Epilepsy treatment

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Epilepsy is a chronic disorder of brain activity characterised by recurrent sudden convulsive or nonconvulsive seizures. The gold standard of diagnosis is electroencephalography (EEG). Medication (antiepileptics) is the main treatment option. In some cases, surgery or electrical stimulation of the nervous system (such as VNS and DBS) may be necessary.

Epilepsy is a disease caused by the increased activity of brain neurons. The power generated during an attack of electrical impulses is so great that the central nervous system cannot control them. It is impossible to predict a seizure. It appears spontaneously. Epilepsy is dangerous because of:

  • Traumatism, including receiving craniocerebral injuries due to falls and blows;
  • Mental disorders;
  • Fatal road accidents (if unconsciousness or loss of control over actions happens while driving).

The epileptic syndrome is characterised by a group of typical symptoms and findings. The signs are common in the cause, treatment and outcome. The majority of epilepsy syndromes begin in childhood or adolescence.

During a seizure, brain function is temporarily disturbed: nerve cells in the brain are overactivated. In most cases, an attack occurs in the context of epilepsy, but the cause is often traumatic brain damage, fever and neoplasm.

There are multiple types of seizures and epilepsy types. Some of them are:

  • Most people think of tonic-clonic (Grand Mal) seizures when talking about an epileptic seizure. It is a particular form of generalised seizure characterised by the affected person falling, convulsing and sometimes biting their tongue.
  • Absence (Petit Mal) is an abrupt loss of consciousness lasting a few seconds. The consciousness pauses for a short time so that the person concerned ignores his surroundings. However, the patient does not lose consciousness.
  • Childhood absence epilepsy (pyknolepsy) is a form of epilepsy in children aged 4-10 years, manifested by multiple short-term attacks of head tossing, eye-rolling, loss of balance, and mental changes. Patients do not remember these attacks. In kids, convulsions can occur against increased body temperature or a decrease in calcium level in the blood (spasmophilia, which is accompanied by spasms of the muscles of the hands, feet, and glottis).
  • Lennox-Gastaut syndrome (LGS) is a rare, age-related and challenging to treat epileptic encephalopathy that presents with various seizure types, including obligate tonic seizures and distinctive EEG patterns.
  • Infantile spasms (West's Syndrome) are rare infant epilepsy that must be taken seriously. For example, the causes are malformations, brain damage, infections, or metabolic disorders.
  • Salaam attacks manifest in infancy, usually between the 2nd and 7th months of life. Series are up to more than 100 short-lasting, bilaterally symmetrical, lightning-like myoclonus with extension or flexion movements of the extremities, a convulsive bending of the head (nodding attack), and throwing up and bending the arms.
  • Status epilepticus (SE) is any epileptic seizure lasting longer than 5 minutes (or more than two consecutive seizures lasting more than 5 minutes without recovery). Every SE is a neurological emergency that requires medical treatment and intensive monitoring with readiness for intubation.

Epilepsy is a relatively common pathology of a neurological nature. In the world, up to 2.4 million cases of seeking medical help due to an epileptic attack are registered annually. However, many people hide the problem by not seeking help after the first attack. Sometimes the disease proceeds without pronounced convulsions and therefore remains unrecognised for a long time.

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What is the cause of seizures?

Various reasons cause violations of the function of neurons. At the same time, epileptic seizures can appear both immediately and after some time after brain damage. Therefore, it is impossible to establish the cause of the disease in complex cases accurately. Nevertheless, the reasons for the development of epilepsy can be:

  • failures in the development of the central nervous system during embryogenesis (development of the child during pregnancy);
  • heredity (the bulk of epilepsy is genetic, so doctors can prescribe genetic tests to check for DNA changes);
  • brain tumours;
  • brain abscess;
  • infectious diseases of the central nervous system — meningitis, encephalitis;
  • inflammatory granulomas;
  • strokes;
  • oxygen starvation of brain structures;
  • exposure to toxic substances;
  • craniocerebral injuries;
  • after brain surgeries.


Sometimes epilepsy is both genetic and structural. For example, in someone with a genetic predisposition to epileptic seizures, epilepsy is triggered only by a stroke, infections, poisoning, or another specific disease.

