Epilepsia, 50(Suppl.
8):51–56, 2009
doi: 10.1111/j.1528-1167.2009.02236.x
REFRACTORY SEIZURES
Treatment algorithms in refractory partial epilepsy
Barbara C. Jobst
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, U.S.A.
SUMMARY
An algorithm is a ‘‘step-by-step procedure for solv-
ing a problem or accomplishing some end....in a
finite number of steps.’’ (Merriam-Webster,
2009). Medical algorithms are decision trees to
help with diagnostic and therapeutic decisions.
For the treatment of epilepsy there is no generally
accepted treatment algorithm, as individual epi-
lepsy centers follow different diagnostic and thera-
‘‘The Problem’’: Refractory
Epilepsy
Epilepsy is considered intractable or refractory if at
least two antiepileptic drugs (AEDs) have failed to control
seizures. AEDs should have been titrated up to maximum
tolerated doses with a sufficient therapeutic level and not
have been discontinued due to side effects (Berg, 2006).
More stringent definitions require one seizure per month
for 18 months (Berg et al., 2006).
‘‘Accomplishing Some End’’:
Outcome Measures
Studies for the treatment of epilepsy use different out-
come measures. In epilepsy surgery, the most common
outcome measure is being free of disabling seizures
(Engel et al., 2003). The widely used Engel scale
defines class I as being free of disabling seizures but
allows for auras (Engel, 1987). The International
League Against Epilepsy (ILAE) requires no auras for a
class I outcome (Wieser et al., 2001). AEDs and device
trials use responder rates as the primary outcome. A
patient is considered a responder if seizures are reduced
by 50%. Because of these differences, surgical and
Address correspondence to Barbara Jobst, Dartmouth-Hitchcock
Medical Center, 1 Medical Center Drive, Lebanon, NH 02756, (603)
653-6118, U.S.A. E-mail: Barbara.c.jobst@hitchcock.org
Wiley Periodicals, Inc.
ª 2009 International League Against Epilepsy
51
peutic guidelines. This article presents two
algorithms to guide decisions in the treatment of
refractory partial epilepsy. The treatment algo-
rithm describes a stepwise diagnostic and thera-
peutic approach to intractable medial temporal
and neocortical epilepsy. The surgical algorithm
guides decisions in the surgical treatment of
neocortical epilepsy.
KEY WORDS: Algorithm, Refractory epilepsy,
Intractable, Therapy, Epilepsy surgery.
medical treatment studies are not easily comparable.
Quality-of-life measures, and psychiatric and neuropsy-
chological outcomes are other important measures.
Studies have shown that quality of life only improves
significantly, if the patient is completely seizure free
(Markand et al., 2000). Therefore, seizure freedom is
the final endpoint considered in the algorithms.
Treatment Algorithm
At every decision point in the algorithm (Fig. 1), there
are additional factors that are of vital importance. Man-
agement of adverse events from any intervention needs to
be tailored to the individual patient. Any comorbidities,
especially of a psychiatric nature, can rule out certain
treatment options. Reproductive factors such as pregnancy
and teratogenicity are of concern in young women. Com-
pliance, quality of life, employment, and driving legisla-
tion are important factors. Healthcare systems, access to
resources, costs, and the cultural acceptance of an inter-
vention frequently influence treatment decisions.
Node T1—Video-EEG: Focal epilepsy?
The first step in the treatment of refractory epilepsy is
to confirm the diagnosis with video-EEG (electroencepha-
lography) monitoring. Approximately 20% of patients
evaluated for intractable epilepsy have nonepileptic psy-
chogenic seizures. If video-EEG monitoring suggests a
diagnosis other than focal epilepsy, for example, primarily
generalized epilepsy, appropriate treatment for those con-
ditions should be initiated.
52
B. C. Jobst
Node T2—Syndrome?
