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McIntosh AM, Wynd AW, Berkovic SF. Extended follow-up after anterior temporal lobectomy demonstrates seizure recurrence 20+ years postsurgery. Epilepsia 2023; 64:92-102. [PMID: 36268808 PMCID: PMC10098858 DOI: 10.1111/epi.17440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Anterior temporal lobectomy (ATL) for medication-resistant localized epilepsy results in ablation or reduction of seizures for most patients. However, some individuals who attain an initial extended period of postsurgical seizure freedom will experience a later seizure recurrence. In this study, we examined the prevalence and some risk factors for late recurrence in an ATL cohort with extensive regular follow-up. METHODS Included were 449 patients who underwent ATL at Austin Health, Australia, from 1978 to 2008. Postsurgical follow-up was undertaken 2-3 yearly. Seizure recurrence was tested using Kaplan-Meier analysis, log-rank test, and Cox regression. Late recurrence was qualified as a first disabling seizure >2 years postsurgery. We examined risks within the ATL cohort according to broad pathology groups and tested whether late recurrence differed for the ATL cohort compared to patients who had resections outside the temporal lobe (n = 98). RESULTS Median post-ATL follow-up was 22 years (range = .1-38.6), 6% were lost to follow-up, and 12% had died. Probabilities for remaining completely seizure-free after surgery were 51% (95% confidence interval [CI] = 53-63) at 2 postoperative years, 36% (95% CI = 32-41) at 10 years, 32% (95% CI = 27-36) at 20 years, and 30% (95% CI = 25-34) at 25 years. Recurrences were reported up to 23 years postoperatively. Late seizures occurred in all major ATL pathology groups, with increased risk in the "normal" and "distant lesion" groups (p ≤ .03). Comparison between the ATL cohort and patients who underwent extratemporal resection demonstrated similar patterns of late recurrence (p = .74). SIGNIFICANCE Some first recurrences were very late, reported decades after ATL. Late recurrences were not unique to any broad ATL pathology group and did not differ according to whether resections were ATL or extratemporal. Reports of these events by patients with residual pathology suggest that potentially epileptogenic abnormalities outside the area of resection may be implicated as one of several possible underlying mechanisms.
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Affiliation(s)
- Anne M McIntosh
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia.,Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alex W Wynd
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
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Asadi-Pooya AA, Nabavizadeh SA, Farazdaghi M. Effect of the COVID-19 Pandemic on Seizure Control Status in Patients with Epilepsy. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:588-593. [PMID: 36380979 PMCID: PMC9652500 DOI: 10.30476/ijms.2022.94056.2532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Previous studies have shown that patients with epilepsy (PWE) perceived significant disruption in the quality and provision of care due to the coronavirus disease 2019 (COVID-19) pandemic. The present study aimed to investigate the effect of this pandemic on seizure control status and changes in seizure frequency in PWE. METHODS A consecutive sample of adult PWE registered in the database of Shiraz Epilepsy Center (Shiraz, Iran) was included in the study. In July 2021, phone interviews were conducted with all selected patients. Information such as age, sex, last seizure, seizure type, and frequency during the 12 months before the study, and history of COVID-19 contraction was extracted. The seizure control status of the patients in 2019 (pre-pandemic) was compared with that during the COVID-19 pandemic. Data were analyzed using SPSS software with the Fisher's exact test and Pearson's Chi squared test. P<0.05 was considered statistically significant. RESULTS A total of 158 patients were included in the study, out of which 62 (39.2%) patients had a stable seizure control status, 47 (29.7%) had fewer seizures, and 50 (31.6%) had more seizures. Breakthrough seizures were reported by 32 (34.4%) patients. Seizure frequency increased in 18 (27.7%) and decreased in 46 (70.7%) patients. CONCLUSION Overall, the COVID-19 pandemic has not been a major precipitating factor nor has it affected the seizure control status of PWE. In treated epilepsy, a fluctuating course with periods of seizure freedom followed by relapses is part of its natural history.
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Affiliation(s)
- Ali Akabar Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, PA, USA
| | | | - Mohsen Farazdaghi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Faught E. Reoperations for Epilepsy: How Many Times Should We Bat? Epilepsy Curr 2021; 20:367-368. [PMID: 34025257 PMCID: PMC7818212 DOI: 10.1177/1535759720961059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Long-Term Outcomes of Reoperations in Epilepsy Surgery Yardi R, Morita-Sherman ME, Fitzgerald Z, et al. Epilepsia.