Common signs and complaints of patients with epilepsy

Signs and symptoms of epilepsy in the period between attacks are absent or blurred, which makes it challenging to recognise the disease early. However, immediately before the attack, a short-term aura may occur - a complex of symptoms of a vegetative, motor, mental, sensory, and speech nature:

  • Numbness of the body area;
  • Visual, sound, olfactory phenomena;
  • Speech or motility disorder;
  • Behaviour changes.

The exact symptoms depend on the form and the severity of the seizures. For example, the mildest variant of a generalised seizure is a short-term mental absence: the person affected has briefly "gone away".

On the other hand is the "big seizure" (Grand Mal). First, the whole body cramps and stiffens (tonic phase). Then it begins to twitch uncontrollably (clonic phase). During such a tonic-clonic seizure, patients are unconscious.

In children, epileptic seizures proceed atypically. First, the child falls with a moan and a cry during the attack. Next, there is a tonic tension of all the muscles with the head being thrown back, the body is bluish, and the pupils are dilated. After that, clonic convulsions appear with foaming at the mouth, involuntary urination and defecation.

Modern epilepsy diagnosis

A single seizure in a lifetime is not essential for a diagnosis of epilepsy - about 10% of people have had one. Instead, the doctor checks the condition of the nervous system using various tests and examinations (neurological examination):

  • Laboratory tests are primarily used for differential diagnostics. Blood count, blood sugar, electrolytes, liver and kidney parameters, and serum creatine kinase (CK) should be determined.
  • Measuring the brain waves (electroencephalography, EEG) is an excellent diagnostic tool for confirming the suspected clinical diagnosis, provided potentials typical of epilepsy can be detected yet refuted. Nevertheless, an EEG can help to differentiate between primary focal and primary generalized seizures and to classify different epilepsy syndromes, especially in children and adolescents.
  • Magnetic resonance imaging (MRI) helps doctors to clarify cerebral structural changes. Especially when it comes to identifying small lesions and cortical modifications, it has a higher sensitivity and specificity than cranial computed tomography (CT).
  • Under certain circumstances, cranial CT can still be a suitable examination method, for example, in an acute emergency with seizures in the context of craniocerebral trauma, intracranial haemorrhage/calcification or encephalitis, but also if an MRI cannot be carried out acutely or for technical reasons (e.g. pacemaker).
  • Single-photon computer emission tomography (SPECT) provides information about the dynamics of blood flow changes, and positron emission tomography (PET) - about metabolic influences.
  • The cerebrospinal fluid (lumbar puncture) sample from the spinal canal is another option for differential diagnosis. Analysis in the laboratory helps, for example, to detect or exclude cerebral or meningitis (encephalitis, meningitis).

Along with the test results, your doctor may use a combination of tests to determine where in the brain seizures begin:

  • Statistical parametric mapping (SPM) compares areas of the brain that experience increased blood flow during seizures with a normal brain.
  • Electrical source visualization (ESI) is a technique that collects EEG data and projects it onto an MRI of the brain to show where seizures occur.
  • Magnetoencephalography (MEG) measures the magnetic fields generated by brain activity to identify potential seizure areas.

For example, a lot of patients might have genetic causes of epilepsy. Therefore, doctors commonly prescribe genetic tests to check for possible mutations and establish genetic syndromes. In some cases, additional examinations are necessary, for example, to exclude other types of attacks or clarify underlying diseases' causes.

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Treatment overview for epileptic patients

The goal of treating epilepsy is complete freedom from seizures with the fewest possible side effects. A doctor must make a distinction between long-term therapy and acute treatment. Most epilepsy patients benefit from drug therapy with anticonvulsants.

  • Antiepileptic drugs do not affect the epileptogenicity of underlying epilepsy. Instead, they act as blockers by increasing the brain's threshold for seizures to occur. Therefore, the term anticonvulsants are more appropriate.
  • In total, there are more than 20 drugs used to treat epilepsy. These can be given as monotherapy or in combination. The selection depends on the individual patient situation (patient preference, body weight, gender, cognitive performance, psychiatric comorbidity, co-medication, etc.).
  • Doctors recommend lamotrigine and levetiracetam as the drugs of the first choice. Alternatively, the approved drugs carbamazepine, gabapentin, lacosamide, oxcarbazepine, topiramate, valproic acid or zonisamide can be used.

