Once the diagnosis of epilepsy has been made, consideration turns to appropriate treatment . Some forms of childhood epilepsy may not require any intervention other than education and reassurance For example, benign Rolandic epilepsy is a common idiopathic localization-related epilepsy of childhood that spontaneously resolves by the age of 20.8 Benign Rolandic epilepsy is also referred to as "benign epilepsy with centro-temporal spikes" (BECTS). Approximately 60% of patients with this condition experience very few seizures . When seizures do occur under such circumstances, an abortive therapeutic option—such as a rectally administered form of diazepam—is often prescribed in lieu of daily medical therapy For those children with recurrent unprovoked seizures that are sufficiently frequent to require intervention, there are at least 16 different medications from which to choose . Factors such as type of epilepsy, age of the patient, and comorbidities are important considerations in deciding which medication to use Perhaps the single most important factor in medication choice is the specific side-effect profile of the drug and its suitability for a particular patient . Overall, approximately 60% of patients will become seizure free with one of the first two anticonvulsants prescribed . 17 Unfortunately, for those whose epilepsy does not respond, the chance of treatment success with subsequent medication trials is much less . For this reason, patients who do not respond to one of the first two or three medications are referred to as "medically refractory."
Fortunately, there is an ever-increasing range of options for patients with medically refractory epilepsy One possibility is the use of the ketogenic diet: a high-fat and low-carbohydrate protocol, which results in ketone body production and which produces improved seizure control . 10 For certain carefully selected patients, the best option is epilepsy surgery: for example, neurosurgical removal of the focus of the epi-leptogenic cortex Examples of such procedures range from focal neocortical resection for patients with an area of cortical dysplasia to removal of the anterior temporal lobe in patients with temporal lobe epilepsy to hemispherectomy in patients with hemimegalencephaly Epilepsy surgery candidates undergo an extensive presurgi-cal evaluation that includes neuroimaging, EEG monitoring, and detailed neuropsy-chological studies, as well as other ancillary tests Given the irreversible nature of surgical intervention, it is vital to determine whether potential functional deficits might result from the proposed resection Still, for excellent candidates, the chance of becoming seizure free following surgery is as high as 65-70%, depending principally on the location of the focus and whether or not there exist clear imaging findings related to that focus . 25 At times, surgical procedures are conducted with the goal of decreasing seizure frequency or for palliation . This may involve, for example, partial resection of a lesion if the presence of the eloquent cortex prevents complete removal, or corpus callosotomy to prevent secondary generalization of seizures
Another surgical option used to decrease seizure frequency is implantation of a vagus nerve stimulator (VNS) . 19 This device consists of a generator implanted subcu-taneously over the pectoral muscle, which is connected via leads wrapped around the left vagus nerve The VNS has an adjustable stimulation cycle that delivers pulses of defined intensity and duration to the vagus nerve For unknown reasons, such stimulation significantly decreases seizure frequency in approximately 30% of patients . Although unlikely to make a patient seizure free, it may significantly improve seizure control . Presently in clinical trials is a unique responsive neurostimulator that utilizes focal cortical stimulation to abort partial seizures As the range of therapeutic interventions for medically refractory epilepsy expands, it becomes ever more vital to refer such patients to an epilepsy center where the possible use of such therapies can be considered
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