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Nonpharmacologic options for the treatment of epilepsy include epilepsy surgery, vagus nerve stimulation, and the ketogenic diet. The advantages and limitations of these treatment modalities have been extensively reviewed, but there is no g eneral consensus on when each option should be considered. The authors propose an algorithm based on the type of epilepsy. Generally, nonpharmacologic options should be considered early-i.e., after the first few drug failures. Because of their good out come with resective surgery, mesial temporal and lesional neocortical epilepsies should be considered for resection. Conversely, nonlesional neocortical epilepsies are probably best approached with vagus nerve stimulation first. For symptomatic or crypt ogenic generalized epilepsies, which are commonly intractable, vagus nerve stimulation and the ketogenic diet appear to be reasonable options to consider before palliative surgery such as corpus callosotomy. Idiopathic (i.e., genetic) generalized epileps ies are only rarely refractory to medications and can be outgrown. In rare, cases, vagus nerve stimulation may occasionally play a role in their treatment. |
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