Download Treatment of epilepsy: Medical, diet and surgical Options

Choices in the Treatment of Epilepsy:
What, When, and Who?
Juliann M Paolicchi, MA, MD
Clinical Professor, Pediatrics
Rutgers University
Pediatric Epilepsy,
Co-Director, Pediatric
Clinical Research
Northeastern Regional
Epilepsy Group
Choices in the Treatment of Epilepsy:
What, When, and Who?
Epilepsy, especially when not responsive to medication, affects
the patient’s and familes’ social life, peer interactions,
educational and career decisions, driving ability, and
reproductive life.
Communication on treatment options based on discussion of
patient’s treatment goals
The challenge: Minimizing seizures and maximizing QOL
Disclosures:
-Speaker for Cyberonics,
Lundbeck
- Reseach: Esai, GW
Pharmaceuticals
Choices in the Treatment of Epilepsy:
What, When, and Who?
What: are my options?
Epilepsy, especially when not responsive to medication, affects
When: should I consider
the patient’s and familes’ social life, peer interactions,
theseability,
options?
educational and career decisions, driving
and
Who are the best
reproductive life.
candidates for these
Communication on treatment options
based on discussion of
options?
patient’s treatment goals
The challenge: Minimizing seizures and maximizing QOL
Disclosures:
-Speaker for Cyberonics,
Lundbeck
Reseach: Esai, GW
Pharmaceuticals
Case Reviews
 Case 1: The little jokester
 Family wanted surgery
 Case 2: The soccer goalie
 Family wanted VNS
Case 1: The little Jokester
8 yo former premature boy with history
of hypoxic injury at birth
Right hemiparesis and expressive
language deficit on exam
Initially: ?200 seizures/day = 1/10min,
6/hour while awake
Case 2: The Soccer Goalie
15 yo w/5 yr
History of
seizures
Responsive,
repeats words,
funny feeling,
right hand
tingling
Initially: 1-3 seizures/
mos according to
mother
In reality: 9-12/mos
Treatment Goals for
Epilepsy
Newly Diagnosed
AED Trial 1 Monotherapy
AED Trial 2 Monotherapy
or Polytherapy
Refractory Epilepsy
Surgical Evaluation
Epilepsy Surgery
VNS Therapy
AEDs (Polytherapy)
Ketogenic Diet
Treatment Goal
Treatment Goal
• Seizure freedom
• Maximize quality of life
• Optimize Long-term seizure contro
• Minimize AED side effects
• Maximize adherence
Refractory Population
SF%
SF 1st Drug
35%
50%
SF 2nd Drug
SF 3rd Drug
MRE
4%
11%
Mohanraj R and Brodie MJ. Eur J
Neurol. 2006;13:277-282
Treatment Goals for
Epilepsy
Newly Diagnosed
AED Trial 1 Monotherapy
AED Trial 2 Monotherapy
or Polytherapy
Refractory Epilepsy
Surgical Evaluation
Epilepsy Surgery
Neurostimulation
AEDs (Polytherapy)
Dietary Therapy
Treatment Goal
Treatment Goal
• Seizure freedom
• Maximize quality of life
• Optimize Long-term seizure contro
• Minimize AED side effects
• Maximize adherence
Treatment of Patients with MRE:
Choosing the Procedure
The typical steps involve:
*Epilepsy characterization
*Surgical determination
*Determination of alternative therapies:
- Dietary
- Neurostimulation
- New/Experimental AEDs
-“Herbal/organic”
Risk of Prolonging Treatment
 RISK:
 Patients with chronic epilepsy are at risk for cognitive,
social, and psychiatric impairments that decrease
employment, social interactions, and quality of life
 RISK:
 Patients with chronic epilepsy have increased
mortality due to increased risk of status epilepticus,
injury, and SUDEP
 SUDEP= sudden unexplained death in person with
epilespy
 Likely due to autonomic disturbances prior and during
seizurel
Goals of Earlier Treatment
GOAL: Earlier identification of refractory epilepsy can direct
patients to different treatment options.
 RISK: Patients with chronic epilepsy are at risk for cognitive, social,
and psychiatric impairments that decrease employment, social
