Neurology and Neurosurgery

May 21, 2021

Approximately one-third of people with epilepsy have medically refractory seizures. Those patients, and their physicians, face complex decisions about treatment. Mayo Clinic takes an individualized approach, with comprehensive testing to determine each person's optimal treatment.

"Each patient has a unique epilepsy network that must be closely scrutinized. That means every person needs his or her own set of tests," says Cornelia N. Drees, M.D., an epileptologist at Mayo Clinic in Phoenix/Scottsdale, Arizona. "The testing data are then interpreted by a multidisciplinary team that comes to a consensus tailored to that patient."

Patient education is an important part of the process. Mayo Clinic epileptologists take time to explain the treatment options and to discuss each individual's support system.

"Epilepsy monitoring and treatment can be frightening for patients. Many variables need to be addressed," Dr. Drees says. "Treatment will always be focused on making a person seizure-free, but sometimes that's difficult. Beyond trying to cure epilepsy, one important goal is always to improve a person's quality of life, given the constraints of an individual's condition."

Multiple treatment options

Once an individual's epilepsy hasn't responded to two medications, each additional medication that is tried has a less than 5% chance of making that person seizure-free. Mayo Clinic uses sophisticated testing to help determine the optimal surgical treatment approach.

In addition to inpatient video-electroencephalography epilepsy monitoring, testing might include subtraction ictal SPECT coregistered to MRI, CT, MRI or positron emission tomography. "The evaluation of these patients is a multistep process," Dr. Drees says. "We work closely with our neuroradiologists and neuropsychologists to obtain the information we need to recommend treatment."

The resection, laser ablation or disconnection of a seizure focus can make a person seizure-free. When that isn't possible, nonmedical treatment options at Mayo Clinic include a ketogenic diet, which can significantly lower seizure frequency.

Several stimulation devices, most surgically implanted, also are available, including:

• Vagus nerve stimulation, which uses a device implanted under the skin in the chest to send regular, mild pulses of electrical energy to the brain via the vagus nerve
• Responsive neurostimulation, which monitors brain waves to detect the likely onset of seizures and stop them before they cause clinical symptoms
• Chronic subthreshold cortical stimulation, which provides continuous electrical impulses to an area of seizure onset to suppress the generation of the abnormal seizure discharge
• Deep brain stimulation, which delivers controlled pulses to a target in the brain that is part of a circuit involved in seizures
• Transcranial magnetic stimulation, which uses an electromagnetic coil placed against the scalp to stimulate nerve cells in the brain

"These devices are palliative. They are more likely to reduce seizures than to stop them," Dr. Drees says. "Surgical resection of brain areas that are causing seizures is likelier to lead to cure."

The multidisciplinary team that guides patients through the treatment process includes a neuropsychologist and a social worker, when needed. "Before and even after any procedure, many of our patients need help — with their family dynamics, with transportation, with finishing education or having job training," Dr. Drees says. "In addition to giving medical care, an epilepsy team can provide companionship and expertise to help maximize the quality of life."

All too often, patients are reluctant to seek surgical treatment for epilepsy. "That hesitancy can be overcome with education," Dr. Drees says. "We can help people understand that there are many options to consider."