Pre- and postoperative socioeconomic development of 151 patients with focal epilepsies

How are they doing as adults? Psychosocial and socioeconomic outcomes 11-30 years after pediatric epilepsy surgery

OBJECTIVE

Pediatric epilepsy surgery yields cure from epilepsy or complete seizure control with continued medication in many patients early in life. This study aimed to evaluate the long-term (>10 years) psychosocial and socioeconomic outcomes of pediatric epilepsy surgery and examine the role of comorbid disability, type of surgery, seizure freedom, and age at surgery.

METHODS

A novel ad hoc parent/patient questionnaire was used to assess educational and occupational attainment, marital/familial status, mobility, and other outcomes in patients who underwent unilobar or multilobar surgery for drug-refractory epilepsy during their childhood. The questionnaire also captured information on comorbid disability.

RESULTS

Of the 353 eligible patients, 203 could still be contacted and 101 of these (50%) returned appropriately filled-in questionnaires (follow-up intervals: 11-30 [mean: 19.6] years). The cure from epilepsy rate was 53%. Type of surgery was strongly confounded by comorbid disability. Patients with comorbid disabilities had significantly lower rates of regular school degrees, gainful employment, marriage, and driving license (N = 29; 12%, 4%, 0%, 3%) compared with non-disabled patients (N = 69; 89%, 80%, 43%, and 67%, respectively). Patients achieved lower school degrees than their siblings and parents. Non-disabled seizure-free patients had better employment and mobility outcomes compared with non-seizure-free patients. Age at surgery (<10 vs. ≥10 years of age) did not have any effect on any outcome in patients with preschool seizure onset.

SIGNIFICANCE

Pediatric epilepsy surgery can lead to permanent relief from epilepsy in many patients, but comorbid disability strongly impacts adult life achievement. In non-disabled patients, favorable outcomes in academic, occupational, marital, and mobility domains were achieved, approaching respective rates in the German population. Complete seizure freedom had additional positive effects on employment and mobility in this group. However, in case of chronic comorbid disability the overall life prospects may be limited despite favorable seizure outcomes.

How patients' psycho-social profiles contribute to decision-making in epilepsy surgery: A prospective study

OBJECTIVE

Identifying factors associated with surgical decision-making is important to understand reasons for underutilization of epilepsy surgery. Neurologists' recommendations for surgery and patients' acceptance of these recommendations depend on clinical epilepsy variables, for example, lateralization and localization of seizure onset zones. Moreover, previous research shows associations with demographic factors, for example, age and sex. Here, we investigate the relevance of patients' psycho-social profile for surgical decision-making.

METHODS

We prospectively studied 296 patients from two large German epilepsy centers. Multiple logistic regression analyses were used to investigate variables linked to neurologists' recommendations for and patients' acceptance of surgery or intracranial video-electroencephalographic monitoring. Patients' psycho-social profiles were assessed via self-reports and controlled for various clinical-demographic variables. Model selection was performed using the Akaike information criterion.

RESULTS

As expected, models for neurologists' surgery recommendations primarily revealed clinical factors such as lateralization and localization of the seizure onset zone, load with antiseizure medication (ASM), and site of the epilepsy-center. For this outcome, employment was the only relevant psycho-social aspect (odds ratio [OR] = .38, 95% confidence interval [CI] = .13-1.11). In contrast, three of the five relevant predictors for patients' acceptance were psycho-social. Higher odds were found for those with more subjective ASM adverse events (OR = 1.04, 95% CI = .99-1.00), more subjective seizure severity (OR = 1.12, 95% CI = 1.01-1.24), and lower subjective cognitive impairment (OR = .98, 95% CI = .96-1.00).

SIGNIFICANCE

We demonstrated the relevance of the patients' psycho-social profile for decision-making in epilepsy surgery, particularly for patients' decisions. Thus, in addition to clinical-demographic variables, patients' individual psycho-social characteristics add to the understanding of surgical decision-making. From a clinical perspective, this calls for individually tailored counseling to assist patients in finding the optimal treatment option.

Clinical adult outcome 11-30 years after pediatric epilepsy surgery: Complications and other surgical adverse events, seizure control, and cure of epilepsy

OBJECTIVE

Pediatric epilepsy surgery promises seizure freedom or even cure of epilepsy. We evaluated the long-term (≥10 years) adult clinical outcome including surgery-related adverse events and complications, which are generally underreported.

METHODS

A monocentric, single-arm, questionnaire study in now adult patients who underwent epilepsy surgery during childhood. A novel ad hoc parental/patient questionnaire, which addressed diverse outcome domains was applied.

