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Treatment for Epilepsy

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How Long Epilepsy Treatment Lasts

In some types of epilepsy, patients can be taken off treatment after a few years, while other types of epilepsy require lifelong treatment. With few exceptions, patients who are seizure-free for a certain period should be re-evaluated to determine whether the drug can be discontinued. How long the seizure-free period should be varies among the types of epilepsy and is controversial even for a given type. The decision to discontinue a medication also depends on more than the length of the seizure-free period.

What is clear, however, is that epilepsy drugs should at least be considered for discontinuation in patients who are seizure-free for 10 years. If a medication is going to be discontinued, it should be weaned gradually to avoid triggering a seizure.

Surgery for Epilepsy

Most patients with epilepsy do not require surgery. However, if seizures are not controlled after a trial of two or three medications (usually accomplished within two years) then re-evaluation is suggested. This information is critical in deciding if epilepsy surgery is an option. Of the 30% of patients whose seizures cannot be controlled with drugs, approximately one third (more than 100,000 in the U.S.) may be candidates for epilepsy surgery. However, only about 3,000 epilepsy surgeries are performed annually.

Before surgery is considered, a comprehensive presurgical exam is performed. This evaluation is performed to ensure that the operation will likely improve the seizures and will not cause damage to essential functions such as speech and memory. The evaluation requires prolonged EEG-video monitoring and other tests to pinpoint the exact location of the injured brain cells causing the seizures. The location of the damaged cells determines whether the surgery can be performed and what technique should be used.

The multidisciplinary evaluation is directed by a neurologist specializing in epilepsy (an epileptologist). A patient's eligibility for surgery is determined jointly by the neurosurgeon, neuroradiologist, neuropsychologist, social worker, and epileptologist. The decision to have the surgery is made jointly by the patient and the epileptologist after carefully reviewing the risks and benefits of the procedure.

Surgery is most commonly performed to treat partial epilepsy, since only one area of the brain is involved. During surgery, the area of the brain that triggers the seizures (usually a portion of the anterior temporal lobe) is removed. After surgery, some patients will be completely free of seizures; in others, the seizures will be better controlled. A few patients may need additional surgery.

Other surgical approaches are reserved for specific types of epilepsy and are most often performed in young children. One approach is to remove a large part of one side of the brain (a hemispherectomy); another is to cut the nerve fibers connecting the two sides of the brain (a corpus callosotomy).

Surgery is also done to implant devices. In vagus nerve stimulation (VNS), 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. There’s also the responsive neurostimulation device (RNS), which 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.

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