Naturally people with epilepsy or the parents of children with epilepsy wish to know what the future holds. What are the chances of the fits abating? How long will it be necessary to take medication? There are a number of general points that should be made:
People with absences or grand mal seizures show the best response to anticonvulsant medication, while those with temporal lobe seizures do not respond as well.
Features associated with epilepsy which has a poorer outlook for ‘cure’ are:
the more difficult the seizures are to control in the first place;
the longer the person has seizures;
the presence of more than one seizure type;
the association with mental retardation, readily identifiable abnormalities of the nervous system and psychological problems.
As a general rule, the outlook for people with primary (idiopathic) epilepsy is better than that for secondary epilepsy.
How long does epilepsy need to be treated?
This obviously depends on the severity and type of the epilepsy. However, most physicians would feel that a patient should be seizure-free for two to four years before stopping treatment. Stopping treatment should be a gradual process over one to three months. Never stop medication suddenly as this can lead to withdrawal fits and status epilepticus. There is no single test which will guarantee that the fits will not return.
What are the chances of the seizures returning?
This is always difficult to predict for an individual. However, over the past ten years there have been a number of long-term follow-up studies of 15-20 years duration of people with epilepsy, which have provided some answers. A good example of these studies is that by Thurston in 1982. This study was of 148 epileptic children whose anticonvulsant treatment was stopped after they had been seizure-free for four years. The children were followed up for 18 years, during which time the overall relapse rate was 28 per cent. It was also noted that:
two-thirds of the relapses occurred in the first two years off treatment;
85% of the relapses occurred in the first five years off treatment;
the EEG was of little use in predicting those patients who would subsequently relapse;
certain factors were commonly associated with relapse:
focal fits
different seizure types in one patient
uncontrolled fits for six years or more
neurological abnormalities on physical examination, suggestive of brain damage (secondary epilepsy).
The results of this, and other studies, suggest that people with the problems listed in the last point above are less likely to come off treatment successfully than people without such problems.
The outlook for different types of epilepsies
Grand mal seizures. In general, grand mal epilepsy is the most likely to remit (go away) and the least likely to relapse. However, this does not apply if the attacks are due to some form of structural brain damage such as after a severe head injury, damage related to birth and so on.
Absences (petit mal). There is some disagreement about the course which absences may take. Some believe that it occurs in children, rarely in adolescence and never in adults. Others believe it does occur in adults. The reason for this difference of opinion probably revolves around the fact that the term ‘petit mal’ is used loosely to describe all absences, some of which are really of temporal lobe origin. It can be expected that 75% of children with absences (true petit mal) will remit completely. Children who develop absences before the age of five or after ten years of age more often have other associated seizure types (grand mal or temporal lobe) and do not respond as well to treatment.
Temporal lobe seizures. Temporal lobe epilepsy is frequently the most difficult type of epilepsy to treat and usually requires treatment for many years. The outlook for ‘cure’ is slight.
Infantile spasms. This is a rare condition and the outlook is not encouraging. In rough terms, it can be proposed that about one-third of children will recover fully and attend normal schools, one-third will be retarded and the remaining third may be severely retarded with abnormalities of the nervous system. A proportion of children in the last two groups will develop other seizure types.
Lennox-Gastaut Syndrome. This form of epilepsy begins in the preschool years with several seizure types. These may include absences, drop attacks, head nodding, tonic seizures and grand mal fits. The majority of children with this syndrome are mentally retarded. Control of seizures is often very difficult and the overall outlook is not encouraging.
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Epilepsy