RESULTS

From a total of 353 eligible patients, 203 could be contacted (3 patients died of causes unknown) and 101 (50%) returned appropriately filled-in surveys. No evidence for a survey-response bias was found. The rate of surgical complications according to the patient records was 9%. As regards the survey, half of the parents/patients reported surgical adverse events (expected and unexpected issues) and one-third reported permanent aversive sequels. Two-thirds of the patients were seizure-free during the last year before follow-up; 63% were Engel class 1A; favorable seizure outcomes (including auras only) were obtained in 73%; and 54% were seizure-free and off antiseizure medicine (ASM), that is, cured of epilepsy. In non-seizure-free patients, seizure relapse occurred at any time during the follow-up interval but 87% of those with a seizure-free first postoperative year were seizure-free at follow-up. One patient experienced a seizure relapse during the ASM withdrawal trial but became seizure-free again with ASMs. Eleven patients reported an increased number of ASMs as compared to the time before surgery. Earlier focal surgery did not affect the long-term clinical outcome.

SIGNIFICANCE

Pediatric epilepsy surgery was capable of curing epilepsy in about one-half of the children and to significantly control seizures in about three-fourths. Long-term success of focal surgery did not depend on age at surgery or duration of epilepsy. Surgical adverse events including complications may be underreported and must be assessed more thoroughly.

Long-term seizure, psychiatric and socioeconomic outcomes after frontal lobe epilepsy surgery

OBJECTIVE

Resective surgery for selected individuals with frontal lobe epilepsy can be effective, although multimodal outcomes are less established than in temporal lobe epilepsy. We describe long-term seizure remission and relapse patterns, psychiatric comorbidity, and socioeconomic outcomes following frontal lobe epilepsy surgery.

METHODS

We reviewed individual data on frontal lobe epilepsy procedures at our center between 1990 and 2020. This included the presurgical evaluation, operative details and annual postoperative seizure and psychiatric outcomes, prospectively recorded in an epilepsy surgery database. Outcome predictors were subjected to multivariable analysis, and rates of seizure freedom were analyzed using Kaplan-Meier methods. We used longitudinal assessment of the Index of Multiple Deprivation to assess change in socioeconomic status over time.

RESULTS

A total of 122 individuals with a median follow-up of seven years were included. Of these, 33 (27 %) had complete seizure freedom following surgery, with a further 13 (11 %) having only auras. Focal MRI abnormality, histopathology (focal cortical dysplasia, cavernoma or dysembryoplastic neuronal epithelial tumor) and fewer anti-seizure medications at the time of surgery were predictive of a favorable outcome; 67 % of those seizure-free for the first 12 months after surgery never experienced a seizure relapse. Thirty-one of 50 who had preoperative psychiatric pathology noticed improved psychiatric symptomatology by two years postoperatively. New psychiatric comorbidity was diagnosed in 15 (13 %). Persistent motor complications occurred in 5 % and dysphasia in 2 %. No significant change in socioeconomic deciles of deprivation was observed after surgery.

SIGNIFICANCE

Favorable long-term seizure, psychiatric and socioeconomic outcomes can be seen following frontal lobe epilepsy surgery. This is a safe and effective treatment that should be offered to suitable individuals early.

Can We Anticipate and Prevent the Occurrence of Iatrogenic Psychiatric Events Caused by Anti-seizure Medications and Epilepsy Surgery?

Psychiatric disorders and behavioral manifestations in patients with epilepsy have complex and multifactorial etiologies. The psychotropic properties of anti-seizure medications (ASMs) and psychiatric effects of epilepsy surgery can result in iatrogenic psychiatric symptoms or episodes or can yield a therapeutic effect of underlying psychiatric disorders and have a significant impact on the patients' quality of life. The aims of this chapter are to review the available evidence of psychotropic properties of ASMs, which may be responsible for iatrogenic psychiatric symptoms and/or disorders. Moreover, the several aspects associated with the impact of epilepsy surgery on the possible improvement/development of psychiatric disorders were addressed.

Cognitive disorders in epilepsy II: Clinical targets, indications and selection of test instruments

This is the second of two narrative reviews on cognitive disorders in epilepsy (companion manuscript: Cognitive disorders in epilepsy I: Clinical experience, real-world evidence and recommendations). Its focus is on the clinical targets, indications, and the selection of neuropsychological test instruments. Cognitive assessment has become an essential tool for the diagnosis and outcome control in the clinical management of epilepsy. The diagnostics of basic and higher brain functions can provide valuable information on lateralized and localized brain dysfunctions associated with epilepsy, its underlying pathologies and treatment. In addition to the detection or verification of deficits, neuropsychology reveals the patient's cognitive strengths and, thus, information about the patient reserve capacities for functional restitution and compensation. Neuropsychology is an integral part of diagnostic evaluations mainly in the context of epilepsy surgery to avoid new or additional damage to preexisting neurocognitive impairments. In addition and increasingly, neuropsychology is being used as a tool for monitoring of the disease and its underlying pathologies, and it is suited for the quality and outcome control of pharmacological or other non-invasive medical intervention. This narrative review summarizes the present state of neuropsychological assessments in epilepsy, reveals diagnostic gaps, and shows the great need for education, homogenization, translation and standardization of instruments.

Epilepsy Surgery in Childhood Versus Adulthood: What Are We Waiting for?

