Non-pharmacological Management of epilepsy

1. Non-pharmacological Management of epilepsy

2. Behavioural Avoidance A small minority of patients do have seizures following well defined stimuli. This is known as reflex epilepsy. If seizure triggers can be identified then perhaps the most obvious way to increase seizure control is to avoid such triggers. Desensitization In desensitization the individual will be exposed to gradual approximations of the seizure trigger. Exposure at each of the steps stops once it fails to trigger an epileptic response. This technique can require many sessions over days or weeks before the patient is able to be exposed to the full stimulus without experiencing a seizure.

3. Lifestyle ....Craig Hassed would be proud Exercise It is recommended that epilepsy patients participate in a range of sporting and physical activities (after appropriate risk assessment/control). This was at first thought to merely enhance the quality of life, however evidence now suggests that an increase in physical activity can lead to better seizure control. However the effectiveness varies considerably among patients. Diet The Ketone diet is the most common dietary treatment for epilepsy, and was started in the 1920’s when it was observed that fasting epilepsy patients experienced fewer seizures. This diet produces some of the effects of starvation while providing enough nutrients to keep the patient healthy. This diet is high fat, low carbohydrate and low protein.

4. Surgical The basic aim of surgical management in epilepsy is to locate and remove the portion of the brain which is giving rise to seizure activity. There are various procedures which have been proven effective and can be classified as follows: Resection techniques: Lesionectomy Some seizures occur as a result of lesions in the brain. If these lesions can be removed completely it generally stops the seizures. This type of procedure has a much higher success rate than those where a discrete lesion is not found. Where there is no visible lesion causing the seizures it is possible to map out the brain using EEG and functional MRI monitoring and isolate the area of the brain responsible for the seizures. This is then removed through other resection techniques, the most common of which is the Temporal resection. Others include Extra-temporal resection and Hemispherectomy.

5. Surgical Disconnection techniques: Corpus Callosotomy This has been offered as an alternative to hemispherectomy in patients who still have valuable language/motor function on the affected side of the brain. As a general rule this in most useful for those suffering from general seizures or seizures arising bilaterally from the frontal lobe. In the first procedure the anterior 2/3 of the corpus callosum is cut. If adequate results are not achieved then a second procedure can be done to cut the remaining third. Disconnection effects are not common if only the first procedure is performed, however they are frequent in those who receive both. There is often difficulty in bimanual tasks, apraxia for commands directed to the non-dominant lobe and vision problems. Multiple subpialtransections offer an alternative to resection. The vertical columnar arrangement of the cortex is preserved, but seizure spread is prevented.

6. Surgical Augmentation techniques: Cerebellar stimulation Cerebellar electrical stimulation has been used to treat generalised, focal and myoclonic seizures. Has a theoretical basis from animal studies in which lesion induced seizures were inhibited by cerebellar electrical stimulation. However this is not a recommended treatment. Vagus nerve stimulation Recently a number of patients with generalised and focal seizures underwent a procedure wherein a nerve stimulator was implanted near the left vagus nerve. However less than half experienced up to a >50% reduction in seizures and only rarely did patients become seizure free.