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Red flags in epilepsy surgery: Identifying the patients who pay a high cognitive price for an unsuccessful surgical outcome. Epilepsy Behav 2018; 78:269-272. [PMID: 29117924 DOI: 10.1016/j.yebeh.2017.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/05/2017] [Accepted: 08/02/2017] [Indexed: 11/22/2022]
Abstract
Preoperative estimates of cognitive and seizure outcome must be as accurate as possible if the candidate is to make an informed decision about epilepsy surgery. Significant declines in memory function are reported in approximately 30% of temporal lobe surgery patients. The percentage varies according to the ways in which a postoperative deterioration is defined but since the majority of outcome studies do not take into account the patient's capacity to deteriorate if they are functioning at or close to the floor of a memory test prior to surgery, the published percentages may be an underrepresentation of the true extent of memory decline following epilepsy surgery. We examined the cognitive 'cost' of epilepsy surgery in a consecutive series of 474 patients who underwent elective surgery for medically intractable epilepsy. All patients underwent a presurgical assessment prior to and 1year after the surgery. Reliable change indices were used to identify significant postoperative memory decline. Postoperative outcome was dichotomized using the ILAE 2008 classification. All patients in class one were classified as seizure-free (67.5% of the sample). Excluding patients already functioning at or below the 2nd percentile on standardized memory tests, 37.8% experienced a significant postoperative decline in memory function. Twelve percent experienced the 'double hit' of significant postoperative memory decline and ongoing seizures following surgery. Patients with pathologies other than hippocampal sclerosis and with signs of limited cognitive reserve, both in terms of memory function and overall intellectual ability were most likely to suffer a double hit. Our results indicate that caution should be exercised when operating on these patients and preoperative counseling should be tailored to reflect the likely risk/benefit ratio of a temporal lobe resection for medically intractable epilepsy in this group.
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Bell GS, de Tisi J, Gonzalez-Fraile JC, Peacock JL, McEvoy AW, Harkness WFJ, Foong J, Pope RA, Diehl B, Sander JW, Duncan JS. Factors affecting seizure outcome after epilepsy surgery: an observational series. J Neurol Neurosurg Psychiatry 2017; 88:933-940. [PMID: 28870986 DOI: 10.1136/jnnp-2017-316211] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/22/2017] [Accepted: 08/10/2017] [Indexed: 11/03/2022]
Abstract
IMPORTANCE Surgical treatment can bring seizure remission in people with focal epilepsy but requires careful selection of candidates. OBJECTIVES To determine which preoperative factors are associated with postoperative seizure outcome. DESIGN We audited seizure outcome of 693 adults who had resective epilepsy surgery between 1990 and 2010 and used survival analysis to detect preoperatively identifiable risk factors of poor seizure outcome. RESULTS Seven factors were significantly associated with increased probability of recurrence of seizures with impaired awareness postsurgery: MRI findings (eg, HR adjusted for other variables in the model 2.5; 95% CI 1.6 to 3.8 for normal MRI compared with hippocampal sclerosis), a history of secondarily generalised convulsive seizures (2.3; 95% CI 1.7 to 3.0 for these seizures in the previous year vs never), psychiatric history (1.3; 95% CI 1.1 to 1.7), learning disability (1.8; 95% CI 1.2 to 2.6) and extratemporal (vs temporal) surgery (1.4; 95% CI 1.02, 2.04). People with an older onset of epilepsy had a higher probability of seizure recurrence (1.01; 95% CI 1.00, 1.02) as did those who had used more antiepileptic drugs (1.05; 95% CI 1.01 to 1.09). Combinations of variables associated with seizure recurrence gave overall low probabilities of 5-year seizure freedom (eg, a normal MRI and convulsive seizures in the previous year has a probability of seizure freedom at 5 years of approximately 0.19). CONCLUSIONS AND RELEVANCE Readily identified clinical features and investigations are associated with reduced probability of good outcome and need consideration when planning presurgical evaluation.