Long-Term Employment Outcomes After Epilepsy Surgery in Childhood

Reinholdson J, Olsson I, Edelvik Tranberg A, Malmgren K. Neurology. 94;2020:e205-e216. doi: 10.1212/WNL.0000000000008681

Objective:

To analyze long-term employment outcomes in a population-based cohort of adults who underwent epilepsy surgery in childhood or adolescence and to compare the results to general population reference data.

Methods:

Prospective data on epilepsy surgery procedures performed on patients <19 years of age between 1995 and 2012 were extracted from the Swedish National Epilepsy Surgery Register. Five-, 10-, 15- and 20-year follow-up data were analyzed. Patients aged ≥19 years at follow-up were eligible for inclusion. Educational attainment and employment status were analyzed in relation to seizure outcome. Education and employment outcomes of seizure-free patients with a preoperative IQ of ≥70 were compared to general population reference data.

Results:

A total of 203 patients were included. The mean age at surgery was 13.6 years and 66% had IQ ≥70. Of these, a majority had attained at least high school education 5 years after surgery. Employment rates were 44%, 69%, 71%, and 77% at the 5-, 10-, 15-, and 20-year follow-ups, respectively. Seizure-free patients were significantly more likely to work full-time. Educational attainment and rates of full-time employment of seizure-free patients were similar to the general population. A majority of patients with IQ <70 had attended special education and were reliant on social benefits.

Conclusion:

Long-term overall employment rates were higher compared to most previous studies on surgery in adults. Seizure-free patients with a preoperative IQ ≥70 showed rates of full-time employment similar to the general population. Further research is needed to determine whether this also applies for occupational complexity and wages.

Long-term employment outcomes after epilepsy surgery in childhood

Objective

To analyze long-term employment outcomes in a population-based cohort of adults who underwent epilepsy surgery in childhood or adolescence and to compare the results to general population reference data.

Methods

Prospective data on epilepsy surgery procedures performed on patients <19 years of age between 1995 and 2012 were extracted from the Swedish National Epilepsy Surgery Register. Five-, 10-, 15- and 20-year follow-up data were analyzed. Patients aged ≥19 years at follow-up were eligible for inclusion. Educational attainment and employment status were analyzed in relation to seizure outcome. Education and employment outcomes of seizure-free patients with a preoperative IQ of ≥70 were compared to general population reference data.

Results

A total of 203 patients were included. The mean age at surgery was 13.6 years and 66% had IQ ≥70. Of these, a majority had attained at least high school education 5 years after surgery. Employment rates were 44%, 69%, 71%, and 77% at the 5-, 10-, 15-, and 20-year follow-ups, respectively. Seizure-free patients were significantly more likely to work full-time. Educational attainment and rates of full-time employment of seizure-free patients were similar to the general population. A majority of patients with IQ <70 had attended special education and were reliant on social benefits.

Conclusion

Long-term overall employment rates were higher compared to most previous studies on surgery in adults. Seizure-free patients with a preoperative IQ ≥70 showed rates of full-time employment similar to the general population. Further research is needed to determine whether this also applies for occupational complexity and wages.

[Epilepsy as a social problem]

The article considers the problem of social restrictions caused by epilepsy. Information on historical aspects and discrimination of patients with epilepsy is presented. The authors consider factors influencing marital status of patients in different countries and present information on the differences in medical restrictions to driving in different countries and in the Russian Federation. Employment status of patients with epilepsy, restrictions related to objective reasons and attitudes of patients and others toward epilepsy are elucidated.

Socioeconomic outcome of epilepsy surgery: A controlled national study

PURPOSE

Epilepsy surgery has been a standard treatment for refractory epilepsies that cannot be controlled by standard medical treatment. We aimed to evaluate the health and social consequences of resective surgery relative to controls from a study of national data.

METHODS

Using the Danish National Patient Registry we identified all subjects with an epilepsy diagnosis between 1996 and 2009 and compared them with a group of patients with an epilepsy diagnosis who had had neither epilepsy surgery nor a vagus stimulation diagnosis by the index date, and who were matched by gender, index year for epilepsy diagnosis, and index year for epilepsy surgery. We considered all the health and social information available in the Danish health, medication and social registers. The duration of follow-up was three years.

RESULTS

254 epilepsy patients and 989 controls were analyzed. Surgery patients were more severely affected by their disease as indicated by health care use and social impact before the surgical procedure. Patients who underwent epilepsy surgery had a significantly lower costs associated with the use of medication, outpatient services, inpatient admissions, and accident and emergency visits after surgery. The surgical intervention had no significant effects on social status in terms of occupation and educational level.

CONCLUSION

Although epilepsy surgery was followed by a reduction in inpatient and outpatient health care use, medication and use of accident and emergency facilities, suggesting a positive effect on the epileptic disease, there was no significant effect on social outcome measures.

Prospective and longitudinal long-term employment outcomes after resective epilepsy surgery

Objective:

To investigate long-term employment outcomes after resective epilepsy surgery in a national population-based cohort of adults.