2020;61(3):465-470. https://pubmed.ncbi.nlm.nih.gov/32108946/ Objective: To analyze longitudinal seizure outcomes following epilepsy surgery, including
reoperations, in patients with intractable focal epilepsy. Methods: Clinicoradiological characteristics of patients who underwent epilepsy surgery from
1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing
reoperations, the latest resection was considered the index surgery. The primary
outcome was complete seizure freedom (Engel I) at last follow-up. Potentially
significant outcome variables were first identified using univariate analyses and
then fit in multivariate Cox proportional hazards models. Results: Of 898 patients fulfilling study criteria, 110 had reoperations: 92 had one
resection prior to the index surgery and 18 patients had 2 or more prior resective
surgeries. Two years after the index surgery, 69% of patients with no prior
surgeries had an Engel score of I, as opposed to only 42% of those with one prior
surgery, and 33% of those with 2 or more prior resections (P <
.001). Among surgical outcome predictors, the number of prior epilepsy surgeries,
female sex, lesional initial magnetic resonance imaging, no prior history of
generalization, and pathology correlated with better seizure outcomes on univariate
analysis. However, only sex (P = .011), history of generalization
(P = .016), and number of prior surgeries (P =
.002) remained statistically significant in the multivariate model. Significance: Although long-term seizure control is possible in patients with failed prior
epilepsy surgery, the chances of success diminish with every subsequent resection.
Outcome is additionally determined by inherent biological markers (sex and secondary
generalization tendency), rather than traditional outcome predictors, supporting a
hypothesis of “surgical refractoriness.”
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Petrik S, San Antonio-Arce V, Steinhoff BJ, Syrbe S, Bast T, Scheiwe C, Brandt A, Beck J, Schulze-Bonhage A. Epilepsy surgery: Late seizure recurrence after initial complete seizure freedom. Epilepsia 2021; 62:1092-1104. [PMID: 33778964 DOI: 10.1111/epi.16893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was undertaken to improve understanding of late relapse following epilepsy surgery in pharmacoresistant epilepsy. METHODS Retrospective comparison was made of 99 of 1278 patients undergoing surgery during 1999-2015 with seizure relapses after at least 2 years of complete seizure freedom with matched controls experiencing continued long-term seizure freedom. Univariate and multivariate analyses were performed. RESULTS With a mean follow-up of 9.7 years, mean time to seizure relapse was 56.6 months. In multivariate analysis, incomplete resection based on magnetic resonance imaging (MRI), bilateral lesions on preoperative MRI, and epilepsy onset in the first year of life carried a significantly higher risk of late relapse. In patients with late relapse, additional functional imaging with positron emission tomography had been performed significantly more often. Although the differences were not significant in multivariate analysis, doses of antiepileptic drugs were higher in the relapse group preoperatively and in the first 24 months and complete withdrawal was more frequent in the control group (68% vs. 51%). Regarding seizure frequency, most patients had mild seizure relapse (single relapse seizure or <1/month). SIGNIFICANCE In our predominantly lesional cohort, complete resection of the MRI lesion is the most important factor to maintain long-term seizure freedom. Two patterns of recurrence were identified: (1) incomplete resected lesions with seizure generation in proximity to the initial resection and (2) epileptogenic networks not detected preoperatively or evolving in the postoperative interval and manifesting with new clinical and diagnostic features.
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Affiliation(s)
- Stephan Petrik
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Victoria San Antonio-Arce
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Steffen Syrbe
- Division of Child Neurology and Inherited Metabolic Diseases, Center for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Bast
- Kork Epilepsy Center, Kehl-Kork, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Brandt
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juergen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Lillis KP, Staley KJ. Optogenetic dissection of ictogenesis: in search of a targeted anti-epileptic therapy. J Neural Eng 2018; 15:041001. [PMID: 29536948 PMCID: PMC6257979 DOI: 10.1088/1741-2552/aab66a] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
For over a century, epileptic seizures have been characterized as a state of pathological, hypersynchronous brain activity. Anti-epileptic therapies have been developed largely based on the dogma that the altered brain rhythms result from an overabundance of glutamatergic activity or insufficient GABAergic inhibition. The most effective drugs in use today act to globally decrease excitation, increase inhibition, or decrease all activity. Unfortunately, such broad alterations to brain activity often lead to impactful side effects such as drowsiness, cognitive impairment, and sleep disruption. Recent advances in optical imaging, optogenetics, and chemogenetics have made it feasible to record and alter neuronal activity with single neuron resolution and genetically directed targeting. The goal of this review it to summarize the usage of these research tools in the study of ictogenesis (seizure generation) and propose a translational pathway by which these studies could result in novel clinical therapies. This manuscript is not intended to serve as an exhaustive list of optogenetic tools nor as a summary of all optogenetic manipulations in epilepsy research. Rather, we will focus on the tools and research aimed at dissecting the basic neuron-level interactions underlying ictogenesis.
