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Kaur N, Nowacki AS, Lachhwani DK, Berl MM, Hamberger MJ, Klaas P, Bingaman W, Busch RM. Characterization and Prediction of Short-term Outcomes in Memory After Temporal Lobe Resection in Children With Epilepsy. Neurology 2023; 100:e1878-e1886. [PMID: 36927884 PMCID: PMC10159761 DOI: 10.1212/wnl.0000000000207143] [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: 08/30/2022] [Accepted: 01/19/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to characterize short-term outcomes in episodic memory, as assessed by the Children's Memory Scale (CMS), after temporal lobe resection in children with epilepsy using empirical methods for assessing cognitive change (i.e., reliable change indices [RCI] and standardized regression-based change scores [SRB]) and develop and internally validate clinically applicable models to predict postoperative memory decline. METHODS This retrospective cohort study included children aged 6-16 years who underwent resective epilepsy surgery that included the temporal lobe (temporal only: "temporal" and multilobar: "temporal plus") and who completed preoperative and postoperative neuropsychological assessments including the CMS. Change scores on the CMS delayed memory subtests (Faces, Stories, and Word Pairs) were classified as decline, no change, or improvement using epilepsy-specific RCI and SRB. Logistic regression models for predicting postoperative memory decline were developed and internally validated with bootstrapping. RESULTS Of the 126 children included, most of them demonstrated either no significant change (54%-69%) or improvement (8%-14%) in memory performance using RCI on individual measures at a median of 7 months after surgery. A subset of children (23%-33%) showed postoperative declines. Change distributions obtained using RCI and SRB were not statistically significantly different from each other. Preoperative memory test score, surgery side, surgery extent, and preoperative full-scale IQ were predictors of memory decline. Prediction models for memory decline included subsets of these variables with bias-corrected concordance statistics ranging from 0.70 to 0.75. The models were well calibrated although slightly overestimated the probability of verbal memory decline in high-risk patients. DISCUSSION This study used empiric methodology to characterize memory outcome in children after temporal lobe resection. Provided online calculator and nomograms may be used by clinicians to estimate the risk of postoperative memory decline for individual patients before surgery.
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Affiliation(s)
- Navkiranjot Kaur
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Amy S Nowacki
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Deepak K Lachhwani
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Madison M Berl
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Marla J Hamberger
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Patricia Klaas
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - William Bingaman
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH
| | - Robyn M Busch
- From the Cleveland Clinic Lerner College of Medicine (N.K., A.S.N., R.M.B.), Case Western Reserve University; Quantitative Health Sciences (A.S.N.), Lerner Research Institute, Cleveland Clinic; Epilepsy Center (D.K.L., W.B., R.M.B.), Neurological Institute, Cleveland Clinic, OH; Division of Pediatric Neuropsychology (M.M.B.), Childrens National Medical Center, Washington, DC; Department of Neurology (M.J.H.), Columbia University Medical Center, New York, NY; and Department of Psychiatry & Psychology (P.K., R.M.B.), and Department of Neurology (P.K., R.M.B.), Neurological Institute, Cleveland Clinic, OH.
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Samanta D, Singh R, Gedela S, Scott Perry M, Arya R. Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers. Epilepsy Behav 2021; 117:107853. [PMID: 33678576 PMCID: PMC8035223 DOI: 10.1016/j.yebeh.2021.107853] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Rani Singh
- Department of Pediatrics, Atrium Health/Levine Children's Hospital, United States
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, United States
| | - M Scott Perry
- Cook Children's Medical Center, Fort Worth, TX, United States
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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