Methods:

In the Swedish National Epilepsy Surgery Register, all adults who were operated with resective epilepsy surgery from 1995 to 2010 were identified. Two-year follow-up was available for 473/496, 5-year follow-up for 220/240, 10-year follow-up for 240/278, and 15-year follow-up for 85/109 patients.

Results:

There were no significant changes in employment outcome over time at group level, but for those with full-time employment at baseline, 79%, 79%, 57%, and 47% of seizure-free patients were in full-time work at 2-, 5-, 10-, and 15-year follow-up, compared to patients with benefits at baseline, where 16%, 27%, 31%, and 33% of seizure-free patients worked full time at these time points (p = 0.018 at 10 years). More patients with full-time work had ability to drive, a family of their own, and higher educational status than patients in part-time work or on benefits. Univariate predictors for employment at long term were having employment preoperatively, higher education, favorable seizure outcome, male sex, and younger age at surgery. Multivariate predictors were having employment preoperatively, favorable seizure outcome, and younger age.

Conclusions:

The best vocational outcomes occurred in seizure-free patients who were employed or students at baseline, which may reflect a higher general psychosocial level of function. Younger age also predicted better employment outcomes and it therefore seems plausible that early referral for surgery could contribute to better vocational outcomes.

Cognitive impairment predicts social disability in persons with epilepsy

Introduction.Cognitive dysfunction is one of the main comorbidities of epilepsy which co-exists with seizures and contributes to the adverse impact of the disease on employment, education and interpersonal relationships. A fundamental question regarding cognitive dysfunction in epilepsy goes as follows: in comparison to seizures, what role does cognitive dysfunction play in causing social disability? The purpose of this review was to evaluate our understanding of the role cognitive impairment plays in social disability in persons with epilepsy (PWE). We systematically searched the medical literature and identified studies which assessed the impact of seizures and cognitive function on some aspect of social disability in PWE.

Results and Discussion.We identified 12 studies which adequately measured all variables in non-surgical cohorts, and 9 studies of cohorts following epilepsy surgery. We found evidence from non-surgical and from surgical series that cognitive variables strongly correlate with levels of social disability.

Conclusions.We conclude that efforts to better understand the origins of cognitive dysfunction in epilepsy and subsequently at developing treatment modalities will be needed in order to reduce the degree of social disability caused by the condition.

The societal integration of individuals with epilepsy: perspectives for the 21st century

Epilepsy is a common neurologic disorder seen throughout the world. Advances in therapy have made it possible for persons with epilepsy (PWEs) to have improved seizure control and a better quality of life. However, it is not entirely clear whether this has resulted in their successful integration into society. This review examines the societal integration of PWEs, identifying both the progress made and the challenges that continue to hamper further advances. In general, PWEs are more integrated in western-oriented cultures. However, there continue to be ongoing difficulties due to poor education and intellectual functioning, poor social and family support, the undertreatment of coexisting psychiatric conditions, transportation and mobility limitations, and problems obtaining employment. This review also discusses the effects of low socioeconomic status on integration and the persisting prejudices that affect certain racial groups. Most importantly, this review underscores the fact that societal stigma towards PWEs is still very much alive. At the beginning of the 21st century, PWEs still encounter difficulties in their quest for full societal integration. Along with medical advances being made to improve seizure control, much still has to be done to bring about the reforms necessary to help PWEs live more meaningful and productive lives.

Psychosocial status 10 years after temporal lobe resection for epilepsy, a longitudinal controlled study

Knowledge about long-term psychosocial outcome of temporal lobe resection (TLR) for epilepsy is limited. The aims of this study were to describe vocational outcome 10 years after TLR and to analyze the effect on the vocational situation by seizures, laterality of resection, verbal memory, and mood. Fifty-one patients were prospectively followed 10 years after TLR. Psychosocial and neuropsychological data were ascertained at baseline and 10 years after surgery and at corresponding time points for 23 controls. Fewer patients worked 10 years post-operatively compared with controls (TLR patients: 61% and controls: 96%). However, seizure-free patients were more likely to retain employment (71%) than patients who had seizures (41%). The odds of working full-time were 9.5 times higher for patients with seizure freedom than for those with continuing seizures. There were no associations between working at 10 years and side of resection or mood, and impairment of verbal memory did not have an influence on vocational outcome.

Long-term intellectual outcome after temporal lobe surgery in childhood

OBJECTIVE

Temporal lobe resection is an established treatment for medication-resistant temporal lobe epilepsy, which in recent years has increasingly been performed in children. However, little is known about the long-term outcome in these children. The aim of this study was to characterize intellectual and psychosocial functioning of children after temporal lobe resection as they progress into late adolescence and adulthood.

METHODS

We report the long-term follow-up of 42 children who underwent temporal lobe surgery after an average postoperative period of 9 years. Longitudinal change in IQ was documented, psychosocial outcome including quality of life was assessed, and preoperative and postoperative T1-weighted MRI brain scans were evaluated quantitatively. A well-matched nonsurgical comparison group of 11 children with similar clinical characteristics was also assessed.

