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Summer 2012

Updated Thinking on Epilepsy Treatment

Driven by a concern that some common practice patterns endanger patients, UCSF epilepsy experts are finding new ways to deliver safer, more effective long-term care for both adult and pediatric epilepsy.

Drawing on an interdisciplinary team of more than 20 clinicians and its Level 4 status, the UCSF Epilepsy Center is:

  • Implementing new evaluation procedures to help tailor treatments.
  • Demonstrating that the underuse of surgery and lack of timely referrals is putting patients at risk.

The Dangers

"Patients who have not had their seizures controlled with two or more medications have a less than 20 percent chance of becoming seizure-free," says Daniel Lowenstein, M.D., director of the UCSF Epilepsy Center.

Dr. Daniel Lowenstein

Dr. Daniel Lowenstein

Seizures, of course, have comorbidities and can be fatal, including the risk of sudden, unexpected epilepsy death. Even when medications work well, the long-term consequences of antiseizure drugs can include cognitive disturbances and other side effects. "It's difficult to design optimal therapies, which is why early, expert evaluation is so important," Lowenstein says.

State-of-the-Art Evaluation

At UCSF, evaluations and treatment recommendations draw on collaborations that include, as appropriate:

  • Epileptologists
  • Neurologists
  • Neuropsychologists
  • Neuroradiologists
  • Neurosurgeons
  • Nurse practitioners
  • Social workers

Evaluation also includes, where necessary, leading-edge technologies:

While the center sees both new-onset and refractory patients, its experts believe that referral of new-onset patients is particularly important.

Dr. Joseph Sullivan

Dr. Joseph Sullivan

"Fifteen to 20 percent of new-onset seizures will become intractable," says pediatric epileptologist Joseph Sullivan, M.D., director of the UCSF Pediatric Epilepsy Center.

"Depending on the scenario, a skilled epileptologist and neuroradiologist can use an initial evaluation to zero in on medication that can optimize treatment." The team then works with referring physicians to manage patients over the long term.

"We also offer sophisticated genetic analysis of certain forms of the disease," says Lowenstein, who leads two major national studies on genetic factors in epilepsy. "Even when that doesn't change treatment, providing the etiology can bring families closure and help them understand if loved ones are at risk."

Timely Surgery Can Alleviate Suffering

Surgical treatment is an option that is too often underused. Studies showing surgery can decrease mortality and improve long-term survival and quality of life were published a decade ago.

The studies continue to demonstrate excellent results for many forms of epilepsy. For example, neurosurgeon Edward Chang, M.D., recently co-authored a paper in Annals of Neurology showing that with proper workup and localization, many patients with malformations of cortical development — long believed to be poor surgical candidates — can become seizure-free.

"There is good evidence for not waiting once a patient has failed two medications, especially since ongoing seizures and medication put patients at risk," Chang says. "Yet we've shown that the timing of surgical referrals hasn't changed. We'll do these surgeries and relieved patients will ask, 'Why didn't we do this 15 years ago? ' "

For more information, contact the UCSF Epilepsy Center at (415) 353-2437.

 

Neurosciences — Summer 2012 Index

Related Information

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