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Despite the development of new epilepsy medications, approximately one-third of pediatric patients with epilepsy remain medically refractory. While anti-seizure drugs remain the mainstay of treatment, efforts are underway to expand nonpharmaceutical options to decrease seizure frequency and improve quality of life.

The following is an overview of some of these advances — from new surgical approaches and devices to websites and apps.

Neuromodulatory/neurostimulatory devices

New types of neuromodulatory devices have been approved to treat epilepsy (as well as other neurologic disorders). These treatments offer an alternative for medically resistant patients who often struggle with complex polypharmacy or live with unacceptable side effects. While these devices may require surgery, intracranial procedures may not be necessary. Trials also are underway for noninvasive neuromodulatory devices.

Vagus nerve stimulator (VNS) therapy has been available for decades and has been approved by the Food and Drug Administration (FDA) for patients as young as 4 years of age with refractory partial-onset epilepsy. VNS therapy has new technology allowing for a closed-loop system that can detect and respond to increased heart rate (as a presumed sign of seizure). Pre-planned changes in VNS settings also can be programmed into the device, thus reducing the need for office visits. Other newer software can monitor convulsive seizures by correlation with rapid and repetitive changes in body position.

On the horizon for pediatric patients is responsive neurostimulation therapy, which has been approved by the FDA for adults with refractory, focal-onset seizures with one or two epileptogenic foci.

This closed-loop, brain-responsive neurostimulation system is designed to prevent seizures at the source. Electrodes are inserted in the presumed seizure-onset zone and are attached to a neurostimulator implanted in the patient’s skull, which is stimulated by ictal activity. The device is programmed using wireless technology, and information can be uploaded from home. This allows physicians to view patients’ electrographic data remotely on a secure website and program device settings in person as necessary.

Even more cutting edge is deep brain stimulation therapy, which recently was approved for adults with refractory epilepsy. It involves placing electrodes in various locations within the thalamus and other brain structures. This technology has been adapted from experience with other movement and psychiatric disorders in adults. Initial experience has demonstrated effectiveness in refractory epilepsy cases that are not amenable to surgical resection, even those with multifocal epilepsy or without a clear seizure onset.

Durability and cosmetic impact of these devices keeps improving. Battery life is extended, memory capacity is improved and the size is decreased with each new generation.

Wearable devices

Another novel device for epilepsy approved for patients ages 6 and older with generalized tonic-clonic seizures is a wearable seizure detector. This not only detects generalized tonic-clonic seizures, but it can be programmed to alert a caregiver that a seizure has occurred. There are other wearable devices, such as smartwatches with seizure detector apps, but they have not yet been approved by the FDA.

Apps and websites

Medical smartphone apps and secure websites related to epilepsy are multiplying, whether the goal is to monitor seizure frequency, send reminders to maintain medication compliance, provide education, improve patient safety or create an online community for emotional support. Many of these apps are free.

Electronic seizure diaries can track seizures and side effects. They also can correlate seizures with menstrual cycles, diet, sleep schedule, etc. Some apps send reminders to take medications, renew prescriptions or attend appointments, all of which may be important for the treatment of epilepsy.

Increasingly, these apps can generate reports or can be uploaded to health care providers or researchers. Some are even able to be integrated into the patient’s electronic health record.

Additionally, patient safety can be advanced by apps that put medical information on a phone’s lock screen, allow for daily check-ins for those living alone, send emergency notifications to designated recipients should the patient feel an aura or seizure, or offer an outline of standard seizure first aid if a bystander encounters someone having a seizure.

These devices and applications are just a small sample of the many novel ways that health care can be improved for those with epilepsy; new advances continue to occur almost daily.

Source: By Lawrence W. Brown, M.D., FAAP and Marissa DiGiovine, M.D., FAAP. Drs. Brown and DiGiovine are members of the AAP Section on Neurology.Copyright © 2019 American Academy of Pediatrics

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