Diagnostika a léčba epilepsie

Despite advances in pharmacological treatment, long-term seizure freedom remains unachievable in 20–30% of patients with epilepsy, even when they adhere strictly to lifestyle recommendations and take antiepileptic medications correctly. In such cases, surgical treatment becomes a viable therapeutic option.

Epilepsy surgery is currently considered an effective and safe approach for many patients with drug-resistant epilepsy. In a significant proportion of these individuals, seizures can be eliminated entirely or at least substantially reduced in frequency.

Key criteria for considering epilepsy surgery include:

• Proven diagnosis of drug-resistant epilepsy
• Expected improvement in quality of life due to seizure reduction or elimination
• Surgical risks are outweighed by anticipated benefits
• Strong motivation from the patient (or, in pediatric cases, from the child’s caregivers)

Whether surgery is indicated—and which surgical procedure is most appropriate—must be carefully evaluated on a case-by-case basis by a specialized interdisciplinary team.

The final decision regarding surgery is made by the center’s surgical board only after comprehensive diagnostic evaluations and multidisciplinary assessment.

Resective surgery (curative surgery), where the brain area responsible for seizure onset (epileptogenic zone) is removed, offers the best chance for complete seizure freedom and, essentially, a cure. Unfortunately, this outcome is not possible for all patients.

Resection is not feasible if the epileptogenic zone overlaps with eloquent cortex—brain regions responsible for essential functions like movement, sensation, speech, or vision. It is also typically not an option for patients with multifocal epilepsy (multiple seizure foci), idiopathic generalized epilepsy, or most developmental epileptic encephalopathies such as Dravet syndrome or Lennox-Gastaut syndrome.

Neurostimulation therapies, such as Vagus Nerve Stimulation (VNS) and Deep Brain Stimulation of the anterior thalamic nuclei (DBS-ANT), are considered alternatives when resective surgery is not appropriate. Though seizure freedom is not the primary expected outcome of neurostimulation, complete seizure elimination is seen in approximately 5% of VNS or DBS-treated patients, and a >90% seizure reduction in about 10%. Additionally, 50–60% of patients typically experience a significant (>50%) reduction in seizure frequency.

It is crucial to note that neurostimulation should only be considered when curative surgery is not an option, as resective procedures remain the first-line surgical treatment for suitable candidates.

To determine the most appropriate treatment for each patient, several additional diagnostic tests are necessary to clarify the cause and characteristics of epilepsy. All patients under the care of our Epilepsy Center undergo basic evaluations, which always include an EEG and MRI. If your epileptologist begins considering surgical treatment, the first essential step is to rule out pseudoresistance—a situation where seizures persist for reasons other than true drug resistance. In nearly half of these cases, the cause of ongoing seizures is an incorrect diagnosis.

Once true drug resistance is confirmed, the patient undergoes a comprehensive two-week diagnostic hospitalization at our center. During this stay, we complete a series of non-invasive presurgical tests, which typically include:

• Video-EEG monitoring
• High-resolution brain MRI using an epilepsy-specific protocol
• Comprehensive neuropsychological evaluation
• In most cases, we also perform PET imaging of the brain on an outpatient basis.

In patients with non-lesional epilepsy—those whose MRI shows no obvious abnormality—additional advanced testing is necessary. This may include:

• SISCOM (Subtraction Ictal SPECT Coregistered to MRI)
• SPM-PET (Statistical Parametric Mapping of PET data)
• Stereo-EEG (SEEG) — an invasive video-EEG investigation using depth electrodes

Only after all necessary diagnostic procedures have been completed and thoroughly reviewed, a multidisciplinary surgical team meets to evaluate the findings and decide whether epilepsy surgery is a suitable and safe option.

For the vast majority of patients with epilepsy, treatment requires the use of medication. These medications are commonly referred to as antiseizure medications (ASMs), a term now preferred over the older “antiepileptics” because currently available drugs do not cure epilepsy—they only help prevent seizures.

The general approach to starting treatment with ASMs follows these principles:

1. Treatment is initiated after a thorough evaluation of the seizure’s origin. Medications are prescribed only when the seizure is clearly epileptic in nature, or when there is reasonable suspicion of epilepsy. In uncertain cases, doctors may proceed with a “therapeutic trial” using a broad-spectrum ASM at appropriate doses.
2. Monotherapy is the first step. Treatment begins with a single first-line ASM, started at a low dose and gradually increased to the maximum tolerated dose (MTD)—the highest dose that does not produce unacceptable side effects. This approach leads to complete seizure control in approximately 50% of patients.
3. If the first medication is ineffective, it is usually replaced with a different ASM. This change brings seizure freedom to an additional 13% of patients.
4. In cases where seizures persist, a second medication is added to the initial one, moving to combination therapy.

If seizure freedom is not achieved after trying two appropriately chosen, correctly dosed, and consistently used ASMs—along with adherence to all lifestyle recommendations—the likelihood of reaching long-term remission with additional medication becomes significantly lower. At this point, the patient meets the criteria for drug-resistant epilepsy.