ADVANCES IN THE ASSESSMENT OF REFRACTORY EPILEPSY

The assessment of patients with refractory epilepsy presents both a ch allenge and an opportunity. The use of appropriate instruments to care fully and consistently measure a patient's seizure type and frequency, hormonal function, and medication side effects and the impact of thos e variables on quality of life ensures consistent, standardized assess ment. A patient's epilepsy then can be classified as refractory based on any combination of factors that preclude a reasonably normal life-s tyle by current practice standards, given the person's capabilities. D iagnostic studies and treatment strategies should address all signific ant adverse findings resulting from the assessment process. Accurate d iagnosis of seizure type usually requires electroencephalographic (EEG ) monitoring. Postictal hormonal assays and periodic measurements of e strogen and progesterone may be useful diagnostically in a selected gr oup of patients. Awareness of a patient's compliance history, environm ental stressors, and seizure triggers may reduce seizure frequency wit hout a change in medication. For patients with medication intolerance, the usual strategy is to modify the medication regimen or treatment s chedule to minimize side effects while maximizing seizure control and compliance. For most patients, monotherapy provides a greater therapeu tic window than combination therapy. Devising an effective and safe th erapeutic regimen is an ongoing process and can be lengthy depending o n seizure type(s), frequency, and temporal pattern; anticonvulsant pha rmacokinetics; drug interactions and side effects; patient's life-styl e; and other factors. Serial measurements of quality-of-life variables may assist in the process. Rapid strides have been recently made, and as the pace of new antiepileptic drug development quickens and surgic al centers become more widely available, clinicians will need to redef ine refractoriness as the expectations improve for patients with epile psy.