INTRACTABLE EPILEPSY

YUSTIANI DIKOT
SUBBAGIAN EPILEPSI
BAGIAN I.P SYARAF
RSHS/FKUP

DEFINITION
Epilepsy with multiple seizures despite
appropriate treatment.
Patients with uncontrolled seizures within 1 year
after appropriate therapy.
Patients developed intolerable side effects that
interfere with their quality of life, despite
maximally tolerated trials of one or more AEDs.
Patients who continue to exhibit 2 or more
disabling seizures per month for a period of 2
years or more despite supervised trials twice
with monotherapies and once with polytherapy.

Factors contributing to intractability:

Intractability varies from patient to patient,
depend on :
Subjective handicap:
Patients expectation.

Medical intractability :
The degree of disability due to seizures or AED toxicity.
Aversion to AED intake.

Social disability:
Other factors such as employment, marriage and driving
license

Evaluation of intractability

Diagnosis :epilepsy or non epileptic events

Seizure/syndrome classification.
Etiological considerations.
Drug treatment including compliance
(dosage, plasma level, seizure
monitoring).
Evaluation of learning and psychosocial
problems, which could contribute to
uncontrolled seizures.

Epidemiology
20-30% epileptic patients continue to have
epileptic seizures regardless of treatment
with all AEDs.
They have chronic epilepsy, medically
unsatisfactory controlled epilepsy or
pharmaco-resistant epilepsy.

Factors associated with resistance

to AED therapy:
Onset in infancy.
Organic brain damage: Mental retardation,
Neurological signs, Cerebral palsy.
Seizures type: Tonic, atonic, myoclonic, multiple
seizure types.
High seizures frequency.
Long duration of uncontrolled seizures.
Failure of past AED treatments.
Abnormal (epileptiform) EEG.

Pseudo refractory epilepsy

Diagnostic error.
Inadequate dosage of antiepileptic drugs.
Inappropriate assessment.
Patients lack of cooperation.

Problems encountered among

patients with refractory epilepsy

Incorrect or imprecise diagnosis.

No seizures diary
Inappropriate AED therapy.
Inadequate poly therapy.
Frequent AED adverse effects and their erroneous interpretations.
Physical injuries resulting from seizure related falls.
Significant psychosocial problems
Disturbed family life.
Educational and occupational under-achievements.
Frequent hospital admissions.
Inability to cope with economic burden.
Poor quality of life.

Management
Appropriate counseling with the patient
and family about the diagnosis of epilepsy.
Obtaining detailed information about the ictal
and post ictal behavior, aura, oral alimentary
or gestural automatism, ictal paretic posturing.
ictal dysphasia and postictal neurological
deficit.

Non invasive protocol for evaluation

of patients with intractable epilepsy
Review history of past AED treatments, seizure frequency and
EEGs.
Medical and neurological examinations.
16 channel EEG recording awake and sleep.
Neuropsychologic evaluation.
Psychosocial evaluation.
Psychiatric evaluation.
Visual field testing.
MRI with protocol for hippocampal volume loss and sclerosis.
Ictal VEEG recording (3-5 days)
Wada test for language and memory distributions.

Therapeutic options
Surgery:
50-60 % patients with anterior temporal (mesial
temporal sclerosis /MTS) lobectomy become seizure
free.

The most important feature of MTS:

History of febrile convulsions.

Biphasic course with complex partial seizures.
Aura with fear and vegetative symptoms.
Rare or no secondary generalization.
Anterior temporal spike/sharp wave focus in the EEG.
Ipsilateral hippocampal atrophy/increased signal
intensity on T2 MRI.

General terms of epileptic surgery:

Patients with partial epilepsies.
Patients has medically intractable epilepsy
To define the outcome goals of the chosen surgical
procedure, and estimate the chances of attaining this
successful program.
Gains of quality of life after surgery.
To determine the risk and benefit of surgical procedures.
The patients is medically fit for surgical procedures.
The minimum disease duration before surgery is two
years,
To counsel about the outcome and risk.

Timing of operation
Surgery early: Epileptic syndromes with
high probability of medical intractability
and a favorable surgical prognosis.
Increasing evidence for a progressive
nature of some epileptic syndromes or for
a possible complication related to the
nature of lesion.

 Vagal nerve stimulation.

Conditioning and behavioral modification.
Patient is able to identify seizure provocative
situations
Can give a precise description of the initial
phenomena of seizures.
Has previous experience in aborting seizures.

Progressive relaxation training