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Vessell M, Willett A, Ugiliweneza B, Sharma M, Mutchnick I, Boakye M, Chern J, Weiner H, Neimat J. National 22-year epilepsy surgery landscape shows increasing open and minimally invasive pediatric epilepsy surgery. Epilepsia 2024. [PMID: 38943543 DOI: 10.1111/epi.18030] [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: 01/16/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES A surgical "treatment gap" in pediatric epilepsy persists despite the demonstrated safety and effectiveness of surgery. For this reason, the national surgical landscape should be investigated such that an updated assessment may more appropriately guide health care efforts. METHODS In our retrospective cross-sectional observational study, the National Inpatient Sample (NIS) database was queried for individuals 0 to <18 years of age who had an International Classification of Diseases (ICD) code for drug-resistant epilepsy (DRE). This cohort was then split into a medical group and a surgical group. The former was defined by ICD codes for -DRE without an accompanying surgical code, and the latter was defined by DRE and one of the following epilepsy surgeries: any open surgery; laser interstitial thermal therapy (LITT); vagus nerve stimulation; or responsive neurostimulation (RNS) from 1998 to 2020. Demographic variables of age, gender, race, insurance type, hospital charge, and hospital characteristics were analyzed between surgical options. Continuous variables were analyzed with weight-adjusted quantile regression analysis, and categorical variables were analyzed by weight-adjusted counts with percentages and compared with weight-adjusted chi-square test results. RESULTS These data indicate an increase in epilepsy surgeries over a 22-year period, primarily due to a statistically significant increase in open surgery and a non-significant increase in minimally invasive techniques, such as LITT and RNS. There are significant differences in age, race, gender, insurance type, median household income, Elixhauser index, hospital setting, and size between the medical and surgical groups, as well as the procedure performed. SIGNIFICANCE An increase in open surgery and minimally invasive surgeries (LITT and RNS) account for the overall rise in pediatric epilepsy surgery over the last 22 years. A positive inflection point in open surgery is seen in 2005. Socioeconomic disparities exist between medical and surgical groups. Patient and hospital sociodemographics show significant differences between the procedure performed. Further efforts are required to close the surgical "treatment gap."
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Affiliation(s)
- Meena Vessell
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Austin, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew Willett
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Mayur Sharma
- Department of Neurological Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ian Mutchnick
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Pediatric Neurosurgery, Norton Neuroscience Institute, Louisville, Kentucky, USA
| | - Maxwell Boakye
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Chern
- Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Howard Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Austin, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Neimat
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Lado FA, Ahrens SM, Riker E, Muh CR, Richardson RM, Gray J, Small B, Lewis SZ, Schofield TJ, Clarke DF, Hopp JL, Lee RR, Salpekar JA, Arnold ST. Guidelines for Specialized Epilepsy Centers: Executive Summary of the Report of the National Association of Epilepsy Centers Guideline Panel. Neurology 2024; 102:e208087. [PMID: 38306606 PMCID: PMC10962912 DOI: 10.1212/wnl.0000000000208087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 02/04/2024] Open
Abstract
The National Association of Epilepsy Centers first published the guidelines for epilepsy centers in 1990, which were last updated in 2010. Since that update, epilepsy care and the science of guideline development have advanced significantly, including the importance of incorporating a diversity of stakeholder perspectives such as those of patients and their caregivers. Currently, despite extensive published data examining the efficacy of treatments and diagnostic testing for epilepsy, there remain significant gaps in data identifying the essential services needed for a comprehensive epilepsy center and the optimal manner for their delivery. The trustworthy consensus-based statements (TCBS) process produces unbiased, scientifically valid guidelines through a transparent process that incorporates available evidence and expert opinion. A systematic literature search returned 5937 relevant studies from which 197 articles were retained for data extraction. A panel of 41 stakeholders with diverse expertise evaluated this evidence and drafted recommendations following the TCBS process. The panel reached consensus on 52 recommendations covering services provided by specialized epilepsy centers in both the inpatient and outpatient settings in major topic areas including epilepsy monitoring unit care, surgery, neuroimaging, neuropsychology, genetics, and outpatient care. Recommendations were informed by the evidence review and reflect the consensus of a broad panel of expert opinions.
