Treatment of epilepsy following rejection of epilepsy surgery

Important progress has been made with the development of both surgical and medicinal treatment of epilepsy but these two developments are rarely seen in a common perspective. Today epilepsy surgery should be discussed with the patient when a reasonable degree of pharmacoresistance has been established, and the chances of an operation clearly outweigh its risks. At that time, there will still be a number of pharmacological options. A study of 15 patients who were evaluated for at least four years after surgery had been considered but rejected after intensive monitoring, pharmacological pursuit was successful in eight, and failed in seven. The successfully treated patients comprise three who became seizure free, and one with isolated auras as the only persisting seizure type. The successful regimens were highly individual, stretching from monotherapies to one four-drug combination. The idea of presenting this small series is not to promote or establish any therapeutic strategies and guidelines but, rather, to draw attention to a neglected interface between surgical and medicinal procedures, and to increase awareness that epilepsy therapy will still be most successful when it is seen as a whole, and must not be split up into competing ideologies. Concerns are not well founded that epilepsy surgery may be seen as the last hope for pharmacoresistant patients, and that, if surgery is declined, a loss of this hope may be intolerable to the patient.