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Vysakha KV, Jain K, Nandana J, Manisha KY, Menon RN, Vilanilam G, Abraham M, Thomas B, Kesavadas C, Radhakrishnan A. Do we have to continue antiseizure medications post surgery in long-term epilepsy associated tumors (LEATs)? Clin Neurol Neurosurg 2024; 244:108433. [PMID: 38991393 DOI: 10.1016/j.clineuro.2024.108433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE To identify the rate of successful antiseizure medication (ASM) withdrawal after resective surgery in patients with long-term epilepsy-associated tumors (LEATs). METHODS A retrospective analysis (from our prospectively archived data) on the post-operative ASM profile of 123 consecutive patients who completed a minimum of 2 years after resection of LEATs for ASM-resistant epilepsy. A comparison between recurred and non-recurred groups in terms of seizure recurrence was used to identify the potential predictors of seizure recurrence whose attributes were further analyzed using univariate and multiple logistic regression analysis. Kaplan-Meier survival curves were used to study the probability of ASM freedom following surgery. RESULTS We attempted ASM withdrawal in 102 (82.9 %) patients. Forty-eight (47.1 %) had seizure recurrence while reducing ASM, of which 22 (21.6 %) continued to have seizures even after ASM optimisation. On univariate analysis, presence of pre-operative secondary generalized seizure(s) was the only factor associated with seizure recurrence. At a mean follow-up of 6.1 years, 72 (58.5 %) patients were seizure-free and aura-free at terminal follow-up (53 patients were off any ASM). The cumulative probability of achieving complete ASM-free status was 29 % at fourth year, 42 % at sixth year, 55 % at eighth year, and 59 % at 10th year after surgery. CONCLUSIONS Following resective surgery for LEATs, ASM(s) could be successfully discontinued in half of the patients. About one-third of the patients may have recurrent seizures on follow-up. Presence of secondary generalized seizure(s) prior to surgery predicts seizure recurrence, whereas MRI defined completeness of resection will not. This information will help in rationalising decisions on ASM management post-resection.
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Affiliation(s)
- Kavadisseril Vivekanandan Vysakha
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Kshiteeja Jain
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Jayakumari Nandana
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Karamala Yalapalli Manisha
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Ramshekhar N Menon
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - George Vilanilam
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Mathew Abraham
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Bejoy Thomas
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Chandrashekharan Kesavadas
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India
| | - Ashalatha Radhakrishnan
- R. Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India.
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Hoppe C, Beeres K, Witt JA, Sassen R, Helmstaedter C. Clinical adult outcome 11-30 years after pediatric epilepsy surgery: Complications and other surgical adverse events, seizure control, and cure of epilepsy. Epilepsia 2023; 64:335-347. [PMID: 36468792 DOI: 10.1111/epi.17477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Christian Hoppe
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kassandra Beeres
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Robert Sassen
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
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Makridis KL, Atalay DA, Thomale UW, Tietze A, Elger CE, Kaindl AM. Epilepsy surgery in the first six months of life: A systematic review and meta-analysis. Seizure 2022; 96:109-117. [DOI: 10.1016/j.seizure.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 11/16/2022] Open
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Choi SA, Kim SY, Kim WJ, Shim YK, Kim H, Hwang H, Choi JE, Lim BC, Chae JH, Chong S, Lee JY, Phi JH, Kim SK, Wang KC, Kim KJ. Antiepileptic Drug Withdrawal after Surgery in Children with Focal Cortical Dysplasia: Seizure Recurrence and Its Predictors. J Clin Neurol 2019; 15:84-89. [PMID: 30618221 PMCID: PMC6325372 DOI: 10.3988/jcn.2019.15.1.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose This study investigated the seizure recurrence rate and potential predictors of seizure recurrence following antiepileptic drug (AED) withdrawal after resective epilepsy surgery in children with focal cortical dysplasia (FCD). Methods We retrospectively analyzed the records of 70 children and adolescents with FCD types I, II, and IIIa who underwent resective epilepsy surgery between 2004 and 2015 and were followed for at least 2 years after surgery. Results We attempted AED withdrawal in 40 patients. The median time of starting the AED reduction was 10.8 months after surgery. Of these 40 patients, 14 patients (35%) experienced seizure recurrence during AED reduction or after AED withdrawal. Half of the 14 patients who experienced recurrence regained seizure freedom after AED reintroduction and optimization. Compared with their preoperative status, the AED dose or number was decreased in 57.1% of patients, and remained unchanged in 14.3% after surgery. A multivariate analysis found that incomplete resection (p=0.004) and epileptic discharges on the postoperative EEG (p=0.025) were important predictors of seizure recurrence after AED withdrawal. Over the mean follow-up duration of 4.5 years after surgery, 34 patients (48.6% of the entire cohort) were seizure-free with and without AEDs. Conclusions Children with incomplete resection and epileptic discharges on postoperative EEG are at a high risk of seizure recurrence after drug withdrawal. Complete resection of FCD may lead to a favorable surgical outcome and successful AED withdrawal after surgery.
