Treatment
Antiepileptic drugs (AEDs) can prevent seizure activity by altering neurotransmitter activity in nerve cells, but cannot correct the underlying condition. Approximately 70% of patients successfully control seizures with medication. Nearly 50% of those require two drugs to be seizure free. Because medications interact, the drug regimen must be carefully designed to maximize the effectiveness and to avoid serious complications and side effects.
The goals of treatment are no seizures and no side effects. If possible, treatment should consist of one drug (called monotherapy). Seizure management is complicated when patients are given more than one drug. The patient may experience drug interactions, increased side effects, and other adverse reactions.
Compliance is essential. To control seizures, a constant level of medication must be maintained in the body. Antiepileptic drugs should not be discontinued abruptly because of the risk for triggering life-threatening status epilepticus.
Although, antiepileptic drugs may cause abnormal embryo development (i.e., have teratogenetic potential), most women with epilepsy require treatment to prevent seizures during pregnancy. To control seizures and minimize risk to the fetus, women should educate themselves about medication and pregnancy prior to conception.
Surgery
Surgery is an option for a small number of patients whose epilepsy cannot be controlled with medication. A good candidate for surgery has seizures that always begin in the same cerebral location, which can be removed (resected) without creating deficits. Neurosurgeons generally avoid performing surgery in areas of the brain responsible for speech, hearing, and other important functions.
Lobectomy (lesionectomy) —This procedure removes a small part of the brain where seizures originate. It is appropriate only for partial seizures.
Multiple Subpial Transection—When seizures originate in part of the brain that cannot be removed, the surgeon may use this procedure, in which a series of small incisions are made that impede the spread of nerve activity.
Corpus Callosotomy—In this procedure, the surgeon severs the nerve fibers that connect the hemispheres of the brain to each other. This procedure is used to treat uncontrolled generalized tonic-clonic seizures, complex partial seizures with drop attacks, and other generalized seizures. Reduced seizure activity usually continues on one side of the brain.
Hemispherectomy—This procedure is a last resort in children with severe brain damage on one side and seizures that do not respond to medication. It involves removing the entire affected side of the brain. The remaining hemisphere develops language and motor areas for both sides of the body. With intense rehabilitation, many patients will lead functional lives.
Vagus Nerve Stimulator
This small device is implanted near the collarbone and attached to the vagus nerve, which connects the lower part of the brain to the heart, lungs, and gastrointestinal tract. It delivers small bursts of electrical energy to the brain at regular, preprogrammed intervals. In some patients, seizure frequency is reduced. Most patients remain on antiepileptic medication but may be able to reduce the dosage.
Research is being conducted to determine if deep brain stimulation (DBS) can help reduce seizures in patients who have epilepsy. This treatment, which is approved to treat other neurological disorders (e.g., essential tremor, Parkinson's disease), is not yet approved to treat epilepsy and is considered experimental in epilepsy patients. DBS is similar to vagus nerve stimulation (VNS), except the electrodes are placed deep in the brain (e.g., in the anterior nucleus of the thalamus). Deep brain stimulation, which has shown some promise in recent studies, is adjustable and reversible. Serious risks associated with DBS include bleeding in the brain.
Ketogenic Diet
The ketogenic diet is used in children who do not respond to standard therapy or cannot tolerate the side effects produced by antepileptic drugs. The diet is a high-fat, low-carbohydrate diet that fundamentally changes the body's metabolism from using glucose as a primary energy source to using fats. Ketones are a type of lipid, or fat, that provides energy for skeletal muscle, the heart, kidneys, and the brain.
It is most effective in children 10 years of age and younger. Compliance, which is essential for controlling seizures, is difficult to maintain. The regimen often is initiated with fasting period (12-24 hours). Every meal includes exact amounts of fats, proteins, carbohydrates, and beverages, and only those foods listed for the diet can be eaten. Snacking is discouraged and sugars are not allowed. A vitamin and mineral supplement must be given.
The diet should be undertaken only with close medical supervision. Children must be monitored for growth and nutritional deficiencies. Common complications include poor growth and poor weight gain, high cholesterol (hypercholesterolemia), and constipation.
Management
Many patients believe that yoga, acupuncture, aromatherapy, biofeedback, behavior psychotherapy, and meditation can improve their quality of life. However, there is little scientific proof that these therapies are effective. Some of these therapies reduce stress, which decreases seizure activity in some patients.
Physician-developed and -monitored.
Original Date of Publication: 01 Feb 2002
Reviewed by: Gordon R. Kelley, M.D., Stanley J. Swierzewski, III, M.D.
Last Reviewed: 01 Aug 2008
Epilepsy/Seizures, Treatment, Management reprinted with permission from neurologychannel.com
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