Epilepsy info badly needed

Stephan Blaschke stephan at wistar.ruhr.de
Fri Aug 9 18:20:00 EST 1996

Hello Peter,

I am in my training to become a neurologist in Germany. With the following  
considerations I hope to help you and your friend a little.

Anti epileptic surgery, is only a possibility in epilepsy treatment for  
very special cases: The epilepsy must be non-responsive to pharmacological  
treatment (tx) or pharmaco-tx has unbearable side effects. Not only one  
anticonvulsive substance should have been tried, but also a second, and  
then a combination tx of several medications. Also, in the last couple  
years, some new add on therapeutics have brought to market, which also  
should have been tried. With these regimens of tx, about 80 % of all  
epilepsies could be controlled. New medication should not be applied on a  
deliberate choice, but effectiveness depends on the type of seizures a  
patient has. Also, the combinations should be considered with a good  
background of knowledge, as not every combination is good, some will have  
interactions in metabolism while others may potentiate their effects.  
Overall, at least 3 anticonvulsive drugs over the last two years should  
have been tried in adequate dosage.

A second condition for anticonvulsive surgery is that the pt. has a  
'epileptogenic focus' present in the brain, that is, epileptic activity  
not starting from the whole brain, but from one more or less limited area  
of brain; secondary, the activity may spread throughout the entire brain,  
but primarily their must be a focus. Sometimes, the description of the  
seizure type _from the beginning_ (which sensations does the pt. have  
before the start [i.e. 'aura'], is there a kind of stereotype movement  
[repetition of one and the same complexe movement], do the convulsions  
start at one part of the body etc.). This focus in most cases could be  
seen in the EEG, also special EEG methods often should be applied  
(surgically implanted electrodes recording activity of deep brain areas,  
while conventional EEG only records surface areas [i.e. close to the skull  
bone], simultaneous recording of EEG and video imaging to correlate  
seizure morphology and EEG activity [is the focus seen in EEG responsible  
for the predominant type of seizures?]); these special EEG methods are  
only available in specialized centres for epileptology where also the  
surgery could be done (in Germany we have 3 of them in the cities of Bonn,  
Erlangen and Bielefeld). Also, several types of neuro imaging should be  
performed to visualize possible focuses (CAT scan, MRI, PET, SPECT).

If a pt. is pharmacoresistant (first paragraph above) and has an  
epileptogenic focus, it depends on the localization of the focus, if  
surgery is considered (is it close to important brain areas like speech,  
could it be reached by the surgeon without harming too much 'healthy'  
brain...). Also the odds of obtaining seizure freedom by surgery depend on  
these factors. All these questions should be discussed between the  
epilepsy specialist and the neurosurgeon and the patient, of course.

I would recommand the following procedure: Your friend should be referred  
to a neurologist (if she doesn't have one yet) and talk to him about her  
seizure history, what medications have been applied so fare... If they  
come to the conclusion that surgery should be considered (or specialized  
pharmacotherapy), the neurologist should refer your friend to a  
specialized epilepsy center (I don't know, if there is one in Ireland),  
where usually first she will be seen as an outpatient. If the specialists  
consider her as a possible surgery candidate, they will schedule her  
admission for further diagnostic procedures (the EEG/video simultaneous  
recording mentioned above, special EEG recordings, neuro imaging,  
neuropsychological tests). If after all these diagnostics surgery is  
recommanded, the patient will be put on a waiting list for surgery (in  
Germany about 1 year).

Hope that helps,

        Stephan Blaschke, M.D.

P.S. Copy posted to newsgroup.

Stephan Blaschke <stephan at wistar.ruhr.de> D-45888 Gelsenkirchen (Germany)

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