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Affiliation(s)
- Gail S Bell
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, London, UK
| | - Jane de Tisi
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Juan Carlos Gonzalez-Fraile
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Janet L Peacock
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Andrew W McEvoy
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - William F J Harkness
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Jacqueline Foong
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Rebecca A Pope
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
| | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, London, UK.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, UK
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Abstract
BACKGROUND Despite optimal medical treatment, including epilepsy surgery, many epilepsy patients have uncontrolled seizures. Since the 1970s interest has grown in invasive intracranial neurostimulation as a treatment for these patients. Intracranial stimulation includes both deep brain stimulation (DBS) (stimulation through depth electrodes) and cortical stimulation (subdural electrodes). This is an updated version of a previous Cochrane review published in 2014. OBJECTIVES To assess the efficacy, safety and tolerability of DBS and cortical stimulation for refractory epilepsy based on randomized controlled trials (RCTs). SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register on 29 September 2015, but it was not necessary to update this search, because records in the Specialized Register are included in CENTRAL. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 11, 5 November 2016), PubMed (5 November 2016), ClinicalTrials.gov (5 November 2016), the WHO International Clinical Trials Registry Platform ICTRP (5 November 2016) and reference lists of retrieved articles. We also contacted device manufacturers and other researchers in the field. No language restrictions were imposed. SELECTION CRITERIA RCTs comparing deep brain or cortical stimulation versus sham stimulation, resective surgery, further treatment with antiepileptic drugs or other neurostimulation treatments (including vagus nerve stimulation). DATA COLLECTION AND ANALYSIS Four review authors independently selected trials for inclusion. Two review authors independently extracted the relevant data and assessed trial quality and overall quality of evidence. The outcomes investigated were seizure freedom, responder rate, percentage seizure frequency reduction, adverse events, neuropsychological outcome and quality of life. If additional data were needed, the study investigators were contacted. Results were analysed and reported separately for different intracranial targets for reasons of clinical heterogeneity. MAIN RESULTS Twelve RCTs were identified, eleven of these compared one to three months of intracranial neurostimulation with sham stimulation. One trial was on anterior thalamic DBS (n = 109; 109 treatment periods); two trials on centromedian thalamic DBS (n = 20; 40 treatment periods), but only one of the trials (n = 7; 14 treatment periods) reported sufficient information for inclusion in the quantitative meta-analysis; three trials on cerebellar stimulation (n = 22; 39 treatment periods); three trials on hippocampal DBS (n = 15; 21 treatment periods); one trial on nucleus accumbens DBS (n = 4; 8 treatment periods); and one trial on responsive ictal onset zone stimulation (n = 191; 191 treatment periods). In addition, one small RCT (n = 6) compared six months of hippocampal DBS versus sham stimulation. Evidence of selective reporting was present in four trials and the possibility of a carryover effect complicating interpretation of the results could not be excluded in five cross-over trials without any or a sufficient washout period. Moderate-quality evidence could not demonstrate statistically or clinically significant changes in the proportion of patients who were seizure-free or experienced a 50% or greater reduction in seizure frequency (primary outcome measures) after one to three months of anterior thalamic DBS in (multi)focal epilepsy, responsive ictal onset zone stimulation in (multi)focal epilepsy patients and hippocampal DBS in (medial) temporal lobe epilepsy. However, a statistically significant reduction in seizure frequency was found for anterior thalamic DBS (mean difference (MD), -17.4% compared to sham stimulation; 95% confidence interval (CI) -31.2 to -1.0; high-quality evidence), responsive ictal onset zone stimulation (MD -24.9%; 95% CI -40.1 to -6.0; high-quality evidence) and hippocampal DBS (MD -28.1%; 95% CI -34.1 to -22.2; moderate-quality evidence). Both anterior thalamic DBS and responsive ictal onset zone stimulation do not have a clinically meaningful impact on quality life after three months of stimulation (high-quality evidence). Electrode implantation resulted in postoperative asymptomatic intracranial haemorrhage in 1.6% to 3.7% of the patients included in the two largest trials and 2.0% to 4.5% had postoperative soft tissue infections (9.4% to 12.7% after five years); no patient reported permanent symptomatic sequelae. Anterior thalamic DBS was associated with fewer epilepsy-associated injuries (7.4 versus 25.5%; P = 0.01) but higher rates of self-reported depression (14.8 versus 1.8%; P = 0.02) and subjective memory impairment (13.8 versus 1.8%; P = 0.03); there were no significant differences in formal neuropsychological testing results between the groups. Responsive ictal-onset zone stimulation seemed to be well-tolerated with few side effects.The limited number of patients preclude firm statements on safety and tolerability of hippocampal DBS. With regards to centromedian thalamic DBS, nucleus accumbens DBS and cerebellar stimulation, no statistically significant effects could be demonstrated but evidence is of only low to very low quality. AUTHORS' CONCLUSIONS Except for one very small RCT, only short-term RCTs on intracranial neurostimulation for epilepsy are available. Compared to sham stimulation, one to three months of anterior thalamic DBS ((multi)focal epilepsy), responsive ictal onset zone stimulation ((multi)focal epilepsy) and hippocampal DBS (temporal lobe epilepsy) moderately reduce seizure frequency in refractory epilepsy patients. Anterior thalamic DBS is associated with higher rates of self-reported depression and subjective memory impairment. There is insufficient evidence to make firm conclusive statements on the efficacy and safety of hippocampal DBS, centromedian thalamic DBS, nucleus accumbens DBS and cerebellar stimulation. There is a need for more, large and well-designed RCTs to validate and optimize the efficacy and safety of invasive intracranial neurostimulation treatments.