interactions, and quality of life
GOAL: Timely management can prevent long-term disability,
social maladjustment, and impaired QOL
 RISK: Patients with chronic epilepsy have increased mortality due to
increased risk of status epilepticus, injury, and SUDEP
GOAL: Early intervention in children can potentially prevent or
reduce epilepsy-induced disabilities, improve development, and
promote neuronal plasticity
Overview
 Approach to the MRE patient
 New/Emerging and Experimental Therapies
 New Anti-epileptic Agents
 Old Meds/New Uses
 Organic Medications, esp CBD, MMJ
 Epilepsy surgery: review of types
 Dietary therapies
 Neurostimulation: Multiplel types: VNS,
Neuropace, DBS
Resective Surgery
 Temporal Lobectomy
 Most common surgically
treated epilepsy, accounting
for 75% of operated pts
 TLE with mesial temporal
sclerosis (MTS) is the most
frequent pharmacoresistant
epilepsy in adults and
adolescents
 Now considered a progressive
disorder due to the developing
encephalopathy, cognitive
deterioration, and worsening of
the epilepsy commonly seen in
the disorder
Resective Surgery:
Temporal Lobectomy
 For Diagnostic accuracy:
 MRI:
 Tumor: 98 – 100 % accurate
 Hippocampal Sclerosis: 90-97%
accurate
 Cortical dysplasia: 41- 46%
accurate
 FDG-PET: 85%
 Ictal SPECT: 85%
 Interictal SPECT: 65%
 MEG: 56%
Resective Surgery:
Temporal Lobectomy
 1st Randomized control trial of
efficacy (Wiebe, et al, 2001
NEJM)
 80 pts with medically
intractable TLE randomized to
surgery vs continued medical
therapy.
 58% surgical group SF ( seizurefree) vs 8% medical group (p <
0.001). 83
 Surgical group: improved scores
of QOL, employment rates,
school attendance, decreased
mortality
Temporal
Lobecotomy
 1st Randomized control trial
of efficacy (Wiebe, et al,
2001 NEJM)
 80 pts with medically
intractable TLE randomized
to surgery vs continued
medical therapy.
 58% surgical group SF (
seizure-free) vs 8% medical
group (p < 0.001). 83
 Surgical group: improved
scores of QOL, employment
rates, school attendance,
decreased mortality
 2nd Randomized control
trail: ERST Trial( Engel et al,
JAMA, 2012)
 Randomized trial to early
surgical intervention vs
medical therapy after 2
years of epilepsy and 2
failed AEDs
 Trial halted due to slow
enrollment and early
outcome data
 0/23 medical vs 11/15
surgical SF, 2 years
outcome (p<0.001, 95%CI)
Resective Surgery:Temporal
Lobectomy
 Outcome: Best indicators of
success in adults and adolescents
is presence of lesion: MTS and
tumors with the best outcome.
 Tumors (65 -86% SF)
 MTS (75- 79% SF)
 Elsharkawy 2009; Engel, et al,
2003
 In young children, inherent
neurobiologic differences in the
etiology and expression of
temporal lobe epilepsy are
different than that of adults, so that
preclinical factors are less
predictive
 Goldstein wt al, 1996
Types of Temporal Lobe
resection
 “Classic” non-dominant
 “Classic” dominant
 Selective amygdala-hippocampectomy (
focused resection of the mesial structures)
 Mesial resection with neocortex as defined
on pre-operative testing +/- Phase ll
monitoring
Types of Temporal Lobe
resection
 “Classic” non-dominant
 “Classic” dominant
 Selective amygdala-
hippocampectomy ( focused
resection of the mesial structures)
 Mesial resection with neocortex as
defined on pre-operative testing +/Phase ll monitoring
Types of Temporal
Lobe Resection
 “Mesial
resection with
neocortex as defined on preoperative testing +/- Phase ll
monitoring
Resective Surgery:
Frontal Lobectomy
 Second most common surgical intervention, accounts for
30% of epilepsy surgeries
 MRI remains a crucial element, but up to 29% of pediatric
cases do not demonstrate a lesion
 Localization dependent on ictal semiology, and a
concordance of data from:

ictal EEG, FDG-PET, and if needed, ictal SPECT data

Anterior frontal, orbitofrontal, and interhemispheric epileptogenic
regions are more likely to require subdural implantation for mapping
of the epileptogenic zone, motor, and/or language function

Outcome reports are variable, but overall 50-57% Engel Class 1
outcome, with a mean time to first seizure, 33 months
 Recent report with 32% gains in employment, 52% reduction in
meds, only 9% dc’d AEDs
 No correlation with MRI, localization, neuropscyh status (Lazow,
et al, Epilepsia, 2012)
Resective Surgery:
Multi-Lobar Resection
 Account for < 2% of procedures
 Typically reserved for known, static
etiologies of epilepsy:
 large cortical dysplasias
 pre and perinatal insults
 vascular insults leading to porencephalic
cysts
 Defined lesions such as tumors, trauma,
and Sturge-Weber syndrome (SWS)
 Outcomes are generally lower than
single lobar resections -- expected
given the extent of epileptogenic
region
 Palliation or Seizure reduction rather than
seizure freedom may be the goal
Disconnection Surgery:
Hemispherectomy
 Functional vs Anatomic: Former
typically performed due to lower
complication rate of hydrocephalus (228%) and hemosiderosis,
 Reserved for specific, refractory
epilepsies:
 Sturge Weber Syndrome
 hemispheric cortical dysplasia
 hemimegalencephaly (HME)
 Acquired: Rasumussen’s
Disconnection Surgery:
Hemisphereotomy
 Mortality 7%
 Outcomes:
 In multiple studies, Rasmussen’s, SWS, and post-
perinatal infarction: 70-90%SF
 Cortical dysplasia, HME: 60-80% SF
 Developmental outcome improved, even in
patients with severe developmental quotients
 Deficit: Hemiparesis of hand, foot drop, and
homonymous hemiparesis are expected
deficits and included in pre-operative
counseling
 Kossoff et al, 2003
Disconnection Surgery:
Corpus Callosotomy
 Separation of the callosal fibers
 often anterior, but can be complete
 More deficits with complete resection:
 Motor 56% vs 8% anterior only
 Language 14% vs 8% anterior only
 Cognitive 11% vs 8% anterior only
 (Yale data)
 Reserved as a palliative procedure for
patients with generalized epilepsies,
especially drop seizures where it has most
efficacy
 In more recent usage, may be used as an intial
surgery to help identify epileptogenic focus:
 Ie, in bifrontal epilepsy may identify a unitlateral
Specific Conditions and
Indications
 Hemimegalencephaly: Hemispherectomy
 Tuberous Sclerosis:
 PET with 11CAMP indicated to identify epileptogenic region
around tubers
 Medically refractory IS in TS: surgical evaluation
 Excision of epileptogenic tuber associated with high rate of
seizure freedom
 CCH, MCH, DCH
 Hypothalamic Hamartoma: Surgical approaches vary
based on location and size of lesion.
 New theraputic options may also be options: gamma knife,
Visualase
Specific Conditions and
Indications
 Hemimegalencephaly: Hemispherectomy
 Tuberous Sclerosis:
 PET with 11CAMP indicated to identify epileptogenic region
around tubers
 Medically refractory ES in TS: surgical evaluation
 Excision of epileptogenic tuber associated with high rate of
seizure freedom
 CCH, MCH, DCH
 Hypothalamic Hamartoma: Surgical approaches vary
based on location and size of lesion.
 New theraputic options may also be options: gamma knife,
Visualase
Specific Conditions and
Indications
 Hemimegalencephaly: Hemispherectomy
 Tuberous Sclerosis:
 PET with 11CAMP indicated to identify epileptogenic region
around tubers
 Medically refractory IS in TS: surgical evaluation
 Excision of epileptogenic tuber associated with high rate of
seizure freedom
 CCH, MCH, DCH
 Hypothalamic Hamartoma: Surgical approaches vary
based on location and size of lesion.
 New theraputic options may also be options: gamma knife,
endoscopy, Visualase
New Techniques/Procedures
 Visualase:
 MRI directed laser resectionMR-guided laser interstitial
thermal therapy (MRgLITT) allows for real-time thermal
monitoring of the ablation process and feedback control
over the laser energy delivery.
 Gamma knife procedure:
 Targeted radiosurgery that is noninvasive, and has
excellent side effect profile. Indicated for small, deep
lesions, ie Small Hypothalamic hamartomas, but effects
are delayed
Outcome in Pediatric Epilepsy Pts:
Need to be Complete!