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Affiliation(s)
- Fred A Lado
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Stephanie M Ahrens
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Ellen Riker
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Carrie R Muh
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - R Mark Richardson
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Johanna Gray
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Barbara Small
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Sandra Z Lewis
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Thomas J Schofield
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Dave F Clarke
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Jennifer L Hopp
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Roland R Lee
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Jay A Salpekar
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
| | - Susan T Arnold
- Zucker School of Medicine at Hofstra/Northwell (F.A.L.), Hempstead, NY; The Ohio State University College of Medicine (S.M.A.), Columbus; National Association of Epilepsy Centers (E.R., J.G., B.S.), Washington, DC; New York Medical College (C.R.M.), Valhalla, NY; Harvard Medical School (R.M.R.), Boston, MA; EBQ Consulting (S.Z.L., T.J.S.), Santa Monica, CA; University of Texas at Austin Dell Medical School (D.F.C.); University of Maryland School of Medicine (J.L.H.), Baltimore; University of California San Diego School of Medicine (R.R.L.); Johns Hopkins University Medical School (J.A.S.), Baltimore, MD; Yale School of Medicine (S.T.A.), New Haven, CT
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Subramaniam VR, Mu L, Kwon CS. Comparing vagus nerve stimulation and resective surgery outcomes in patients with co-occurring autism and epilepsy to patients with epilepsy alone: A population-based study. Autism Res 2023; 16:1924-1933. [PMID: 37646480 DOI: 10.1002/aur.3020] [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: 01/24/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
Autism and epilepsy commonly co-occur. Understanding trends in healthcare utilization and in-hospital outcomes amongst patients with autism and epilepsy can help optimize care and reduce costs. We compared hospital outcomes amongst patients with autism and epilepsy to those with epilepsy alone undergoing vagus nerve stimulation (VNS) and resective/disconnective surgery. Differences in discharge status, in-hospital mortality, mean length of stay (LOS), cost and surgical/medical complications were examined. Elective surgical admissions amongst patients with epilepsy alone and co-occurring autism and epilepsy were identified in the 2003-14 National Inpatient Sample (NIS) using previously validated ICD-9-CM case definitions. One patient with co-occurring epilepsy and autism was matched to three epilepsy patients for age, sex and (1) VNS and (2) resective/disconnective surgery. Multinomial logistic regressions were performed to examine the outcomes of interest. Data were collected on: (1) VNS-52 (mean age: 12.79 ± 1.03; 19.27% female) hospital admissions in persons with comorbid autism and epilepsy, 156 (mean age: 12.84 ± 0.71; 19.31% female) matched controls with epilepsy alone; (2) resective/disconnective surgery-113 (mean age: 12.99 ± 0.84; 24.55% female) with comorbid autism and epilepsy, 339 (mean age: 13.37 ± 0.68; 23.86% female) matched controls with epilepsy alone. Compared to patients with epilepsy alone, patients with autism and epilepsy who underwent either surgery showed no differences for in-hospital mortality, discharge status, mean LOS, hospitalization cost, and surgical/medical complications. Our study shows the feasibility and safety of epilepsy VNS and resective surgery in those with ASD do not differ with those with epilepsy alone, contrary to the prevalent safety concerns of epilepsy surgery in patients with ASD.
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Affiliation(s)
- Varun R Subramaniam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lan Mu
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Churl-Su Kwon
- Columbia University Irving Medical Center, Department of Neurosurgery, Neurology, Epidemiology, The Gertrude H. Sergievsky Center, New York, New York, USA
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Paulo DL, Ball TJ, Englot DJ. Emerging Technologies for Epilepsy Surgery. Neurol Clin 2022; 40:849-867. [DOI: 10.1016/j.ncl.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Punia V. The State of Specialized Epilepsy Care in the States: Increased Access, New Tools, but the Same Dismal Underutilization of Epilepsy Surgery. Epilepsy Curr 2022; 22:228-230. [PMID: 36187142 PMCID: PMC9483761 DOI: 10.1177/15357597221099065] [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: 11/24/2022] Open
Abstract
United States Epilepsy Center Characteristics: A
Data Analysis From the National Association of
Epilepsy Centers Ostendorf AP, Ahrens SM, Lado FA, et al.
