Treatment of epilepsy

Epilepsy is the most common neurological disorder, with a frequency of 0.5-1% in the entire population as a whole. For the majority of patients, the prognosis remains positive with long-term control of seizures in the amount of 65% -70% of cases from the first or second dose of antiepileptic drug (AEP). However, approximately 30-40% of all patients suffering from epilepsy do not lead to remission, despite the regular intake of the drug. In such cases, it is mandatory to conduct a complete assessment of the patient's condition to determine the reasons for the lack of drug response and to find alternative ways to treat non-responsive epilepsy. In the past 20 years, significant advances and important developments have been recorded in the field of epilepsy treatment, such as:

  • Magnetic resonance imaging of the brain of high resolution
  • Antiepileptic drugs of the second and third generation
  • Neuro-stimulation systems
  • Widespread use of dietary methods of treatment
  • Ketogenic diet

Antiepileptic drugs of new generation

Antiepileptic drugs are the main form of therapy, which is used in most cases with epilepsy. Until 1993, the only available antiepileptic drugs were Phenobarbital, Primidone, Hydantoins, Ethosuximide, Carbamazepine and Valproate are currently used for long-term treatment, while Phenobarbital and Hydantoins have good indicators in the treatment of acute epilepticus. Nevertheless, in recent decades, a large number of new antiepileptic drugs have been added, which are now widely available and tested in clinical settings, providing the physician with a large selection of personal treatment options and the ability to control seizures with fewer side effects to the patient. The most common in modern clinical practice are Levetiracetam, Lamotrigine, Oxcarbazepine, Topiramate and Zonisamide, although even more new drugs are being used, such as Rufinamide, Lacosamide and Perampanel.

Dietary treatment.

Diet treatment with the appointment of a basically ketogenic diet has proven to be an effective alternative for the treatment of many patients with drug resistance or with epileptic encephalopathy. In the 90s, this procedure returned to clinical practice and now the effectiveness has been proven by numerous studies, although the mechanism by which seizure control is achieved is not yet known. This is a diet high in fat, normal protein and very low carbohydrate, which causes the body to work in fasting conditions, processing fat instead of carbohydrates. To achieve these goals, greater rigor in restricting carbohydrates is required, since even a small amount of sugar can divert the metabolism from the production and burning of glucose, which the body prefers instead of ketones for energy production. The implementation of treatment with a ketogenic diet requires a highly qualified and experienced nutritionist in close cooperation with the neurologist and the patient's family.

Surgical treatment of epilepsy

In the past, surgical intervention was considered the last resort in the treatment of resistant epilepsy only when all medical and non-medical means were tried and did not lead to a remission of seizures. Today, surgical intervention is a very successful and effective way to combat epilepsy if there are appropriate indicators, or it is the only therapy that can lead to recovery. Any patient with refractory focal seizures is screened for the likelihood of treatment by surgery, after failures of at least two AEDs. Additional criteria that determine the possibility of an operation are: a serious impact of the frequency and degree of seizures on daily life, the presence of clearly localized damage to the cerebral cortex and the possibility of eliminating the eliptogenic activity without causing neurological complications. The possibility of surgical treatment of epilepsy should be taken without delay in the presence of the above conditions, especially in children with known anatomical lesions. Particularly important is the detailed preoperative examination of the patient, which includes high resolution neuroimaging of the brain, video electroencephalography and examination by the Neuropsychologist and Psychiatrist. Surgical treatment of epilepsy may include a partial resection of the epileptogenic focus by removing the entire cortical fraction (lobectomy) or even resection of one hemisphere of the brain (hemisferotomy).

The most successful is resection of the temporal lobe and interference in the frontal lobe. In some cases of refractory epilepsy, in which resection is not possible, other methods may be used. The most widely used today is the incision of the corpus callosum, or partially (two-thirds), or a complete incision, with positive results in generalized tonic and atopic attacks and with Lennox-Gastaut syndrome.

Neuro-stimulation and neuromodulation

Neuro-stimulation is gaining momentum in the treatment of many neurological diseases and has already established itself as a treatment option in cases such as Parkinson's disease. As for epilepsy, three methods of neurostimulation have become clinically useful: electrical stimulation of the vagus nerve (VNS), Deep Stimulation of the nuclei of the middle group of the hypothalamus.

 The use of the vagus nerve stimulator was approved as an adjunctive therapy in children aged 12 and in adults with continuous focal attacks and it was noted that in addition to control of seizures, it could significantly improve the quality of life of patients with epilepsy. A number of new methods are currently under development, such as transcranial magnetic stimulation, with promising results. Nevertheless, all methods of Neuro-stimulation are used extremely rarely, only when the probability of surgical treatment is tested and was unsuccessful or not possible for the patient.