Epilepsy Care: Integrating Medical, Surgical, and Behavioral Options

It is an exciting time in the treatment of people with epilepsy, with the advent of new therapies and expanding understandings of how to adapt existing medications and treatment modalities for both on- and off-label use. In light of all these new possibilities, developing a coherent approach can pose a challenge for neurologists. This issue of Practical Neurology provides a framework for better understanding the emerging strategies to treat both adult and pediatric patients with medically refractory epilepsy and its comorbidities.

We start on familiar ground: Dr. Sankar provides an overview of the long history of targeting the voltage-gated sodium channel with antiseizure medications. Then, through a nuanced discussion of the subunit structure of the sodium channel and the currents passing through the channel, we can better understand the advantages of new and upcoming medications targeting various aspects of the sodium channel current.

From familiar medication targets we transition to newer immunotherapy approaches to the treatment of refractory and super-refractory status epilepticus (RSE/SRSE). Drs. Silverman, Nagesh, Ho and Santoro explain the neuroinflammatory cascade that occurs in RSE and outline the evidence behind first-line, second-line, and exploratory immunomodulatory treatments.

Next, Drs. Gallagher and Fallah discuss why concerns about surgical risks should now be tempered by understanding how innovations in less-invasive neurosurgical techniques have significantly improved the morbidity and recovery time from epilepsy surgery.

Dr. Edmonds then expands on how one of those less-invasive surgical strategies is opening new avenues of treatment for some individuals who have had limited viable options until now. Although neuromodulation approaches such as vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation are generally approved for focal epilepsies, we are developing a better understanding of how these devices can help patients with generalized and multifocal epilepsies such as Lennox-Gastaut Syndrome (LGS), which can be highly resistant to treatment.

Next, we turn toward the cognitive deficits associated with aberrant electrical activity in the brain. The impact of developmental and epileptic encephalopathy with spike-and-wave activation in sleep (DEE-SWAS) is gaining increasing recognition. Drs. Rao, Stowe, Kelley, Pavuluri, Liu, and Patel from the DEE-SWAS Special Interest Group of the Pediatric Epilepsy Research Consortium discuss the challenges of treating this condition, including lack of established electroclinical phenotype, limited options for standardized therapy, and issues with defining treatment success.

Finally, we conclude with perhaps the most frequently encountered type of challenge in treating individuals with epilepsy: the behavioral and psychiatric comorbidities associated with this condition. Dr. Waldron shares her expertise as a neurodevelopmental disabilities specialist in the pharmacologic management of depression, anxiety, behavioral issues and autism spectrum disorder, including misconceptions which may arise from Food and Drug Administration warnings regarding risk of suicidal ideation in people who are prescribed selective serotonin reuptake inhibitors (SSRIs).

Each of these articles provides useful, practical insights on various aspects of treating people with medically refractory epilepsy. I extend my sincere thanks to all of the authors for sharing their expertise for this issue of Practical Neurology.