Neurology. 2022;98(5):e449-e458.
doi:10.1212/WNL.0000000000013130. Background and objectives: Patients with drug-resistant epilepsy (DRE) may benefit
from specialized testing and treatments to better
control seizures and improve quality of life. Most
evaluations and procedures for DRE in the United
States are performed at epilepsy centers accredited
by the National Association of Epilepsy Centers
(NAEC). On an annual basis, the NAEC collects data
from accredited epilepsy centers on hospital-based
epilepsy monitoring unit (EMU) size and admissions,
diagnostic testing, surgeries, and other services.
This article highlights trends in epilepsy center
services from 2012 through 2019. Methods: We analyzed data reported in 2012, 2016, and 2019 from
all level 3 and level 4 NAEC accredited epilepsy
centers. Data were described using frequency for
categorical variables and median for continuous
variables and were analyzed by center level and
center population category. EMU beds, EMU
admissions, epileptologists, and aggregate procedure
volumes were also described using rates per
population per year. Results: During the period studied, the number of NAEC
accredited centers increased from 161 to 256, with
the largest increases in adult- and pediatric-only
centers. Growth in EMU admissions (41%), EMU beds
(26%), and epileptologists (109%) per population
occurred. Access to specialized testing and services
broadly expanded. The largest growth in procedure
volumes occurred in laser interstitial thermal
therapy (LiTT) (61%), responsive neurostimulation
(RNS) implantations (114%), and intracranial
monitoring without resection (152%) over the study
period. Corpus callosotomies and vagus nerve
stimulator (VNS) implantations decreased (−12.8% and
−2.4%, respectively), while growth in temporal
lobectomies (5.9%), extratemporal resections
(11.9%), and hemispherectomies/otomies (13.1%)
lagged center growth (59%), leading to a decrease in
median volumes of these procedures per center. Discussion: During the study period, the availability of specialty
epilepsy care in the United States improved as the
NAEC implemented its accreditation program. Surgical
case complexity increased while aggregate surgical
volume remained stable or declined across most
procedure types, with a corresponding decline in
cases per center. This article describes recent data
trends and current state of resources and practice
across NAEC member centers and identifies several
future directions for driving systematic
improvements in epilepsy care.
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Ahrens SM, Ostendorf AP, Lado FA, Arnold ST, Bai S, Bensalem-Owen MK, Chapman KE, Clarke DF, Eisner M, Fountain NB, Gray JM, Gunduz MT, Hopp JL, Riker E, Schuele SU, Small B, Herman ST. Impact of the COVID-19 Pandemic on Epilepsy Center Practice in the United States. Neurology 2022; 98:e1893-e1901. [PMID: 35292559 PMCID: PMC9141627 DOI: 10.1212/wnl.0000000000200285] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Persons with epilepsy, especially those with drug resistant epilepsy (DRE), may benefit from inpatient services such as admission to the epilepsy monitoring unit (EMU) and epilepsy surgery. The COVID-19 pandemic caused reductions in these services within the US during 2020. This article highlights changes in resources, admissions, and procedures among epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). METHODS We compared data reported in 2019, prior to the COVID-19 pandemic, and 2020 from all 260 level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level, center population category, and geographical location. Qualitative responses from center directors to questions regarding the impact from COVID-19 were summarized utilizing thematic analysis. Responses from the NAEC center annual reports as well as a supplemental COVID-19 survey were included. RESULTS EMU admissions declined 23% (-21,515) in 2020, with largest median reductions in level 3 centers [-55 admissions (-44%)] and adult centers [-57 admissions (-39%)]. The drop in admissions was more substantial in the East North Central, East South Central, Mid Atlantic, and New England US Census divisions. Survey respondents attributed reduced admissions to re-assigning EMU beds, restrictions on elective admissions, reduced staffing, and patient reluctance for elective admission. Treatment surgeries declined by 371 cases (5.7%), with the largest reduction occurring in VNS implantations [-486 cases (-19%)] and temporal lobectomies [-227 cases (-16%)]. All other procedure volumes increased, including a 35% (54 cases) increase in corpus callosotomies. DISCUSSION In the US, access to care for persons with epilepsy declined during the COVID-19 pandemic in 2020. Adult patients, those relying on level 3 centers for care, and many persons in the eastern half of the US were most affected.
