Determinants of quality of life after epilepsy surgery: systematic review and evidence summary

Outcomes after Epilepsy Surgery

Epilepsy surgery is a highly effective and durable treatment for specific types of drug resistant epilepsy such as temporal lobe epilepsy. assessment of outcomes is essential in epilepsy surgery, which is an irreversible intervention for a chronic condition. Excellent short-term results of resective epilepsy surgery have been established. In the last years more information regarding long term outcomes have been published. This article reviews the best available evidence about the best measures to assess outcomes and the most important evidence. The outcomes reviewed in this article are the following: seizure outcome, social and psychiatric outcomes, complications and mortality.

Health-related quality of life, mood, and patient satisfaction after epilepsy surgery in Sweden--a prospective controlled observational study

Objective

To evaluate health-related quality of life (HRQOL), mood, and patient satisfaction in epilepsy surgery candidates before and 2 years after epilepsy surgery or presurgical investigation.

Methods

In this prospective study of 141 patients, 96 underwent surgery and 45 did not. Questionnaires at baseline and at 2-year follow-up included the generic 36-item Short Form Health Survey (SF-36), the Hospital Anxiety and Depression scale (HAD), and operated patients answered patient satisfaction questions. SF-36 scores were compared with scores from a matched sample from the Swedish norm population. Numbers were calculated of patients achieving a minimum important change (MIC) in the SF-36 Physical Composite Summary (PCS) and Mental Composite Summary (MCS).

Results

At baseline, patients had significantly lower values than the norm on all SF-36 domains. At follow-up, operated patients were divided into seizure-free (International League Against Epilepsy [ILAE] class 1 and 2, n = 53) or with continued seizures (n = 43). No differences in baseline HAD or SF-36 values were found between these groups. Seizure-free patients reached the same levels as the norm in all SF-36 domains except Social Function. Operated patients with continued seizures and nonoperated patients had unchanged scores. Fifty-one percent of seizure-free patients had an improvement reaching MIC for PCS and 45% for MCS. Corresponding results for patients with continued seizures were 28% in PCS and 28% in MCS, for nonoperated 33% in PCS and 29% in MCS. HAD anxiety scores improved significantly in only the seizure-free patients. Of all operated patients, 80% were satisfied with having had surgery and 86% considered that they had benefited, whereas 20% thought that surgery caused some harm.

Significance

In patients who were seizure-free after epilepsy surgery HRQOL normalized and anxiety decreased. Operated patients overwhelmingly considered epilepsy surgery to be beneficial. Nonetheless, only about half of the seizure-free patients achieved important HRQOL improvements, suggesting that seizure freedom does not in and of itself guarantee improved patient well-being.

Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy

PURPOSE

The aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit.

METHODS

Patients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again.

RESULTS

A significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p<0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p=0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p=0.016).

DISCUSSION

Patient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.

The effect of epilepsy surgery on caregiver quality of life

PURPOSE

Epilepsy surgery has been shown to improve patient quality of life (QOL). Little is known about its effect on caregiver QOL.

METHODS

The study population comprised of 26 persons with epilepsy (PWE) who underwent long term video EEG monitoring at Massachusetts General Hospital for presurgical evaluation along with 16 caregivers. The PWE completed epilepsy directed QOL (QOLIE-31) and psychological (Beck depression-BDI and anxiety inventory-BAI) questionnaires before and after surgery. Their participating caregivers completed generic health related QOL (SF36v2) and disease burden (Zarit caregiver burden inventory-ZCBI) questionnaires before and after surgery. Demographic data for all participants and disease/surgery related data for the PWE were collected. Statistical analysis was performed to compare PWE and caregiver QOL before and after surgery.

RESULTS

Mean patient age was 37 years. Most (77%) suffered from symptomatic partial epilepsy for approximately 18 years prior to surgery, averaging 4 seizures per month and 2.2 antiepileptic drugs (AEDs). 78% of them underwent an anterior temporal lobectomy and the rest extra-temporal resections. On follow up at approximately 9 months, 69% had a surgical outcome of Engel class I, 23% of class II and 8% class IV. Postoperatively, the PWE remained on average on 1.9 AEDs. There was a statistically significant improvement for both the aggregate QOLIE-31 score and all its subscales (except for medication effects) as well as the BAI scores. 96% of the PWE felt that the decision to go through surgery was worthwhile. Mean caregivers age was 47 years. Half of them were spouses to the PWE and the majority of the rest their parents. 50% of them stated that their overall time devoted to patient's care decreased after surgery and 50% that it remained unchanged. The mental component scale (SF36v2, MCS) of caregiver QOL showed statistically significant improvement. ZCBI score and the physical component scale of their QOL (SF36v2, PCS) did not significantly vary before and after surgery. 75% of caregivers deemed their QOL better post surgery vs 19% similar. 94% of the caregivers felt that the decision to go through surgery was worthwhile.

CONCLUSIONS

Successful epilepsy surgery has a positive impact not only to patient QOL but also to their caregiver. To the best of our knowledge, this is the first pilot study to systematically address the impact of epilepsy surgery on caregivers providing additional support to epilepsy surgery as the optimal treatment modality in carefully selected patients. These findings call for further investigation on the caregiver quality of life in epilepsy and for its inclusion in the treatment plan and quality indicators for epilepsy surgery.

Long-term seizure, cognitive, and psychiatric outcome following trans-middle temporal gyrus amygdalohippocampectomy and standard temporal lobectomy

OBJECT

Previous comparisons of standard temporal lobectomy (STL) and selective amygdalohippocampectomy (SelAH) have been limited by inadequate long-term follow-up, variable definitions of favorable outcome, and inadequate consideration of psychiatric comorbidities.

METHODS

The authors performed a retrospective analysis of seizure, cognitive, and psychiatric outcomes in a noncontemporaneous cohort of 69 patients with unilateral refractory temporal lobe epilepsy and MRI evidence of mesial temporal sclerosis after either an STL or an SelAH and examined seizure, cognitive, and psychiatric outcomes.

RESULTS

The mean duration of follow-up for STL was 9.7 years (range 1-18 years), and for trans-middle temporal gyrus SelAH (mtg-SelAH) it was 6.85 years (range 1-15 years). There was no significant difference in seizure outcome when "favorable" was defined as time to loss of Engel Class I or II status; better seizure outcome was seen in the STL group when "favorable" was defined as time to loss of Engel Class IA status (p=0.034). Further analysis revealed a higher occurrence of seizures solely during attempted medication withdrawal in the mtg-SelAH group than in the STL group (p=0.016). The authors found no significant difference in the effect of surgery type on any cognitive and most psychiatric variables. Standard temporal lobectomy was associated with significantly higher scores on assessment of postsurgical paranoia (p=0.048).

CONCLUSIONS

Overall, few differences in seizure, cognitive, and psychiatric outcome were found between STL and mtg-SelAH on long-term follow-up. Longer exposure to medication side effects after mtg-SelAH may adversely affect quality of life but is unlikely to cause additional functional impairment. In patients with high levels of presurgical psychiatric disease, mtg-SelAH may be the preferred surgery type.

Specificity of psychopathology in temporal lobe epilepsy

An investigation into the specificity of psychopathology in temporal lobe epilepsy was conducted using the Minnesota Multiphase Personality Inventory second edition (MMPI-2) profiles. Consecutive series of patients with left temporal lobe epilepsy (n = 49) and those with right temporal lobe epilepsy (n = 45) were compared with patients with other forms of epilepsy (n = 46) and other heterogeneous neurological conditions (n = 69). The investigation focused on the Clinical, Content, and Subscales scales that resembled descriptions of the Interictal Dysphoric Disorder symptoms and Temporal Lobe Epilepsy Personality Traits. Patients with right temporal lobe epilepsy and those with left temporal lobe epilepsy did not have different patterns of scale elevation, nor did they have clinical elevations compared with patients with other types of epilepsy or neurological controls. The MMPI-2 scales that resemble descriptions of the Interictal Dysphoric Disorder or Temporal Lobe Epilepsy Personality Syndrome were not elevated in either group of patients with temporal lobe epilepsy compared with the group of patients with non-temporal lobe epilepsy or heterogeneous neurological controls. This study adds to the mounting body of empirical research that has used standardized measures and matched groups, but failed to detect a special affinity between psychopathology and temporal lobe epilepsy.

Epilepsy surgery utilization: who, when, where, and why?

PURPOSE OF REVIEW

Using the most recent evidence, we provide an update on epilepsy surgery, focusing on its effectiveness, reasons for underutilization, considerations of candidacy and timing for referral for epilepsy surgery evaluation.

RECENT FINDINGS

The course of illness of epilepsy is being characterized. Well conducted studies describe the patterns of seizure remission and relapse with medical therapy and also in response to epilepsy surgery. Epilepsy surgery is highly effective in selected patients with drug-resistant epilepsy (DRE). The risk-benefit of epilepsy surgery is well known and consistent around the world. However, epilepsy surgery remains underutilized. A randomized controlled trial and Clinical Practice Guidelines (CPGs) supporting epilepsy surgery have had no discernible impact on referral rates for epilepsy surgery evaluation. Criteria and guidelines are being developed for identifying patients who need to be referred for epilepsy surgery evaluation. Quality indicators for epilepsy care now also include the need to consider surgical candidacy every 3 years in DRE. New developments in imaging and neurophysiology promise to help clinicians identify and treat patients more accurately.

SUMMARY

Surgery is effective but underused. Comprehensive interventions to translate evidence to practice in epilepsy surgery are urgently needed.

Prediction of neuropsychological outcome after resection of temporal and extratemporal seizure foci

Resection of seizure foci is an effective treatment for the control of medically intractable epilepsy. However, cognitive morbidity can occur as a result of surgical intervention. This morbidity is dependent on several factors, including location and extent of resection, disease characteristics, patient demographic characteristics, and functional status of the tissue to be resected. In this review article, the authors provide a summary of the neurocognitive outcomes of epilepsy surgery with an emphasis on presurgical predictors of postsurgical cognitive decline.