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Vakharia VN, Sparks R, Li K, O'Keeffe AG, Miserocchi A, McEvoy AW, Sperling MR, Sharan A, Ourselin S, Duncan JS, Wu C. Automated trajectory planning for laser interstitial thermal therapy in mesial temporal lobe epilepsy. Epilepsia 2018; 59:814-824. [PMID: 29528488 PMCID: PMC5901027 DOI: 10.1111/epi.14034] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Surgical resection of the mesial temporal structures brings seizure remission in 65% of individuals with drug-resistant mesial temporal lobe epilepsy (MTLE). Laser interstitial thermal therapy (LiTT) is a novel therapy that may provide a minimally invasive means of ablating the mesial temporal structures with similar outcomes, while minimizing damage to the neocortex. Systematic trajectory planning helps ensure safety and optimal seizure freedom through adequate ablation of the amygdalohippocampal complex (AHC). Previous studies have highlighted the relationship between the residual unablated mesial hippocampal head and failure to achieve seizure freedom. We aim to implement computer-assisted planning (CAP) to improve the ablation volume and safety of LiTT trajectories. METHODS Twenty-five patients who had previously undergone LiTT for MTLE were studied retrospectively. The EpiNav platform was used to automatically generate an optimal ablation trajectory, which was compared with the previous manually planned and implemented trajectory. Expected ablation volumes and safety profiles of each trajectory were modeled. The implemented laser trajectory and achieved ablation of mesial temporal lobe structures were quantified and correlated with seizure outcome. RESULTS CAP automatically generated feasible trajectories with reduced overall risk metrics (P < .001) and intracerebral length (P = .007). There was a significant correlation between the actual and retrospective CAP-anticipated ablation volumes, supporting a 15 mm diameter ablation zone model (P < .001). CAP trajectories would have provided significantly greater ablation of the amygdala (P = .0004) and AHC (P = .008), resulting in less residual unablated mesial hippocampal head (P = .001), and reduced ablation of the parahippocampal gyrus (P = .02). SIGNIFICANCE Compared to manually planned trajectories CAP provides a better safety profile, with potentially improved seizure-free outcome and reduced neuropsychological deficits, following LiTT for MTLE.
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Affiliation(s)
- Vejay N. Vakharia
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
- Epilepsy Society MRI UnitChalfont St PeterUK
| | - Rachel Sparks
- Wellcome/EPSRC Centre for Interventional and Surgical SciencesUniversity College LondonLondonUK
| | - Kuo Li
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
- The First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | | | - Anna Miserocchi
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Andrew W. McEvoy
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Michael R. Sperling
- Department of Neurology, Vickie and Jack Farber Institute for NeuroscienceJefferson Comprehensive Epilepsy CenterThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Ashwini Sharan
- Division of Epilepsy and Neuromodulation NeurosurgeryVickie and Jack Farber Institute for NeuroscienceThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Sebastien Ourselin
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
- Wellcome/EPSRC Centre for Interventional and Surgical SciencesUniversity College LondonLondonUK
| | - John S. Duncan
- Department of Clinical and Experimental EpilepsyUCL Institute of NeurologyNational Hospital for Neurology and NeurosurgeryLondonUK
- Epilepsy Society MRI UnitChalfont St PeterUK
| | - Chengyuan Wu
- Division of Epilepsy and Neuromodulation NeurosurgeryVickie and Jack Farber Institute for NeuroscienceThomas Jefferson UniversityPhiladelphiaPAUSA
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A classification system for verifying the long-term efficacy of resective surgery for drug-resistant seizures. Epilepsy Res 2018; 141:23-30. [PMID: 29414384 DOI: 10.1016/j.eplepsyres.2018.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To verify the long-term efficacy of resective surgery, we created a classification system in which strictly defined patterns of postoperative seizure emergence are incorporated as basic components and the seizure states throughout the entire follow-up period are assessed comprehensively. METHODS In our system, Class I has three subclasses (A-C); subclasses A and B are identical to Engel I-A and I-B, respectively. Subclass C comprises patients whose disabling seizures remit within the first 2 years postoperatively. Patients in Class II have only 1-3 days with disabling seizures throughout follow-up after the first 2 years. Patients in Class III have a maximum of 3 seizure days annually, and those in Class IV have ≥4 seizure days annually after the first 2 years. Classes II-IV each have 2 subclasses (A and B): subclass A, late recurrence (i.e., the first seizure occurs after 2 years postoperatively); and subclass B, early recurrence (i.e., first