Medically refractory epilepsy remains a significant clinical challenge, affecting approximately 30 percent of the 3.4 million Americans living with epilepsy. These patients experience persistent seizures, despite appropriate and adequate trials of anti-seizure medications, necessitating a comprehensive evaluation and consideration of alternative therapeutic modalities.

A landmark study by Kwan and Brodie (2000) established that achieving seizure freedom diminishes substantially with each failed medication trial: 47 percent of epilepsy patients became seizure-free on their first drug, 13 percent with their second medication and only 4 percent with their third drug or a combination of two drugs.

Pooja Patel, MD

The data underscores the critical importance of referral to specialized epilepsy centers for patients who have failed two anti-seizure medications, says neurologist Pooja Patel, M.D., director of the Epilepsy Program and the Epilepsy Monitoring Unit at Marcus Neuroscience Institute at Boca Raton Regional Hospital, part of Baptist Health.

“If the patient has epilepsy and has failed two anti-seizure medications, one after the other or in combination, then we need to consider alternatives to medication,” says Dr. Patel, who shared her expertise recently at the Marcus Neuroscience Institute’s Brain & Spine Symposium, an educational meeting to bring the latest advances to physicians and other healthcare providers.

A thorough evaluation will take into account the types of seizures the patient is having and how disabling they are before moving to other treatments, and will include the patient’s history, an EEG, MRI seizure protocol, functional neuroimaging, neuropsychological testing and intracranial EEG monitoring, she says.

Among the treatments for medically refractory epilepsy that Dr. Patel discussed were:

• Surgical interventions — Intended to disrupt the neural network creating seizures, surgical options include temporal lobectomy, extra temporal resection, hemispherectomy, corpus callosotomy and hypothalamic hamartoma resection. Minimally invasive surgery is a great option in certain cases, as well.

• Neurostimulation — Less invasive than surgery, therapies such as vagus nerve stimulation (VNS), responsive neurostimulation system (RNS) and deep brain stimulation (DBS), employ neurostimulators or devices that can help reduce seizure frequency and intensity. “These involve implanting a small generator in the chest or the skull,” she says. “All three devices can provide seizure reduction and reduce the intensity of seizures, and long-term data shows the results are lasting.”
• Dietary therapies — Used for years as a treatment for those who are not candidates for  surgery or do not want to undergo neurostimulation, dietary therapy can change how the brain gets its energy and help to stabilize electrical activity. “Multiple studies show that dietary therapies are effective for 50 percent or higher seizure reduction in the short term, compared with care as usual,” Dr. Patel says. A classic ketogenic diet, high in fats and extremely low in carbs, or the modified Atkins diet, which is a less restrictive alternative, have comparable efficacy.

Physician-scientists at Baptist Health and around the world are working to find new answers for people with difficult-to-treat epilepsy, studying focused ultrasound, gene therapy and cell therapy. “Our treatment goal is seizure freedom, but it is also good quality of life,” Dr. Patel says. “Today we have many more options for our patients, even compared to just a decade ago.”

Baptist Health offers two nationally accredited epilepsy clinics — a Level 4 Epilepsy Center at Miami Neuroscience Institute in Miami-Dade County and a Level 3 Epilepsy Center at Marcus Neuroscience Institute in Palm Beach County. Both locations feature Epilepsy Monitoring Units, and their multidisciplinary teams are capable of delivering the full spectrum of advanced epilepsy therapies.