Identifying factors involved in the development of drug resistant epilepsy (DRE) remains a challenge. Candidate gene studies have shown modulation of resistance to drugs by various multidrug resistance proteins in DRE. However the resistance to drugs in DRE could be more complex and multifactorial involving molecules in different pharmacokinetic processes.
A study for the first time analyzed the relative expression of four molecules with different drug resistance mechanisms in two most common DRE pathologies, mesial temporal lobe epilepsy (MTLE) and focal cortical dysplasia (FCD) with respect to each other and also with different non-epileptic controls.
Upregulation of breast cancer resistance protein (BCRP) and major vault protein (MVP) is associated with MTLE and FCD and these molecules not only may have the potential to predict pathology specific phenotypes but may also have therapeutic potential as adjunct treatment in these pathologies. 1).
Up to one third of epilepsy patients develop pharmacoresistant seizures and many benefit from resective surgery. However, patients with non-lesional focal epilepsy often require intracranial monitoring to localize the seizure focus. Intracranial monitoring carries operative morbidity risk and does not always succeed in localizing the seizures, making the benefit of this approach less certain.
Intracranial monitoring is favored over VNS and medical management in young and elderly patients over a wide, clinically-relevant range of pertinent model variables such as the chance of localizing the seizure focus and the surgical morbidity rate 2).
see epilepsy surgery
The current practice under which patients with refractory epilepsy are surgically treated is based mainly on the identification of specific cortical areas, mainly the epileptogenic zone, which is believed to be responsible for generation of seizures. A better understanding of the whole epileptic network and its components and properties is required before more effective and less invasive therapies can be developed.
Despite significant underutilization of surgical treatment for drug-resistant epilepsy, no studies have quantified patient desire for surgery within a representative population.
An online survey was administered to all clients connected with a core epilepsy community access center. It obtained information about demographics, clinical characteristics, knowledge of epilepsy surgery, and interest in receiving surgery before and after receiving risk/benefit information about it.
Of 118 potential respondents, 48 (41%) completed the questionnaire, of which 67% had failed more than two AEDs and 78% experienced seizures in the past year. Eleven ( 26%) were uninterested in receiving surgery at baseline, and this decreased significantly to 7 (16%) following knowledge translation regarding the benefits (p = 0.001). Significance was lost with subsequent complication rate information despite fewer respondents still being uninterested compared to baseline (20% vs. 26%). Having experienced seizures within the past month was correlated with being interested in or undecided regarding surgery at baseline and following all steps of knowledge translation. Subjects had conservative views regarding the benefits of surgery and largely overestimated the risks.
A significant portion of those with active epilepsy in the community do not desire surgical treatment. Passive knowledge translation regarding the risks and benefits enhanced optimistic attitudes and mobilized interest within a subset of participants. Preexisting views regarding the risks of surgery were exaggerated, and analysis suggests that these views can be modified with information about the benefits of surgery. However, exaggerated risk perceptions return following crude descriptions of the risks, underlying the importance of sensitive counseling from primary care physicians 3).