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Affiliation(s)
- Stephanie M Ahrens
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Adam P Ostendorf
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Fred Alexander Lado
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Susan T Arnold
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Shasha Bai
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Meriem K Bensalem-Owen
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Kevin E Chapman
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Dave F Clarke
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Mariah Eisner
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Nathan B Fountain
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Johanna M Gray
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Muhammed Talha Gunduz
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Jennifer L Hopp
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Ellen Riker
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Stephan U Schuele
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Barbara Small
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
| | - Susan T Herman
- From the Department of Pediatrics (S.M.A., A.P.O., M.T.G.), Nationwide Children's Hospital and Ohio State University, Columbus; Department of Neurology (F.A.L.), Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY; Department of Pediatrics (S.T.A.), Children's Medical Center, Dallas, TX; Pediatric Biostatistics Core (S.B.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (M.K.B.O.), University of Kentucky, Lexington; Department of Child Health (K.E.C.), University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital; Division of Pediatric Neurology, Department of Neurology (D.F.C.), Dell Medical School, University of Texas at Austin; Biostatistics Resource at Nationwide Children's Hospital (M.E.), Columbus, OH; Department of Neurology (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; National Association of Epilepsy Centers (J.M.G., E.R., B.S.), Washington, DC; University of Maryland Medical Center (J.L.H.), Baltimore; Ken and Ruth Davee Department of Neurology (S.U.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Department of Neurology (S.T.H.), Barrow Neurological Institute, Phoenix, AZ
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7
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Richardson RM. Closed-Loop Brain Stimulation and Paradigm Shifts in Epilepsy Surgery. Neurol Clin 2022; 40:355-373. [PMID: 35465880 PMCID: PMC9271409 DOI: 10.1016/j.ncl.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Advances in device technology have created greater flexibility in treating seizures as emergent properties of networks that exist on a local to global continuum. All patients with drug-resistant epilepsy are potential surgical candidates, given that intracranial neuromodulation through deep brain stimulation and responsive neurostimulation can reduce seizures and improve quality of life, even in multifocal and generalized epilepsies. To achieve this goal, indications and strategies for diagnostic epilepsy surgery are evolving. This article describes the state-of-the-art in epilepsy surgery and related changes in how we define indications for diagnostic and therapeutic surgical intervention.
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Wu C, Schwalb JM, Rosenow JM, McKhann GM, Neimat JS. The American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy. Neurosurgery 2022; 90:155-160. [PMID: 34995216 DOI: 10.1227/neu.0000000000001799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a novel tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the recent introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN position statement is based.
