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Abstract
The current paradigm for treatment of epilepsy begins with trials of antiepileptic drugs, followed by evaluation for resective brain surgery in drug-resistant patients. If surgery is not possible or fails to control seizures, some patients benefit from implanted neurostimulation devices. In addition to their therapeutic benefit, some of these devices have diagnostic capability enabling recordings of brain activity with unprecedented chronicity. Two recent studies using different devices for chronic EEG (i.e., over months to years) yielded convergent findings of daily and multiday cycles of brain activity that help explain seizure timing. Knowledge of these patient-specific cycles can be leveraged to gauge and forecast seizure risk, empowering patients to adopt risk-stratified treatment strategies and behavioral modifications. We review evidence that epilepsy is a cyclical disorder, and we argue that implanted monitoring devices should be offered earlier in the treatment paradigm. Chronic EEG would allow pharmacologic treatments tailored to days of high seizure risk—here termed chronotherapy—and would help characterize long timescale seizure dynamics to improve subsequent surgical planning. Coupled with neuromodulation, the proposed approach could improve quality of life for patients and decrease the number ultimately requiring resective surgery. We outline challenges for chronic monitoring and seizure forecasting that demand close collaboration among engineers, neurosurgeons, and neurologists.
Glossary
- AED=
- antiepileptic drug;
- cEEG=
- chronic EEG;
- IEA=
- interictal epileptiform activity;
- RNS=
- Responsive Neurostimulation System;
- SUDEP=
- sudden unexpected death in epilepsy
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received February 24, 2018.
- Accepted in final form July 11, 2018.
- © 2018 American Academy of Neurology
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