In a large study of children undergoing
surgery over a 10 year period:

Overall: 78% good outcome (SF or
>90% reduction), 60% SF (seizure-free)

Lesional cases vs Non-lesional cases :



Site of seizures:



80% good outcome, 65% SF
74% good outcome, 51% SF (no statistical
difference)
Temporal 80% good, 70% SF,
Non-temporal 78% good outcome, 61%
SF (no statistical difference)
Most significant feature:

Completeness of the resection: 92% good
outcome, 76% SF (p<0.0001)

Paolicchi et al, Neurology 2000; 54 (3): 642647
Outcome in Pediatric Epilepsy Pts:
Need to be Complete!
 Single best determinant of outcome in
children: completeness of the
resection.
 Probability of poor outcome 11x greater
for incomplete resections
 No other presurgical factor ( etiology,
lobe, pathology, cognitive state,
duration of epilepsy, age statistically
significant variable)
 Similar reports from CCF, have shown
88% seizure freedom after complete
resection
 Wylie et al, 1998
 Other studies have demonstrated
improved outcomes in patients with MRIvisible lesions, unilobar resections, and
tumors
Developmental Outcome of
Epilepsy Surgery in Children
 Developmental outcome improved after
early resection:
 Variable factors of influence, but including for
children with low development at baseline,
 Several studies have demonstrated that earlier
age, epileptic spasms, and/or less duration of
epilepsy show more improvement with
developmental outcome
Factors that improve developmental
outcome:





Younger age at the time of surgery
Short duration of epilepsy
Seizure freedom/outcome
Improved developmental, dependent on
the study is estimated at 59-70%