RESULTS

At follow-up, 86% of the surgical group were seizure-free, and 57% were no longer taking antiepileptic medication. A significant increase in IQ was found in the surgical group after an extended follow-up period of >5 years. This IQ change was not found in the nonsurgical comparison group. IQ increases were associated with cessation of antiepileptic medication and changes in MRI-derived gray matter volume. The surgical group also reported better psychosocial outcome including quality of life, which was more strongly associated with seizure freedom rather than surgery per se.

CONCLUSIONS

Surgery for temporal lobe epilepsy performed in childhood results in excellent long-term seizure control and favorable cognitive outcome along with positive effects on brain development.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that temporal lobectomy in children with temporal lobe epilepsy is associated with improved long-term intellectual outcomes compared with those undergoing standard medical treatment.

Patient-reported outcome of pediatric epilepsy surgery: social inclusion or exclusion as young adults?

PURPOSE

The purpose of this study was to examine the social relationships and participation in educational, vocational, and community life in young adults who had undergone epilepsy surgery during childhood or adolescence.

METHODS

This was a retrospective, cross-sectional, case-controlled, and multisite design study. Findings were compared between young adults who had undergone epilepsy surgery and were seizure-free in the previous 12 months (n = 38), those who had undergone epilepsy surgery and were not seizure-free (n = 33), and a group of individuals with epilepsy who had not undergone surgery (n = 31).

RESULTS

The surgical seizure-free group had significantly better general social well-being than the other two groups. Specifically, these participants were employed for more months over the past year, were less likely to report that epilepsy had affected their employment, and were more likely to belong to at least one community organization. However, these participants were not any more likely to be involved in a relationship than those in the other two groups. In addition, there were no group differences in the reported number of friends or the frequency of visits with friends, or in what participants described as their principal activity (i.e., student, employed or unemployed).

DISCUSSION

There are a number of benefits to social functioning associated with having had epilepsy surgery and being seizure-free in the past year. Further research is recommended to increase our understanding of the mechanisms involved in the social and personal challenges that these individuals face.

Postoperative quality of life outcome and employment in patients undergoing resection of epileptogenic lesions detected by magnetic resonance imaging

The long-term postoperative improvement of quality of life (QOL) and employment were investigated in patients undergoing resection of epileptogenic lesions detected by magnetic resonance (MR) imaging to identify the associated preoperative factors. Thirty of 47 patients who underwent lesionectomy between 1987-2001 replied to questionnaires. Patients with extratemporal resection outnumbered those with temporal lobe resection. The mean follow-up period was 12.4 +/- 3.7 years. An arbitrary score for quantitatively assessing QOL was assigned. The mean increases in QOL score points were significantly higher in the late childhood onset group than those in the early childhood onset group, and were also significantly higher in the temporal resection group and extratemporal resection of non-dysplastic cortical pathology group than in the extratemporal resection of dysplastic cortical pathology group. Postoperative QOL improvement and occupational status of patients depended on the completeness of seizure control. Resection of lesions detected by MR imaging in patients with intractable epilepsy resulted in effective long-term QOL improvement and postoperative occupational status. Favorable outcome was related mainly to the pathology of the epileptogenic lesions, whether the lesion site was temporal or extratemporal, and the completeness of seizure control.

Long term follow-up of the first 70 operated adults in the Goteborg Epilepsy Surgery Series with respect to seizures, psychosocial outcome and use of antiepileptic drugs

OBJECTIVE

To compare long term (10 years) seizure outcome, psychosocial outcome and use of antiepileptic drugs (AED) with the 2 year follow-up in adults after resective epilepsy surgery.

METHODS

All adults (n = 70) who underwent resective epilepsy surgery from 1987 to 1995 in the Göteborg Epilepsy Surgery Series were included. Fifty-four had undergone temporal lobe resections and 16 extratemporal resections (12 frontal). A cross-sectional follow-up in the form of a semistructured interview was performed in late 2003.

RESULTS

Mean follow-up was 12.4 years (range 8.6-16.2). Of the 70 patients (51% males), five (7%) were dead (three as a result of non-epilepsy related causes). Of the 65 patients interviewed, 38 (58%) were seizure-free at the long term follow-up: 65% of the patients with temporal lobe resections and 36% of the patients with extratemporal resections. Of the 35 patients who were seizure-free at the 2 year follow-up, 3 (9%) had seizures at the long term follow-up. Of the 30 patients who had seizures at the 2 year follow-up, 6 (20%) were seizure-free at the long term follow-up. Of all 65 patients, 45 (69%) had the same seizure status as the 2 year follow-up. Sixteen (25%) had an improved seizure status and 4 (6%) had a worsened status. Of the seizure-free patients, 11 (29%) had ceased taking AED, 28 (74%) were working and 25 (66%) had a driving license.

CONCLUSIONS

Adult patients who are seizure-free 2 years after resective epilepsy surgery are most likely to still be seizure-free 10 years later. Most are working and have obtained a driving license.

