Wednesday, February 25, 2015

Blog #55: Too Few Neurologists Know it! Brain Surgery Really Can Cure Some Uncontrolled Epilepsy

Fifty percent of all people with epilepsy are free of seizures so long as they and their doctors have found the best antiseizure drug regimen for them. The remaining patients are refractory: that is, they continue to have seizures even with medical treatment. Sadly, almost half of this group cannot lead fulfilling lives because their epilepsy interferes with ordinary daily activities. Furthermore, they are at risk for greater cognitive decline and death.
Fewer than 5% of epilepsy patients who have scars or other abnormalities identified on MRI brain scans as epilepsy-inducing and in whom two antiseizure drugs fail to control their seizures ever gain total seizure control. Epilepsy surgery is an important treatment option for those with poorly controlled epilepsy who are “fortunate” to have A) an identifiable brain area causing their seizures, and B) this abnormality is in a so-called “silent” or, as neurologists say, “non-exquisite” area of the brain. I say these people are “fortunate” because these areasthe very front of the frontal lobe and of the temporal lobecan be surgically removed without causing any significant deficits showing up in thinking, intelligence, or in speech, memory, movement, or sensation.
 Surgery can be their answer for marked improvement in quality of life and even for total control of their epilepsy. Epilepsy surgery is superior to medical management in temporal lobe epilepsy. 1 The earlier the surgery following diagnosis, the greater its benefit. Successful epilepsy surgery is now routine; delaying it can lessen the chance for successful seizure control. 2 
 However, a Canadian study found a gap in neurologists’ awareness of the newest treatment data and indications for epilepsy-surgery referral. 3 Roberts et. al. found that only 43% of those neurologists who participated in a questionnaire survey correctly responded that any of their patients who had ongoing seizures should be referred and the earlier, the better chance for a successful outcome. Only 51% of the respondents correctly identified that “drug-resistant” patients are those who fail two antiseizure drugs. These patients should be referred for surgical evaluation once they are recognized to be drug-resistant.
 To date too few patients are currently being referred to epilepsy-surgical centers by their treating physiciansusually neurologistsfor potentially curative epilepsy surgery and its life-changing benefits. It is recommended that patients introduce the possibility of surgical treatment even if their neurologist has not suggested it. Epilepsy-surgery centers are very common throughout the United States and Canada and the surgery definitely can improve quality of life.
1.      Engel J Jr, McDemott MP, et al. Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA 2012; 307: 922-930.
2.       Berg AT, Mathern GW, et al. Frequency, prognosis and surgical treatment of structural abnormalities seen with magnetic resonance imaging in childhood epilepsy. Brain 2009; 132: 2785–2797.
3.      Roberts J I, Hrazdil C, et al. Neurologists’ knowledge of and attitudes toward epilepsy surgery. Neurology 2015; 84: 159-165.
Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy.