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Treatment of Epilepsy

Epilepsy is a controllable long-term neurological disease. Through correct diagnosis, effective drug treatment and good lifestyle management, most patients can effectively control seizures.

Image by Derek Finch

Treatment of Epilepsy

The primary goal of epilepsy treatment is to achieve complete seizure control while minimising side effects.

Antiepileptic Drugs (AEDs)

  • Antiepileptic drugs (AEDs) are medications used to control and prevent seizures in patients with epilepsy.

  • The overall therapeutic objective is to reduce the frequency and severity of seizures, enabling patients to live safer and more normal lives.

  • Most patients can achieve satisfactory seizure control through an individualised antiepileptic drug regimen.

  • Commonly prescribed AEDs include carbamazepine, valproate (valproic acid salts), levetiracetam, lamotrigine, phenytoin, and topiramate.

  • Their main mechanisms of action include:

    • Stabilising neuronal electrical activity: AEDs stabilise overexcited neurons in the brain, thereby reducing abnormal electrical discharges that trigger seizures.

    • Regulating neurotransmitter activity: By enhancing inhibitory signalling (such as gamma-aminobutyric acid, GABA) or reducing excitatory signalling (such as glutamate), AEDs help maintain electrical balance within the brain.

    • Blocking sodium and calcium channels: Many AEDs act by blocking specific ion channels in neuronal membranes, suppressing excessive excitability and hyperactivity of neurons.

    • Reducing neuronal synchrony: These drugs can decrease the tendency of neurons to discharge synchronously, a key feature of epileptic seizures.

  • Key considerations for AED therapy:

    • The choice of AED and treatment regimen depends on seizure type, frequency, underlying causes, comorbid conditions, side effect profile, patient age, and overall health status.

    • Medication adherence and consistency are crucial for effective seizure prevention.

    • Regular follow-up appointments are essential for monitoring therapeutic efficacy and potential side effects.

Surgical Intervention for Epilepsy

  • For patients with drug-resistant epilepsy whose seizures cannot be adequately controlled by medication, surgical intervention may be considered.

  • The most common structural abnormalities causing medically refractory epilepsy occur in the temporal lobe (approximately 60%), followed by the frontal lobe (20%), parietal lobe (10%), periventricular regions (5%), and occipital lobe (5%).

  • Surgical treatment can significantly reduce seizure frequency or even achieve complete seizure freedom in selected patients.

  • The type of surgery depends on the location of the epileptogenic zone, seizure characteristics, and the patient’s overall condition.

Common Minimally Invasive Neurosurgical Procedures for Epilepsy

  • Resection Surgery

    • Purpose: To remove epileptogenic lesions such as brain tumours or scar tissue associated with mesial temporal sclerosis (e.g., lesionectomy or lobectomy).

    • Typical locations: Temporal lobe (most common), frontal lobe, parietal lobe, or occipital lobe.

    • Example: Temporal lobectomy involves resecting part of the temporal lobe to control seizures in temporal lobe epilepsy.

    • Selective amygdalohippocampectomy targets the amygdala and hippocampus within the mesial temporal lobe, preserving the surrounding neocortex to minimise cognitive impact.

    • This approach maximises therapeutic benefit while reducing adverse effects, especially cognitive deficits.

    • Efficacy: When the epileptogenic lesion is clearly localised, surgical success rates are high, with many patients achieving seizure freedom.

  • Laser Interstitial Thermal Therapy (LITT)

    • Purpose: A minimally invasive technique that uses laser energy to ablate epileptogenic tissue.

    • Advantages: Minimal tissue damage, shorter recovery time, and suitable for small or deep-seated lesions.

  • Disconnective Surgery

    • Corpus Callosotomy

      • Purpose: To sever the corpus callosum — the bundle of nerve fibres connecting the two cerebral hemispheres — to prevent seizure propagation, particularly in drop attacks or generalised seizures.

      • Outcome: Reduces the severity of disabling seizures but seldom achieves complete seizure remission.

    • Multiple Subpial Transection (MST)

      • Purpose: To interrupt the cortical pathways responsible for seizure propagation within critical brain areas, without impairing vital functions such as speech or movement.

      • Advantages: Suitable for patients whose epileptogenic focus lies within or near functional cortex, where conventional resection carries unacceptable neurological risks.

  • Neuromodulation Techniques

    • Vagus Nerve Stimulation (VNS):

      • An implanted device stimulates the vagus nerve to reduce seizure frequency.

    • Responsive Neurostimulation (RNS):

      • A device that detects abnormal electrical activity and delivers targeted stimulation to prevent seizure onset.

    • Deep Brain Stimulation (DBS):

      • Targets specific brain regions associated with epileptic activity.

