seizures andthe cause of seizures is an electrical focus which may be localized to a structure, then seizures can be controlled after appropriate surgery. During the last decade, there has been satisfactory progress in this field. Hence, in refractory cases where a focus can be defined as a cause of epilepsy, surgery can fully control seizures in 30 to 35 % patients. In another 30 to 35 % cases, seizures are fairly reduced after surgery. The facilities for these surgeries are available in our Country and they do not carry much risk. The cost of surgery comes to Rs. 50,000 to 2,00,000 approximately. A team of experienced Neurosurgeon - Neurophysician can decide as to which of the following surgeries would be beneficial to the patient.

(a) ResectiveSurgery  (b) Functional Surgery

 

(a) Resective Surgery

Microscopic Dissection

Temporal Lobe Surgery

Extra Temporal Surgery

Lesionectomy

Lobectomy

Multi Lobar Surgery

Hemispherectomy

 

(b)Functional- Nonresective Surgery

Corpus Callosotomy

Multiple SubpialTransection

Stereotactic Procedure

Ionising Radiation

Comissurotomy

 

(c) Stimulation

Vagus Nerve Stimulation

Thalamic Stimulation

Cerebellar Stimulation Vagus Nerve Stimulation :

 

In 1980 Joseph zarbara proposed this therapy. This surgical procedure costing about Rs.8-10 lacs entails stimulation of vagus nerve with a computerized system. This can reduce the frequency of seizures to less than 50%. One can continue anti-epileptic drugs with this therapy. If a patient has aura, he can stimulate the electrode and abort the oncoming fit. This is a safe and hence increasingly popular mode of treatment. The parameters can be changed: For those patients who are not appropriate candidates for surgery, in whom a focus is not dependable or those who are awaiting surgery this method is beneficial, specially when anti-epileptic drugs have not worked.

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