When drugs don't work - An algorithmic approach to medically intractable epilepsy

Nonpharmacologic options for the treatment of epilepsy include epilepsy sur gery, vagus nerve stimulation, and the ketogenic diet. The advantages and l imitations of these treatment modalities have been extensively reviewed, bu t there is no general consensus on when each option should be considered. T he authors propose an algorithm based on the type of epilepsy. Generally, n onpharmacologic options should be considered early-i.e., after the first fe w drug failures. Because of their good outcome with resective surgery, mesi al temporal and lesional neocortical epilepsies should be considered for re section. Conversely, nonlesional neocortical epilepsies are probably best a pproached with vagus nerve stimulation first. For symptomatic or cryptogeni c generalized epilepsies, which are commonly intractable, vagus nerve stimu lation and the ketogenic diet appear to be reasonable options to consider b efore palliative surgery such as corpus callosotomy. Idiopathic (i.e., gene tic) generalized epilepsies are only rarely refractory to medications and c an be outgrown. In rare cases, vagus nerve stimulation may occasionally pla y a role in their treatment.