Paolicchi, Nature Clinical Practice
Neurology, 2007; 3, 662-663.
Treatments for
MRE
Dietary Treatments
Ketogenic Diet: The “Cadillac”
of the Dietary treatments
 The typical dietary intake is “inverted” from
predominantly carbohydrates in the typical
diet, to predominantly fat and protein
 75% of cals from fat, with 1g/kg protein, and 5-
10g carbohydrate/day
 The ratio of fat: protein-carb ranges from 2:1 4:1, with higher ratios seen as more restrictive,
and typically more effective
 ABSOLUTELY requires the supervision of a
trained nutritionist/dietician, trained in
familiarity with the diet.
Ketogenic
Diet
 Meals include typical protein/fat sources:
 Bacon, eggs, tuna, shrimp, mayonnaise, heavy cream,
sausage, beef jerky
 Fat is dietary, but supplemented by dairy ( cream), nut
(sesame/peanut), vegetable ( coconut) or MCT (
medium chain triglyceride) oil which has made the
diet better tolerated, palpated, less side effects
 Available for multi-cultures, customable to the patient
 Can continue infants on breastfeeding
 Easiest for patients who are bottle or GT fed
 Variety of formulas available for use on the diet
Ketogenic Diet
 Best Indications?
 Studied most extensively in children, but NOT restricted to
use in this population.
 Certain Epilepsy conditions:
 1. Epileptic spasms:
 Abdelmoity ( 2014) prospective: >50% achieved in 70% of
pts in 3mos, majority after 1mos of the diet ( 60%). Less
EEG improvement (60%)
 Kosoff, et al ( 2002): New onset, >50% in 70% in 3 mos, > in
mos, 38% > 90% improved, Less EEG improvement ( 50%);
56% remained on diet for 12 mos, all were > 50% improved
 Developmental improvements noted in both studies tied
to seizure control
Ketogenic Diet
 2. Dravet Syndrome ( SCN1a mutation)
 Multiple, small, adjunctive treatment trials of MRE pts demonstrate benefit of
KD in this group of patients [Caraballo, et al, 2011 : >75% reduction in 10/13
children]
 Prospective trial of 14 pts ( Nabbout et al, 2011): 75% improvement in 10/15
pts ( 67%), 40% continued to respond at 9 mos. Behavioral improvement (
hyperactivity/inattention) 56%
 3.Lennox-Gastaut Syndrome
 Frequently used for this syndrome
 JHU trial of 41 pts after 6 mos on diet:(Lemmon et al, 2012):51% > 50%
improvement, 23%>90%, 1% SF (41 pts)
 4.Tuberous Sclerosis Complex: multiple, small studies indicating longterm
safety, and indication that children with TSC more likely to have ruecurrence
after weaning KD (Nangia, et al, 2012)
 5. NCL ( neuronal Ceroid Lipofusinosis)
 6. FIRES ( Febrile infection-related epilepsy syndome
Ketogenic Diet
 Direct Indications
 1 Doose Syndrome/Epilepsy with Myoclonic-Atonic
Seizures:
 Multiple, small clinical trials have demonstrated significant
benefit on seizures, AND EEG
 ie Caraballo et al ( 2006): after 18 mos on KD, 66%> 50%
improved, 44% > 75% improved, 22% SF
 2. GLUT1 deficiency ( glucose transporter 1 deficiency
 3. PDH: pyruvate dehydrogenase deficiency
Ketogenic diet and other dietary treatments for
epilepsy
Review of Results:
- Kossoff 2007: less seizures in 10g Carb KD vs 20g MA
- Neal 2008: KD seizure improvement > control,
p>.0001
-Seo 2007: KD 4:1 less seizures than 3:1, p<0.05
Side effects:
-GI: 30%; Long term potential: Cardiovascular
-Discontinuation primarily due to lack of
effectiveness or restrictive nature:
-only 10% on diet at 3-6 yrs.
Robert G Levy1,*, et al
Editorial Group: Cochrane Epilepsy Group
Published Online: 14 MAR 2012
Assessed as up-to-date: 28 JAN 2012
DOI: 10.1002/14651858.CD001903.pub2
The Cochrane Library
Epilepsy Behav. 2013 Dec;29(3):437-42.
A decade of the modified Atkins diet (2003–2013):
Results, insights, and future directions.
Kossoff EH, Cervenka MC, Henry BJ, Haney CA,
Turner Z.
Abstract
-The modified Atkins diet has been used since 2003
for the treatment of children and adults with MRE
-10 years of continued use, approximately 400
patients have been reported in over 30 studies of
the modified Atkins diet as treatment for
intractable seizures
-Results demonstrating similar efficacy to the
ketogenic diet and improved tolerability.
-The modified Atkins diet is being increasingly used
in the adult population.
LGI: Low-glycemic index diet
 Less available research for epilepsy, but
extensive use in metabolic syndrome ( prediabetes)
 Easily accessible for most families, and more
straightforward as an add-on adjunctive
treatment
 Does not require the complete “buy-in” and
weighing of all foods as the keto diet
Low Glycemic Index Diet
Essential basis is to limit the
TYPE of carbohydrates, as
opposed to the the
proportion:
-Low glycemic index
carbohydrates:
--Whole grain rice
--Whole grain bread
--Whole grain pasta
--Eliminate fruit juices,
starches, dried fruits
--NO PROCESSED SUGARS;
sugar substitutes
accessible
Neuromodulation Options
 VNS: Vagal Nerve Stimulator:
 FDA approval for partial seizures, > 12 yrs
 AAN review and additional studies:



Children, LGS, Generalized epilepsy
Post-operative seizures
Anecdotal studies: TSC, Dravets, SMEI, LKS, CAE
 NeuroPace:Responsive Neurostimulation
 Partial seizures in adults (not FDA approved/studied in
children)
 Identified epileptogenic regions
 On demand, direct brain stimulation
 DBS: Deep Brain Stimulator:
 Partial seizures in adults w/,
 w/o secondarily generalized
 Trigeminal Nerve Stimulator
% of Patients with
50 seizure frequency reduction
Long-term effectiveness confirmed
across multiple studies
45
70%
60%
59%
57%
64%
51%
50%
* 24% >
90%
40%
improved
30%
20%
10%
0%
Labar
Vonck
De Herdt
Elliott
(n=269)
Mean follow up:
12 months
(n=118)
Mean follow up:
33 months
(n=138)
Mean follow up:
44 months
(n=400)
Mean follow up:
59 months*
1. Labar DR. Seizure 2004;13:392-8. 2. Vonck K, et al. J Clin Neurophysiol 2004;21:283-9. 3. De Herdt V, et al. Eur J Paediatr Neurol 2007;11:261-9.
4. Elliott RE, et al. Epilepsy Behav 2011;20(1):57-63.
VNSOV15-11-1000-WW
Mean Seizure Reduction
Seizure reduction improves over time and is
sustained for at least 10 years post-VNS
Therapy 75.5% 75.5% 76.3%
58.3%
60.4%
2 Years
4 Years
65.7%
52.1%
35.7%
6 months 1 Year
6 Years
8 years 10 Years
LVCF
• Seizure frequency was significantly reduced from baseline
at each of the recorded intervals (P<0.01); N=65
46
VNSOV15-11-1000-WW
Elliott RE, et al. Epilepsy & Behavior 20: 57-63, 2011
PuLsE trial showed significantly greater
seizure reductions with VNS Therapy vs AEDs
alone
VNS + BMP
Medianpercent change from
baseline seizure frequency
BMP only
0
-5
-10
-15
-20
-25
0
47
3
BMP = Best Medical Practice
VNSOV15-11-1000-WW
Ryvlin P, et al. Epilepsia 2014;55:893.
6
Time (months)
9
12
PuLsE trial showed superior quality of life with
VNS Therapy vs AEDs alone
VNS Therapy + BMP showed significantly
greater improvements in quality of life (QOLIE-89)
Ryvlin P. et
al Epilepsia
(in Medical
press) 2014
BMP
= Best
48
VNSOV15-11-1000-WW
Ryvlin P, et al. Epilepsia 2014;55:893.
Practice
VNS: Aspire System
Approved 5/15
82% of epilepsy patients
experience ictal
tachycardia
The AutoStim
Mode feature:
Aspire Trial: 66% seizures ended with
automatic stimulation
Desynchronization
Ictal tachycardia
detected/automatic stimulation
Narrow Versus Broad Spectrum AEDs
New/Emerging Therapies
 New(er) AEDs: Novel Mechanisms
 Ezogabine: partial seizures (Volt-gated K
channels)
 Vigabatrin: Epileptic seizures and refractory
partial seizures ( irreversible inhibition of GABA
transaminase)
 Perampanel: partial and generalized seizures.
seizures ( antagonist of AMPA receptors glutamate)
 Eslicarbazepine acetate: Oxcarbmaxepine
analog/daily dosing schedule
 Specific AEDs:
 Stiripentol ( alcohol compound than increases
opening of GABA channels)
 Fenflouramine: Used for cardiac disease– effect
in genetic epilepsies
Initial Focus on a Particularly Difficult to
Treat Genetic Epileptic Syndrome:
Dravet’s Syndrome
Herbal/Organic: Cannabidiol
Epidiolex : Class I in many
states, IND in US, RCT trial
for Dravet, LGS
Medical Marijuana: Statewide registration laws vary
“Self Trials” common
Preclinical Models of Efficacy:
1. Mg-free Hippocampal Slices
2. 4-AP Hippocampal Slices
3. PTZ- induced seizures in rats
4. Electro-shock seizures in mice
5. Audiogenic seizures in mice
6. Pilocarpine-induced seizures in rats
Current need and initiation
of double-blind randomized
control trials
Current need and initiation
of double-blind randomized
control trials
-8 pts had EEGs before and
after treatment, and
showed no effect
-Response of pts who had
MOVED to CO, 2x that of pts
who resided in state
Current Cannibidoil Trials
 1. ‘Availability” trial: 137 pts treated, mean
reduction in seizure number, 54% of pts had a
50% reduction in seizures
 2. Effect of Cannibidoil on Neuropsychological
profile for patients with refractory Epilepsy:
RESULTS AVAILABLE SOON
 3. Randomized “Placebo” clinical trial in pts
with Dravet syndrome: RESULTS AVAILABLE
SOON
 4. Randomized “Placebo” clinical trial in pts
with Lennox-Gastaut syndrome: RESULTS
AVAILABLE SOON
 5. Smaller trials in specific patient populations
Current Cannibidoil Trials
 NEREG TRIAL:
 High CBD/low THC concentration




