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What to do IF Medications Fail?

What to do IF Medications Fail?. Dr Linda Huh Pediatric Neurologist BCCH. Outline and Objectives. What is intractable epilepsy? Discuss why medications may fail Learn more about alternate treatments to medications Epilepsy Surgery Vagal Nerve Stimulator Ketogenic Diet

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What to do IF Medications Fail?

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  1. What to do IF Medications Fail? Dr Linda Huh Pediatric Neurologist BCCH

  2. Outline and Objectives • What is intractable epilepsy? • Discuss why medications may fail • Learn more about alternate treatments to medications • Epilepsy Surgery • Vagal Nerve Stimulator • Ketogenic Diet • Discuss future potential therapies

  3. Intractable Epilepsy • 47% seizure free on first medication • 13% seizure free on second medication • <5% seizure free on third medication • 30% of patients have difficult to control epilepsy

  4. Intractable Epilepsy

  5. Why may anticonvulsants fail? • Incorrect diagnosis • Incorrect anticonvulsant • Intolerable side effects or noncompliance • Drug-resistant epilepsy

  6. Goals of Epilepsy Surgery • Seizure-freedom • Improvement of quality of life • Do no harm (minimize deficits) • Decrease anticonvulsants

  7. Aims of Epilepsy Surgery Workup • Find where seizures are coming from • To spare important brain functions

  8. Evaluation for Epilepsy Surgery • History and Physical Examination

  9. Evaluation for Epilepsy Surgery • History and Physical Examination • Video EEG monitoring

  10. Evaluation for Epilepsy Surgery • History and Physical Examination • Video EEG monitoring

  11. Evaluation for Epilepsy Surgery • History and Physical Examination • Video EEG monitoring • Neuropsychological assessment • MRI – 1.5 or 3T

  12. Evaulation for Epilepsy Surgery • Ictal SPECT, PET • MEG • fMRI • Wada test • EcoG (electrocorticography) • Subdural/Depth electrodes +/- mapping

  13. Ictal SPECT • Increased blood flow

  14. PET • Decreased metabolism

  15. Magnetoencephalogram

  16. Finger Tapping- Right vs. Left Left Finger Tapping q= 0.01 Right Finger Tapping

  17. Finger Tapping- Right vs. Left Left Finger Tapping q= 0.01 Right Finger Tapping

  18. PRE-RESECTION - POSITION 1 29 5 32 8

  19. What to do? • Resective surgery • Focal neocortical resection • Anteromedial temporal lobectomy • Hemispherectomy • Palliative surgery • Corpus callosotomy • Multiple subpial transections • Vagal nerve stimulation

  20. Julie • Prolonged febrile seizures • Developed partial seizures age 9 • Tried 5 medications • Video EEG showed left temporal • MRI

  21. Anterior Medial Temporal Lobectomy

  22. Hemispherectomy

  23. Corpus Callosotomy • Anterior 2/3 • Full

  24. Multiple Subpial Transections

  25. Outcome • Seizure Freedom or reduction • Decrease in medications • Improvement in Cognition and behaviour • Improvement in Quality of Life

  26. Vagus Nerve Stimulation

  27. Vagal Nerve Stimulator • 1997: approved by FDA (US) as adjunctive treatment of medically refractory epilepsy in adolescents and adults • 1998: approved by HPB (Canada) • > 40,000 patients world-wide have been implanted

  28. Indications • No correlation with type of epilepsy • Intractable epilepsy with no better surgical option

  29. Magnet Use • To shorten a seizure • To stop a seizure • To decrease severity • To shorten post-ictal phase

  30. Vagal Nerve Stimulator

  31. VNS for Intractable Epilepsy • 50% of patients have >50% reduction in seizures • May allow reduction in dosage of antiepileptic medications • Majority have improved quality of life • Magnet use can abort seizures

  32. Ketogenic Diet

  33. Ketogenic Diet • 15-35% seizure-free • 30-50% with >90% reduction in seizures • 50-75% with >50% reduction in seizures • Improved alertness and development

  34. Ketogenic Diet • Modified Atkins Diet • Low Glycemic Diet

  35. Ketogenic Diet • Prescribed therapy by Ketogenic Diet Team • Side effects

  36. Ketogenic Diet

  37. Ketogenic Diet • Hundreds of seizures/day • Plateauing of development • > 6 medications in 6 months • Seizure free on the Ketogenic Diet with improvement of development

  38. Future therapies to look to… • New Anticonvulsants • Seizure prediction • Neurostimulation • Neuropace (Responsive Neuronal Stimulation) • Deep brain stimulation • Magnetic Stimulation and Cooling • Gene and biological agent therapy

  39. What can WE do when medications fail? • Optimize quality of life • Look for comorbidities and treat as needed • Maintain good relationships – family and friends • Optimize school and employment • Maintain a healthy lifestyle • Exercise • Diet • Bone health

  40. Thank you for your attention

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