In drug-resistant forms of epilepsy, neurosurgeons provide surgical interventions such as temporal lobe resection or selective removal.

  • At around 60%, most surgical interventions in the temporal lobe are performed as an adapted temporal lobe resection. With continued drug treatment, publications show more than 60% success rates.
  • Other surgical interventions are topectomy (excision of selected portions of the frontal cortex of the brain), lesionectomy (procedure to remove a lesion, or abnormality, in the brain), and hemispherectomy (the removal of one sphere).
  • Treating doctors may consider the possibility of a so-called callosotomy. The surgeon entirely or partially cuts the corpus callosum in the brain during a procedure. It is the connection between the right and left hemispheres of the brain. This procedure allows reducing the number of falls significantly.
  • The new surgical approach is MRI-guided laser ablation for some areas of the brain that cause seizures. The technique is similar to the surgical procedure but less invasive and targeted.

The specialists can stimulate peripheral neuronal networks or directly the epileptogenic focus. Continuous stimulation at different rates and intervals between stimulus series or shortly after the onset of a seizure is intended to minimise epilepsy activity.

  • Vagus nerve stimulation (VNS) is the most widely used method in epilepsy. After VNS treatment, epileptic seizures are reduced by up to 50%. An additional benefit is the antidepressant effect of the treatment.
  • Deep brain stimulation (DPS) is not yet widespread. Procedures include stimulation of the anterior thalamic nucleus, nucleus accumbens, and hippocampus. Responsive focal cortical stimulation is also approved in treating epilepsy in the USA.

In addition to individual patient training, a multimodal treatment concept may include social therapeutic, psychological, psychotherapeutic and psychiatric treatment methods.

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Epilepsy outlook

The prognosis for the disease depends on many factors and is not uniformly predictable. However, every epilepsy should be controlled therapeutically.

Despite significant advances in drug treatment for epilepsy, only two-thirds of newly diagnosed epilepsy patients become seizure-free. They remain without seizures for a whole year: most patients at the first attempt of therapy, around 12% at the second and about 4% at each subsequent attempt.

The success rate for generalised epilepsy is 68%, and 63% - for focal epilepsy. Furthermore, frequent seizures before the start of therapy are associated with an unfavourable prognosis.

FAQ

Is epilepsy curable or not?

The disease cannot be cured completely, but doctors can control epileptic seizures in 70% of cases with appropriate treatment. In addition, drug therapy, successfully selected by an experienced doctor, can prevent the occurrence of attacks until the development of remission.

What is the latest treatment approach in epilepsy?

Antiepileptic drugs are the most common method of treating epilepsy. They help control seizures in about 70% of patients. Epilepsy surgery (removing a small part of the brain that causes seizures), vagus nerve, and deep brain stimulation are also effective treatments in case of drug failure or contraindications.

What are the best drugs for epilepsy?

Epilepsy drugs change the levels of chemicals in the patient's brain. They do not cure epilepsy, but they can stop seizures. Common types include sodium valproate, carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, ethosuximide, and topiramate. The doctor chooses the best treatment scheme for you, considering the type of seizure, age, and whether the patient wants to have a child. Modern medical treatment of epilepsy is available in various forms.

Can surgery cure epilepsy permanently? 

Surgery is most effective when hyperactivity always occurs in the same place in the brain. Epilepsy surgery is not the first line of treatment but is considered when at least two anticonvulsant drugs fail to control seizures. However, it does not cure the disease. After the intervention, it is necessary to take medication to achieve remission.

How successful is surgery for epilepsy?

Statistics show that a successful operation to remove a part of the brain (with increased epileptic activity) significantly reduces the number of seizures or their complexity in 70% of cases. In addition, if there were no seizures a year after the intervention with permanent drug therapy, then with a probability of 90%, there will be no seizures in the next two years.

Where can I get Epilepsy treatment?

Germany, Israel, Poland, Turkey, Spain are among the best for Epilepsy treatment.

9 countries and 24 cities for Epilepsy