What Is Refractory Epilepsy: Symptoms, Causes And Treatment

Regarding the classification of the typology, we find the following types of epilepsy:

• Idiopathic epilepsies: This type of epilepsy is characterized by the absence of any other disease apart from epilepsy and by the lack of knowledge of its cause. However, there is the possibility of the involvement of genetic factors.
• Symptomatic epilepsies: Symptomatic epilepsy is characterized by the knowledge of a clear and determined cause. Furthermore, in this type of epilepsy there is a disorder of the central nervous system that is not epilepsy itself and that increases the risk and chances of suffering from it. For example, it could be craniocerebral trauma, meningitis, etc., which by the simple fact of suffering from it increases the chances of developing epilepsy.
• Cryptogenetic epilepsies: This type of epilepsy is closely related to symptomatic epilepsy, since cryptogenetic epilepsy occurs when there is a suspicion that the patient suffers from a disorder of the central nervous system or other symptomatic causes that cannot be determined with existing resources. but it could possibly explain the cause of epilepsy.

Epilepsy is a disease characterized by epileptic seizures, which are episodes of abnormal brain function. What is refractory epilepsy? When we talk about refractory epilepsy we are referring to that epilepsy that resists pharmacological treatment and, therefore, the crises are uncontrollable and their side effects limit the patient’s normative development. In this sense, epilepsy becomes refractory when epileptic seizures are so frequent that limit the patient’s daily life as well as his abilities to live according to his desires and his physical and mental capacity.

Types of refractory epilepsy

So, there are three types of refractory epilepsy or refractoriness:

• Biological refractory epilepsy: Biological refractoriness is characterized by having a poor prognosis in relation to seizure control, cognitive development and social skills. In this case, the factors that can facilitate the prediction of this biological refractoriness are the early age of onset (before two years), the presence of a symptomatic cause, suffering various types of epileptic seizures, having an abnormal electroencephalogram, the association from epilepsy to mental retardation, among others.
• Pharmacological refractory epilepsy: In this type of refractoriness, poorly treated epilepsy must be differentiated from epilepsy that resists any type of pharmacological treatment. Before being able to ensure that it is a pharmacological refractoriness, the drugs are usually used prudently and with controls that allow us to determine whether or not it is an appropriate combination of drugs that allows us to determine the effect of the treatment. . However, there are scales or approximation guides that allow evaluating the indicated treatment, giving intractability indices.
• Psychological and social refractory epilepsy: This type of refractoriness demonstrates the interference of epilepsy and its seizures in the daily lives of people who suffer from it, both in the social and psychological spheres. In this sense, the persistence of epileptic seizures, the severity and specific type of these seizures, and the side effects of the drugs explain the magnitude of interference of this disease in the daily lives of people with epilepsy. Furthermore, it should be noted that the side effects of drugs can significantly interfere with people’s cognition and emotion.

Referring to the epilepsy in general and not refractory epilepsy, we find a series of symptoms related to the sensations that the patient experiences at the moment when the groups of neurons that are responsible for epileptic seizures are activated:

• Fear.
• Nausea.
• Déjà-vu: feeling of having previously experienced that situation.
• Sensation of tingle: anywhere on the body.
• Another symptom of epilepsy is seeing lights, figures or colors.
• Alteration in level of consciousness: loss of consciousness absent state, without responding to questions or stimuli, there is a lack of awareness of oneself and one’s surroundings.
• They detach smells abnormal and unpleasant.
• They perform noises abnormal and with sound distortions.
• Another symptom refers to the automations, that is, repetitive movements with the mouth or hands. Furthermore, it is likely that after some time the patient will be unable to remember these movements, although it may occur in moments of altered consciousness or not.
• Patients usually appear rigid: it may be a rigidity on the extremities, on the face or throughout the body.
• The muscle twitches They are another of the symptoms of epilepsy: in this case, it may be jerks that affect the extremities, the face or the entire body.
• Presence of seizures: Seizures usually last approximately two to three minutes and, in addition, both rigidity and muscle jerks (shaking especially in the arms and legs) are usually witnessed. Additionally, on some occasions, seizures may be accompanied by incontinence urinary (inability to control urine) and tongue biting.
• People with epilepsy also often have confusion as a symptom of this disease: normally the feeling of confusion is usually experienced after an epileptic seizure in which there is an alteration in the level of consciousness.
• Trouble speaking: These problems are typical of crises in which the patient has difficulty finding words even though he makes an effort to try and is aware of it (these could be crises in which aphasia and anomia predominate). Speech problems can occur during the epileptic seizure or once it has occurred.

However, focusing on the refractory epilepsy, we must consider that these are people who present a series of symptoms, related to difficulties derived from resistance to treatment. For example, these are patients with difficulties in adhering to treatment, difficulties in achieving a state free of epileptic seizures, difficulties in controlling epileptic seizures, among others.

