Epilepsy Medications

For 70% of patients with epilepsy, medication can control seizures. However, they can’t cure epilepsy, and most people will need to continue taking medications.

An accurate diagnosis of the type of epilepsy (not just the type of seizure, because most seizure types occur in different types of epilepsy) a person has is very important in choosing the best treatment. The type of medication prescribed will also depend on several factors specific to each patient, such as which side effects can be tolerated, other illnesses he or she may have, and which delivery method is acceptable.

Your doctor may prefer that you take the brand name of AED and not the generic substitution. Talk with your doctor about this important issue.

Surgery

Medication can control seizures in most people with epilepsy, but for about 30% of patients, they aren’t effective or are intolerable. In some cases, brain surgery may be an option.

Epilepsy surgery is an operation on the brain to control seizures and improve the person’s quality of life. There are three main types of epilepsy surgery:

• Surgery to remove the area of the brain producing seizures
• Surgery to interrupt the nerve pathways through which seizure impulses spread within the brain
• Surgery to implant a device used to treat epilepsy

Surgery is considered only if the area of the brain where the seizures start, called the seizure focus, can be clearly identified, and if the area to be removed is not responsible for any critical functions, such as language, sensation and movement. Extensive evaluation and testing are necessary to determine if surgery is appropriate.

Who Is a Candidate for Epilepsy Surgery?

Surgery may be an option for people with epilepsy whose seizures are disabling and/or are not controlled by medication, or when the side effects of medication are severe and greatly affect the person’s quality of life. Patients with other serious medical problems, such as cancer or heart disease, usually are not considered for epilepsy surgery.

What Surgical Options Are Available?

Different surgical procedures are available to treat epilepsy. The type of surgery used depends on the type of seizures and the area of the brain where the seizures start. The surgical options include:

• Lobe resection: The largest part of the brain, the cerebrum, is divided into four paired sections, called lobes — the frontal, parietal, occipital and temporal lobes. Temporal lobe epilepsy, in which the seizure focus is located within the temporal lobe, is the most common type of epilepsy in teens and adults. In a temporal lobe resection, brain tissue in the temporal lobe is resected, or cut away, to remove the seizure focus. The anterior (front) and mesial (deep middle) portions of the temporal lobe are the areas most often involved. Extratemporal resection involves removing brain tissue from areas outside of the temporal lobe.
• Lesionectomy: This is surgery to remove isolated brain lesions — areas of injury or defect such as a tumor or malformed blood vessel — that are responsible for seizure activity. Seizures usually stop once the lesion is removed.
• Corpus callosotomy: The corpus callosum is a band of nerve fibers connecting the two halves (hemispheres) of the brain. A corpus callosotomy is an operation in which all or part of this structure is cut, disabling communication between the hemispheres and preventing the spread of seizures from one side of the brain to the other. This procedure, sometimes called split-brain surgery, is for patients with extreme forms of uncontrollable epilepsy who have intense seizures that can lead to violent falls and potentially serious injury.
• Functional hemispherectomy: This is a variation of a hemispherectomy, a radical procedure in which one entire hemisphere, or one half of the brain, is removed. With a functional hemispherectomy, one hemisphere is disconnected from the rest of the brain, but only a limited area of brain tissue is removed. This surgery generally is limited to children younger than 13 years old who have one hemisphere that is not functioning normally.
• Multiple subpial transection (MST): This procedure is used to help control seizures that begin in areas of the brain that cannot be safely removed. The surgeon makes a series of shallow cuts (transections) in the brain tissue. These cuts interrupt the movement of seizure impulses but do not disturb normal brain activity, leaving the person’s abilities intact.
• Vagus nerve stimulation (VNS): This is a device that electronically stimulates the vagus nerve (which controls activity between the brain and major internal organs) is implanted under the skin. This reduces seizure activity in some patients with partial seizures.
• Responsive neurostimulation device (RNS): This device consists of a small neurostimulator implanted within the skull under the scalp. The neurostimulator is connected to one or two wires (called electrodes) that are placed where the seizures are suspected to originate within the brain or on the surface of the brain. The device detects abnormal electrical activity in the area and delivers electrical stimulation to normalize brain activity before seizure symptoms begin.

Dietary Therapies

Ketogenic Diet – The ketogenic diet, is a special high-fat, low-carbohydrate diet, and is prescribed and monitored by a physician and nutritionist can help control seizures in some people.

Modified Atkins Diet – The modified Atkins diet is a less restrictive, higher protein and carbohydrate, outpatient-initiated dietary therapy for epilepsy in both children and adults who would otherwise use the ketogenic diet.

Low Glycemic Index treatment (LGIT) – The LGIT for epilepsy was developed in 2002 as an alternative to the ketogenic diet for treatment of intractable epilepsy. The LGIT monitors not only the total amount of carbohydrates consumed daily, but focuses on carbohydrates that have a low Glycemic Index.