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Affiliation(s)
- Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Joshua M Rosenow
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University Medical Center, New York, New York, USA
| | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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9
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Ostendorf AP, Ahrens SM, Lado FA, Arnold ST, Bai S, Bensalem Owen MK, Chapman KE, Clarke DF, Eisner M, Fountain NB, Gray JM, Hopp JL, Riker E, Schuele SU, Small BV, Herman ST. United States Epilepsy Center Characteristics: A Data Analysis From the National Association of Epilepsy Centers. Neurology 2021; 98:e449-e458. [PMID: 34880093 PMCID: PMC8826463 DOI: 10.1212/wnl.0000000000013130] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background and Objectives Patients with drug-resistant epilepsy (DRE) may benefit from specialized testing and treatments to better control seizures and improve quality of life. Most evaluations and procedures for DRE in the United States are performed at epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). On an annual basis, the NAEC collects data from accredited epilepsy centers on hospital-based epilepsy monitoring unit (EMU) size and admissions, diagnostic testing, surgeries, and other services. This article highlights trends in epilepsy center services from 2012 through 2019. Methods We analyzed data reported in 2012, 2016, and 2019 from all level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level and center population category. EMU beds, EMU admissions, epileptologists, and aggregate procedure volumes were also described using rates per population per year. Results During the period studied, the number of NAEC accredited centers increased from 161 to 256, with the largest increases in adult- and pediatric-only centers. Growth in EMU admissions (41%), EMU beds (26%), and epileptologists (109%) per population occurred. Access to specialized testing and services broadly expanded. The largest growth in procedure volumes occurred in laser interstitial thermal therapy (LiTT) (61%), responsive neurostimulation (RNS) implantations (114%), and intracranial monitoring without resection (152%) over the study period. Corpus callosotomies and vagus nerve stimulator (VNS) implantations decreased (−12.8% and −2.4%, respectively), while growth in temporal lobectomies (5.9%), extratemporal resections (11.9%), and hemispherectomies/otomies (13.1%) lagged center growth (59%), leading to a decrease in median volumes of these procedures per center. Discussion During the study period, the availability of specialty epilepsy care in the United States improved as the NAEC implemented its accreditation program. Surgical case complexity increased while aggregate surgical volume remained stable or declined across most procedure types, with a corresponding decline in cases per center. This article describes recent data trends and current state of resources and practice across NAEC member centers and identifies several future directions for driving systematic improvements in epilepsy care.
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Affiliation(s)
- Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Stephanie M Ahrens
- Department of Pediatrics, Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Fred Alexander Lado
- Department of Neurology, Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY
| | - Susan T Arnold
- Department of Pediatrics, Children's Medical Center, Dallas, TX
| | - Shasha Bai
- Pediatric Biostatistics Core, Emory University School of Medicine, Atlanta, GA
| | | | - Kevin E Chapman
- Department of Child Health, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Dave F Clarke
- Division of Pediatric Neurology, Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Mariah Eisner
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH
| | - Nathan B Fountain
- Department of Neurology, Comprehensive Epilepsy Program, University of Virginia, Charlottesville, Virginia
| | - Johanna M Gray
- National Association of Epilepsy Centers, Washington, DC
| | | | - Ellen Riker
- National Association of Epilepsy Centers, Washington, DC
| | - Stephan U Schuele
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Susan T Herman
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ
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10
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Watson GDR, Afra P, Bartolini L, Graf DA, Kothare SV, McGoldrick P, Thomas BJ, Saxena AR, Tomycz LD, Wolf SM, Yan PZ, Hagen EC. A journey into the unknown: An ethnographic examination of drug-resistant epilepsy treatment and management in the United States. Epilepsy Behav 2021; 124:108319. [PMID: 34563807 DOI: 10.1016/j.yebeh.2021.108319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/14/2022]
Abstract
Patients often recognize unmet needs that can improve patient-provider experiences in disease treatment management. These needs are rarely captured and may be hard to quantify in difficult-to-treat disease states such as drug-resistant epilepsy (DRE). To further understand challenges living with and managing DRE, a team of medical anthropologists conducted ethnographic field assessments with patients to qualitatively understand their experience with DRE across the United States. In addition, healthcare provider assessments were conducted in community clinics and Comprehensive Epilepsy Centers to further uncover patient-provider treatment gaps. We identified four distinct stages of the treatment and management journey defined by patients' perceived control over their epilepsy: Gripped in the Panic Zone, Diligently Tracking to Plan, Riding a Rollercoaster in the Dark, and Reframing Priorities to Redefine Treatment Success. We found that patients sought resources to streamline communication with their care team, enhanced education on treatment options beyond medications, and long-term resources to protect against a decline in control over managing their epilepsy once drug-resistant. Likewise, treatment management optimization strategies are provided to improve current DRE standard of care with respect to identified patient-provider gaps. These include the use of digital disease management tools, standardizing neuropsychiatrists into patients' initial care team, and introducing surgical and non-pharmacological treatment options upon epilepsy and DRE diagnoses, respectively. This ethnographic study uncovers numerous patient-provider gaps, thereby presenting a conceptual framework to advance DRE treatment. Further Incentivization from professional societies and healthcare systems to support standardization of the treatment optimization strategies provided herein into clinical practice is needed.