MMJ
Open label trial
Various age categories
Variable seizure types, but all
Medically refractory epilepsy
Following:

Seizure frequency

Effect of Anti-epileptic medications

Measuring Patient Questionnaires on:
Sleep
 Behavioral Health, especially Anxiety,
Mood

-
What happened to our cases?
 Case 1: The little jokester
 Family wanted surgery
 Case 2: The soccer player
 Family wanted VNS
Case 1: The little jokester
-
-
Reduction from
200/day to cluster
in am of about 10
seizures
Returned to
school!
Case 2: The Soccer Goalie
Initially: 1-3 seizures/
month according to
mother
In reality: 9-12/mos
Outcome:
- Seizure-free
w/
Intermittent
auras
controlled
with AED
changes
- Driver’s
License!
Summary: Treatment of Medical
Intractability The typical steps involve:
*Comprehensive Epilepsy
Evaluation *Surgical determination
*Determination of alternative
therapies:
- Dietary
- Neurostimulation
- New/Experimental AEDs
-“Herbal/organic”
Choices in the Treatment of
Epilepsy: What, When, and
Who?
What: are my options?
When: should I consider these
options?
Who are the best candidates for
these options?
Timely referral can
alter the
progressive
disability of
medically
intractable
epilepsy
Timely referral
can potentially
Improve the
developmental
outcome of
patients with
chronic
epilepsy
Timely referral
can potentially
reduce the need
for more extensive
resections/therapi
es
Treatment of Medically Resistant Epilepsy
:
If medically- resistant, the treatment goal switches to QOL:
 Maximizing QOL, minimizing seizures and sedation
 Goals are determined by the team of the patient, caregivers,
and medical staff as to realistic and individual attainable goals
 The family and patient are key members of that determination
 Frequently asses the goals of the patients and caregivers as to the
success of the goals, not just seizure count
Questions?
JM Paolicchi, MA, MD
NEREG
Manhattan, NY
Hackensack, NJ
White Plains, NJ
Middleton, NY
@JMPaolicchiMD
[email protected]