December 1, 2023 9:54 AM

How Epilepsy Is Treated When Medications Fail Or Surgery Cannot Be Performed

Epilepsy is a neurological disorder in which repeated seizures occur, which are sudden alterations in one’s behaviour due to a temporary change in the electrical functioning of the brain. In normal patients, tiny electrical impulses are generated inside the brain in an orderly pattern. The electrical impulses travel inside the brain via neurons, and throughout the body via chemical messengers known as neurotransmitters. 

However, in an epileptic patient, the brain’s electrical rhythms often become imbalanced, as a result of which recurrent seizures occur. When a seizure occurs, sudden and synchronised bursts of electrical energy disrupt the normal electrical pattern, affecting the person’s consciousness, movements, or sensations, according to the American Association of Neurological Surgeons. 

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When a person has had at least two seizures that did not occur to some known medical condition, they are diagnosed with epilepsy. 

About 50 million people worldwide are epileptic, according to the Epilepsy Foundation. 

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Epilepsy can be treated with the help of antiepileptic medications (AEDs), diet therapy, and surgery. Most patients with multiple seizures choose medications as the initial treatment choice. 

There are some patients who only have a single seizure, and the tests they undergo do not indicate a high probability of seizure recurrence. Such patients do not require any medications. 

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Medications do not cure the underlying condition of epilepsy, but only treat the symptoms. About 70 per cent of epileptic patients obtain positive results after taking medications, which work by reducing the tendency of brain cells to send excessive and confused electrical signals. 

Some patients receive diet therapy which involves a ketogenic diet and a modified Atkins diet. A ketogenic diet involves foods with high-fat, adequate protein, and low carbohydrates, while a modified Atkins diet is similar to the ketogenic diet, but is less restrictive. The ketogenic diet is given for three to four days in the hospital, while the modified Atkins diet can be initiated as an outpatient. 

“Dietary therapies like the ketogenic diet can be considered. There have been instances where this high-fat, low-carb diet has proven effective,” Dr Aditya Gupta, Director, CyberKnife, Artemis Hospital, Gurugram, told ABP Live.

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How epilepsy is treated when medications fail, and when surgery cannot be conducted

In about 30 per cent epileptic patients, medications and diet therapy do not work. They are considered medically-resistant. 

For medically-resistant epileptic patients, surgery is the best option to completely control seizures. However, surgery may not be possible if the epileptic region is a part of the brain that, if removed, will result in major neurological complications. 

If antiepileptic medications do not control one’s seizures, and brain surgery is not possible because the epileptic region is located near sensitive areas in the brain, procedures such as vagus nerve stimulation (VNS) and deep brain stimulation (DBS) may help, according to the National Health Service (NHS). 

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What is vagus nerve stimulation?

VNS is a technique in which a small electrical device similar to a pacemaker is placed under the skin of the patient’s test, and is attached to a wire that goes under the skin and connects to a nerve in the neck called the vagus nerve. When abnormal activity occurs in the brain, bursts of electricity are sent along the wire to the nerve.

According to the NHS, this can help control seizures by changing the brain’s electrical signals. 

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VNS is effective because the device emits controlled impulses to the vagus nerve to reduce seizures. 

“VNS entails placing a device in the chest, which emits controlled impulses to the vagus nerve, effectively reducing seizures,” Dr Sonia Lal Gupta, Senior Neurologist & Director, Metro Group of Hospitals, told ABP Live.

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While VNS does not usually completely stop seizures, it can help make them less severe and less frequent. 

However, VNS has some side effects such as a hoarse voice, a cough, and a spread throat when the device is activated. 

A VNS device’s battery lasts up to 10 years, following which a new procedure will be used to replace it. 

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What is deep brain stimulation?

While DBS is similar to VNS, the device placed in the chest is connected to wires that run directly into the brain, instead of being connected to the vagus nerve.

When bursts of electricity from the brain are sent along the wires due to abnormal activity in the brain, the wires change the electrical signals, helping prevent seizures. Electrodes are implanted in certain regions of the brain.

“In the case of DBS, electrodes are implanted to modulate specific brain areas linked to seizures,” said Dr Lal Gupta.

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DBS is a new technique, and is not used commonly. 

Some serious risk factors associated with DBS include bleeding of the brain, memory problems, and depression.

“When epilepsy is close to sensitive brain regions and is not responsive to medication or surgery, other treatments such as vagus nerve stimulation (VNS) or responsive neurostimulation (RNS) may be explored. While RNS monitors brain activity and provides targeted electrical stimulation to avoid seizures, VNS entails implanting a device to stimulate the vagus nerve. When more conventional techniques are impractical because they may damage important brain regions, these strategies try to control epilepsy,” said Dr Gupta. 

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What is responsive neurostimulation?

Responsive neurostimulation (RNS) is another technique employed to control seizures when medications do not work. As part of the RNS technique, a neurotransmitter is placed under the scalp and within the skull, and is connected to two electrodes placed either on the surface of the brain, into the brain, or a combination of both, according to the University of Pittsburgh.

The neurotransmitter continuously monitors brain activity and can detect seizures. The device helps stop, shorten, or prevent seizures by delivering a small amount of electrical current to the brain when a seizure-like activity is detected in the brain.

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Research is being conducted to develop gene therapies and advanced neurostimulation techniques that can help control seizures in patients who are unresponsive to traditional therapy, according to Dr Gupta. 

For those dealing with difficult epileptic situations, individualised techniques that cater to their requirements can prove to be helpful.

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