Road to refractory epilepsy: the Glasgow story

This short article reviews 30 years of prospective observations on outcomes relevant to an expanding cohort of adolescent and adult patients with newly diagnosed epilepsy, who received their first antiepileptic drug (AED) and subsequent long-term follow-up at the Epilepsy Unit at the Western Infirmary in Glasgow, United Kingdom. Despite the fact that the overall prognosis has slowly improved over this time, >30% of the patients remain uncontrolled despite the introduction of a range of new AEDs, some with unique mechanisms of action, over the last 20 years. Most patients followed a constant course (59% controlled, 25% refractory), which could usually be predicted early. The remaining 16% fluctuated between periods of remission and relapse. The likelihood of seizure freedom declined with successive drug regimens, most markedly from the first to the third. A number of factors predicting poorer outcomes have been identified, particularly high pretreatment seizure density and concomitant psychiatric comorbidities. Novel approaches to identifying and treating the processes underpinning the generation and propagation of seizures are required if the current rather disappointing scenario is to be substantially improved.