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Affiliation(s)
- Mathieu Sprengers
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Kristl Vonck
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Evelien Carrette
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Paul Boon
- Ghent University HospitalDepartment of Neurology1K12, 185 De PintelaanGhentBelgiumB‐9000
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Abstract
In common with other stereotactic procedures, stereotactic laser thermocoagulation (SLT) promises gentle destruction of pathological tissue, which might become especially relevant for epilepsy surgery in the future. Compared to standard resection, no large craniotomy is necessary, cortical damage during access to deep-seated lesions can be avoided and interventions close to eloquent brain areas become possible. We describe the history and rationale of laser neurosurgery as well as the two available SLT systems (Visualase® and NeuroBlate®; CE marks pending). Both systems are coupled with magnetic resonance imaging (MRI) and MR thermometry, thereby increasing patient safety. We report the published clinical experiences with SLT in epilepsy surgery (altogether approximately 200 cases) with respect to complications, brain structural alterations, seizure outcome, neuropsychological findings and treatment costs. The rate of seizure-free patients seems to be slightly lower than for resection surgery. Due to the inadequate quality of studies, the neuropsychological superiority of SLT has not yet been unambiguously demonstrated.
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Veersema TJ, Ferrier CH, van Eijsden P, Gosselaar PH, Aronica E, Visser F, Zwanenburg JM, de Kort GAP, Hendrikse J, Luijten PR, Braun KPJ. Seven tesla MRI improves detection of focal cortical dysplasia in patients with refractory focal epilepsy. Epilepsia Open 2017; 2:162-171. [PMID: 29588945 PMCID: PMC5719847 DOI: 10.1002/epi4.12041] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2016] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this study is to determine whether the use of 7 tesla (T) MRI in clinical practice leads to higher detection rates of focal cortical dysplasias in possible candidates for epilepsy surgery. Methods In our center patients are referred for 7 T MRI if lesional focal epilepsy is suspected, but no abnormalities are detected at one or more previous, sufficient‐quality lower‐field MRI scans, acquired with a dedicated epilepsy protocol, or when concealed pathology is suspected in combination with MR‐visible mesiotemporal sclerosis—dual pathology. We assessed 40 epilepsy patients who underwent 7 T MRI for presurgical evaluation and whose scans (both 7 T and lower field) were discussed during multidisciplinary epilepsy surgery meetings that included a dedicated epilepsy neuroradiologist. We compared the conclusions of the multidisciplinary visual assessments of 7 T and lower‐field MRI scans. Results In our series of 40 patients, multidisciplinary evaluation of 7 T MRI identified additional lesions not seen on lower‐field MRI in 9 patients (23%). These findings were guiding in surgical planning. So far, 6 patients underwent surgery, with histological confirmation of focal cortical dysplasia or mild malformation of cortical development. Significance Seven T MRI improves detection of subtle focal cortical dysplasia and mild malformations of cortical development in patients with intractable epilepsy and may therefore contribute to identification of surgical candidates and complete resection of the epileptogenic lesion, and thus to postoperative seizure freedom.
