From the Guidelines
The current management for focal cortical dysplasia (FCD) primarily involves surgical resection of the dysplastic tissue when possible, as this offers the best chance for seizure freedom, with approximately 65% of patients becoming seizure-free after surgery 1.
Overview of FCD Management
The management of FCD involves a comprehensive approach, including:
- Antiseizure medications such as levetiracetam, carbamazepine, lamotrigine, or valproate, though these drugs rarely achieve complete seizure control in FCD cases
- Comprehensive pre-surgical evaluation, including high-resolution MRI with specific epilepsy protocols, video-EEG monitoring, neuropsychological testing, and sometimes functional imaging like PET or SPECT to precisely localize the dysplastic region
- Early surgical referral for patients with drug-resistant epilepsy, defined as failure of two or more appropriate antiseizure medications
Role of Imaging in FCD Management
Imaging plays a crucial role in the management of FCD, with:
- High-resolution MRI being the first imaging investigation to identify structural aetiology for the patient’s epilepsy
- Functional imaging like PET or SPECT being useful in localizing the seizure onset for a tailored resection, especially in cases with normal or nonspecific MRI findings
- [18F]FDG PET being a valuable tool in the pre-surgical evaluation and postsurgical outcome estimation, with a sensitivity of 63% to 67% and specificity of 94% in localization-related epilepsy with nonlesional MRI 1
Alternative Approaches
When complete resection of the dysplastic tissue is not possible due to the location in eloquent cortex, alternative approaches include:
- Laser interstitial thermal therapy
- Responsive neurostimulation
- Vagus nerve stimulation
- Dietary therapies like the ketogenic diet
Post-Surgical Management
Post-surgical management includes:
- Continued antiseizure medication for at least 1-2 years, with potential tapering if the patient remains seizure-free
- Monitoring for potential complications and adjusting treatment as needed The effectiveness of surgery relates to the pathophysiology of FCD, where abnormal neuronal organization and function create hyperexcitable cortical networks that generate seizures 1.
From the Research
Current Management for Focal Cortical Dysplasia (FCD)
The current management for FCD includes:
- Surgical management: Surgical resection is an important alternative treatment for patients with intractable epilepsy related to FCD 2, 3, 4, 5
- Non-invasive treatments: Non-invasive management strategies such as mammalian target of rapamycin (mTOR) inhibitors, ketogenic diet (KD), and vagus nerve stimulation (VNS) have been identified 6
- Antiepileptic drugs (AEDs): AEDs have been widely used in the treatment of FCD, however, evidence to suggest their specific effect on the treatment of FCD remains to be established 6
Surgical Management
Surgical management is considered an effective treatment option for FCD, with:
- Complete resection of the assumed epileptogenic area being a positive prognostic indicator of long-term seizure freedom 5
- Lower age at surgery and unilobar localization being positive prognostic indicators of long-term seizure freedom 5
- Incomplete resection of FCD being a poor prognostic factor 2
Non-Invasive Treatments
Non-invasive treatments such as:
- mTOR inhibitors: Experiments conducted with mammals detailing rapamycin gene mutations in FCD have produced vital information for exploring treatment options using mTOR inhibitors 6
- Ketogenic diet (KD): KD has been shown to modify disease progression by attenuating chromatin modification, a master regulator for gene expression and functional adaptation of the cell 6
- Vagus nerve stimulation (VNS): VNS has been shown to produce responder rates of >50% for widespread dysplasias 6