seizure within 2 years). In 646 patients who underwent resective surgery (temporal lobe resection, 74.6%) and were followed for at least 8 years (mean, 14.6 years), we analyzed three patterns of postoperative seizures: early remission, late recurrence, and occasional seizures. In addition, we investigated the differences between the long-term seizure outcomes of the cohort as determined according to our system and the Engel scale. RESULTS Overall, 52.9% of the cohort experienced at least one disabling seizure postoperatively throughout the follow-up period; in 1/3 of these patients, the first seizure occurred after 2 years. In 73.8% of the 80 patients who manifested the running-down phenomenon, seizure remission occurred within the first 2 years. In addition, 36.7% of the 283 patients who had disabling seizures after 2 years experienced only 1-3 seizure days. Engel Class I-C included about 30% of the patients who had ≥4 seizure days after 2 years. The long-term seizure outcomes, determined according to our system, were: Class I, 56.2% (C, 9.1%) of the overall cohort; Class II, 16.1% (A, 11.0%); and Class III/IV, 27.7% (A, 6.6%). CONCLUSION Our system clarifies the actual effect of resective surgery more precisely than the Engel scale and thus may be useful for comparing outcomes between different surgical procedures or for identifying potential risk factors predicting unfavorable outcome.
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Petito GT, Wharen RE, Feyissa AM, Grewal SS, Lucas JA, Tatum WO. The impact of stereotactic laser ablation at a typical epilepsy center. Epilepsy Behav 2018; 78:37-44. [PMID: 29172137 DOI: 10.1016/j.yebeh.2017.10.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/29/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Stereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes. METHODS A retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan-Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset. RESULTS One hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55-60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p=0.79). Stereotactic laser ablation patients were older than those with resections (47.0years vs. 35.4years, p=0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18days) compared with open resection (3.43days; SD: 3.16 days) (p=0.0002). CONCLUSION We now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA.
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Affiliation(s)
- Gabrielle T Petito
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Robert E Wharen
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Anteneh M Feyissa
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Sanjeet S Grewal
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - John A Lucas
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - William O Tatum
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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9
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Kitwitee P, Unnwongse K, Srikijvilaikul T, Yadee T, Limwattananon C. Cost-Utility of Video-Electroencephalography Monitoring Followed by Surgery in Adults with Drug-Resistant Focal Epilepsy in Thailand. World Neurosurg 2016; 98:750-760.e3. [PMID: 27913266 DOI: 10.1016/j.wneu.2016.11.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/05/2016] [Accepted: 11/07/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study assessed whether video-electroencephalography (VEEG) monitoring followed by surgery was cost-effective in adult patients with drug-resistant focal epilepsy under Thai health care context, as compared with continued medical treatment without VEEG. METHODS The total cost (in Thai Baht, THB) and effectiveness (in quality-adjusted life years, QALYs) were estimated over a lifetime horizon, using a decision tree and a Markov model. Data on short-term surgical outcomes, direct health care costs, and utilities were collected from Thai patients in a specialized hospital. Long-term outcomes and relative effectiveness of the surgery over medical treatment were derived, using systematic reviews of published literature. RESULTS Seizure-free rates at years 1 and 2 after surgery were 79.4% and 77.8%, respectively. Costs of VEEG and surgery plus 1-year follow-up care were 216,782 THB, of which the VEEG and other necessary investigations were the main cost drivers (42.8%). On the basis of societal perspective, the total cost over a 40-year horizon accrued to 1,168,679 THB for the VEEG option, 64,939 THB higher than that for no VEEG. The VEEG option contributed to an additional 1.50 QALYs over no VEEG, resulting in an incremental cost-effectiveness ratio of 43,251 THB (USD 1236) per 1 QALY gained. Changes in key parameters had a minimal impact on the incremental cost-effectiveness ratio. Accounting for uncertainty, there was an 84% probability that the VEEG option was cost-effective on the basis of Thailand's cost-effective threshold of 160,000 THB/QALY. CONCLUSIONS For patients with drug-resistant epilepsy, VEEG monitoring followed by epilepsy surgery was cost-effective in Thailand. Therefore it should be recommended for health insurance coverage.