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Affiliation(s)
- Tim J. Veersema
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Cyrille H. Ferrier
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Pieter van Eijsden
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Peter H. Gosselaar
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Eleonora Aronica
- Department of (Neuro)PathologyAcademic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- Center for NeuroscienceSwammerdam Institute for Life SciencesUniversity of AmsterdamAmsterdamthe Netherlands
- SEIN—Stichting Epilepsie Instellingen NederlandHeemstedethe Netherlands
| | | | - Jaco M. Zwanenburg
- Department of RadiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | | | - Jeroen Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Peter R. Luijten
- Department of RadiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Kees P. J. Braun
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtthe Netherlands
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Moon HJ, Kim DW, Chung CK, Shin JW, Moon J, Kang BS, Lee ST, Jung KH, Chu K, Jung KY, Cho YW, Lee SK. Change of Patient Selection Strategy and Improved Surgical Outcome in MRI-negative Neocortical Epilepsy. J Epilepsy Res 2016; 6:66-74. [PMID: 28101477 PMCID: PMC5206102 DOI: 10.14581/jer.16013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/14/2016] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose It is crucial to make selection strategy to identify surgical candidates among medically refractory MRI-negative neocortical epilepsy patients. In our previous study, we suggested two or more concordance between noninvasive studies (EEG, ictal scalp EEG, interictal FDG-PET, and SPECT) as a new patient selection strategy for MRI-negative neocortical epilepsy surgery. The objective of this study was to evaluate the surgical outcomes of MRI-negative neocortical epilepsy patients before and after the implementation of a new selection strategy. Methods From 1995 to 2011, we included 153 consecutive MRI-negative neocortical epilepsy patients who received focal resection and had a follow-up period of at least 2 years. These patients were divided into two groups according to their date of surgery (before and after July 2002). The old group consisted of 89 patients and the new one consisted of 53 patients. Clinical characteristics, presurgical evaluations, and pathology were reviewed. Results The new patient selection strategy led to a significant increase in the concordance between two or more modalities. The improvement in surgical outcome after 2002 was significant (seizure-free outcome, 47.2% vs. 75.5%; p = 0.001). Concordance between two or more presurgical evaluations and localizing PET were related to a seizure-free outcome in a multivariate analysis. Conclusions After a change in surgical strategy to select patients with two or more concordance between noninvasive studies, the seizure-free outcome improved up to 75.5%. MRI-negative neocortical epilepsy patients with two or more concordance between noninvasive studies seem to be good candidates for epilepsy surgery.
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Affiliation(s)
- Hye-Jin Moon
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Chun-Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Won Shin
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Jangsup Moon
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Bong Su Kang
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Ki-Young Jung
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
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Atim-Oluk M, Jackson CF, Marson AG. Oxcarbazepine add-on for drug-resistant partial epilepsy. Hippokratia 2016. [DOI: 10.1002/14651858.cd012433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Cerian F Jackson
- Institute of Translational Medicine, University of Liverpool; Department of Molecular and Clinical Pharmacology; Clinical Sciences Centre for Research and Education, Lower Lane Fazakerley Liverpool UK L9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of Liverpool; Department of Molecular and Clinical Pharmacology; Clinical Sciences Centre for Research and Education, Lower Lane Fazakerley Liverpool UK L9 7LJ
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Jetté N, Sander JW, Keezer MR. Surgical treatment for epilepsy: the potential gap between evidence and practice. Lancet Neurol 2016; 15:982-994. [DOI: 10.1016/s1474-4422(16)30127-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 01/23/2023]
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Jehi L, Jetté N. Not all that glitters is gold: A guide to surgical trials in epilepsy. Epilepsia Open 2016; 1:22-36. [PMID: 29588926 PMCID: PMC5867837 DOI: 10.1002/epi4.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 02/03/2023] Open
Abstract
Epilepsy surgery is often the only effective treatment in appropriately selected patients with drug‐resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). Abstracts were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra‐TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.
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Affiliation(s)
- Lara Jehi
- Epilepsy Center Cleveland Clinic Neurological Institute Cleveland Ohio U.S.A
| | - Nathalie Jetté
- Department of Clinical Neurosciences and Hotchkiss Brain Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada.,Department of Community Health Sciences and O'Brien Institute for Public Health Cumming School of Medicine University of Calgary Calgary Alberta Canada
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Choy M, Duffy BA, Lee JH. Optogenetic study of networks in epilepsy. J Neurosci Res 2016; 95:2325-2335. [PMID: 27413006 PMCID: PMC5548626 DOI: 10.1002/jnr.23767] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 01/23/2023]
Abstract
Currently, approximately 30% of patients with epilepsy do not have adequate seizure control. A greater understanding of the underlying mechanisms by which seizures start or propagate could lead to new therapeutic strategies. The recent development of optogenetics, because of its unprecedented precision for controlling activity within distinct neuronal populations, has revolutionized neuroscience, including epilepsy research. This Review discusses recent breakthroughs made with optogenetics in epilepsy research. These breakthroughs include new insights into the key roles that different cell types play in mediating seizures as well as in the development of epilepsy. Subsequently, we discuss how targeting different brain regions and cell populations has opened up the possibility of highly specific therapies that can stop seizures on demand. Finally, we illustrate how combining newly available neuroscience tools with whole-brain imaging techniques will allow researchers to understand better the spread of seizures on a network level. © 2016 The Authors. Journal of Neuroscience Research Published by Wiley Periodicals, Inc.
