Ghazala Perven, M.D. Answers Questions On: Intractable Epilepsy

Neurologists who treat patients with epilepsy now have an array of diagnostic technologies that help us pinpoint the area of the brain causing seizures. Stereo EEG, for example, allows us to precisely identify the source of the neurological disruption, such as within the frontal cortex.

With the ambulatory monitoring technology known as responsive neurostimulation (RNS), electrodes are implanted that detect a seizure as it begins. The technology then sends an electrical stimulus to abort the seizure. The data from these events is continuously recorded, downloaded to a computer, stored in the cloud, and reviewed.

By precisely locating the neurological origin of seizures, these diagnostic and monitoring techniques can help make surgery available to patients for whom it was previously not an option. Neurologists partner with neurosurgeons to optimize surgical outcomes. For example, our performing cortical mapping during operative procedures can help the surgeon to avoid specific functional areas, such as the hand motor area, to minimize functional deficits.

In addition to standard surgical procedures, Gamma Knife laser radiation therapy is sometimes used to treat seizures when they have been found to emanate from a precisely defined focal point within the brain.

This is an area of growing interest. Recent studies suggest that autoimmune-mediated epilepsy caused by high levels of certain antibodies may be much more common in several types of drug-resistant epilepsy than previously thought. Research suggests that a multimodal approach can be effective in the treatment of autoimmune epilepsies. However, because different types of antibodies may be causing the symptoms, treatment must be carefully tailored to the individual patient. So, after a thorough autoimmune workup, patients are started on a trial of immunotherapy in conjunction with antiepileptic agents. These regimens may require several weeks of in-hospital treatment, but it is sometimes possible to achieve a complete resolution of seizures.

Sometimes, autoimmune epilepsy may be associated with certain cancers, so patients who test positive for neural antibodies should be assessed further. Treatment of any underlying malignancy will help reduce seizures.

Status epilepticus is a condition in which patients experience nonstop or back-to-back seizures. The seizures maybe subtle and only accompanied by confusion and diminished control of bodily functions. Sometimes patients with no previous history of epilepsy are in the ICU for other reasons, such as to receive dialysis treatment or after a traumatic brain injury, and develop mental status changes that are unexplained. In such patients during EEG monitoring we find out that they are having subclinical seizures resulting in mental status changes.

When a patient comes into the hospital with symptoms of status epilepticus, he or she is placed in the ICU for monitoring and management. Status epilepticus is mostly treated medically. There are many intravenous seizure medications that can be used. In severe cases we may have to use anesthetics to induce a coma. The causes of status epilepticus are too numerous to list but sometimes these seizures occur because of a tumor or a prior stroke.