Yale-New Haven Hospital's neurosciences program brings together state-of the-art resources with the professional experience and expertise found at few other medical centers in the country. In HealthLINK: Neurosciences, some of YNHH's best minds weigh in on developments and controversies in one of medicine's most complex disciplines.

May 2012

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Patients with drug-resistant epilepsy should undergo surgery sooner rather than later

Brain surgery is often a last resort for people with drug-resistant epilepsy, but performing surgery earlier may prevent years of suffering, according to a recent study in the Journal of the American Medical Association (JAMA).

What the news means to you

The number of patients resistant to medical control remains around 30 to 40 percent.

Spencer, MD

Dennis Spencer, MD

Epilepsy is a disorder of brain function that causes recurrent seizures. Nearly 3 million Americans and 50 million people worldwide have epilepsy, and 30 to 40 percent of them do not achieve seizure control with drugs alone. The American Academy of Neurology recommends referring certain epilepsy patients who have failed two antiseizure drugs to specialized epilepsy centers for evaluation.

A designated epilepsy center, like the one at Yale-New Haven Hospital, has the professional expertise and facilities to provide the highest-level medical and surgical evaluation for patients with complex epilepsy. A multidisciplinary team composed of neurologists, neurosurgeons, neuroradiologists, neurophysiologists and specialized nurses, share the goal of finding the right treatment to help each patient control their epilepsy.

Although 13 new anticonvulsant drugs have been developed in the past 20 years, the number of patients resistant to medical control remains around 30 to 40 percent. It may be that the numbers of new medications available are in part responsible for the delay of referral to surgical programs. Despite the evidence that after failing two anticonvulsant trials the chance of seizure control is poor, some physicians may switch and/or combine multiple medications. It is important, then, that both physicians and patients be aware of when to refer to an epilepsy center for surgical consideration.

The study described in the JAMA article further emphasizes this point. Multiple surgical centers recruited patients for consideration of early surgery after failing medical control, but only 38 participants enrolled, and for this reason, the trial was terminated. Despite the small number of candidates, the statistics were very significant. After two years, none of the patients randomized to continue medical therapy were seizure-free, compared to the 11 of the 15 patients who underwent epilepsy surgery.

The comprehensive epilepsy program at Yale-New Haven Hospital pioneered the surgical treatment of epilepsy in the 1970s. Medical and surgical solutions are considered for both our pediatric and adult patients, and resective procedures are offered early, when the patient is an ideal candidate for surgical cure. Our multidisciplinary team meets weekly to discuss the phased evaluation of patients with difficult-to-manage chronic epilepsy. We lead in the development of surgical approaches that will optimize the chance of seizure control while minimizing side effects. This includes the modified anterior medial temporal resection for the treatment of temporal lobe epilepsy, which we developed in the early 1980s and that was reported in the JAMA study.

An early referral of an epilepsy patient to Yale-New Haven Hospital's comprehensive center does not mean that the patient will definitely have surgery, rather recommendations may be offered for medical, surgical, or novel interventions with follow-up by the patient's primary physician.

Dr. Spencer is chair of neurosurgery and director of epilepsy surgery at Yale-New Haven Hospital. He is the Harvey and Kate Cushing Professor of Neurosurgery at Yale School of Medicine.

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