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Affiliation(s)
- ManKin Choy
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Ben A Duffy
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Jin Hyung Lee
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California.,Department of Bioengineering, Stanford University, Stanford, California.,Department of Neurosurgery, Stanford University, Stanford, California.,Department of Electrical Engineering, Stanford University, Stanford, California
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Abstract
BACKGROUND This is an updated version of the Cochrane review published in The Cochrane Library 2010, Issue 1.Epilepsy is a common neurological disorder, affecting almost 0.5% to 1% of the population. For nearly 30% of these people, their epilepsy is refractory to currently available drugs. Pharmacological treatment remains the first choice to control epilepsy. Lamotrigine is one of the newer antiepileptic drugs and is the topic of this review. Lamotrigine in combination with other antiepileptic drugs (add-on) can reduce seizures, but with some adverse effects. The aim of this systematic review was to overview the current evidence for the efficacy and tolerability of lamotrigine when used as an adjunctive treatment for people with refractory partial epilepsy. OBJECTIVES To determine the effects of lamotrigine on (1) seizures, (2) adverse effect profile, and (3) cognition and quality of life, compared to placebo controls, when used as an add-on treatment for people with refractory partial epilepsy. SEARCH METHODS For the previous version of the review, the authors searched the Cochrane Epilepsy Group Specialized Register (January 2010), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 1), MEDLINE (1950 to January 2010), and reference lists of articles.For this update, we searched the Cochrane Epilepsy Group Specialized Register (28 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Ovid, 1946 to May 2015), and reference lists of articles. We also contacted the manufacturers of lamotrigine (GlaxoSmithKline). No language restrictions were imposed. SELECTION CRITERIA Randomised placebo-controlled trials of people with drug-resistant partial epilepsy of any age, in which an adequate method of concealment of randomisation was used. The studies were double-, single- or unblinded. For cross-over studies, the first treatment period was treated as a parallel trial. Eligible participants were adults or children with drug-resistant partial epilepsy. DATA COLLECTION AND ANALYSIS For this update, two review authors independently assessed the trials for inclusion, and extracted data. Outcomes included 50% or greater reduction in seizure frequency, treatment withdrawal (any reason), adverse effects, effects on cognition and quality of life. Primary analyses were by intention-to-treat. Sensitivity best and worse case analyses were undertaken to account for missing outcome data. Pooled Risk Ratios (RR) with 95% confidence intervals (95% Cl) were estimated for the primary outcomes of seizure frequency and treatment withdrawal. For adverse effects, pooled RRs and 99% Cls were calculated. MAIN RESULTS We did not identify any new studies for this update, therefore, the results are unchanged.For the previous version of the review, the authors found five parallel add-on studies and eight cross-over studies in adults or children with refractory focal epilepsy, and one parallel add-on study with a responder-enriched design in infants. In total, these 14 studies included 1958 participants (38 infants, 199 children, and 1721 adults). Baseline phases ranged from 4 to 12 weeks; treatment phases from 8 to 36 weeks. Overall, eleven studies (n = 1243 participants) were rated as having a low risk of bias, and three (n = 715 participants) had un unclear risk of bias due to lack of reported information around study design. Effective blinding of studies was reported in three studies (n = 504 participants). The overall risk ratio (RR) for 50% or greater reduction in seizure frequency was 1.80 (95% CI 1.45 to 2.23; 12 RCTs) for twelve studies (n = 1322 participants, adults and children) indicating that lamotrigine was significantly more effective than placebo in reducing seizure frequency. The overall RR for treatment withdrawal (for any reason) was 1.11 (95% CI 0.90 to 1.36; 14 RCTs) for fourteen studies (n = 1958 participants). The adverse events significantly associated with lamotrigine were: ataxia, dizziness, diplopia, and nausea. The RR of these adverse effects were as follows: ataxia 3.34 (99% Cl 2.01 to 5.55; 12 RCTs; n = 1524); dizziness 2.00 (99% Cl 1.51 to 2.64;13 RCTs; n = 1767); diplopia 3.79 (99% Cl 2.15 to 6.68; 3 RCTs; n = 943); nausea 1.81 (99% Cl 1.22 to 2.68; 12 RCTs; n = 1486). The limited data available precluded any conclusions about effects on cognition and quality of life. No important heterogeneity between studies was found for any of the outcomes. Overall, we assessed the evidence as high to moderate quality, due to incomplete data for some outcomes. AUTHORS' CONCLUSIONS Lamotrigine as an add-on treatment for partial seizures appears to be effective in reducing seizure frequency, and seems to be fairly well tolerated. However, the trials were of relatively short duration and provided no evidence for the long-term. Further trials are needed to assess the long-term effects of lamotrigine, and to compare it with other add-on drugs.Since we did not find any new studies, our conclusions remain unchanged.