Factors associated with employment in epilepsy patients

OBJECTIVE

The aim of the study described here was to determine those variables associated with employment in patients followed at a level 4 epilepsy center.

METHOD

A survey was sent to patients seen at the University of Florida Health Science Center/Jacksonville Comprehensive Epilepsy Program.

RESULTS

Two hundred sixty-two eligible subjects constituted the study population. By univariate analysis, variables that distinguished employed patients included: younger age, Caucasian race, higher education and household income, not receiving disability benefits, currently studying, fewer seizure medications, having no other medical conditions that interfere with work, previous work experience, perceived importance of work for personal and financial reasons, and decreased fears of workplace discrimination. By logistic regression, higher annual family income, perceived importance of work for personal reasons, and decreased fears of workplace discrimination were the only variables independently associated with employment.

CONCLUSION

Psychosocial factors such as a high self-perceived importance of work and decreased fears of workplace discrimination are significantly associated with employment in epilepsy patients.

Memory, emotional and vocational impairments before and after anterior temporal lobectomy for complex partial seizures

PURPOSE

To assess the pre- and postsurgical frequency of memory, emotional, and vocational impairments in patients who underwent anterior temporal lobectomy (ATL), and to assess the relationship between emotional disturbance and memory abilities after ATL.

METHODS

Retrospective analysis of data was performed on 90 patients with medically intractable complex partial seizures who underwent ATL between 1981 and 2003. Patients were evaluated an average of 5 months before surgery and 11.3 months after surgery.

RESULTS

A moderate to high frequency of memory impairment (44.4%; verbal or nonverbal), emotional disturbance (38.9%) and unemployment (27.8%) existed in the same individuals both before and after surgery. There were small to moderate rates of new onset memory (18.9%), emotional (11.1%), and vocational (7.8%) difficulties after surgery often regardless of seizure control outcome. Patients who underwent left-ATL and had emotional disturbance after surgery had the lowest verbal memory test scores.

CONCLUSIONS

Results highlight the importance of taking into account emotional status when assessing memory abilities after ATL. Results replicate the finding of moderate to high frequencies of memory impairment, emotional disturbance, and unemployment both before and after ATL. Results provide support for the rationale that cognitive, psychiatric and vocational interventions are indicated to mitigate the problems that exist before and persist after ATL.

Correlation of health-related quality of life after surgery for mesial temporal lobe epilepsy with two seizure outcome scales

PURPOSE

The objective of this study was to correlate health-related quality of life (HRQOL) after surgery for mesial temporal lobe epilepsy, as revealed by a postoperative screening tool, to different modalities of seizure outcome classification (Engel, International League Against Epilepsy (ILAE)).

METHOD

One hundred twenty-eight of one hundred forty consecutive patients returned a HRQOL questionnaire at a mean of 36 months after selective amygdalohippocampectomy. Patients answered in two ways: with an absolute estimation (values 1-4) and with a self-rated relative change (-1, 0, +1) after surgery.

RESULTS

Eighty patients were seizure- and aura-free (63.3% ILAE 1), 16 continued to have auras (12.5% ILAE 2), and 13 experienced 1-3 seizure days per year after surgery (10.2% ILAE 3). Ninety-two patients were classified seizure-free (71.9% Engel I), and 17 had two or fewer seizures per year (13.3% Engel II). Of 110 patients in ILAE 1-3, 100 (91%) stated good or even very good postoperative HRQOL, and 99 (90.0%) reported improvements in HRQOL. Only 9 of the remaining 18 (50%) reported good or very good HRQOL after surgery (P=0.01). Corresponding results were obtained with Engel classes I and II, suggesting a trend toward ILAE 1-3 and Engel I and II as overall satisfactory outcomes. A more detailed HRQOL assessment yielded lowest scores in the cognitive domain, and a significant correlation of self-rated changes in cognitive functioning with seizure control (P=0.01). Changes in physical capabilities and mood were significantly better with satisfactory seizure outcome (P=0.006 and P<0.001, respectively), whereas the social aspects were not significantly dependent on seizure outcome (P=0.06).

CONCLUSION

Correlation of HRQOL and seizure control suggested that ILAE 1-3 and Engel I and II most likely represent overall satisfactory outcome. Subdomain analyses revealed cognitive abilities as the most critical feature associated with seizure control, whereas social aspects remained mainly stable.

Epilepsy surgery: patient-perceived long-term costs and benefits

PURPOSE

The goal of this study was to assess the patient-perceived costs and benefits associated with the longer-term outcomes of epilepsy surgery in patients who underwent anterior temporal lobectomy or selective amygdalohippocampectomy.

METHODS

Surgery patients who were assessed in 1997 were reassessed in 2003. Demographic, clinical, and psychosocial details were collected using a validated self-completion questionnaire. Data were collected from 67 patients who had undergone surgery.

