Epilepsy has affected humans for thousands of years, and for most of that time treatment ranged from bizarre to nonexistent. It’s only over the last 150 years that drugs and later surgery have been used to control seizures. More recent advances have seen a resurgence in treatment options, offering new hope to many with difficult-to-control seizures.
The last decade of the 20th century was known as the Decade of the Brain. It was a period of renewed commitment to research in neurology, spurred in part by major advances in neuroimaging, making it possible for researchers to literally watch the brain in action. Epilepsy patients benefitted from the introduction of a number of new drugs, improvements in surgical techniques and new treatment options including gamma knife surgery and electrical stimulation.

Epilepsy affects about one percent of the population in the United States, totaling about 2.3 million people. It occurs in all cultures and affects men and women equally. In about 70 percent of cases there is no known cause, and symptoms typically begin in childhood or young adulthood. When it first begins in an older adult, it is often secondary to a stroke, Alzheimer’s disease or a brain tumor.

During a seizure, the brain becomes disorganized. Instead of working in an orderly sequence, brain cells all fire at the same time. The brain becomes overloaded and is no longer able to respond to normal stimuli. Symptoms may be mild, especially when only one part of the brain is affected. A person experiencing a mild seizure may appear to be daydreaming but actually is mentally absent from the surroundings.
Other seizures affect the whole brain and are much more dramatic. Generalized seizures can lead to loss of control of body function and movement and cause loss of consciousness.

Controlling Seizures with Drugs
A number of new drugs were developed in the 1990s, after a 15-year period during which no new epilepsy drugs came to market. Although the new drugs may be comparable to older medications in their ability to reduce the frequency of seizures, they tend to have fewer side effects, a marked drawback of older drugs.

Traditional drugs (such as carbamazepine, phenytoin, phenobarbitol, primidone and valproic acid) caused problems with memory, attention, mood, behavior and intellectual function as well as birth defects when used by pregnant women.

Newer drugs such as gabapentin and lamotrigine cause fewer cognitive problems. A study comparing lamotrigine to carbamazepine and phenytoin found lamotrigine was less likely to cause cognitive problems, tiredness, worry and negative moods.

Drug therapy is effective for a majority of patients. A recent study of patients newly diagnosed with epilepsy and treated with either the newer or older antiepileptic drugs found that up to 63 percent of patients were seizure-free during drug treatment. Most patients were controlled by the first drug tried.

Surgery is an option for some patients when medication fails to control seizures. Advances in magnetic resonance imaging (MRI) that allows non-invasive mapping of the brain have made it possible to better identify which patients might benefit from surgery. A number of specialized medical centers are able to pinpoint areas of abnormal brain function and perform surgery to remove lesions. Patients with temporal lobe epilepsy whose lesions are visible on MRI are those most likely to benefit.

A number of trials have shown that when epilepsy was not controlled by medication, surgery was able to eliminate seizures in 70 percent of patients and produced significant improvement in another 10 percent.

Surgery is often a last resort after many years of educational, social and occupational problems associated with uncontrolled seizures. Studies are beginning to provide more information about which patients might benefit from surgery earlier in the course of the disease.

A body of research shows that when abnormalities are visible on an MRI scan and seizures haven’t been controlled by two antiepileptic drugs, the patient is unlikely to go into remission with continued attempts at drug therapy and may be a good candidate for surgery.

The Gamma Knife
Surgery is usually a last resort, in part because of the danger of damaging nearby brain tissue during surgery. A new technique, the gamma knife, functions as a virtual knife, allowing lesions in the brain to be destroyed without any cutting–an approach that significantly lowers the risk of damage to nearby brain tissue.

Clinical trials are currently under way for gamma knife surgery that involves targeting beams of radiation at the precise area of the brain identified as the focus of seizures by MRI. Healthy areas of the brain are spared from exposure to the high-dose radiation. Patients are usually able to return home after only one night’s hospital stay, and recovery is much faster than with traditional surgery.

Patients with seizures that originate in one temporal lobe of the brain are good candidates for gamma knife surgery. The trials currently underway, sponsored by the National Institutes of Health, are designed to determine the optimum dose of radiation for eliminating the seizure focus in the brain.

Vagus nerve stimulation (VNS) is another option for patients whose seizures are not controlled by medications. VNS has been used for some time to treat patients with central nervous system disorders and has been proven safe and effective for persons with epilepsy. A small device, similar to a pacemaker is implanted under the skin on the upper left chest. The device sends a mild electrical current to the brain via the left vagus nerve.
A recent study found that VNS therapy was more effective when used earlier in the course of therapy, within five years of seizure onset, than with patients who had had epilepsy for many years and had failed many medications. One study found that after three months of treatment with VNS 15 percent of patients were free of seizures, a threefold improvement over the control group. Other studies show that 23 to 31 percent of patients show significant improvement with VNS therapy. It offers the advantage of being free of the unwanted side effects associated with drug therapy.

Adequate seizure control and quality of life are intricately linked in the management of epilepsy. Patients whose seizures aren’t well controlled need to continue to work with physicians or seek referral to specialists so they can stay informed about new treatment approaches, including clinical trials, that might work for them. The Decade of the Brain closed the last century on a note of hope for epilepsy. The opening decades of this century will see many of those hopes realized.

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