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Affiliation(s)
- Sridharan Ramaratnam
- The Nerve CentreDepartment of Neurology5/1 Rajachar StreetT NagarChennaiTamil NaduIndia600017
| | - Mariangela Panebianco
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
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Rolston JD, Englot DJ, Knowlton RC, Chang EF. Rate and complications of adult epilepsy surgery in North America: Analysis of multiple databases. Epilepsy Res 2016; 124:55-62. [PMID: 27259069 DOI: 10.1016/j.eplepsyres.2016.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 04/05/2016] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
Epilepsy surgery is under-utilized, but recent studies reach conflicting conclusions regarding whether epilepsy surgery rates are currently declining, increasing, or remaining steady. However, data in these prior studies are biased toward high-volume epilepsy centers, or originate from sources that do not disaggregate various procedure types. All major epilepsy surgery procedures were extracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File and the American College of Surgeons National Surgical Quality Improvement Program. Procedure rates, trends, and complications were analyzed, and patient-level predictors of postoperative adverse events were identified. Between 2000-2013, 6200 cases of epilepsy surgery were identified. Temporal lobectomy was the most common procedure (59% of cases), and most did not utilize electrocorticography (63-64%). Neither temporal nor extratemporal lobe epilepsy surgery rates changed significantly during the study period, suggesting no change in utilization. Adverse events, including major and minor complications, occurred in 15.3% of temporal lobectomies and 55.6% of hemispherectomies. Our findings suggest stagnant rates of both temporal and extratemporal lobe epilepsy surgery across U.S. surgical centers over the past decade. This finding contrasts with prior reports suggesting a recent dramatic decline in temporal lobectomy rates at high-volume epilepsy centers. We also observed higher rates of adverse events when both low- and high-volume centers were examined together, as compared to reports from high-volume centers alone. This is consistent with the presence of a volume-outcome relationship in epilepsy surgery.
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Affiliation(s)
- John D Rolston
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
| | - Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Robert C Knowlton
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Jin P, Wu D, Li X, Ren L, Wang Y. Towards precision medicine in epilepsy surgery. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:24. [PMID: 26889477 DOI: 10.3978/j.issn.2305-5839.2015.12.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Up to a third of all patients with epilepsy are refractory to medical therapy even in the context of the introduction of new antiepileptic drugs (AEDs) with considerable advantages in safety and tolerability over the last two decades. It has been widely accepted that epilepsy surgery is a highly effective therapeutic option in a selected subset of patients with refractory focal seizure. There is no doubt that accurate localization of the epileptogenic zone (EZ) is crucial to the success of resection surgery for intractable epilepsy. The pre-surgical evaluation requires a multimodality approach wherein each modality provides unique and complimentary information. Accurate localization of EZ still remains challenging, especially in patients with normal features on MRI. Whereas substantial progress has been made in the methods of pre-surgical assessment in recent years, which widened the applicability of surgical treatment for children and adults with refractory seizure. Advances in neuroimaging including voxel-based morphometric MRI analysis, multimodality techniques and computer-aided subtraction ictal SPECT co-registered to MRI have improved our ability to identify subtle structural and metabolic lesions causing focal seizure. Considerable observations from animal model with epilepsy and pre-surgical patients have consistently found a strong correlation between high frequency oscillations (HFOs) and epileptogenic brain tissue that suggest HFOs could be a potential biomarker of EZ. Since SEEG emphasizes the importance to study the spatiotemporal dynamics of seizure discharges, accounting for the dynamic, multidirectional spatiotemporal organization of the ictal discharges, it has greatly deep our understanding of the anatomo-electro-clinical profile of seizure. In this review, we focus on some state-of-the-art pre-surgical investigations that contribute to the precision medicine. Furthermore, advances also provide opportunity to achieve the minimal side effects and maximal benefit individually, which meets the need for the current concept of precision medicine in epilepsy surgery.
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Affiliation(s)
- Pingping Jin
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100029, China ; 2 Department of Neurology, China-Japan Friendship Hospital, Beijing 100029, China ; 3 Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Dongyan Wu
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100029, China ; 2 Department of Neurology, China-Japan Friendship Hospital, Beijing 100029, China ; 3 Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xiaoxuan Li
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100029, China ; 2 Department of Neurology, China-Japan Friendship Hospital, Beijing 100029, China ; 3 Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Liankun Ren
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100029, China ; 2 Department of Neurology, China-Japan Friendship Hospital, Beijing 100029, China ; 3 Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Yuping Wang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing 100029, China ; 2 Department of Neurology, China-Japan Friendship Hospital, Beijing 100029, China ; 3 Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Response to placebo in clinical epilepsy trials--Old ideas and new insights. Epilepsy Res 2016; 122:15-25. [PMID: 26921852 DOI: 10.1016/j.eplepsyres.2016.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/24/2016] [Accepted: 02/09/2016] [Indexed: 11/22/2022]
Abstract
Randomized placebo-controlled trials are a mainstay of modern clinical epilepsy research; the success or failure of innovative therapies depends on proving superiority to a placebo. Consequently, understanding what drives response to placebo (including the "placebo effect") may facilitate evaluation of new therapies. In this review, part one will explore observations about placebos specific to epilepsy, including the relatively higher placebo response in children, apparent increase in placebo response over the past several decades, geographic variation in placebo effect, relationship to baseline epilepsy characteristics, influence of nocebo on clinical trials, the possible increase in (SUDEP) in placebo arms of trials, and patterns that placebo responses appear to follow in individual patients. Part two will discuss the principal causes of placebo responses, including regression to the mean, anticipation, classical conditioning, the Hawthorne effect, expectations from symbols, and the natural history of disease. Included in part two will be a brief overview of recent advances using simulations from large datasets that have afforded new insights into causes of epilepsy-related placebo responses. In part three, new developments in study design will be explored, including sequential parallel comparison, two-way enriched design, time to pre-randomization, delayed start, and cohort reduction techniques.
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Abstract
BACKGROUND Nearly 30% of patients with epilepsy continue to have seizures in spite of using several antiepileptic drug (AED) regimens. Such patients are regarded as having refractory, or uncontrolled, epilepsy. No definition of uncontrolled, or medically refractory, epilepsy has been universally accepted, but for the purposes of this review, we will consider seizures as drug resistant if they have failed to respond to a minimum of two AEDs. It is believed that early surgical intervention may prevent seizures at a younger age, which, in turn, may improve the intellectual and social status of children. Many types of surgery are available for treatment of refractory epilepsy; one such procedure is known as subpial transection. OBJECTIVES To determine the benefits and adverse effects of subpial transection for partial-onset seizures and generalised tonic-clonic seizures in children and adults. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialised Register (29 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; May 2015, Issue 5) and MEDLINE (1946 to 29 June 2015). We imposed no language restrictions. SELECTION CRITERIA We considered all randomised and quasi-randomised parallel-group studies, whether blinded or non-blinded. DATA COLLECTION AND ANALYSIS Two review authors (BK and SR) independently screened trials identified by the search. The same two review authors planned to independently assess the methodological quality of studies. When studies were identified for inclusion, one review author would have extracted the data, and the other would have verified the data. MAIN RESULTS We found no relevant studies. AUTHORS' CONCLUSIONS We found no evidence to support or refute use of subpial transection surgery for patients with medically refractory epilepsy. Well-designed randomised controlled trials are needed to guide clinical practice.
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Affiliation(s)
- Balaji Krishnaiah
- Department of Neurology, Penn State Center, 30 Hope Drive, Hershey, Philadephia, USA, PA 17033
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