RESULTS

Forty-five percent were seizure-free. There were significant differences (P<0.001) between the seizure-free (SF) and continuous seizure (CS) groups with respect to anxiety, depression, impact of epilepsy, self-esteem, mastery, stigma, affect balance, self-reported health, and quality of life. More SF patients were also employed and driving (P<0.001). Despite these differences there were no differences for regret over surgery but there were differences for satisfaction and success ratings.

CONCLUSIONS

Patients who were not SF, in the longer term, had little regret undergoing surgery but were less likely to be satisfied and had a poorer psychosocial profile.

Neuropsychological aspects of epilepsy surgery

Neuropsychological evaluation of a patient's cognitive capabilities before and after epilepsy surgery is essential in elective epilepsy surgery. On the one hand, neuropsychology provides accessory information regarding the localization and lateralization of epilepsy-associated cognitive impairment; on the other hand, it is a useful tool for quality and outcome control of epilepsy surgery which helps to make surgery more effective and safe. Evaluation of the adequacy of the brain tissues to be resected and of the patient's mental reserve capacities allows for a prediction of the postoperative cognitive development. Successful surgery can stop mental decline due to chronic epilepsy and it can reverse this negative trend by release of functions and capacities that were secondarily affected before surgery. However, surgery bears the risk of additional impairments which, in interaction with normal or even pathological processes of mental aging, may accelerate cognitive decline at an older age. From a neuropsychological point of view, early recognition of pharmacoresistance is important along with early and complete seizure control with maximal sparing of functional tissues.

Chronic epilepsy and cognition: A longitudinal study in temporal lobe epilepsy

It remains unclear whether uncontrolled epilepsy causes mental decline. This longitudinal study contrasts change of memory and nonmemory functions in 147 surgically and 102 medically treated patients with temporal lobe epilepsy. All participants were evaluated at baseline (T1) and after 2 to 10 years (T3). Surgical patients underwent additional testing 1 year postoperatively (T2). Data were analyzed on an individual and group level. Sixty-three percent of the surgical and 12% of the medically treated patients were seizure-free at T3. Fifty percent of the medically treated and 60% of the surgical patients showed significant memory decline at T3 with little change in nonmemory functions (difference not significant). Surgery anticipated the decline seen in the medically treated group and exceeded it when surgery was performed on the left, or if seizures continued postoperatively. Seizure-free surgical patients showed recovery of nonmemory functions at T2 (p < 0.001) and of memory functions at T3 (T3, p = 0.03). Multiple regression indicated retest interval, seizure control, and mental reserve capacity as predictors of performance changes. In addition, psychosocial outcome was better when seizures were controlled. In conclusion, chronic temporal lobe epilepsy is associated with progressive memory impairment. Surgery, particularly if unsuccessful, accelerates this decline. However, memory decline may be stopped and even reversed if seizures are fully controlled.

Practice parameter: temporal lobe and localized neocortical resections for epilepsy

PURPOSE

To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures.

METHODS

Systemic review and analysis of the literature since 1990.

RESULTS

One intention-to-treat Class I randomized controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available.

CONCLUSIONS

A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons

OBJECTIVES/METHODS

To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures by systematic review and analysis of the literature since 1990.

RESULTS

One intention-to-treat Class I randomized, controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available.

CONCLUSIONS

A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

Standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy

OBJECTIVES

Patients with intractable epilepsy may benefit from epilepsy surgery especially if they have a radiologically demonstrable cerebral lesion. Dedicated magnetic resonance imaging (MRI) protocols as performed at epilepsy surgery centres can detect epileptogenic abnormalities with great sensitivity and specificity. However, many patients with epilepsy are investigated with standard MRI sequences by radiologist outside epilepsy centres ("non-experts"). This study was undertaken to compare standard MRI and epilepsy specific MRI findings in patients with focal epilepsy.

METHODS

Comparison of results of standard MRI reported by "non-expert" radiologists, standard MRI evaluated by epilepsy "expert" radiologists, and epilepsy specific MRI read by "expert" radiologists in 123 consecutive patients undergoing epilepsy surgery evaluation between 1996 and 1999. Validation of radiological findings by correlation with postoperative histological examination.

RESULTS

Sensitivity of "non-expert" reports of standard MRI reports for focal lesions was 39%, of "expert" reports of standard MRI 50%, and of epilepsy dedicated MRI 91%. Dedicated MRI showed focal lesions in 85% of patients with "non-lesional" standard MRI. The technical quality of standard MRI improved during the study period, but "non-expert" reporting did not. In particular, hippocampal sclerosis was missed in 86% of cases. Neuropathological diagnoses (n=90) were predicted correctly in 22% of "non-expert" standard MRI reports but by 89% of dedicated MRI reports.

CONCLUSIONS

Standard MRI failed to detect 57% of focal epileptogenic lesions. Patients without MRI lesion are less likely to be considered candidates for epilepsy surgery. Patients with refractory epilepsy should be referred to an MRI unit with epileptological experience at an early point.