Preoperative Considerations

  • Consultation with a neurologist or neurosurgeon is essential to determine the most appropriate surgical plan for each patient.

  • Comprehensive preoperative evaluation — including EEG, MRI, PET scans, and neuropsychological testing — is critical for localisation of epileptogenic foci and assessment of surgical risk.

  • When the lesion responsible for focal epilepsy is clearly identified and the risk to critical neurological functions is minimal, surgical success rates are significantly higher.

Benefits and Risks of Surgery

  • Benefits:

    • Potential for complete seizure control or significant reduction in seizure frequency and intensity.

    • Noticeable improvement in quality of life and daily functioning.

    • Possible reduction in medication dependency and associated side effects.

  • Risks:

    • Surgical complications such as infection or haemorrhage.

    • Possible neurological deficits, including speech, motor, or sensory impairment.

    • Potential cognitive effects, particularly if surgery involves critical brain regions, careful assessment and monitoring are required.

 

​Different surgical techniques carry varying levels of risk. The treating specialist will perform a case-specific evaluation and provide tailored recommendations.

Lifestyle Modification and Management Strategies to Minimise Seizures

Patients are advised to:

  • Maintain regular sleep patterns.

  • Avoid known seizure triggers, such as alcohol, flashing lights, or stress.

  • Manage stress through relaxation techniques and counselling.

  • Follow a medically supervised ketogenic diet, especially in children with epilepsy.

  • Use seizure alert devices or wear medical identification.

Living with Epilepsy: Support, Education, and Safety

  • Enhance awareness to strengthen self-management and social support.

  • Increase understanding of epilepsy to help eliminate stigma and prejudice.

  • Empower patients with greater confidence and autonomy.

  • Encourage patients and families to understand the following key information:

    • Early recognition of seizure symptoms: Including sudden muscle jerks, staring episodes, abnormal sensations, loss of awareness or other unusual behaviours.

    • Recognising the importance of proper response: Timely and appropriate first aid measures can reduce harm.

    • When to seek emergency assistance: Prolonged seizures (lasting over 5 minutes), repeated seizures without regaining consciousness, or serious physical injury and life-threatening breathing difficulty require immediate emergency medical attention.

  • Education is vital: Teach family members, friends, and colleagues proper seizure first-aid skills, including ensuring the patient’s safety, placing them in a side-lying position, avoiding restraint, and keeping harmful objects away.

  • Establish comprehensive support and counselling systems:

    • Mental health care: Provide psychological counselling, stress management, and emotional support to help patients cope with anxiety and depression, thereby improving overall quality of life.

    • Information and resource sharing: Offer professional educational materials and build support networks, enabling patients and their families to exchange experiences, reduce isolation, and alleviate anxiety associated with the condition.

  • Preventive Measures and Emergency Guidelines:
    Although epilepsy cannot be completely prevented, the following actions can effectively reduce risk and ensure safety:

    • Use protective equipment during high-risk activities, such as wearing helmets during sports or when operating machinery, to prevent injuries.

    • Control and treat underlying conditions, for example, hypertension, diabetes, brain infections, or trauma, to reduce the likelihood of seizures.

    • Avoid exposure to seizure triggers, including excessive alcohol consumption, overheating, or contact with toxic substances, to minimise seizure risk.

Conclusion

  • Epilepsy is a manageable chronic neurological condition. With accurate diagnosis, effective medication, and proper lifestyle management, most patients can achieve good seizure control.

  • Early intervention facilitates rapid symptom control and reduces the risk of complications and accidents.

  • Close collaboration between patients, families, and healthcare professionals is essential to maintain a safe and fulfilling quality of life.


At the HKBSSP, we provide comprehensive neurological diagnostics and personalised long-term treatment plans to help patients reduce seizures and lead healthy, fulfilling lives.

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Selective Amygdalohippocampectomy:
A procedure involving the selective removal of the amygdala and hippocampus within the mesial temporal lobe, specifically targeting the structures associated with seizure onset. The surrounding neocortex is preserved to minimise cognitive side effects.

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Corpus Callosotomy:
A surgical procedure that involves severing the corpus callosum — the bundle of nerve fibres connecting the two cerebral hemispheres — to prevent the spread of epileptic activity.
Multiple Subpial Transection (MST): Performed to interrupt cortical fibres within the affected region, thereby preventing the propagation of seizures.

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Vagus Nerve Stimulation (VNS):
An implanted device placed in the chest wall delivers electrical stimulation to the vagus nerve, helping to reduce seizure frequency.

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Deep Brain Stimulation (DBS):
A device implanted in the chest wall provides targeted stimulation to deep brain structures, reducing seizure frequency.

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