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Affiliation(s)
- Sun Ah Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Joong Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Kyu Shim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hunmin Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee Hwang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Eun Choi
- Department of Pediatrics, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Byung Chan Lim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hee Chae
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sangjoon Chong
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Yeoun Lee
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Ki Kim
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Chang Wang
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Joong Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Does early postoperative drug regimen impact seizure control in patients undergoing temporal lobe resections? J Neurol 2018; 265:500-509. [PMID: 29307009 DOI: 10.1007/s00415-017-8700-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/30/2017] [Accepted: 12/02/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the impact of postoperative antiepileptic drug (AED) load on seizure control in patients who underwent surgical treatment for pharmacoresistant mesiotemporal lobe epilepsy during the first two postoperative years. PATIENTS AND METHODS 532 consecutive patients (48.7% males and 51.7% females) who underwent surgical treatment for mesiotemporal lobe epilepsy were retrospectively evaluated regarding effects of AED load on seizures control during the first 2 years following epilepsy surgery. We analyzed whether postoperative increases in postoperative AED load are associated with better seizure control in patients initially not seizure free, and if postoperative decreases in postoperative AED load would increase the risk for seizure persistence or recurrence. For statistical analyses, Fisher's exact and Wilcoxon test were applied. RESULTS 68.9, 64.0 and 59.1% of patients were completely seizure free (Engel Ia) at 3, 12 and 24 months after surgery, respectively. Patients in whom daily drug doses were increased did not have a higher rate of seizure freedom at any of the three follow-up periods. Of 16 patients achieving secondary seizure control at 12 months after surgery, only one did so with an increase in drug load in contrast to 15 patients who experienced a running down of seizures independent of drug load increases. Decreases in drug load did not significantly increase the risk for seizure recurrence. Of postoperatively seizure free patients at 3 months after surgery in whom AED were consequently reduced, 85% remained completely seizure free at 1 year and 76% at 1 year after surgery, respectively, as opposed to 86% each when AED was not reduced (differences n.s.). Mean daily drug load was significantly lower in seizure free patients at 12 and 24 months compared to patients with ongoing seizures. CONCLUSION In this large patient cohort stratified to the epilepsy syndrome neither did a postoperative reduction in drug load significantly increase the risk for seizure relapse nor did increases in drug dosages lead to improved seizure control. Mean drug load was on average lower in seizure free- than non-seizure free patients at 12 and 24 months of follow-up. Secondary seizure control after initial postoperative seizures in > 90% of cases occurred as a running down, independent of an AED increase. Thus, the effect of the surgical intervention rather than the postoperative drug regimen was the key determinant for seizure control. This finding supports a curative role of temporal lobe surgery rather than an effect rendering the majority of patients' pharmacoresponsive with a critical role of the antiepileptic drug regime for seizure control.
