Epilepsy is one of the most common neurological disorders in the world, affecting millions of people and profoundly impacting their quality of life. It is characterized by sudden, uncontrolled bursts of electrical activity in the brain that result in epileptic seizures. These seizures can manifest in various ways, from brief lapses of consciousness to severe convulsions that can lead to loss of consciousness and subsequent disorientation. Living with epilepsy brings daily challenges; common activities like cooking, driving a car, or even swimming can become dangerous, placing the individual and those around them at constant risk.

Although modern medicine offers a wide range of about thirty antiepileptic drugs, we face the devastating fact that approximately one-third of patients do not achieve complete seizure control. This group of patients, known as pharmacoresistant, lives in constant uncertainty, wondering when the next seizure will occur. For them, advances in neurosurgery and implantable device technology open new doors of hope and offer the possibility of a life free from seizures.

Why does standard drug therapy sometimes fail?

One of the surprising but key reasons why antiepileptic drugs don't work is the possibility of a misdiagnosis. Statistics from specialized epilepsy centers show that a significant number of patients referred for treatment of pharmacoresistant epilepsy do not actually suffer from the condition. Accurate diagnosis, which often includes multi-day video-EEG monitoring in a hospital setting, is crucial for distinguishing true epileptic seizures from other conditions. The most common misdiagnosis is psychogenic non-epileptic seizures (PNES), which occur in about 25% of patients in specialized centers. Although they can mimic epileptic seizures in appearance, PNES has psychological roots, often related to previous traumatic experiences, and requires a completely different treatment approach that does not include antiepileptics.

Another reason for treatment failure lies in drug intolerance. Antiepileptics work by reducing the excitability of nerve cells in the brain. Unfortunately, they often do not distinguish between the abnormal electrical activity that causes seizures and the normal brain activity necessary for thinking, memory, and emotions. The consequence is frequent and debilitating side effects such as dizziness, chronic fatigue, coordination problems, and a feeling of "brain fog." For some patients, the doses required to control seizures cause side effects so severe that continuing therapy is unsustainable. Finally, in a certain number of patients, the mechanisms by which drugs simply do not work remain unclear, indicating the complexity and individuality of this neurological disorder.

Surgical treatment as an alternative

When patients try several different drugs without success, the likelihood that the next drug will help them drops drastically to less than 1%. At that point, surgical treatment becomes not just an option, but the most effective path toward a life without seizures. A surgical approach can offer up to an 80% chance of complete seizure control, which represents a huge difference in outcome and quality of life. It is important to emphasize that surgery does not necessarily mean an immediate stop to taking medication. Patients who are seizure-free for a year after surgery can, in agreement with their doctor, begin a gradual dose reduction, but some will still require long-term medication therapy, although often in smaller doses and with fewer side effects.

Advanced surgical methods

For the approximately 60% of patients whose seizures originate from a single, clearly defined area of the brain (focal epilepsy), there are several surgical options. Traditional resective surgery involves an open procedure to carefully remove the brain tissue identified as the source of the seizures. This procedure is performed with the help of advanced brain mapping techniques to minimize the risk of damaging key functions such as speech or movement.

For seizures originating from deep or hard-to-reach parts of the brain, a minimally invasive technique known as Laser Interstitial Thermal Therapy (LITT) is used. Through a small incision in the scalp and a tiny hole in the skull, the surgeon inserts a laser probe guided by real-time magnetic resonance imaging (MRI). The heat from the laser precisely destroys the abnormal tissue, causing minimal trauma to the surrounding healthy tissue and allowing for a much faster patient recovery.

Implantable devices: Neurostimulation as the future of treatment

For patients who are not candidates for resective surgery, implantable neurostimulator technology offers a revolutionary approach. These devices, often called "pacemakers for the brain," deliver electrical impulses to modulate brain activity and prevent seizures.

Responsive Neurostimulation (RNS): This smart device is a closed-loop system that continuously monitors the brain's electrical activity via electrodes implanted directly at the source of the seizures. When it detects patterns that precede a seizure, the RNS system automatically delivers a short and imperceptible electrical impulse to interrupt the abnormal activity before the seizure develops. In addition to its therapeutic function, the device collects invaluable data on the patient's brain activity, allowing doctors to optimize therapy over time.

Deep Brain Stimulation (DBS): DBS works on a different principle. Instead of reacting to the onset of a seizure, this system provides continuous or intermittent electrical stimulation to deep brain structures, such as the thalamus, to reduce the overall excitability of brain networks and thereby reduce the frequency and severity of seizures. This technique is already successfully used in the treatment of other neurological disorders like Parkinson's disease.

Vagus Nerve Stimulation (VNS): As the oldest of these three techniques, VNS does not require brain surgery. A small generator, similar to a cardiac pacemaker, is implanted in the chest, and a thin wire is wrapped around the vagus nerve in the neck. The device sends regular, mild electrical signals to the brain via this nerve, which helps to stabilize brain activity. VNS is the only one of these devices approved for use in children and represents an important option for a wide range of patients.

Research that pushes the boundaries

The field of epilepsy treatment is constantly evolving, and current clinical research promises even better outcomes. One such trial is using the RNS system to treat patients with generalized seizures, which affect both hemispheres of the brain simultaneously. Preliminary data show clinically significant results. Another important trial is focused on children and adults with Lennox-Gastaut Syndrome (LGS), a severe and rare form of epilepsy that often begins in early childhood and is resistant to most therapies.

A particularly exciting development is a project that uses long-term data collected by RNS devices to predict the likelihood of a seizure within the next 24 hours. A smartphone application has been developed that gives patients a seizure risk assessment for the day, similar to how a weather forecast predicts the chance of rain. Although it cannot provide an absolute guarantee, surveys show that patients greatly appreciate the ability to know what to expect in advance, which allows them to better plan their activities and provides a sense of control over their own condition.

Life change after achieving seizure control

Achieving freedom from seizures opens up a world of possibilities that were denied to many patients. It is not just a matter of health, but a fundamental transformation of one's entire life. Patients can drive again, which restores their independence. They can find and keep a job, achieve financial stability, and build meaningful relationships without the constant fear of having a seizure in public. For patients who have experienced cognitive decline due to years of seizures, successful treatment can halt this process and, in some cases, even lead to an improvement in cognitive functions.

Although surgical procedures and implantable devices do not work for everyone, it is crucial to maintain hope and be aware of all available options. In neurology, few areas offer as many different therapeutic possibilities as epilepsy. There is always something new to try, which is why the fight against this challenging condition is never given up.