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Affiliation(s)
- Pimprapa Kitwitee
- Pharmacy and Health System Program, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen
| | | | | | - Tinonkorn Yadee
- Department of Neurology, Prasat Neurological Institute, Bangkok
| | - Chulaporn Limwattananon
- Department of linical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
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10
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King-Stephens D, Mirro E, Weber PB, Laxer KD, Van Ness PC, Salanova V, Spencer DC, Heck CN, Goldman A, Jobst B, Shields DC, Bergey GK, Eisenschenk S, Worrell GA, Rossi MA, Gross RE, Cole AJ, Sperling MR, Nair DR, Gwinn RP, Park YD, Rutecki PA, Fountain NB, Wharen RE, Hirsch LJ, Miller IO, Barkley GL, Edwards JC, Geller EB, Berg MJ, Sadler TL, Sun FT, Morrell MJ. Lateralization of mesial temporal lobe epilepsy with chronic ambulatory electrocorticography. Epilepsia 2015; 56:959-67. [PMID: 25988840 PMCID: PMC4676303 DOI: 10.1111/epi.13010] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with suspected mesial temporal lobe (MTL) epilepsy typically undergo inpatient video-electroencephalography (EEG) monitoring with scalp and/or intracranial electrodes for 1 to 2 weeks to localize and lateralize the seizure focus or foci. Chronic ambulatory electrocorticography (ECoG) in patients with MTL epilepsy may provide additional information about seizure lateralization. This analysis describes data obtained from chronic ambulatory ECoG in patients with suspected bilateral MTL epilepsy in order to assess the time required to determine the seizure lateralization and whether this information could influence treatment decisions. METHODS Ambulatory ECoG was reviewed in patients with suspected bilateral MTL epilepsy who were among a larger cohort with intractable epilepsy participating in a randomized controlled trial of responsive neurostimulation. Subjects were implanted with bilateral MTL leads and a cranially implanted neurostimulator programmed to detect abnormal interictal and ictal ECoG activity. ECoG data stored by the neurostimulator were reviewed to determine the lateralization of electrographic seizures and the interval of time until independent bilateral MTL electrographic seizures were recorded. RESULTS Eighty-two subjects were implanted with bilateral MTL leads and followed for 4.7 years on average (median 4.9 years). Independent bilateral MTL electrographic seizures were recorded in 84%. The average time to record bilateral electrographic seizures in the ambulatory setting was 41.6 days (median 13 days, range 0-376 days). Sixteen percent had only unilateral electrographic seizures after an average of 4.6 years of recording. SIGNIFICANCE About one third of the subjects implanted with bilateral MTL electrodes required >1 month of chronic ambulatory ECoG before the first contralateral MTL electrographic seizure was recorded. Some patients with suspected bilateral MTL seizures had only unilateral electrographic seizures. Chronic ambulatory ECoG in patients with suspected bilateral MTL seizures provides data in a naturalistic setting, may complement data from inpatient video-EEG monitoring, and can contribute to treatment decisions.