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Radhakrishnan A, Menon R, Abraham M, Vilanilam G, Sharma S, Thomas B, Kesavadas C, Cherian A, Varma R, Thomas SV. Predictors of outcome after surgery in 134 children with drug-resistant TLE. Epilepsy Res 2018; 139:150-156. [DOI: 10.1016/j.eplepsyres.2017.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 11/23/2017] [Accepted: 11/29/2017] [Indexed: 12/01/2022]
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Stagi S, Lasorella S, Piccorossi A, Iapadre G, Verrotti A. Cessation of epilepsy therapy in children. Expert Rev Neurother 2016; 16:549-59. [DOI: 10.1586/14737175.2016.1168296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Management of antiepileptic drugs following epilepsy surgery: A meta-analysis. Epilepsy Res 2014; 108:765-74. [DOI: 10.1016/j.eplepsyres.2014.01.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 01/26/2014] [Indexed: 11/18/2022]
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Yardi R, Irwin A, Kayyali H, Gupta A, Nair D, Gonzalez-Martinez J, Bingaman W, Najm IM, Jehi LE. Reducing versus stopping antiepileptic medications after temporal lobe surgery. Ann Clin Transl Neurol 2014; 1:115-23. [PMID: 25356390 PMCID: PMC4212478 DOI: 10.1002/acn3.35] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/27/2013] [Accepted: 12/30/2013] [Indexed: 02/05/2023] Open
Abstract
Objective To study the safety of antiepileptic drug (AED) withdrawal after temporal lobe epilepsy (TLE) surgery. Methods We reviewed patients who underwent TLE surgery from 1995 to 2011, collecting data on doses, dates of AED initiation, reduction, and discontinuation. Predictors of seizure outcome were defined using Cox-proportional hazard modeling and adjusted for, while comparing longitudinal seizure-freedom in patients for whom AEDs were unchanged after resection as opposed to reduced or stopped. Results A total of 609 patients (86% adults) were analyzed. Follow-up ranged from 0.5 to 16.7 years. Most (64%) had hippocampal sclerosis. Overall, 229 patients had remained on their same baseline AEDs, while 380 patients stopped (127 cases) or reduced (253 cases) their AEDs. Mean timing of the earliest AED change was shorter in patients with recurrent seizures (1.04 years) compared to those seizure-free at last follow-up (1.44 years; P-value 0.03). Whether AEDs were withdrawn 12 or 24 months after surgery, there was a 10–25% higher risk of breakthrough seizures within the subsequent 2 years. However, 70% of patients with seizure recurrence after AED discontinuation reachieved remission, as opposed to 50% of those whose seizures recurred while reducing AEDs (P = 0.0001). Long-term remission rates were similar in both AED discontinuation and “unchanged” groups (82% remission for AEDs withdrawn after 1 year and 90% for AEDs withdrawn after 2 years), while only 65% of patients whose recurrences started during AED reduction achieved a 2-year remission by last follow-up. Interpretation AED withdrawal increases the short-term risk of breakthrough seizures after TLE surgery, and may alter the long-term disease course in some patients.
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Affiliation(s)
- Ruta Yardi
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
| | - Anna Irwin
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
| | - Husam Kayyali
- The Children's Mercy Hospital, University of Missouri Kansas, Missouri
| | - Ajay Gupta
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
| | - Dileep Nair
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
| | | | | | - Imad M Najm
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
| | - Lara E Jehi
- Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio
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Hauptman JS, Pedram K, Sison CA, Sankar R, Salamon N, Vinters HV, Mathern GW. Pediatric epilepsy surgery: long-term 5-year seizure remission and medication use. Neurosurgery 2013; 71:985-93. [PMID: 22895408 DOI: 10.1227/neu.0b013e31826cdd5a] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is unclear whether long-term seizure outcomes in children are similar to those in adult epilepsy surgery patients. OBJECTIVE To determine 5-year outcomes and antiepilepsy drug (AED) use in pediatric epilepsy surgery patients from a single institution. METHODS The cohort consisted of children younger than 18 years of age whose 5-year outcome data would have been available by 2010. Comparisons were made between patients with and without 5-year data (n = 338), patients with 5-year data for seizure outcome (n = 257), and seizure-free patients on and off AEDs (n = 137). RESULTS Five-year data were available from 76% of patients. More seizure-free patients with focal resections for hippocampal sclerosis and tumors lacked 5-year data compared with other cases. Of those with 5-year data, 53% were continuously seizure free, 18% had late seizure recurrence, 3% became seizure free after initial failure, and 25% were never seizure free. Patients were more likely to be continuously seizure free if their surgery was performed during the period 2001 to 2005 (68%) compared with surgery performed from 1996 to 2000 (61%), 1991 to 1995 (36%), and 1986 to 1990 (46%). More patients had 1 or fewer seizures per month in the late seizure recurrence (47%) compared with the not seizure-free group (20%). Four late deaths occurred in the not seizure-free group compared with 1 in the seizure-free group. Of patients who were continuously seizure free, 55% were not taking AEDs, and more cortical dysplasia patients (74%) had stopped taking AEDs compared with hemimegalencephaly patients (18%). CONCLUSION In children, 5-year outcomes improved over 20 years of clinical experience. Our results are similar to those of adult epilepsy surgery patients despite mostly extratemporal and hemispheric operations for diverse developmental etiologies.
