MANAGEMENT OF EPILEPSY :WHAT.S NEW?
Dr Gigy KuruttukulamMD DM
Epilepsy is a disease, which is known from time immemorial. Descriptions of epilepsy can be found in the Bible. It was thought to be due to the evil spirit entering the body of the patient. Naturally, driving the evil spirit out was considered to be the treatment of choice. Even now, various false beliefs associated with epilepsy and the stigma attached with it, makes the life miserable for the patient.
There have been tremendous advances in the management of epilepsy in the last decade, mainly in the following
1. Newer insights, 2. Newer investigations, 3. Newer drugs, 4. Epilepsy surgery
One of the main developments in the last decade is a better understanding of the disease. The ILAE (International
League Against Epilepsy) advocates the 5-axis approach, which includes
1. Seizure semiology, 2. Seizure type, 3. Seizure syndrome, 4. Aetiology, 5. Impairment
In every patient attempt should be made to address these five issues. The main advance is the identification of various epilepsy syndromes. A syndrome is a complex of signs and symptoms, which define a unique epileptic condition. Factors taken into consideration include seizure type, etiology, genetics, anatomical substrate, precipitating factors, interictal EEG changes and neuroimaging abnormalities.
This gives a clear understanding about the disease process, natural history, helps in choosing the appropriate
drug and prognostication.
A variety of new drugs with novel modes of action have become available, mense value in situations where the diagnosis is in doubt and in presurgical evaluation of intractable epilepsy patients. With the newer protocols in neuroimaging MRI, many structural abnormalities are identified which were not seen with routine imaging. Functional imaging like Ictal SPECT helps in identifying the epileptogenic zone.
With all the recent advances mentioned, approximately 70-80% of patients will have their disease either under control or cured. But still there are around 20-30% of patients who continue to have seizures, in spite of medications. Medically refractory epilepsy is defined as a situation where a patient continues to
have more than 2 seizures per month for a period of 2 years, in spite of at least 2 trials of first line antiepileptics and
polytherapy.Such patients should be evaluated for epilepsy surgery. The epileptogenic zone is the area of the brain
that is responsible for the initiation of seizures and whose removal or disconnection leads to abolition of seizures. The basis of presurgical evaluation is to identify the epileptogenic zone,so that it can be safely removed.
Mesial Temporal Sclerosis Syndrome (MTLS)
Patients with this syndrome are usually refractory to medical therapy and they should be evaluated for possible
epilepsy surgery. The typical characteristics of this syndrome are 1. H/o complex febrile seizures in childhood,
2. Family h/o febrile seizures, 3. Auras in isolation, 4. Infrequent Generalised seizures, 5. Seizure remission for 4-5 years from 5 years of age, 6. Medical intractability, 7. MRI shows Mesial temporal sclerosis
The protocol for presrugical evaluation is 1. History, 2. Clinical examination, 3. EEG, 4. Video EEG (at least 3 habitual seizures, should be recorded), 5. MRI with special protocol, 6. Neuropsychological evaluation,7. SPECT (when indicated)