Health Innovations

What is refractory epilepsy?

Epilepsy is a common brain condition that causes a person to have seizures—resulting in brain cells experiencing a burst of abnormal electrical activity. When normal connections between nerve cells in the brain are interrupted and depending on the type of seizure, people can experience stiffening of the body, loss of consciousness, breathing problems and confusion.

The goal of epilepsy treatment is to control, stop or reduce how often seizures occur. The most common type of treatment for epilepsy is medication. However, according to David Ficker, MD, UC Health neurologist, director of the epilepsy monitoring units at UC Medical Center and West Chester Hospital, and professor in the Department of Neurology & Rehabilitation Medicine at the University of Cincinnati College of Medicine, about one out of three patients with epilepsy has medication-resistant epilepsy—also known as refractory epilepsy. Refractory epilepsy happens when medications fail to control a patient’s seizures. Another term for refractory epilepsy is medication-resistant epilepsy.

“Refractory epilepsy is first diagnosed in the clinic when we sit down with our patients and intake a careful history, getting a description of the seizure types that they have and their prior treatment response. Once a patient has been identified as having tried two different medications, we diagnose them as having refractory epilepsy,” explained Dr. Ficker.

When diagnosed with refractory epilepsy, patients may need to undergo additional diagnostic testing to determine the exact type of seizure. These methods can help evaluate refractory epilepsy and pinpoint where in the brain the seizures are occurring. This often includes:

• Video electroencephalogram (EEG) monitoring, or simultaneous video and EEG recordings of a patient’s brain activity and physical behaviors during a seizure. This involves a hospital stay in an epilepsy monitoring unit, which is an inpatient unit specially designed for patients with seizures that helps doctors characterize the seizures, determine the seizure source and guide proper treatment.
  
• Advanced imaging including magnetic resonance imaging (MRI), functional MRI, positron emission tomography (PET) and ictal single-photon emission computed tomography (SPECT).

Refractory epilepsy can significantly affect patients’ daily lives and their ability to function well in society. They can face additional stress or anxiety about when or where their next seizure will come and can often struggle to participate at work and school.

Treatment options for refractory epilepsy

When patients suffer from uncontrollable seizures, they should seek an advanced evaluation at a specialized epilepsy center, such as the Epilepsy Center at the UC Gardner Neuroscience Institute, to determine the most appropriate treatment plan.

“One of the unique features that we offer here at UC Health is a comprehensive epilepsy conference where our team reviews every patient who comes through the epilepsy monitoring unit and is diagnosed with refractory epilepsy. We then determine as a team how to best treat that patient,” said Dr. Ficker.

Every refractory epilepsy case is unique and treatment options will vary from patient to patient. Treatments considered for patients diagnosed with refractory epilepsy include:

• Medication management, or a reevaluation of the anti-seizure medications a patient is taking to ensure he or she is on the most appropriate regimen for their seizure type.
  
• Epilepsy surgery, which includes removing the area of the brain causing the seizures, or inactivating the seizure focus through laser ablation, a minimally invasive procedure that uses light and heat to target and remove brain cells causing the seizures.
• Neuromodulation devices, such as responsive neurostimulation (RNS), deep brain stimulation (DBS) and vagus nerve stimulation (VNS), which are implanted in the brain to detect and control seizures.
• Dietary modifications for specific types of epilepsy.
• Research studies and clinical trials for qualified patients.

“Unfortunately, not only here in Cincinnati, but across the country, these advanced treatment options, such as surgery for epilepsy, are often underutilized and we don’t see patients early on in their disease course where these treatments might offer the best outcomes,” stated Dr. Ficker.

The importance of seeking specialty care for refractory epilepsy.

The Epilepsy Center at the UC Gardner Neuroscience Institute is Greater Cincinnati’s only Level IV epilepsy center—the highest rating possible—designated by the National Association of Epilepsy Centers (NAEC). This designation means our epilepsy team has access to some of the most advanced diagnostics and treatments available and has the expertise to treat some of the most complex epilepsy conditions, including refractory epilepsy. This level of subspecialty care is critical to perform the extensive testing needed to localize the seizure focus making modern techniques more accurate and safer for patients.

“Here at our Level IV epilepsy center, we have over 30 years of experience treating patients with difficult to control seizures,” said Dr. Ficker. “We have a multidisciplinary team comprised of physicians, neurologists, neurosurgeons, neuropsychologists, EEG technologists and social workers that work as a team to provide the best patient care and outcomes for our patients.”