Video-EEG determines whether the patient has a
temporal lobe syndrome or any other neocortical epilepsy
syndrome. Medial temporal lobe epilepsy is characterized
by seizures with epigastric, olfactory or dj vu auras,
altered awareness, oral and manual automatisms, as well
as dystonia contralateral to the seizure onset (Williamson
et al., 1998). Ictal EEG shows lateralized anterior tempo-
ral theta build-up. Neocortical syndromes also have typi-
cal seizure characteristics and EEG findings. Frontal lobe
seizures present with bizarre hyperactive automatisms or
asymmetric tonic seizures, depending on the seizure-onset
zone (Jobst et al., 2000). There is a paucity of ictal EEG
findings. Parietal lobe seizures may present with pain, and
occipital seizures with visual phenomena (Jobst &
Williamson, 2005).
Node T3—MRI/MTS?
The presence of mesial temporal sclerosis (MTS) on
magnetic resonance imaging (MRI) confirms medial tem-
poral seizure onset, and surgical intervention is superior to
best medical management (Wiebe et al., 2001; Engel
et al., 2003). However, how many medications should be
tried before surgery is entertained is still subject to debate
(see following contribution by Kwan and Sperling). The
absence of MTS on MRI warrants certainly more exten-
sive medication trials, as surgical intervention is less
likely to be successful.
Node T4—Memory evaluation
Memory evaluation is indispensible in temporal lobe
surgery. Neuropsychological testing gives an overall
estimate of intellectual functioning and can localize
Epilepsia, 50(Suppl. 8):51–56, 2009
doi: 10.1111/j.1528-1167.2009.02236.x
Figure 1.
Treatment algorithm (T) for
refractory partial epilepsy.
Epilepsia ILAE
deficits to the left or right hemisphere. Good performance
on verbal memory tasks is predictive of significant mem-
ory loss after resection of the dominant temporal lobe.
Small hippocampal volumes and significant hippocampal
atrophy predict less memory decline after surgery.
Traditionally the likelihood of postoperative memory
loss was estimated with the intracarotid amytal procedure
(IAP, or WADA test). Etomidate or methobrevital sodium
are used alternatively (Jones-Gotman et al., 2005). There
is still discussion of whether the IAP needs to demonstrate
sufficient memory function of the nonresected hippocam-
pus (functional reserve model) or whether memory loss
correlates with the function of the hippocampus that is to
be resected (functional adequacy model) (Andelman et al.,
2006). The morbidity of the intracarotid amytal procedure
is low; 0.36% have a permanent neurologic deficit (Haag
et al., 2008), but it is still an invasive test. The IAP has
been questioned to be a good predictor of post-operative
memory loss (Dodrill & Ojemann, 1997). Memory pro-
cessing is dependent on frontal structures in addition to
the hippocampal structures (Ojemann & Kelley, 2002).
Functional MRI has been suggested as an additional non-
invasive predictor of postoperative memory loss and the
IAP may not add any additional information (Binder et al.,
2008).
Node T5—Surgery
A temporal lobectomy or a selective amygdalo-hippo-
campectomy is the appropriate treatment for MTS if the
risk for additional memory loss is low. Surgery rendered
58% of patients seizure-free but only 8% were seizure free
with best medical management in a class I randomized
trial (Wiebe et al., 2001). A meta-analysis of 24 class IV

studies reported 59–67% of patients free of disabling sei-
zures (Engel et al., 2003).
After successful surgery, AEDs can be reduced after
2 years, and if surgery is not successful intensification of
medical treatment, surgical reevaluation, or implantation
of a vagus nerve stimulator (VNS) is appropriate.
Node T6—Optimize medical treatment
In neocortical epilepsy, optimizing medical treatment is
the initial mainstay of therapy. Phenytoin, carbamazepine,
valproic acid, phenobarbital, primidone are more tradi-
tionally prescribed AEDs. Topiramate, lamotrigine,
oxcarbazepine, and felbamate are approved as monothera-
py in the United States. Levetiracetam, pregabalin,
tiagabine, zonisamide, and gabapentin are adjunctive for
partial seizures. Rufinamide and Lacosamide have
recently been approved. Clobazam and vigabatrin are not
yet available in the United States.
Medical treatment includes hormonal treatment and
dietary treatment. In small studies, progesterone has been
shown to be effective in catamenial epilepsy. A large mul-
ticenter trial is under way (Clinicaltrials.gov number
NCT00029536). In a multicenter study in children, the ke-
togenic diet was effective in reducing seizures in 54%, as
shown in a multicenter study (Vining et al., 1998). The
low glycemic index diet and the Atkins diet are alternative
dietary options. The Atkins diet has a responder rate of
47% (Kossoff et al., 2008).
