What Are the Best Treatment Options for Epilepsy That Doesn’t Respond to Medications?

3-D segmented coronal MRI demonstrating bilateral deep brain stimulation.

About one-third of people with epilepsy do not experience adequate control of their seizures with medication alone, making them potential candidates for surgical interventions. But some of these candidates do not qualify for more traditional surgeries due to the location of seizures in the brain, so they need better options.

At Brigham and Women’s Hospital, surgeons and physicians are developing several new treatments that offer the possibility of better seizure control. These therapies require a great deal of diagnostic and surgical expertise along with the latest cutting-edge tools.

“We’re fortunate because we not only have the most advanced technology, but also have an unbelievably dedicated team of experts, including neuroradiologists, neuropsychologists and epileptologists,” says Garth Rees Cosgrove, MD, director of epilepsy and functional neurosurgery at the Brigham. “This ensures that every patient we see receives the best care available.”

Robotic Guidance Improves Seizure Diagnosis

The first step to offering the best care for every patient is a comprehensive evaluation to determine the location of the brain seizures. Among the diagnostic tools available at the Brigham are a 7T MRI scanner, PET scanner, magnetoencephalography scanner and state-of the-art, six-bed EEG monitoring unit (EMU). Patients’ seizure activities are monitored 24 hours a day, which enables the team to hypothesize about where the seizures are coming from.

For patients in whom the seizure locations cannot be identified with regular scalp EEG monitoring in the EMU, phase two evaluations can be done by using a robotic guidance system that implants electrodes into the brain to monitor seizure activity. The Brigham also houses the Advanced Multimodality Image Guided Operating (AMIGO) suite, which holds an array of advanced imaging equipment and interventional surgical systems.

“Patients will see the best outcomes if we can accurately identify where the seizures are coming from and resect or laser ablate those areas,” Dr. Cosgrove says. “Minimally invasive approaches are also available, and this is where the AMIGO suite is so important. While patients are asleep in the MRI scanner, we use guidance systems to very precisely ensure we are in the right location. This approach is more comfortable for the patient, as well as safer and more accurate.”

Neuromodulatory and Laser Surgery Offer Seizure Relief

Open surgical resection may not be an option for patients who have multiple seizure sites in the brain or seizure sites that are within areas that control critical functions. In these cases, laser ablation, which is used when the seizure site is in a part of the brain that would be difficult to resect, and neuromodulation treatments can provide relief from seizure activity.

For patients whose seizures are located within critical areas for movement, language or thinking—and that would cause neurological deficits if destroyed—two neuromodulation approaches are increasingly used at the Brigham: responsive neural stimulation (RNS) and deep brain stimulation (DBS).

With both techniques, a surgeon implants a neurostimulation device in the brain. These specialized devices are programmed to detect and then deliver electric currents that disrupt seizure activity. With RNS, the device can detect and then stimulate the area to abort seizures. This stimulation interrupts the brain’s abnormal electrical activity. With DBS, more constant stimulation is used to reset the brain’s normal activity.

Providing Long-lasting Seizure Control

RNS and DBS have been proven to provide beneficial, long-lasting control of seizures for most patients who receive them.

“When you add a new medication to somebody’s regimen, they tend to do better for a few months, but then the brain finds a way to adapt and the seizures return,” Dr. Cosgrove says. “With these brain stimulation techniques, the results don’t happen immediately, but at the three- to five-year mark, about 75% of patients will have improvement in their seizures.”

For these patients, this can lead to an extraordinary improvement in quality of life. “It’s not a cure, but it makes a big difference for people who otherwise have no options,” Dr. Cosgrove says.

Epilepsy Research and Development

The Brigham’s focus on research will continue to drive the development of new and improved treatments in the future. Among the novel techniques being developed by Brigham investigators are low-intensity and high-intensity focused ultrasound. These noninvasive treatments, which were developed to treat Parkinson’s disease, are now being investigated in clinical trials for patients with epilepsy.

“For adults who have had epilepsy their whole lives and have tried every other kind of treatment, this research has the potential to truly be life-changing,” Dr. Cosgrove says.

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