Epilepsy affects approximately 3 million Americans, with a lifetime risk of 1 in 26. While antiseizure medications (ASMs) remain the first line treatment, many patients require increasing dosages or burdensome combination therapies, both of which are inconveniences to the patient. Furthermore, as higher dosages are prescribed, patients can experience side effects that diminish quality of life.
“The major side effects are lethargy and tiredness,” says Ed Hogan, MD, a WashU Medicine neurologist specializing in epilepsy and seizures in adults at Barnes-Jewish Hospital. “Many times, that’s what limits someone when treating patients — you have to try to find the right dose for the right patient.”
Often seizures can be controlled with careful, comprehensive evaluation to find the appropriate ASM based on the type of epileptic seizures, as well as finding the best-tolerated medication for an individual. Still, for some patients, ASMs are ineffective. There are more than 20 ASMs prescribed for symptomatic treatment of epilepsy, but one-third of patients are resistant to them. The Washington University and Barnes-Jewish Comprehensive Epilepsy Center in St. Louis is at the forefront of addressing these challenges with a wide arsenal of leading-edge treatments, comprehensively evaluating patients for treatment options, both with medical and surgical approaches.
The Epilepsy Center is nationally certified as a center of excellence and the only center in the region with the comprehensive infrastructure to carry a patient through all phases of surgical evaluation. Our Epilepsy Center offers epilepsy patients access to a multidisciplinary team of WashU Medicine board-certified epileptologists and functional neurosurgeons, as well as allied specialists. This balanced approach to care offers a range of treatment options that include medications, implantable neuromodulatory devices and surgical interventions. Our physicians are highly experienced in tailoring antiseizure strategies to the unique needs of patients.
For drug-resistant epilepsy (DRE) patients, WashU Medicine physicians at Barnes-Jewish Hospital have been at the forefront of clinical trials to evaluate the safety and efficacy of newer medications that can be given around the time of an anticipated seizure, providing cushion for patients from the sequelae of breakthrough seizures. “We are collaborating with academic and industry partners to expand the pipeline of available medications and already possess extensive real-world experience working with an expanded armamentarium of treatments," says Adam Greenblatt, MD, a WashU Medicine neurologist specializing in adult epilepsy at Barnes-Jewish Hospital.
Specific considerations for specialized treatment approaches include:
- Medications around menses: For patients with catamenial epilepsy, treatments are timed to align with menstrual cycles.
- Post-seizure intervention: Administered shortly after a seizure to prevent subsequent seizure clusters.
- Intranasal rescue medications: For patients with a history of prolonged seizures, these offer a rapid and dignified alternative to traditional oral and rectal rescue options.
In addition to medications, the Center uses neuromodulatory strategies to enhance the effectiveness of antiseizure medications in the pursuit of seizure control. One important modality, responsive neurostimulation (RNS), involves intracranial implantation of a device that detects and responds to seizure activity in real time. This technology not only offers patients a therapeutic intervention for their epilepsy but also enables continuous monitoring of ongoing seizure burden. The longitudinal data acquired from this modality offers the opportunity to conduct long-term seizure surveillance.
“This monitoring provides epileptologists with a way of measuring the impact of our treatments objectively while offering a therapeutic treatment for patients in parallel,” Dr. Greenblatt says. In this way, RNS for a patient with drug-resistant epilepsy is similar to a cardiac pacemaker and defibrillator, but also confers additional long term-benefits. “Chronic RNS recordings have revealed that in many people, seizures have predictable circadian or multidien cycles, facilitating potential opportunities to anticipate periods in which patients may have higher risk of increased seizure burden. This affords us the opportunity to modify our treatment strategies proactively to address these periods of increased risk.”
For DRE patients, our epilepsy team is experienced in both traditional and minimally invasive surgical treatments including:
- Deep brain stimulation
- Vagus nerve stimulation (VNS)
- Responsive neurostimulation
- Radiofrequency ablation
- Selective laser ablation
- Lesionectomy
- Lobectomy and topectomy
- Callosotomy and hemispherotomy
We encourage physicians to refer patients to the Epilepsy Center for specialized care if they meet any of the following criteria:
- New-onset seizure(s)
- Worsening seizure burden despite medical adherence
- Drug-resistant seizures, defined as continued seizures despite adherence to two appropriately selected and well-tolerated medications
- History of epilepsy and planning a pregnancy or already pregnant
- Seizures in the setting of a brain lesion (tumor, vascular malformation, cortical malformation)
- Seizures in the setting of an intellectual disability or autism spectrum disorder
- Recurrent spells of unclear cause in the elderly
Learn more about our advanced treatment options for epilepsy at Barnes-Jewish Hospital. To refer a patient, call 314-362-7845.
