Transcranial magnetic stimulation for treatment of epilepsy | Figure 1
%27%3e%3cg%20id=%27Group-14%27%20transform=%27translate(13.000000,%20103.176124)%27%3e%3cg%20id=%27Group-Copy-5%27%20transform=%27translate(0.000000,%20182.676124)%27%3e%3crect%20id=%27Rectangle-8%27%20fill=%27%23E2E0DE%27%20x=%270%27%20y=%270%27%20width=%2736%27%20height=%2736%27%20rx=%2718%27%3e%3c/rect%3e%3cpath%20d=%27M28,27.6503435%20C28,22.127496%2023.5228474,17.6503435%2018,17.6503435%20C12.4771525,17.6503435%208,22.127496%208,27.6503435%20M18,16.3472505%20C20.8165136,16.3472505%2023.099749,14.0640151%2023.099749,11.2475015%20C23.099749,8.43098783%2020.8165136,6.1477524%2018,6.1477524%20C15.1834863,6.1477524%2012.9002509,8.43098783%2012.9002509,11.2475015%20C12.9002509,14.0640151%2015.1834863,16.3472505%2018,16.3472505%20Z%27%20id=%27Combined-Shape%27%20fill=%27%23FFFFFF%27%20fill-rule=%27nonzero%27%3e%3c/path%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/svg%3e)
Deleted account
Some actions are only available when you log in.
Report case
Report this to our moderators
Transcranial magnetic stimulation for treatment of epilepsy
You can view up to 4 cases without signing up Sign up for unlimited access
Background
Epilepsy is a common neurological disorder that appears in various forms. Many individuals with epilepsy have satisfactory seizure control with the use of antiepileptic medications. Yet, nearly a third of people with epilepsy suffer from frequent and uncontrolled seizures despite the use of medication, or are unable to tolerate the side effects of those medications. Surgery is an option for some people with uncontrolled seizures, but it is invasive and not suitable for all individuals. As a result, there remains a substantial unmet need for safe, effective therapies for these harder‐to‐treat epilepsies.
Transcranial magnetic stimulation (TMS) is one of several newer treatments that can potentially offer people with epilepsy a safe and non‐invasive alternative to surgery. Long used as a research tool to study brain function, TMS has also been studied as a possible treatment for a number of nervous system conditions, including epilepsy. This non‐surgical and painless treatment uses induced magnetic currents to regulate brain function in order to reduce the tendency to have seizures.
Objective
We aimed in this review to evaluate the evidence for the use of repetitive transcranial magnetic stimulation (rTMS) in individuals with epilepsy compared with other available treatments in reducing seizure frequency, improving quality of life, reducing epileptiform discharges (abnormalities on brain electrographic testing that suggest underlying brain disturbance or seizure tendency), antiepileptic medication use, and side effects.
Methods
The latest search for trials was 2 June 2020. We assessed the evidence from eight randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) involving a total of 241 participants comparing rTMS to control treatments (sham treatment, antiepileptic medication, or low‐frequency rTMS).
Results
Some of the included trials showed that rTMS reduces the number of seizures individuals had compared to before the therapy, but other trials did not show any significant differences in seizure frequency. Four trials showed a reduction in epileptiform discharges following rTMS treatment. One study measured changes in quality of life in seven participants; although not statistically analysed they found that a greater proportion of study participants reported increased quality of life scores with active treatments compared to the sham treatment. One trial reported an increase in antiepileptic medication in a single individual but they had received the control treatment. Side effects were uncommon; the most frequently reported side effect was headache (and the majority of individuals completed the treatment with rTMS). However, one study showed an increase in seizure frequency in two individuals: one during the rTMS treatment (who discontinued the treatment early), and one weeks after the treatment.
Certainty of the evidence
Overall, we judged the certainty of the evidence for the main outcome of reduction in seizure frequency to be low due to unclear information in the published papers about study design and the unclear presentation of results. One included study commented on quality of life, but involved only seven participants.
The evidence is current to June 2020.