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Affiliation(s)
| | - Pegah Afra
- Department of Neurology, Weill-Cornell Medicine, New York, NY 10065, USA
| | - Luca Bartolini
- Division of Pediatric Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Daniel A Graf
- Department of Neurology, Geisinger Health System, Danville, PA 17822, USA
| | - Sanjeev V Kothare
- Department of Pediatric Neurology, Northwell Health, New York, NY 10011, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians and Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY 10595, USA
| | - Bethany J Thomas
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Aneeta R Saxena
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, MA, USA
| | | | - Steven M Wolf
- Boston Children's Health Physicians and Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY 10595, USA
| | - Peter Z Yan
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Eliza C Hagen
- LivaNova, Neuromodulation Unit, Houston, TX 77058, USA; Department of Neurology, Alameda County Medical Center, Oakland, CA 94602, USA
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11
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Hussein H, Kokkinos V, Sisterson ND, Modo M, Richardson RM. Extrapial Hippocampal Resection in Anterior Temporal Lobectomy: Technical Description and Clinical Outcomes in a 62-Patient Case Series. Oper Neurosurg (Hagerstown) 2021; 21:312-323. [PMID: 34333663 DOI: 10.1093/ons/opab262] [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: 11/10/2020] [Accepted: 05/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anterior temporal lobectomy (ATL) is the most effective treatment for drug-resistant mesial temporal lobe epilepsy. Extrapial en bloc hippocampal resection facilitates complete removal of the hippocampus. With increasing use of minimally invasive treatments, considering open resection techniques that optimize the integrity of tissue specimens is important both for obtaining the correct histopathological diagnosis and for further study. OBJECTIVE To describe the operative strategy and clinical outcomes associated with an extrapial approach to hippocampal resection during ATL. METHODS A database of epilepsy surgeries performed by a single surgeon between October 2011 and February 2019 was reviewed to identify all patients who underwent ATL using an extrapial approach to hippocampal resection. To reduce confounding variables for outcome analysis, subjects with prior resections, tumors, and cavernous malformations were excluded. Seizure outcomes were classified using the Engel scale. RESULTS The surgical technique is described and illustrated with intraoperative images. A total of 62 patients met inclusion criteria (31 females) for outcome analysis. Patients with most recent follow-up <3 yr (n = 33) and >3 yr (n = 29) exhibited 79% and 52% class I outcomes, respectively. An infarct was observed on postoperative magnetic resonance imaging in 3 patients (1 asymptomatic and 2 temporarily symptomatic). An en bloc specimen in which the subiculum and all hippocampal subfields were preserved was obtained in each case. Examples of innovative research opportunities resulting from this approach are presented. CONCLUSION Extrapial resection of the hippocampus can be performed safely with seizure freedom and complication rates at least as good as those reported with the use of subpial techniques.
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Affiliation(s)
- Helweh Hussein
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nathaniel D Sisterson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michel Modo
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania, USA.,McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania, USA
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Hamade YJ, Palzer EF, Helgeson ES, Hanson JT, Walczak TS, McGovern RA. Persistent racial and ethnic disparities as a potential source of epilepsy surgery underutilization: Analysis of large national datasets from 2006-2016. Epilepsy Res 2021; 176:106725. [PMID: 34304018 DOI: 10.1016/j.eplepsyres.2021.106725] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/10/2021] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE High volume surgical epilepsy centers have reported a decrease in surgical resections and an increase in intracranial monitoring. Despite this increase in complexity, epilepsy surgery remains significantly underutilized. The goal of this study is to examine the utilization of and access to epilepsy surgery in the United States from 2006 to 2016. METHODS We used administrative datasets from the National Inpatient Sample (NIS) and Center for Medicare and Medicaid Services (CMS) to report national estimates of epilepsy surgery and changes in surgery types. We also examined disparities and barriers in access to epilepsy surgery. RESULTS Inpatient epilepsy admissions increased from 2.41 to 5.78 per 100,000 between 2006 and 2016, while surgical epilepsy admissions plateaued after 2011. Open resections comprised 75 % of all surgical cases from 2006 to 2011 then decreased each year to 50 % in 2016 with both temporal and extratemporal resections decreasing proportionally. Intracranial monitoring increased in the last two years of the study due to an increase in SEEG/depth electrode cases. The multivariate analysis showed that patients with Medicaid (OR 0.75, 95 % CI 0.67-0.83) and Medicare (OR 0.62, 95 % CI 0.54-0.70) were significantly less likely to undergo epilepsy surgery compared to those with private insurance. Black patients were less likely to undergo epilepsy surgery than White or Hispanic patients (OR 0.57, 95 % CI 0.49-0.67). No significant difference was found in epilepsy surgery rates after implementation of the Affordable Care Act (ACA) in 2014. CONCLUSION This study identifies recent trends in epilepsy surgical approaches and suggests that improving access to care does not necessarily address disparities present in the treatment of epilepsy patients who need surgical care.
