New Drugs for Epilepsy Mangement 1

8/2/2019 New Drugs for Epilepsy Mangement 1

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Surgical Treatment of Epilepsy

Epilepsy Awareness DayColumbia Comprehensive Epilepsy Center

Anil Mendiratta, M.D.


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Definitions

Seizure

Epilepsy


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Types of seizures

Partial

Generalized


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Scope of the Problem

10% of the population will have aseizure in their lifetime

1% of the population suffers from

epilepsy3,000,000 4,000,000people

in the US


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Advances in the Management ofEpilepsy

Medical Treatment Surgical Treatment

Overall Approach


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Advances: Overall Approach

No seizures

No side effects


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Advances: Medical Treatment

Medications in use before 1993 Phenobarbital 1912

Phenytoin (Dilantin) 1938

Primidone (Mysoline) 1954

Ethosuximide (Zarontin) 1960

Carbamazepine (Tegretol) 1974

Valproate (Depakote) 1978


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Advances: Medical Treatment

New Medications since 1993 Felbamate (Felbatol) 1993

Gabapentin (Neurontin) 1993

Lamotrigine (Lamictal) 1994

Topiramate (Topamax) 1996

Tiagabine (Gabitril) 1997

Levetiracetam (Keppra) 1999

Zonisamide (Zonegran) 2000

Oxcarbazepine (Trileptal) 2000

Pregabalin (Lyrica) 2005


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Advances: Surgical Treatment

Comprehensive epilepsy centers Video-EEG monitoring

MRI, PET, SPECT, MEG, fMRI


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Who is a candidate?

Focal epilepsy

Resistant to medication

Disrupt quality of life


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Epilepsy Surgery

Focal cortical resection

Corpus callosotomy Hemispherectomy

Multiple subpial transections

Vagal Nerve Stimulation


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Brain


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Epilepsy Surgery: Objectives

Resect the epileptogenic focus

Preserve neurological function


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Epilepsy Surgery: Goals

Seizure Freedom

Improved Quality of Life


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Epilepsy Surgery: Outcomes

Structural Lesions (low grade tumors,

vascular malformations)

up to 80 - 90% seizure free


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Arteriovenous Malformation


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Mesial Temporal Sclerosis

up to 80% seizure free


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MRI Right MTS


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Non-lesional or dysplasia

up to 50% seizure free


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Surgical complications

5% complication rate 1-2% permanent


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Surgical Evaluation

Video-EEG monitoring


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Surgical Evaluation

Brain imaging - MRI, PET, SPECT


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Surgical Evaluation

Neuropsychological Testing


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Surgical Evaluation

Intracarotid Amobarbital (Wada)Test

Functional MRI


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Surgical Evaluation

+/- Intracranial Recording Cortical mapping


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Surgical Evaluation

Multidisciplinary Case Conference


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Case 1 Right Temporal Spikes


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Case 1 Right Temporal Seizure


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Case 1 - MRI


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Case 1

Neuropsychological testing

Visual memory impairment

Wada Test

Left hemisphere language dominant

10/11 - right injection

2/8 - left injection


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Case 1 - Outcome

Right Temporal Lobectomy May

2001

No neurological deficits

Remains seizure free


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Case 2

23 y.o. man with epilepsy since age 9

6 8 complex partial seizures permonth

Failed treatment with Dilantin,

Tegretol, Depakote, Lamictal,


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Case 2 - Left Temporal Seizure


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Case 2 - MRI


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Case 2 PET scan


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Case 2

Neuropsychological testing

Mild verbal memory disturbance

Wada Test

Left hemisphere language dominant

9/10 - right injection

5/6 - left injection


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Case 2 - Subdural Electrodes andBrain Mapping


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Case 2 - Outcome

Left temporal lobectomy January

2002

No neurological deficits

Remains seizure free, offmedication now


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Other Surgical treatments

Corpus Callosotomy

Hemispherectomy Multiple subpial transections



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Figure 1: The Vagus Nerve Stimulator: NCP 101 generator (with leads attached).Reprinted with permission of Cyberonics, Webster, Texas.


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Epilepsy Surgery: The Future

Gamma Knife Surgery

Responsive Neurostimulation

Deep Brain Stimulation


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Responsive NeurostimulationTrial

Patients with LRE, with at least 4seizures per month


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SANTE Trial

Stimulation of the anterior thalamicnuclei

LRE, with at least 6 seizures permonth


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Conclusions

Surgery may be curative

Surgical options should be

considered earlyin the course oftreatment

Documents

New Drugs for Epilepsy Mangement 1