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Affiliation(s)
- David King-Stephens
- Pacific Epilepsy Program, Pacific Medical Center, San Francisco, California, 94115, U.S.A
| | - Emily Mirro
- NeuroPace, Inc., Mountain View, California, 94043, U.S.A
| | - Peter B Weber
- Pacific Epilepsy Program, Pacific Medical Center, San Francisco, California, 94115, U.S.A
| | - Kenneth D Laxer
- Pacific Epilepsy Program, Pacific Medical Center, San Francisco, California, 94115, U.S.A
| | - Paul C Van Ness
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
| | - Vicenta Salanova
- Department of Neurology, Indiana University, Indianapolis, Indiana, 46202, U.S.A
| | - David C Spencer
- Oregon Health and Science University, Portland, Oregon, 97239, U.S.A
| | - Christianne N Heck
- USC Comprehensive Epilepsy Program, Los Angeles, California, 90089, U.S.A
| | - Alica Goldman
- Baylor College of Medicine, Houston, Texas, 77030, U.S.A
| | - Barbara Jobst
- Dartmouth-Hitchcock Epilepsy Center, Lebanon, New Hampshire, 03756, U.S.A
| | - Donald C Shields
- George Washington University, Washington, District of Columbia, 20052, U.S.A
| | - Gregory K Bergey
- Johns Hopkins Epilepsy Center, Baltimore, Maryland, 21287, U.S.A
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida, Gainesville, Florida, 32611, U.S.A
| | - Gregory A Worrell
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, 55905, U.S.A
| | | | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Andrew J Cole
- MGH Epilepsy Service, Massachusetts General Hospital, Boston, Massachusetts, 02114, U.S.A
| | - Michael R Sperling
- Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, U.S.A
| | - Dileep R Nair
- Cleveland Clinic Neurological Institute, Cleveland, Ohio, 44195, U.S.A
| | - Ryder P Gwinn
- Swedish Neuroscience Institute, Seattle, Washington, 98052, U.S.A
| | - Yong D Park
- Georgia Regents University, Augusta, Georgia, 30912, U.S.A
| | - Paul A Rutecki
- University of Wisconsin, Madison, Wisconsin, 53792, U.S.A
| | - Nathan B Fountain
- Comprehensive Epilepsy Center, University of Virginia, Charlottesville, Virginia, 22908, U.S.A
| | - Robert E Wharen
- Mayo Clinic Jacksonville, Jacksonville, Florida, 32224, U.S.A
| | - Lawrence J Hirsch
- Yale University School of Medicine, New Haven, Connecticut, 06510, U.S.A
| | - Ian O Miller
- Comprehensive Epilepsy Center, Miami Children's Hospital, Miami, Florida, 33155, U.S.A
| | | | - Jonathan C Edwards
- The Medical University of South Carolina, Charleston, South Carolina, 29425, U.S.A
| | - Eric B Geller
- Institute of Neurology and Neurosurgery at Saint Barnabas, Livingston, New Jersey, 07039, U.S.A
| | - Michel J Berg
- University of Rochester Medical Center, Rochester, New York, 14642, U.S.A
| | - Toni L Sadler
- Via Christi Comprehensive Epilepsy Center, Wichita, Kansas, 67214, U.S.A
| | - Felice T Sun
- NeuroPace, Inc., Mountain View, California, 94043, U.S.A
| | - Martha J Morrell
- NeuroPace, Inc., Mountain View, California, 94043, U.S.A.,Stanford Comprehensive Epilepsy Center, Stanford, California, 94305, U.S.A
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Goellner E, Bianchin MM, Burneo JG, Parrent AG, Steven DA. Timing of early and late seizure recurrence after temporal lobe epilepsy surgery. Epilepsia 2013; 54:1933-41. [DOI: 10.1111/epi.12389] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Eduardo Goellner
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
- Hospital Mãe de Deus; Porto Alegre Rio Grande do Sul Brazil
- Postgraduate Program in Medical Sciences; Federal University of Rio Grande do Sul; Porto Alegre Rio Grande do Sul Brazil
| | - Marino M. Bianchin
- Postgraduate Program in Medical Sciences; Federal University of Rio Grande do Sul; Porto Alegre Rio Grande do Sul Brazil
| | - Jorge G. Burneo
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
| | - Andrew G. Parrent
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
| | - David A. Steven
- Epilepsy Program; Department of Clinical Neurological Sciences; Western University; London Health Sciences Centre; London Ontario Canada
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12
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Kunieda T, Mikuni N, Shibata S, Inano R, Yamao Y, Kikuchi T, Matsumoto R, Takahashi J, Ikeda A, Fukuyama H, Miyamoto S. Long-term seizure outcome following resective surgery for epilepsy: to be or not to be completely cured? Neurol Med Chir (Tokyo) 2013; 53:805-13. [PMID: 24140768 PMCID: PMC4508714 DOI: 10.2176/nmc.oa2013-0065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Surgical intervention is expected to improve the quality of life in patients with intractable epilepsy by providing adequate seizure control. Although many previous studies showed various rates of seizure freedom, definite conclusions have not yet been made regarding outcomes. In order to clarify the long-term postoperative outcome for a period up to 10 years, a retrospective review of our patients was performed longitudinally by using the survival analysis method. The postoperative state of epilepsy in 76 patients who underwent resection surgery was assessed based on Engel’s criteria. In addition, Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom. In this patient group, abnormal lesion were detected by MRI in 70 out of 76 cases, and the ictal onset zone was finally identified within temporal lobe in 51 cases. The most favorable outcome, defined as Engel Class Ia, was observed in 26 (37%), 24 (40%), and 18 (41%) cases at 2, 5, and 10 years after surgery, respectively. The Kaplan-Meier survival curve in the overall group estimated the probability of seizure freedom as 75% (95% confidence interval [CI] 70–80%), 67% (62–72%), and 51% (45–57%) at 2, 5, and 10 years follow up, respectively. Half of all seizure recurrences occurred within the first 2 postoperative years. In this study, we showed that long-term favorable outcome of seizure control following resection surgery can be achieved in more than half of the patients.