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Affiliation(s)
- Youssef J Hamade
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States.
| | - Elise F Palzer
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, United States
| | - Erika S Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, United States
| | - Jacob T Hanson
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
| | - Thaddeus S Walczak
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, 55455, United States
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13
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Englot DJ. In Epilepsy Surgery, Pathology Matters, and Lesions Need to Go. Epilepsy Curr 2020; 21:24-26. [PMID: 34025268 PMCID: PMC7863304 DOI: 10.1177/1535759720968822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
[Box: see text]
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14
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Cramer SW, McGovern RA, Wang SG, Chen CC, Park MC. Resective epilepsy surgery: assessment of randomized controlled trials. Neurosurg Rev 2020; 44:2059-2067. [PMID: 33169227 DOI: 10.1007/s10143-020-01432-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/16/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Abstract
Epilepsy is the most common form of chronic neurologic disease. Here, we review the available randomized controlled trials (RCTs) that examined the efficacy of resective epilepsy surgery in select patients suffering from medically intractable epilepsy (defined as persistent epilepsy despite two or more antiepileptic drugs [AEDs]). Three RCTs (two adult RCTs and one pediatric RCT) consistently supported the efficacy of resective surgery as treatment for epilepsy with semiology localized to the mesial temporal lobe. In these studies, 58-100% of the patients who underwent resective surgery achieved seizure freedom, in comparison to 0-13% of medically treated patients. In another RCT, the likelihood of seizure freedom after resective surgery was independent of the surgical approach (transSylvian [64%] versus subtemporal [62%]). Two other RCTs demonstrated that hippocampal resection is essential to optimize seizure control. But, no significant gain in seizure control was achieved beyond removing 2.5 cm of the hippocampus. Across RCTs, minor complications (deficit lasting < 3 months) and major complications (deficit > 3 months) ranged 2-5% and 5-11% respectively. However, nonincapacitating superior subquadrantic visual-field defects (not typically considered a minor or major complication) were noted in up to 55% of the surgical cohort. The available RCTs provide compelling support for resective surgery as a treatment for mesial temporal lobe epilepsy and offer insights toward optimal surgical strategy.
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, MMC 96, D-429 Mayo Memorial Building, Minneapolis, MN, 55455, USA.
| | - Robert A McGovern
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, MMC 96, D-429 Mayo Memorial Building, Minneapolis, MN, 55455, USA.,Department of Neurology, University of Minnesota, 516 Delaware St SE, 12-100 Phillips Wangensteen Building, Minneapolis, MN, 55455, USA
| | - Sonya G Wang
- Department of Neurology, University of Minnesota, 516 Delaware St SE, 12-100 Phillips Wangensteen Building, Minneapolis, MN, 55455, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, MMC 96, D-429 Mayo Memorial Building, Minneapolis, MN, 55455, USA
| | - Michael C Park
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, MMC 96, D-429 Mayo Memorial Building, Minneapolis, MN, 55455, USA.,Department of Neurology, University of Minnesota, 516 Delaware St SE, 12-100 Phillips Wangensteen Building, Minneapolis, MN, 55455, USA
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