Intensive treatment course to identify pseudoresistant epilepsy and expedite surgery referrals - A prospective intervention study.

Introduction: A significant proportion of patients do not achieve seizure freedom despite treatment attempts with two different anti-seizure medications (ASMs). A subset may not truly have drug-resistant epilepsy ("pseudoresistant"), while rapid referral of patients with genuine drug-resistant epilepsy to surgery is mandated. This study was designed to evaluate a structured and intensive treatment course with the objective of promptly identifying cases of pseudoresistance and accelerating the time to referral to epilepsy surgery.

Methods: From May 2017 to February 2021, this prospective interventional study recruited consecutive adult patients with epilepsy treated at Odense University Hospital, Denmark, who had at least one seizure per month despite attempts with two or more ASMs. The predefined endpoint was improvement in seizure activity. Secondary endpoints were referral to epilepsy surgery, patients with pseudoresistance, and achievement of seizure freedom.

Results: Of the 41 patients enrolled, 39 completed the study. The intervention comprised a initial seizure documentation, specialist evaluation, EEG monitoring as required, and an individualized plan for intensive treatment. The plans included e.g., optimization of medical treatment, seizure classification, and improvement of medication adherence. The subsequent intensive treatment (1-4 contacts/month; 1-13 contacts in total) was led by epilepsy nurses that executed the treatment plan. The intervention significantly improved seizure control, with 41.1 % of patients achieving seizure freedom and an additional 17.8 % of patients experiencing reduced seizure frequency. One-third of the patients turned out to be "pseudoresistant" due to various reasons, including wrong classification of seizures and inadequate adherence to ASMs. Ten patients were offered a referral for epilepsy surgery at the end of the study after an average of 34.8 weeks.

Conclusion: This study demonstrates the efficacy of a standardized, intensive treatment course involving epilepsy nurses in identifying and managing patients with persisting seizures despite treatment attempts with two ASMs. This approach led to favourable seizure outcomes and facilitated expedited referrals for epilepsy surgery where appropriate.