Treatment Options

Anti-epileptic medications are the first line of defense against seizures. Today, there are several anti-epileptic medications available. Deciding which medications will benefit a patient is sometimes a complicated procedure. A variety of factors must be taken into account including seizure type, age, gender and the patient’s history with anti-epileptic drugs. Tools such as the EEG are used to determine seizure type.

Once your doctor prescribes a medication, it is important to follow the regimen he sets for you. Taking the medication in the correct manner is critical. If you are having difficulty remembering to take your medication, consult your physician. Seizure calendars and pill boxes can be helpful tools.

More than one million people in the United States suffer from epilepsy. Their lives are filled with uncertainty and restrictions because they never know a seizure will strike. People who have seizures are denied the opportunity to enjoy simple pleasures like driving a car.

Today, epilepsy surgery provides patients hope for a brighter future. Advances in diagnostic and surgical approaches have greatly improved the outcomes of epilepsy surgery and more people are leading seizure-free lives.

Many patients who suffer from simple and complex partial epilepsy uncontrolled on medications can benefit from surgery. Yet many do not receive this treatment due to misconceptions about the procedure.

Surgical Evaluation

Five phases of evaluation and treatment are required for a patient to be considered for surgery:

Initial Encounter
During an in-depth evaluation of each patient, Epilepsy Program physicians explore several non-surgical options for treatment of seizures.

Phase I-Telemetry Monitoring
If the physician needs further testing to determine the patient’s seizure type or if the patient is a candidate for surgery, Phase I telemetry is required. This requires a stay in the hospital. During this time, electrodes attached to the scalp and wires inserted in to the cheek areas (sphenoidal electrodes) transmit the patient’s EEG to a small amplifier worn by the patient. When seizures do not occur, physicians induce them by withdrawing medication and depriving the patient of sleep. Recording typical seizures (ictal recordings) on EEG and videotape is the single most important goal of Phase I. The location of the EEG seizure onset reveals the focal source of the seizures in most patients. If the patient is a candidate for surgery and the physician obtains sufficient data during Phase I to determine seizure type and to pinpoint the source of the seizures, the patient then proceeds to Phase III (surgery). If there is not sufficient data the patient may be given the option of a medical or dietary regimen to control their seizures, or they may be referred to Phase II. After Phase I, the team reviews the patient’s results from their stay in the hospital to determine what will be best for that patient. This process may take a while.

Phase II – Intracranial Telemetery Monitoring
For surgery candidates, this is necessary if physicians need to evaluate deeper areas of the brain to find the source(s) of the seizures. This is required in about 20% of patients. Grids are placed over lateral seizure areas or depth electrodes are surgically implanted deep in to the brain, near the area which is likely producing seizures. The grid electrodes are used when seizures arise near those areas that govern language and movement. The patient remains in the hospital for about three week or until enough data is captured to determine where the seizures are originating from. Monitoring is similar to Phase I, except that the patient’s movements are more restricted and there may be some discomfort associated with the intracranial placement of the electrodes. As in Phase I, physicians continuously monitor the patient. Most Phase II patients can proceed to surgery. Patients with depth electrodes require about 1 month for their scalp to heal before surgery. Patients with grids have their surgery when the grid is removed at a second craniotomy.

Phase III – Surgery
Neurosurgeons remove the small portions of damaged brain that cause the seizures. Based on the findings of Phases I and II, physicians determine which of several possible procedures will be most successful. The most common procedure is anterior temporal lobectomy, or removal of a section of the anterior temporal lobe and the deep structure (hippocampus). This is the source of seizures in most epilepsy patients evaluated for surgery. Approximately 83 percent of patients undergoing temporal lobectomy eventually become free of seizures. All surgical procedures require close medical follow-up and may involve risks and complications. Patients generally return to normal activities within three to four weeks and to full functioning, including work, within three months.

Phase IV – Long Term Follow-Up
The Epilepsy Program has a long term commitment to patients after surgery. Their progress is followed closely for one year and once annually throughout their lifetime. Psychosocial counseling and cognitive (memory) and vocational rehabilitation help patients in their transition to a more active life.

More than 83 percent of patients undergoing temporal resections are seizure-free and the conditions of more than 97 percent are markedly improved. In frontal lobe epilepsy, seizures are markedly reduced in more than 85 percent of patients undergoing resections.

Vagus Nerve Stimulator Showing Positive Results with Seizure Management

There are many forms of treatment for epilepsy. The VNS (Vagus Nerve Stimulator) has been developed for epilepsy patients who are not candidates for surgery and whose intractable seizures are not managed with anti-seizure medications.

The vagus nerve is one of the primary communication lines from the major organs of the body to the neck to the vagus nerve. Stimulation of the vagus nerve can stop seizures, reduce the intensity and frequency of seizures in some patients. The VNS periodically stimulates the vagus nerve, usually for a brief period.

The VNS is an implanted pacemaker-size stimulator. It has a wire lead that attaches to the vagus nerve by means of an incision. The incision is made on a naturally occurring crease on the neck, thereby making the healed scar practically invisible. The procedure takes a few hours and the patient is usually released from the hospital on the next day. After the patient stabilizes, the physician uses a wand to activate the VNS.

Since 1997, there have been a number of medically intractable patients showing promising results in managing their seizures through the VNS.Preliminary findings indicate that VNS stimulation seems to become more effective over time and has helped improve the patient’s quality of life.Many patients on VNS have also experienced reduction and/or discontinuation of anti-seizure medications.Recent information indicates that some concurrent anti-seizure medications may be reduced during VNS therapy.

After having a seizure, some patients before implantation of the VNS would spend the remainder of the day recovering in bed. Since implantation, the postictal period has improved so that patients are able to resume activities within a short time. Improved eating habits have enabled several seriously underweight patients gain weight. As a result of its effectiveness, 57% of the patients have had their anti-epileptic medications reduced or discontinued.

These interim results show decreased seizure frequency, improved quality of life, and reduced and discontinued AEDs.