Chronic seizure management in patients with drug-resistant epilepsy

Wieslaw Oczkowski, MD, is a professor emeritus in the Department of Medicine at McMaster University and director of the Regional Stroke Network for the Central South Ontario Region.

We have a broad and still growing selection of antiseizure medications available, and yet drug resistance remains a challenge in roughly a third of patients with epilepsy. Why is this rate so high and how can we improve chronic seizure management in these patients?

One thing to understand is that epilepsy and seizures aren’t due to one thing, they’re due to multiple disorders. For example, in the pediatric population, there may be genetic components; in the older population, it may be due to post stroke, post brain tumor, other disorders. With dementia you can develop seizures as well. So the brain’s spinal common pathway may be a seizure, but the exact etiologies are very different. This is one of the reasons why it’s difficult to treat all those different underlying pathophysiologies with one set of drugs or even multiple drugs.

The other part is that the brain itself is an electrical organ and the antiepileptic medications affect the function of the brain just as much as they prevent seizures. Some of the phenomena that we’re trying to treat are in fact the same things that the brain is using to try to think. Once we have more specific targets and a better understanding of the pathophysiology, probably in every individual patient, as to the underlying disorder—what causes the epilepsy or the seizures—then we will be able to better use medications and have a better outcome.