VNS Therapy

VNS Therapy, or vagus nerve stimulation, is a way of controlling seizures in people who do not respond to medications and may not respond to surgery.

What is VNS Therapy?

VNS Therapy consists of a device placed under the skin near the collarbone in the left side of the chest. An electrode attached to the generator is then connected to the vagus nerve in the left side of the neck.

Preprogrammed stimulation can be delivered from the generator in the chest to the vagus nerve. Settings can be adjusted by a nurse and doctor trained in the use of VNS Therapy. A magnet can also be used to trigger bursts of stimulation when a seizure happens.

How well does VNS Therapy work?

The stimulation does not work right away, but after a few months of therapy, about 25 to 30% of people may see that seizures decrease by half or more. Usually seizure control improves over time, with up to about 45% of people having seizures decrease at least by half after 1 to 2 years of therapy.

Complete seizure freedom by VNS happens in only small numbers of people. And in some people, it doesn’t work at all.

VNS is not considered a substitute for seizure medications. People continue to take seizure medications while using VNS. However, if the VNS works, some people can lower the number or dose of medications and lessen side effects.

What are common side effects of VNS?

Side effects of VNS are moderate, including hoarseness and coughing, tingling, and shortness of breath. These usually occur when a person is getting used to the stimulation.

Research has shown that these side effects may occur in up to 29% of people in the first year to no more than 3% in the third year of VNS use.

Additional Information About VNS

• More than 60,000 individuals have implanted VNS devices worldwide.
• The VNS does not interact with medications.
• There is no evidence that the VNS affects fertility or causes harm to a developing baby during pregnancy.
• The VNS has a magnet that you can wear with a wrist strap like a watch.
• Swiping the magnet over the device when an aura (warning sign) occurs can activate the device and may stop a seizure in some people.
• VNS is also approved by the FDA for depression that does not respond to other treatments.

LEARN MORE
VNS Implant Devices are manufactured by LivaNova. Additional information for patients and physicians is available at their website neuropace.com.

RNS® Therapy

Features

• Responsive neurostimulation is known as as RNS® Therapy

• This system is similar to a heart pacemaker. It can monitor brain waves, then respond to activity that is different from usual or that looks like a seizure.

• People cannot feel the stimulation once it’s programmed. It doesn’t cause pain or any unusual feelings.

Brain-responsive neurostimulation with the RNS® System. Image Copyright 2017, NeuroPace, Inc.

An estimated 30% of people do not respond to seizure medicines. Some people can have surgery to remove the origin of the seizures in the brain. This treatment works best for those for people with extreme forms of uncontrollable epilepsy, but it doesn’t work in everyone. On average, only about 60% of people can be free of challenging seizures from removal of a seizure focus in the temporal lobe. RNS® Therapy, a new seizure treatment was approved by the U.S. Food and Drug Administration (FDA) in 2013.

What is the RNS® System?

The RNS® System is a smart device that is adjustable and reversible. Where it is placed and how it is used is tailored to each person. It learns what is going on in a person’s brain, and settings can be adjusted for each person.

Most comprehensive epilepsy centers that provide epilepsy surgery can also offer the RNS® System. Before having the RNS placed, a person must go though detailed testing to see where their seizures are located in the brain.

• The RNS® System is similar to a heart pacemaker. It can monitor brain waves, then respond to activity that is different from usual or that looks like a seizure.
• A device or stimulator is placed in the bone covering the brain. Tiny wires or leads are placed in one or two places on top of the brain where seizure activity may begin. These wires connect to the stimulator. Once the wires and device are placed, nothing can be seen.
• The system can give small pulses or bursts of stimulation to the brain when anything unusual is detected. This can stop seizure activity before the actual seizure begins. Or it could stop seizure activity from spreading from a small focal seizure to a generalized seizure.
• People cannot feel the stimulation once it’s programmed. It doesn’t cause pain or any unusual feelings.
• It’s not permanent. It can be turned off or removed if it doesn’t work or a person doesn’t wish to use it any longer.

How Does The RNS® Work?

• Monitor brain waves at the seizure focus, all the time – even during sleep.
• Detect unusual electrical activity that can lead to a seizure.
• Respond quickly (within milliseconds) to seizure activity by giving small bursts or pulses of stimulation. This goal is to help brainwaves return to normal, even before it could turn into a seizure.

Who Can Use RNS® Therapy?

• The RNS® System has been approved by the FDA to treat focal or partial seizures in adults, 18 years and older.
• It’s used in addition to seizure medications. This is called adjunctive or add-on treatment.
• It’s designed for people with refractory seizures. This means that a person continues to have seizures despite at least trials with two seizure medications.
• It’s used in people who can not have epilepsy surgery to remove where the seizures originate or resective surgery has not worked.

LEARN MORE
The RNS® System is manufactured by NeuroPace, Inc. Additional information for patients and physicians is available at their website neuropace.com.

Source – WebMD, epilepsy.com, American Academy of Neurology