Node T7—Evaluate for surgery/resection possible?
Surgical evaluation is indicated if seizures persist
despite best medical management. For details, see the sur-
gical algorithm (Fig. 2). Surgery in neocortical epilepsy is
Figure 2.
Surgical algorithm (S) for
neocortical epilepsy.
Epilepsia ILAE
53
Treatment Algorithm Epilepsy
less successful than in mesial temporal lobe epilepsy,
however, it is still superior to best medical treatment
(Yang et al., 2008).
Node T8—VNS
Vagus nerve stimulation is indicated if surgery fails or
is not an option. VNS reduces seizure in 50% of patients
by more than 50% (Vonck et al., 2004). Only a small
percentage (7%) of patients become seizure free (Vonck
et al., 2004).
Node T9—Callosotomy, clinical trials, brain
stimulation
Other nonstandard treatment options are indicated if all
previously mentioned treatments failed. Callosotomy pre-
vents falling and generalized tonic–clonic seizures. Clini-
cal trials for novel treatments are another option.
Lately, brain stimulation has been studied for the treat-
ment of intractable partial epilepsy. There are two princi-
ples for applying brain stimulation to treat epilepsy.
Responsive stimulation requires the detection of seizures
and application of an electrical current if a seizure occurs.
A cranially implanted responsive device is currently under
investigation (Clinicaltrials.gov number NCT00079781).
Continuous or open-loop stimulation applies current to an
intracerebral target independent of whether a seizure
occurred. The optimal target is still under discussion. The
only completed randomized trial for brain stimulation in
epilepsy targeted the anterior nucleus of the thalamus with
open-loop stimulation for the treatment partial seizures
(Fisher, 2008). This reduced seizures by 30%. Other small
nonrandomized studies report varying success rates with
stimulation of the hippocampus or the centromedian
Epilepsia, 50(Suppl. 8):51–56, 2009
doi: 10.1111/j.1528-1167.2009.02236.x
54
B. C. Jobst
nucleus of the thalamus (Velasco et al., 2001; Boon et al.,
2007).
Surgical Algorithm for
Neocortical Epilepsy
Node S1—MRI/lesional
In neocortical or other than medial temporal refrac-
tory epilepsy the absence or presence of a lesion on
MRI is crucial for further decision making. Nonlesional
neocortical epilepsy surgery represents a larger chal-
lenge. A visible lesion on MRI is associated with a
higher likelihood of successful epilepsy surgery (Yun
et al., 2006).
Node S2—Video-EEG, PET, ictal SPECT, MEG
The noninvasive evaluation includes video-EEG moni-
toring, ictal and interictal single-photon emission
computed tomography (SPECT), positron emission
tomography (PET), and magnetoencephalography
(MEG). All of these studies are aimed at identifying the
seizure-onset zone. Interictal SPECT is most useful in
temporal lobe epilepsy, and hypoperfusion indicates
the region of seizure onset. Ictal SPECT is logistically
difficult. It involves injection of the tracer during a seizure
and is strongly dependent on the injection time. Hyper-
perfusion indicates seizure onset. Subtraction and coregis-
tration with MRI (SISCOM) improve sensitivity and
specificity (O’Brien et al., 1999). In one center, 52% of
ictal SPECTs localized correctly indicated the lobe of
seizure onset, and another 25% lateralized correctly in an
experienced center (Thadani et al., 2004).
FDG-PET has the best sensitivity in mesial temporal
sclerosis (Knowlton, 2006). It is less helpful in neocortical
epilepsy, but can identify MRI-negative medial temporal
lobe epilepsy (Carne et al., 2004). Other PET ligands are
under investigation (Natsume et al., 2008). MEG registers
small magnetic fields as surrogate for electrical brain
activity. Coregistration with MRI improves sensitivity
and specificity (magnetic source imaging). Correct locali-
zation was achieved in 55% in one study (Knowlton et al.,
2008).
Node S3—concordant?