The causes of refractory epilepsy are divided into two distinct sections:

Intrinsic factors to epilepsy

On the one hand, we find the causes related to intrinsic factors Due to the large number of studies and research, we can conclude that the intrinsic factors of the epileptic disease itself are numerous and different. Among these factors we find the following:

• Intrinsic factors related to epileptic seizures: refer to those seizures that predispose the patient to suffer refractory epilepsy with an adverse prognosis due to its early onset (before the age of 2), its high initial frequency, the complexity of the seizures, the presence of various types of crises in the same person, family history, among others.
• Intrinsic factors related to epilepsy syndrome and its etiology: these factors are closely related to suffering from any of the following aspects: symptomatic and/or cryptogenetic etiology, certain epileptic syndromes (such as West syndrome), structural lesions, certain brain anomalies (such as brain tumors) , abnormal neurological examination, mental retardation, among others.
• Intrinsic factors related to abnormalities in the electroencephalogram: These are predictive factors for refractory epilepsy related to certain electroencephalogram patterns that explain the multiple origins of the discharges or the underlying brain damage.
• Intrinsic factors related to treatment: In this case, the cause of refractory epilepsy depends solely on the failure of pharmacological treatment. Premature resistance to treatment may be an indicator of a predisposition to suffer from refractory epilepsy. In addition, other aspects that may influence treatment failure must also be taken into account, such as a large number of epileptic seizures before starting treatment, a prolonged duration of active epilepsy, the number of drugs taken in previous treatments without any success, among others.

Extrinsic factors to epilepsy

On the other hand, we find the causes related to extrinsic factors These factors are those derived from errors in the diagnosis of refractory epilepsy, in the treatment or derived from non-compliance, on the part of the patient, with the treatment and therapeutic recommendations. Among these factors we find the most common errors that lead us to mistakenly think that the patient suffers from refractory epilepsy:

• The patient does not suffer from epilepsy On some occasions, an erroneous diagnosis may be given due to the confusion of epileptic seizures with other diseases, such as vasovagal syncope. Diagnosing a patient with epilepsy when they really suffer from another disease causes them to not respond adequately to treatment, since the patient is exposed to a treatment designed in relation to epilepsy when they do not really suffer from said disease. Therefore, we can conclude that by resisting treatment it may be refractory epilepsy.
• Not recognized type or all types of epileptic seizures: health professionals usually do not witness the majority of their patients’ seizure episodes, so patients must explain and describe their episodes, a fact that can lead to confusing the description of the patients with the typology of epileptic seizures or omit some typology. Therefore, as in the previous aspect, this can lead to treatment rejection due to the failure to adapt the treatment to the real typology of crisis suffered by the patient.
• Epileptic syndrome has been misidentified or the possible etiology of the epilepsy: in this case, the patient may be reluctant to treatment due to a mistaken identification of the epileptic syndrome and/or etiology of the epilepsy (idiopathic, symptomatic, cryptogenetic). As in the previous aspects, this fact means that the treatment is not adapted to the correct characteristics of the epilepsy suffered by the patient, a fact that leads us to think, erroneously, that the patient is reluctant to treatment due to refractoriness.
• Possible triggering factors have not been taken into account and specific precipitants: this aspect refers to the fact of not taking into account factors such as the ingestion of alcohol, drugs, sleep deprivation, and other factors that can cause the appearance of epileptic seizures, when preparing a treatment for the patient.
• When the drug chosen for treatment is not appropriate for the type of epileptic seizures or epileptic syndrome that the patient suffers: in this case we are referring to the poor choice of drug based on the characteristics of the person’s disease. Furthermore, it should be noted that some drugs can increase the intensity and frequency of seizures, when the drug is chosen inappropriately according to the characteristics of the disease.
• The correct doses are not applied: When the patient does not take the appropriate dose of the drug, it seems that he or she does not obtain a response to the treatment. Therefore, if the dose is not tried to be modified, we can think that we are facing refractoriness since it seems that the patient does not respond to his treatment.
• Withdraw the drug early: to demonstrate that the use of a drug is not effective in a patient, it is necessary to reach the maximum dose and maintain it for a period of time. For this reason, if the drug is withdrawn prematurely, it is likely that the patient will not give an adequate response to the treatment and this will lead to a misdiagnosis of refractory epilepsy.
• When drugs are not appropriate or have interactions: in patients on treatment with two or more drugs, their side effects must be taken into account in order to make an appropriate selection of drugs. It is important to study the combination of drugs, in order to create an interaction that allows the optimal effect for the treatment of the person.
• The coexistence of other diseases or medications that hinder the therapeutic action of drugs: certain diseases (such as epilepsy) and their treatments can reduce the effect of antiepileptic drugs, and can even induce epileptic seizures.
• Patient non-compliance with the treatment regimen advised: poor patient compliance with medical recommendations is one of the most common causes of misdiagnosis of refractory epilepsy.

As we have said before, sometimes an incorrect diagnosis of refractory epilepsy is made. Therefore, before deciding which is the most appropriate treatment for each patient, it is necessary to carry out a proper evaluation that allows a good diagnosis to be made and to propose one type of treatment or another, always taking into account whether it is a refractory epilepsy or not.

Refractory epilepsy surgery

Thus, if after making a correct diagnosis we find ourselves faced with refractory epilepsy, as it is an epilepsy that proves to be resistant to pharmacological treatment, it is common that in many cases these patients may possibly be proposed as ideal candidates for surgical procedures Well, the most common treatment for refractory epilepsy is surgery. Even so, it is essential to turn to health professionals so that they can carry out a correct neuropsychological evaluation that allows them to decide whether or not the patient should undergo surgery. Refractory epilepsy surgery is used when other treatments have not worked and consists of remove or modify part of the brain in which seizures begin.

Ketogenic diet for refractory epilepsy

On the other hand, it is being investigated whether a type of diet could reduce epileptic seizures. since it seems to have worked in some cases. The ketogenic diet for refractory epilepsy consists of consuming a large amount of fat and a low amount of carbohydrates.

This article is merely informative, at PsychologyFor we do not have the power to make a diagnosis or recommend a treatment. We invite you to go to a psychologist to treat your particular case.

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