Evaluation and management of intractable epilepsy.

Seizures remain uncontrolled in 15-20% of all childhood epilepsies despite conventional therapy. This review will focus on the etiologies, effects and treatment strategies in this group of patients. Risk factors for intractable seizures include early age of onset, remote symptomatic seizures, certain seizure types and epileptic syndromes. Adverse effects of chronic epilepsy on academic performance and future employment have been documented. The mechanisms underlying cognitive and behaviour decline are outlined. Errors in diagnosis and therapy often result in pseudo-intractability. Common errors are emphasised. Medical treatment strategies should be based on a complete etiological, syndromic and seizure--type diagnosis sometimes with the help of simultaneous video-EEG and MRI. A detailed past drug use review helps in planning future therapy. New antiepileptic drugs introduced in the last two decades include clobazam, vigabatrin, lamotrigine, gabapentin and topiramate. Strategies of when and how to use these are highlighted. The ketogenic diet has been rejuvenated in severe epilepsy especially in younger, more handicapped patients. Surgical treatment for epilepsy has emerged as a powerful treatment option in selected patients. The patient selection process, types of surgeries and the long-term results are highlighted. Many of these new therapies are now available in India and may offer relief to many of these unfortunate patients.