Long-term psychosocial outcomes of anterior temporal lobectomy

PURPOSE

To examine the long-term psychosocial outcomes of a consecutive series of patients who underwent anterior temporal lobectomy (ATL) compared with medically managed patients. This study focused primarily on actual long-term changes (mean, 5 years) in life performance. There are relatively few long-term controlled studies of actual lifetime performance changes.

METHODS

The sample consisted of 61 adults who underwent ATL and 23 individuals who were evaluated for surgery but did not proceed to surgery and continued to receive medical management. Participants were interviewed 2-9 years after surgery. A structured clinical interview and review of medical records was conducted to obtain information regarding seizure frequency and psychosocial status, focusing on employment, education, driving status, financial assistance, and independent living. In addition, two questions regarding quality of life were included. Seizure frequency was evaluated for the year before the interview.

RESULTS

Significant differences in psychosocial outcome were found between the surgery group and medical management group. Favorable psychosocial outcomes were more common among those who had surgery (46 vs. 4%). Results indicated that 68% of the surgery group exhibited improved psychosocial status compared with 5% of the medical management group. Individuals who had surgery were more likely to be driving, working full-time, living independently, and being financially independent. Remaining seizure free was not a prerequisite for improvements in psychosocial outcomes.

CONCLUSIONS

Compared with medical management, surgery has a significant positive impact on psychosocial outcomes in terms of employment, independent living, driving, and financial independence. Additionally, a person does not necessarily have to be seizure free to achieve positive changes in psychosocial outcomes.

Is refractory epilepsy preventable?

About a third of the patients diagnosed with epilepsy will not be fully controlled with antiepileptic drugs (AEDs), and many of them will have frequent and disabling seizures. These patients will undergo multiple drug trials, most often without complete seizure remission. Moreover, refractory epilepsy is associated with increased morbidity (from seizures and medications), social isolation, unemployment, and overall reduced quality of life. There is evidence that refractory epilepsy can be a progressive disorder, which, if controlled early, might never develop into a full syndrome with all of its associated sequelae. The difficulty lies in identifying at an early stage patients who are likely to progress to intractability. No currently known markers enable clinicians to make this identification with confidence. Advances in pharmacogenomics and our understanding of pharmacologic responsiveness in epilepsy may change this situation. Even now, we are able to identify many patients with a poor prognosis earlier than before, particularly in the pediatric population, in which syndromic classification may provide an approach to predict intractability. The early initiation of aggressive therapy may improve outcome and overall quality of life.

Symptomatic or cryptogenic partial epilepsy of childhood onset: fourteen-year follow-up

This study reports on the seizure and psychosocial outcome of 29 patients with electroclinically well-defined childhood-onset symptomatogenic or cryptogenic partial epilepsy with complex partial seizures who were followed prospectively over 14 years. Many were refractory at the time of enrollment. At 14-year follow-up, we acquired information on seizure type and frequency, psychiatric history, substance abuse, criminal activity, in addition to educational, vocational, and marital status through chart reviews and/or structured telephone interviews. Sixteen patients were only treated medically. They were divided by their following responses to medications: eight patients with less than one seizure per month were in the medically responsive group and eight patients with at least one seizure per month constituted the medically refractory group. Thirteen patients underwent focal resection for medically refractory epilepsy. Medically refractory patients displayed worse educational, vocational, social, and behavioral outcomes than medically responsive patients. Behavioral abnormalities persisted or evolved in five medically refractory patients when they became seizure free. Other studies have indicated that patients with medically refractory complex partial seizures have poor psychosocial outcomes. Although behavioral problems can occur even when seizures are well controlled, their early detection and treatment may be essential to the improvement of psychosocial outcomes.

Surgical treatment of intractable epilepsy in children: indication for resective surgery

Good surgical outcome can be expected for intractable epilepsy in children by resective surgery when a focal cortical abnormality is demonstrated by neuroimaging studies such as MRI, SPECT, and PET. Improvement in behavioral and cognitive development can be expected with seizure cessation after surgery. Early surgical intervention for intractable epilepsy in children is considered a safe and effective choice of treatment to avoid cognitive delay and learning disability.

Cost of epilepsy in Hong Kong: experience from a regional hospital

To study the economic implications of epilepsy in Hong Kong, a cost-of-illness study was performed on a retrospective cohort of medically treated patients from a regional hospital. A societal perspective was examined. Utilization data from 1992 to 1996 were reviewed to obtain the direct costs. Lost productivity was used as a proxy for estimating the indirect costs. Future cost projected over 10 years was derived by incorporating model parameters. Of 745 records reviewed, total direct costs added up to USD 0.98 million and indirect costs to USD 1.32 million. Regarding the overall direct costs, hospitalization was the most consumptive item among patients with a shorter history of epilepsy and those with suboptimal seizure control. The mean total cost per patient increased steadily from 1992 to 1996 except for those with long-standing remission, and was highest in patients with medically refractory epilepsy in terms of both the actual value and rate of increment. Parameters with the most leverage on future cost would be unemployment rate and annual discount rate. The overall economy of the society would exert a major effect on the future cost of epilepsy, in particular, for patients with poorly controlled disease.