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Affiliation(s)
- Takeharu Kunieda
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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13
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Staack AM, Wendling AS, Scholly J, Wisniewski I, Kurth C, Saar J, Mathews K, Bodin F, Fauser S, Altenmüller DM, Freiman TM, Schulze-Bonhage A, Zentner J, Reinshagen G, Steinhoff BJ. Quality control of elective surgery for drug-resistant epilepsy in a German reference centre—A long-term outcome study. Seizure 2013; 22:292-8. [DOI: 10.1016/j.seizure.2013.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/23/2013] [Accepted: 01/24/2013] [Indexed: 11/29/2022] Open
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Mitchell JW, Seri S, Cavanna AE. Pharmacotherapeutic and Non-Pharmacological Options for Refractory and Difficult-to-Treat Seizures. J Cent Nerv Syst Dis 2012; 4:105-15. [PMID: 23650471 PMCID: PMC3619658 DOI: 10.4137/jcnsd.s8315] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
It is currently estimated that about 20%-30% of adults and 10%-40% of children diagnosed with epilepsy suffer from uncontrolled or poorly controlled seizures, despite optimal medical management. In addition to its huge economic costs, treatment-refractory epilepsy has a widespread impact on patients' health-related quality of life. The present paper focuses on the concepts of refractory and difficult-to-treat seizures and their pharmacological management. Evidence on efficacy and tolerability of rational pharmacotherapy with antiepileptic drug combinations and of non-pharmacological treatment options such as epilepsy surgery, neurostimulation, metabolic treatment and herbal remedies is reviewed. The importance of early identification of the underlying etiology of the specific epilepsy syndrome is emphasized, to inform early prognosis and therapeutic strategies.
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Affiliation(s)
- James W. Mitchell
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, United Kingdom
| | - Andrea E. Cavanna
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, United Kingdom
- Institute of Neurology, UCL, London, United Kingdom
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15
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Pimentel J, Peralta AR, Campos A, Bentes C, Ferreira AG. Antiepileptic drugs management and long-term seizure outcome in post surgical mesial temporal lobe epilepsy with hippocampal sclerosis. Epilepsy Res 2012; 100:55-8. [DOI: 10.1016/j.eplepsyres.2012.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 01/12/2012] [Accepted: 01/15/2012] [Indexed: 10/14/2022]
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Sarkis RA, Jehi L, Najm IM, Kotagal P, Bingaman WE. Seizure outcomes following multilobar epilepsy surgery. Epilepsia 2011; 53:44-50. [DOI: 10.1111/j.1528-1167.2011.03274.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE To explore the effect of anterior temporal lobectomy on employment and define demographic and clinical predictors of postoperative employment in a large cohort with a prolonged observational period. METHODS Subjects had an anterior temporal lobectomy for refractory epilepsy. All had an assessment period of 4 years or more with documentation of demographic factors, employment status, and seizure frequency prospectively registered in a database at surgery and at each contact after surgery. McNemar chi-square and a Wilcoxon matched pairs test were used to compare employment status before and after surgery. A multiple logistic regression assessed independent predictors of postoperative employment status based on preoperative employment status. KEY FINDINGS Three hundred sixty-nine patients were evaluated. Employment levels were higher and unemployment levels were lower after surgery (McNemar χ(2) = 3.96; p = 0.047). Working before surgery (Wald's χ(2) = 22.69, p < 0.0001) and having a greater percent of seizure-free years (Wald's χ(2) = 34.43, p < 0.0001) were associated with being employed after surgery. Of 131 patients who were unemployed or homemakers before surgery, 67 (51.1%) became employed postoperatively, with a younger age at surgery, a younger age of epilepsy onset, and driving a motor vehicle associated with gaining employment. Of 172 patients who were working at baseline, 27 (15.7%) became unemployed or homemakers after surgery. Gender was the only variable associated with loss of employment, with women being more likely to become homemakers (χ(2) = 14.98, d.f.= 6, p = 0.02). Most students were working after surgery, with seizure control influencing outcome. SIGNIFICANCE Anterior temporal lobectomy is followed by reduced unemployment and underemployment, with elimination of seizures, relative youth, and operating a motor vehicle serving as the main driving forces for improvement. This is important information for patients and physicians who contemplate surgery as it helps define reasonable expectations, and provides further objective evidence for benefits beyond purely medical outcomes after epilepsy surgery.
