Neurological Conditions: Refractory Seizure

Introduction

Refractory Seizure is the term used usually for medical refractoriness, means the medications (and other medical approaches like ketogenic diet) are not helping with the control of seizure.

Of course literally speaking this phrase can be used for all kinds of refractoriness (medications, surgery everything you try with the seizure patient). In this article the term is used for medical refractoriness.

When do you call a seizure is refractory to medical management?

This is not an easy question to answer. You cannot always come out with one definition which satisfies all the situations. But the general consensus is as follows;

If seizures continue to occur in spite of trying 2 standard AEDs (antiepileptic drugs or anti seizure medications) at their most effective doses then you may call them medically refractory. Of course if 2 AEDs do not help then adding more AEDs may help in some patients and if they truly control seizures then such patients are not called as medically refractory. So we cannot give too much emphasis for 2 AEDs in our definition.

But the point is if 2 standard AEDs do not adequately control the seizures at their most optimum doses, either alone or in combination, then chances are less that adding or switching over to other drugs will help much. Only a small number of patients will respond to these more than 2 drugs regime.

More drugs mean more side effects too.

Once a seizure patient attains the status of medically refractoriness then other therapeutic options need to be explored like surgical interventions.

Surgical Options for Medically Refractory Seizures

There are mainly two types of surgeries available;

1) VNS (vagal nerve stimulator) &
2) Epilepsy brain surgery

VNS is obviously the easier, simpler, safer and less expensive option. But epilepsy surgery is generally more effective and in some cases even can cure it. Unfortunately both these surgeries are less useful for generalized types of epilepsies (unless they are secondary generalized). This is especially so for epilepsy brain surgery which cannot help for idiopathic primary generalized epilepsies like JME (juvenile Myoclonic Epilepsy), petit ma (absence) seizures etc.

When exactly to consider surgical options?

The target is total seizure control, means not a single seizure with the mediations. But this is easier said than done. Seizures are unpredictable. In spite of everything is done correctly still they show up some times. Then there are myriad seizure provoking factors like fever, hypoglycemia, sleep deprivation, stress etc.

Since total control of seizures is not always possible how much control is acceptable for a patient will depend on additional individual situations.

For a person who has to drive daily or frequently even a single seizure could be catastrophic. So a bank official who has to drive, even a single seizure once in a year can be an indication for surgery where as the same single seizure/year may not be a surgical indiction for an 82 years old, retired bank official.

Obviously both will hate this seizure, but the point is for this working-driving individual this seizue is not just an annoyance or stigma but could be life & death situation. So you have no choice other than doing something to control it or else there is a perilous situation. So at times you may want to pursuit aggressive measures like an epilepsy brain surgery.

But surgeries have complications too (bleeding, infection, death etc) so you do not want to chase after that occasional seizure by exposing that retired, non driving individual to the surgical complications.

So these decisions are to be made on case to case basis and there are many different factors to be considered. If that retired individual or his/her family wants to undergo surgery for that occasional seizure then their wish needs to be respected.

Neurologists and Neurosurgeons are frequently involved in the care of refractory seizure.



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