Medically Refractory epilepsy

Approximately 40% of all individuals with epilepsy have medically refractory seizures. Primarily generalized seizures are the most common type of intractable seizures in children; while in adults, complex partial seizures are the most common intractable seizure type. Medically refractory seizures are those seizures that are not completely controlled by medical therapy. That means that seizures continue to occur despite treatment with a maximally tolerated dose of a first-line anti-epilepsy drug (AED) as monotherapy or in at least one combination with an adjuvant medication. The terms "intractable" or "medically refractory" are interchangeable.

Factors Associated With Medically Refractory Seizures
Certain epilepsy etiologies frequently cause intractable seizures. The catastrophic epilepsies are most commonly seen in infants and children. While just about any seizure type may be associated with medically refractory seizures, it is uncommon for absence seizures associated with primarily generalized 3 Hertz spike-and-wave on the electroencephalogram (EEG) to be resistant to the appropriate therapy. This seizure type is typically well controlled with ethosuximide.

Medically refractory seizures produce many psychological and social difficulties. Recurrent seizures impair socialization and psychological development during formative years and may lead to an inability to obtain an education, gainful employment, or driving privileges. The development of a learned helplessness and low self-esteem can worsen as long as epilepsy is intractable. Cognitive performance may be impaired by refractory epilepsy as well as by the effects of AED therapy. Successful treatment of a seizure disorder can appreciably improve psychological, social, sexual, and behavioral functions.

Patient And Family Education
Epilepsy is still shrouded by many myths and misconceptions among the public. Although it is difficult to reverse centuries of sanctioned stigmatization concerning epilepsy, the treatment of patients with epilepsy begins with appropriate counseling for both the patient and the family. This is the first step in eliminating the misconceptions concerning epilepsy. It is important to discuss in simple terms the causes of seizures, endogenous and environmental triggers of seizures, and issues concerning safety and driving privileges at the time the diagnosis is presented. Opportunity to re-address these issues and to discuss other issues, such as pregnancy and the teratogenic effects of AEDs, should be made available.

Epilepsy can be a life-altering and debilitating illness that can rob individuals of their independence and can cause profound behavioral, psychological, social, financial and legal consequences. Those people with medically refractory seizures are the most severely effected. Over the last 50 years, tremendous advances in the knowledge of seizures and epilepsy have occurred. More recently, scientific and technical advances have improved the tools for the evaluation and treatment of seizures. In some cases, the most intractable seizure disorders of 10 to 20 years ago are now disorders that can be effectively treated. With current brain surgery techniques, some forms of medically refractory epilepsy may even be cured. Patients should be offered our best efforts to control their seizures and to improve their quality of life. The message to physicians in the year 2000 is to recognize those patients with a medically refractory seizure disorder early in the course of the illness and refer them to an appropriate epilepsy specialist or comprehensive epilepsy program.

Surgical treatment of medically refractory epilepsy