Different presurgical diagnostic techniques are avail-
able at different centers. If results of video-EEG, PET, ic-
tal SPECT, and MEG, or any combination thereof, are
concordant with the location of the lesion on MRI, an
intracranial EEG study is not necessary.
Node S4—eloquent?
If noninvasive presurgical studies are concordant and
do not localize to eloquent areas of the brain like the
primary motor areas or the language areas, surgical exci-
sion of the lesion is warranted (node S8). If noninvasive
Epilepsia, 50(Suppl. 8):51–56, 2009
doi: 10.1111/j.1528-1167.2009.02236.x
studies localize to eloquent areas, intracranial EEG is nec-
essary for functional mapping and exact localization of
the seizure-onset zone (node S6/7).
Node S5—Lateralization? Localization?
In nonlesional epilepsy noninvasive studies are aimed at
obtaining lateralizing and localizing information about the
seizure-onset zone. In the absence of an MRI lesion, an
intracranial EEG study is warranted even if noninvasive
studies are consistent. However, in some cases an intracra-
nial study represents too much of a ‘‘fishing expedition’’
and should not be performed (return to treatment algo-
rithm).
Node S6—Intracranial EEG: Clear localization?
The implantation strategy should be tailored to the indi-
vidual patient based on preoperative noninvasive studies.
Eighty percent of intracranial EEG studies are followed
by a resection (Yang et al., 2008). Fifty-three percent of
patients were seizure free following resection after an
intracranial EEG study. Only 15.2% were seizure free
with alternative treatment options such as VNS or callos-
otomy (Yang et al., 2008). If no clear seizure-onset zone
on intracranial EEG can be identified during the initial
invasive EEG study, reevaluation with a repeat intracra-
nial EEG can be successful (Siegel et al., 2000). A
well-defined focal seizure onset precedes clinical seizure
manifestations and involves only a few neighboring elec-
trodes. Regional seizure onsets with widespread initial
EEG findings and rapid seizure propagation are less likely
to result in a successful resection (Jung et al., 1999). If
localization is widespread or multifocal on intracranial
EEG, electrodes need to be removed without resection and
medical treatment or VNS are the best options (return to
treatment algorithm).
Node S7—functional mapping: Eloquent?
Functional mapping via intracranial electrodes deter-
mines whether the seizure-onset zone involves eloquent
cortex. Traditionally 2–5 s in duration, 50-Hz pulses with
currents between 1 and 15 mA are applied to electrode
pairs to assess motor or sensory phenomena, or to interrupt
a specific task such as naming or speaking.
Node S8—surgery
Neocortical epilepsy surgery is less successful than sur-
gery for temporal lobe epilepsy (Yang et al., 2008), but
nevertheless has a more than 50% chance of making the
patient seizure free. This is still better than most other
treatment modalities. If the patient is seizure free after sur-
gery, AEDs can be reduced after 2 years.
Node S9—MST, responsive stimulation
If intracranial EEG shows a well-localized seizure-
onset zone that is located in eloquent cortex, alternative

surgical options can be considered. Multiple subpial
transections (MSTs) disconnect the superficial and lateral
cortical neuronal connections without affecting columnar
cortical architecture, and deep white matter tracts, there-
fore, avoid significant postoperative deficits. Success is
variable (Spencer et al., 2002). Alternatively, responsive
brain stimulation is under investigation (Clinicaltrials.gov
number NCT00079781).
Note S10—surgical reevaluation
If initial surgery fails or seizure recur, repeat surgical
evaluation can render an additional 38% seizure free, and
up to 50% have a favorable outcome (Siegel et al., 2004).
Salanova reported a 57% seizure-free rate after reoperation
in temporal lobe epilepsy, only (Salanova et al., 2005). Re-
operation is less successful in mesial temporal sclerosis and
in patients with dysplasia (Gonzalez-Martinez et al., 2007).
Conclusion
Although different epilepsy centers utilize different
diagnostic tests and treatment strategies, algorithms can
be helpful to in decision making in difficult-to-treat
refractory partial epilepsy.
Acknowledgment
In memoriam of Dr. Peter Williamson, a pioneer and leader in the
treatment of epilepsy.
Disclosure: BCJ has received research funding from Neuropace Inc.
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