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Affiliation(s)
- Katherine Zarroli
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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18
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Electrocorticography and seizure outcomes in children with lesional epilepsy. Childs Nerv Syst 2011; 27:381-90. [PMID: 20857122 DOI: 10.1007/s00381-010-1279-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 09/07/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE The use of electrocorticographically (ECoG)-guided cortical resection in children with lesional epilepsy is controversial. Given the important developmental issues associated with recurrent childhood seizures, sustained seizure control is a key therapeutic goal. We therefore evaluated the effect of the decision to perform lesionectomy or ECoG-guided cortical resection on seizure outcome and surgical morbidity in the pediatric population. METHODS We retrospectively analyzed seizure outcomes in 67 patients between the ages of 3 months and 16 years who underwent surgery for lesional epilepsy at British Columbia Children's Hospital. Thirty-four patients underwent ECoG, and 33 patients had lesionectomy without ECoG. RESULTS One year post-operatively, 80% of patients who had ECoG-guided cortical resection or lesionectomy were seizure free. However, there was a trend toward improved seizure freedom in patients who had ECoG at most recent follow-up (79% patients with ECoG seizure free, vs. 61% with lesionectomy only; mean follow-up time 5.8 year, P=0.078). There was no increase in neurological morbidity in patients who had ECoG-guided cortical resection, and these patients were less likely to experience repeat epilepsy surgery. CONCLUSIONS Overall, using ECoG to guide additional cortical resection may lead to more robust seizure freedom in children with lesional epilepsy without increasing their risk of surgical morbidity.
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Buckingham SE, Chervoneva I, Sharan A, Zangaladze A, Mintzer S, Skidmore C, Nei M, Evans J, Pequignot E, Sperling MR. Latency to first seizure after temporal lobectomy predicts long-term outcome. Epilepsia 2010; 51:1987-93. [DOI: 10.1111/j.1528-1167.2010.02721.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The Irish epilepsy surgery experience: Long-term follow-up. Seizure 2010; 19:247-52. [PMID: 20359911 DOI: 10.1016/j.seizure.2010.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 11/09/2009] [Accepted: 03/05/2010] [Indexed: 11/20/2022] Open
Abstract
AIM To assess the long-term seizure outcome of Irish patients who underwent resective surgery for refractory epilepsy since 1975. We also wished to determine the impact of pathology and surgical technique (with particular reference to neocorticectomy) on seizure outcome. METHODS A retrospective review of medical notes, radiological and histopathological records, was undertaken between 1975 and 2005. Missing data was supplemented by telephone calls to patients. One hundred and ninety-nine patients suited the criteria for inclusion and had at least 1-year follow-up (1-24 years, mean 7.0 years). Engel's criteria were used to classify seizure outcome at 1, 2, 5, 10, 15 and >15 years follow-up. RESULTS The percentage of patients seizure free at 2, 5, 10, 15 and >15 years were, 56.6%, 41.4%, 44%, 25% and 31.3%, respectively. Of patients with a pathologically confirmed diagnosis of mesial temporal sclerosis, 55.6% were seizure free at 10 years. Equivalent figures for tumour were 62.5%, for cortical dysplasia, 34.8%, for those without any demonstrable pathologic abnormality, 50%, for dual pathology, 50% and for all others, 33.3%. Of those with 10 years or greater follow-up only 20% of neocorticectomy patients were in Engel class 1, compared with an average of 58.5% for the other surgical techniques. CONCLUSION Seizure freedom rates for Irish Patients were comparable to other large retrospective studies. Patients who underwent selective procedures tended to do better than those undergoing lobar resections, in keeping with international trends. The surgical technique unique to the Irish cohort, temporal necocorticectomy, had the worst long-term outcome.
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Kwan P, Sperling MR. Refractory seizures: Try additional antiepileptic drugs (after two have failed) or go directly to early surgery evaluation? Epilepsia 2009; 50 Suppl 8:57-62. [DOI: 10.1111/j.1528-1167.2009.02237.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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