engleski

Pharmacoresistant epilepsy: possibilities of treatment

Epilepsy is a common neurological disease affecting 1% of the population, which in many instances turns out to be a life-long chronic burden with consequences that can sometimes be quite severe, e.g., excessive bodily injury, neuropsychological and psychiatric impairment, social disability, higher mortality rates, and overall reduced quality of life. The gold standard of epilepsy treatment is permanent therapy with antiepileptic drugs (AEDs) based on the concept of prophylactic suppression of seizure activity. Around one-third of patients have pharmacoresistant epilepsy and interestingly, the proportion of these patients has not considerably changed with the introduction of newer AEDs since the early 1990s. According to the definition of the International League Against Epilepsy, AED resistance is defined as “failure of adequate trials of two tolerated, appropriately chosen and used AED schedules (whether as monotherapies or in combination) to achieve seizure freedom”. Current treatment options for these patients include surgical removal of the seizure focus, and alternative approaches such as neurostimulation (vagus nerve stimulation, responsive neurostimulation, deep brain stimulation), ketogenic diet, as well as lifestyle changes. In these patients, nonpharmacological treatment options should be considered early rather than late, but only resective epilepsy surgery can be curative. Epilepsy surgery is an evidence-based treatment option for patients with pharmacoresistant focal epilepsy, with the rate of seizure-free surgical outcomes ranging from 70% to 80% in well-selected cases. Several randomized controlled trials have demonstrated that surgical treatment is safe and effective for pharmacoresistant epilepsy, yet this therapy is still underutilized. There are examples of epileptic syndromes and diagnoses for which epilepsy surgery may be suggested only by noninvasive presurgical diagnostics (mesial temporal lobe epilepsy associated with hippocampal sclerosis, circumscribed epileptogenic lesions (not near eloquent areas), benign neoplasms, vascular malformations, epileptic encephalopathies and multifocal disease (for corpus callosotomy), etc.). In other cases, surgery may be suggested only after additional invasive presurgical diagnostics (temporal lobe epilepsy with discordant electroclinical data, normal magnetic resonance imaging, extratemporal circumscribed epileptogenic lesions close to eloquent area, malformations of cortical development, and dual pathologies). Data from epilepsy surgery studies show that people with shorter epilepsy duration are more likely to be seizure-free at follow-up. In addition, longer epilepsy duration is the only modifiable predictor of impaired adaptive and cognitive development, thus supporting early surgical intervention. Therefore, patients who might benefit from epilepsy surgery should be referred for presurgical assessment without delay. Early surgical intervention for appropriately chosen patients with pharmacoresistant epilepsy offers the best opportunity to avoid lifetime disability and premature death.

pharmacoresistant epilepsy ; treatment

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