Pharmacoresistance: OP Fixes Epilepsy

23. January 2018

Epilepsy patients for whom medication is not effective might be able to be effectively treated by brain surgery. Neurologists have evaluated the data of 10,000 patients. One precondition for this 'repair' is that the brain region from which the seizures emanate is identified with certainty and is completely removed.

Six out of ten epilepsy patients whose seizures are not eliminated by medication can be successfully treated with brain surgery. An assessment of the EU-funded database European Epilepsy Brain Bank (EEBB), which is derived from 36 epilepsy centres in 12 countries with approximately 10,000 patients, confirms this. The assessment was published in the New England Journal of Medicine (NEJM).

“Individual forms of epilepsy differ in their treatability”: so says Holger Lerche, co-author of the study, board member at the Hertie Institute for Clinical Brain Research and medical director of the Department of Neurology, University of Tübingen (Germany). “A number of genetically based epilepsy cases are very treatable, however this can hardly be stated to be true about the others. This is also due to the fact that patients can be either mildly or severely affected, with those who are severely affected usually also being worse to respond to medication”, he says. “With the focal form as well – that is where only part of the brain is affected by epilepsy, for example after a stroke – very good treatment results are achieved. Other forms that cause seizures in childhood and adolescence are often harder to treat”.

Operation helps treat pharmacoresistance

A comprehensive look shows that about one third of the patients taking medications are not effectively treatable, according to experts. Medicines have been the main treatment of epilepsy and are categorised as either anti-epileptics, anti-convulsants or anti-seizure medications. According to the International League Against Epilepsy (ILAE) a patient is then considered pharmaco-resistant if he or she continues to have seizures following treatment using at least two medications. “Nonetheless this only treats seizures, not the cause of epilepsy itself”, according to Lerche.

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Undergoing surgery for epilepsy makes sense in more cases than would be expected, neurologist Holger Lerche asserts.

More than 600,000 people in Germany suffer epilepsy; about three-quarters of these appear in childhood. “Epilepsy is a brain disorder associated with relapsing unprovoked epileptic seizures, this is the definition”, Lerche says: “The seizures can have different causes. The most common causes are lesions in the brain such as brain tumours, strokes or scars. Other causes of epilepsy include metabolic defects, autoimmune reactions and genetic predispositions. “Epileptic seizures could be very mild, perhaps occurring as nausea that would not be noticeable to the onlooker, with a tingling sensation in the hand or a slight twitching.

The most severe form of seizure is the so-called generalised tonic-clonic seizure in which the whole body cramps and twitches. “We can operate if the seizures originate from a specific brain region and this brain region can also be removed surgically, without permanent failure of brain functions being expected. For example, if the epileptic seizure occurs in the language centre we cannot perform an operation, otherwise the patient might not be able to speak afterwards”.

Remove the focal point through an operation

One refers to these surgically treatable forms of epilepsy as focal epilepsy, because they begin at a certain part of the brain, the epileptogenic focus, Lerche explains: “In contrast to this we have the generalised epilepsies, where one cannot exactly determine at which point an attack begins. in the EEG It looks as though it starts everywhere at the same time. In these cases one cannot operate”.

It is important to distinguish between generalized epilepsy and a generalised seizure, as a generalised seizure may also occur secondarily to focal epilepsy in which epileptic activity spreads from the focus to the entire brain. “Removing the focus via surgery in such patients also stops generalised seizures. Generalised epilepsy, in which the focus of the onset of epileptic activity cannot be localised, is not operable”, the specialist says.

The localisation of the seizure origin occurs first of all through the symptoms at the beginning of a seizure (such as twitching in a part of the body), leading us to look in the respective region of the movement centre, Lerche says. “Using a high-resolution MRI in that region, a check is made as to whether there is a lesion there”, Lerche says: “In addition, the EEG also looks for epilepsy-typical changes. Using these three methods, one can usually locate an epileptic focus quite well”.

Timely operation is important

The present study, initiated and directed by the Director of the Neuropathological Institute at the University of Erlangen (Germany), Ingmar Blümcke, now demonstrates for the first time that it is important that the patient not be operated too late. The chance would then be much better that they end up seizure-free. The large number of findings in the European Epilepsy Brain Bank collection has made it possible to describe the type and frequency of various brain lesions that cause epilepsy which can be treated surgically, Lerche says. Following surgery, 65 percent of all operated children and 58 percent of adults were freed of their attacks.

That is why it is so important not to wait too long to be operated: “Unfortunately, there is no period that can be defined as ‘not too late’. However, we do know that the prognosis is significantly worse for patients who have not been operated and have had seizures over decades than it is for surgery carried out after only a few years”, the specialist states. Physicians should refer patients who have not responded to medication to a specialist sooner rather than later: “The sooner this happens, the greater the chance of recovery”.

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