Why you should join Figure 1
Share your knowledge with our global community of healthcare professionals
Get help from experts in your field
Learn from our library of real-world cases and quizzes
Similar cases
\ \ Background\ Epilepsy is a disorder in which unexpected electrical discharges from the brain cause seizures. Approximately one‐third of patients with epilepsy continue to have seizures, despite treatment with presently used (older) antiepileptic drugs (AEDs). In addition, the older AEDs have a lot of adverse effects. Therefore, the development of effective new therapies for the treatment of drug‐resistant seizures is of considerable importance. As a result, a range of new AEDs has been developed as 'add‐on' treatments. Lamotrigine is one of these drugs.\ Aims of the review\ This review aimed to determine the effects of lamotrigine on seizures, adverse effects, cognition (ability to learn and understand) and quality of life compared to placebo controls, when used as an add‐on treatment for people with focal epilepsy that would not respond to existing AEDs. For this update, we did not identify any new studies to add, and thus, the conclusions remain unchanged. The review included 14 randomised controlled trials with a total number of 1806 participants.\ Results\ Lamotrigine, used in combination with other AEDs in patients who have drug‐resistant focal epilepsy can decrease the frequency of seizures further. However, adding lamotrigine to the usual treatment is more often associated with an increase in adverse effects such as unsteadiness (ataxia), dizziness, double vision (diplopia), and nausea.\ Certainty of the evidence\ We assessed the trials with regards to risk of bias and overall we judged them as low to unclear. We rated the certainty of the evidence as high to moderate.\ Conclusions\ Further high‐quality research is needed to fully evaluate the efficacy and tolerability of lamotrigine and compare it with other newer AEDs.\ The evidence is current to 9 March 2020.](https://app.figure1.com/case-detail/203e88c5-85c4-46a4-a33a-83e0f2a8787f)
\ \ Vagus nerve stimulation for focal seizures\ The aim of this review was to find the current evidence on how effective vagus nerve stimulation is in reducing the frequency of epileptic seizures, and any side effects associated with the treatment.\ We included five multicentre, randomised controlled trials (RCTs) which recruited a total of 439 participants, and compared different types of VNS therapy. Three compared high‐level stimulation to low‐level stimulation in participants from 12 to 60 years old. One trial examined high frequency stimulation versus low frequency stimulation in children. One trial examined three different stimulation frequencies.\ What did we find?\ VNS seems to be an effective treatment for people with intractable focal epilepsy. High‐level stimulation seems to reduce the number of seizures people had compared to low‐level stimulation.\ Common side effects were voice alteration and hoarseness, pain, shortness of breath, cough, feeling sickly, tingling sensation, headache, or infection at the site of the operation. Shortness of breath, voice alteration and hoarseness were more common in people receiving high‐level stimulation compared to people receiving low‐level stimulation.\ What are the limitations of the evidence?\ The evidence for the effectiveness and side effects of VNS therapy was limited and imprecise. There were a small number of studies and participants included in the review, and details about the design and conduct of the trials was sometimes lacking. We rated the evidence as moderate or low certainty. This means that further research is likely, or very likely, to have an important impact on our confidence in the estimate of the effect, and may change the estimate.](https://app.figure1.com/case-detail/454f37f1-ec86-4db1-babc-4fb35190f3a4)
\ \ Background\ Epilepsy is a neurological disorder which causes people to have seizures. Most people can control their epilepsy with a single antiepileptic drug. Some people, however, require multiple antiepileptic drugs to control their epilepsy, and are said to have drug‐resistant epilepsy. Oxcarbazepine is an antiepileptic drug and is similar to an older antiepileptic drug, carbamazepine. Oxcarbazepine can be taken as an add‐on treatment, alongside other antiepileptic medication, to treat drug‐resistant epilepsy.\ Aim of the review\ This review examined whether oxcarbazepine is tolerable and effective when used alongside other antiepileptic medication by people with drug‐resistant focal epilepsy (epilepsy that originates from one area of the brain).\ Results\ We included six clinical trials that investigated oxcarbazepine as an add‐on treatment for people with drug‐resistant focal epilepsy. There were 1593 people across the studies and they were aged from 1 month to 65 years.\ People who received oxcarbazepine in addition to their normal antiepileptic medication were more likely to have a 50% or greater reduction in the frequency of their seizures compared to people who were on a control treatment, which is believed to have little or no effect. They were also nearly three times more likely to be free from all seizures than those receiving control treatment. Both of these findings suggest that oxcarbazepine is effective at treating drug‐resistant focal epilepsy. These findings are, however, based on evidence that was of low certainty. This means that we are not confident that the findings that we have reported are accurate.\ People who received oxcarbazepine add‐on treatment were also more likely to withdraw from the studies and were more likely to experience side effects, including dizziness and drowsiness, than people receiving control add‐on treatment. The evidence for treatment withdrawal was of moderate certainty, and this means that we can be fairly confident that this is a true effect.\ Authors' conclusions\ As a result of the low‐certainty evidence, we cannot be sure that oxcarbazepine is an effective add‐on treatment for people with drug‐resistant focal epilepsy. Instead, we have concerns about the tolerability of oxcarbazepine because of the increased number of people who withdrew from treatment and who experienced side effects.\ The evidence is current to September 2018.](https://app.figure1.com/case-detail/658ac7c2-7da7-446f-9835-d52d25ea0a1b)
\ \ Background\ Epilepsy is a disorder where recurrent seizures are caused by abnormal electrical discharges from the brain. Most seizures can be controlled by a single antiepileptic drug. Unfortunately, some people require more than one antiepileptic medication to control their seizures, especially if these originate from one area of the brain (focal epilepsy), instead of affecting the entire brain (generalised epilepsy). These people are said to have drug‐resistant epilepsy. Topiramate can be used in addition to other antiepileptic drugs, called an add‐on treatment, to try to control drug‐resistant epilepsy.\ Aim of this review\ This review investigated the effectiveness and tolerability of topiramate when used as an add‐on treatment for people with drug‐resistant focal epilepsy.\ Results\ We found 12 trials that investigated topiramate as an add‐on treatment. They included a total of 1650 people with drug‐resistant focal epilepsy. These trials compared the antiepileptic drug topiramate to a placebo drug (an inactive, dummy drug which should not show any effect) for a period of up to 18 weeks. Taking all the evidence of the trials into account, the review found that topiramate is almost three times more effective, when used with other drugs, at reducing the number of seizures in drug‐resistant focal epilepsy than placebo. Adding topiramate to people's usual treatment was, however, associated with an increase in adverse effects such as problems with co‐ordination (ataxia), concentration, dizziness, drowsiness (somnolence), fatigue, 'thinking abnormally', tickling or numbness of the skin (paraesthesia) and weight loss. People taking add‐on topiramate were also more than twice as likely to withdraw from treatment than those taking placebo, most likely due to adverse effects.\ Certainty of the evidence\ We assessed the trials with regards to potential bias and certainty. Overall, we rated the certainty of the evidence as moderate to high which means that we are fairly certain that the findings that we have reported are accurate. The trials included in this review did not examine the long‐term effects of topiramate as an add‐on treatment and only one study investigated the use of add‐on topiramate in children. The findings should, therefore, only be applied to adults with drug‐resistant focal epilepsy. Future research should test which dose is most effective.\ The evidence is current to July 2018.](https://app.figure1.com/case-detail/7c19ecb5-4d93-48b4-90c3-2c74275d0b6a)
Trending now
\ \ A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.\ He had a history of hypertension, long-term smoking, and a sedentary lifestyle.\ On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.](https://app.figure1.com/case-detail/ae0fe999-6875-4474-94f0-ad823dbb9b3a)
\ \ A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.\ Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.](https://app.figure1.com/case-detail/c271070f-2bc7-4052-9895-635277e1a7d5)
\ \ A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.](https://app.figure1.com/case-detail/48f41642-b9db-4089-b120-a94ee52328de)
\ \ patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?](https://app.figure1.com/case-detail/2af390e1-ace8-40ed-ba1c-98fb2d72f4c5)