Management Topics in Epilepsy

Posted in Management Topics in Epilepsy on 31st Jan 2013

Author

Mark Manford

Mark Manford trained in neurology at the National Hospital where he obtained his MD researching into clinical patterns of epilepsy, and at the Wessex Neurological Centre. He has been a Consultant Neurologist at Addenbrooke’s and Bedford Hospitals since 1997 and has continued his interest in epilepsy, including writing a greatly under-rated textbook on the subject. He is also extensively involved in undergraduate medical training in Cambridge.

Correspondence to:
Email. Mark Manford

In the first volume of ACNR, the young and naïve editors invited me to write a  series of articles discussing specific management topics in epilepsy.  Ten years later, they are older and a little wiser. This time, rather than writing them myself, I have been asked to commission proper experts to write the articles.  Consequently there will be some real pearls laid before you.  Last time, I considered refractory epilepsy and the latest kid on the block was levetiracetam, now an established treatment and vagus nerve stimulation was also relatively new. I was a cynic but have had to change my view as VNS has found its niche, the only epilepsy treatment to be awarded the accolade of Grade A evidence  by NICE in 2004.  Now there are more clever boxes of tricks used in the treatment of epilepsy. This is an expanding area with a variety of intracranial and extracerebral devices triggering the migration of my cynicism more rostrally from the vagus nerve. Perhaps in another ten years, I shall be eating humble pie once again.  By that time the wisdom of the editors will be so well developed that somebody else will be writing this article. In my view, at least as exciting is the prospect of devices enabling seizure detection, something which remains at an early stage. This offers the opportunity to intervene in cases of potential SUDEP, one of the great tragedies of epilepsy and an issue which rightly has come to the fore in the last decade and about which we shall be hearing more.  Prof Mark Cook from Melbourne will tell us about developments in clinically relevant seizure detection.

 Introduction

Epilepsy specialists can reasonably be accused of not knowing whether to lump or to split, both in terms of diagnosis and of treatment. In the current series of articles, we shall be doing a little splitting, looking at the specific issues and needs of selected groups  of patients.  Enough about women’s issues I hear you call, we shall burn our boxers and strike a blow for masculinism.  In the true spirit of egalitarianism with an article about men’s issues in epilepsy, written by a woman, Susan Duncan, from Edinburgh.  Another group with specific needs is the elderly for whom a diagnosis of epilepsy may cause particular social isolation and in whom it is more often a marker of serious underlying neurological disease. Choice of anti-epileptic drugs is complicated by comorbidities and drug interactions and may be different from younger patients.  Erica Chisanga, our very own Cambridge Nurse Consultant in Epilepsy will give us her knowledge of the particular issues faced by this group. Epilepsy is, of course, especially common in those with learning disability, from whom it may be difficult to obtain a history and who may express a variety of problems with attacks of one sort or another, making the diagnosis of epilepsy a particular challenge.  They are also especially likely to have complex genetic disorders, which have been identified in the last decade.  The management of epilepsy and related disorders in this group is becoming a subspecialty in its own right.   These patients sit uncomfortably between neurology and learning disability specialties in this country. A select group with the balance and anatomical resilience to straddle this particular fence includes Howard Ring, also from Cambridge, who will expound on the issues.

Disappointingly, the explosion of new anti-epileptic drugs has not seen the number of seizure-free patients grow appreciably in the last twenty years. Increasingly, we recognise that the agents we are currently using are seizure suppressing drugs; treating the symptom, like analgesia for a headache, but not addressing the cause.  The current choice of drug in the management of epilepsy, centres more frequently around adverse effect profile and interactions than on the efficacy of particular drugs, as it is often hard to choose between them on this criterion.  This tells us exactly how poor is our intelligence with regard to choosing the right drug for the right patient. Researchers have struggled to find a new conceptual approach and new paradigms, which may reflect more fundamentally, the underlying processes. Inflammatory molecules such interleukin-1 and key enzymes such as caspase may be targets but there is also a more sophisticated understanding of channels and their changes in regulation in epileptogenesis. They may be a target for gene therapy for example with viral vectors and the Holy Grail is to find an “epileptogenic” target which can be influenced after the epilepsy has started.  Prof Dimitri Kullmann from Queen Square has pioneered work in this area and I am especially pleased that his team will be able to contribute to this series.

Status epilepticus, termed the maximum expression of epilepsy, is terrifying for those who observe it and is potentially rapidy fatal. Whilst treatment has existed for many years, it is of varying success and the evidence underlying treatment choices is poor. Increasingly we are starting to understand how the mechanisms of seizures evolve during status epilepticus, explaining why our treatments may not work in particular cases and how we might use existing drugs or design new drugs which take account of the changes in neuronal physiology and chemistry which occur minute by minute in this emergency.  Prof Matthew Walker from Queen Square will tell us how his work and that of others is bringing science and clinical practice together in this neurological emergency.

I am delighted that you will be hearing from this group of people on new and exciting issues in epilepsy, as well as reviewing key areas of clinical difficulty over the coming months. I hope you will learn from them and enjoy their contributions as much as I shall – good decision Ed!

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