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Affiliation(s)
- Jason S Hauptman
- Department of Neurosurgery, Mattel Children's Hospital, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Lopez-Gonzalez MA, Gonzalez-Martinez JA, Jehi L, Kotagal P, Warbel A, Bingaman W. Epilepsy surgery of the temporal lobe in pediatric population: a retrospective analysis. Neurosurgery 2012; 70:684-92. [PMID: 21904264 DOI: 10.1227/neu.0b013e318235183d] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is still some reluctance to refer pediatric patients for epilepsy surgery, despite evidence of success in retrospective series. OBJECTIVE To describe surgical experience and long-term outcome in pediatric temporal lobe epilepsy (TLE) at a single institution. METHODS Retrospective review of pediatric (<18-years-old) TLE patients who underwent surgery between November 1996 and December 2006 at Cleveland Clinic Epilepsy Center. Cox proportional hazard modeling was used to assess outcome predictors. RESULTS One hundred thirty pediatric patients met study criteria. Mean time between seizure onset and surgery was 6.3 years. Invasive evaluation was used in 32 patients (24.5%). Hippocampal sclerosis was present in 70 patients (53.8%), either alone or associated in dual pathology. The complication rate was 7%. The seizure-freedom rates at 1, 2, 5, and 12 years were 76%, 72%, 54%, and 41%, respectively (Kaplan-Meier). With the use of the Engel outcome classification, 98 (75.3%) patients were class I, 11 (8.5%) class II, 9 (7%) class III, and 12 (9.2%) were class IV at last follow-up. Only 4 (3.1%) patients underwent reoperations. Antiepileptic drugs (AEDs) were discontinued in 36 patients (28.3%) in a mean period of 18 months (SD ± 17 months; range, 6-102 months). Although left-sided resection, lower number of preoperative AED trials (≤ 4), and tumor pathology correlated with favorable seizure outcomes, extensive surgical resection remained the only significant outcome predictor after multivariate analysis (P = .007; HR = 0.13 [95% confidence interval 0.007-0.64]). CONCLUSION Careful selection of surgical candidates by multidisciplinary evaluations is required. Long-term seizure control is achieved successfully with acceptable low complication rates.
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Boshuisen K, Arzimanoglou A, Cross JH, Uiterwaal CSPM, Polster T, van Nieuwenhuizen O, Braun KPJ. Timing of antiepileptic drug withdrawal and long-term seizure outcome after paediatric epilepsy surgery (TimeToStop): a retrospective observational study. Lancet Neurol 2012; 11:784-91. [DOI: 10.1016/s1474-4422(12)70165-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Duchowny M, Cross JH. Preoperative evaluation in children for epilepsy surgery. HANDBOOK OF CLINICAL NEUROLOGY 2012; 108:829-839. [PMID: 22939069 DOI: 10.1016/b978-0-444-52899-5.00031-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Michael Duchowny
- University of Miami Leonard Miller School of Medicine, Miami, FL, USA.
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Hauptman JS, Mathern GW. Epilepsy neurosurgery in children. HANDBOOK OF CLINICAL NEUROLOGY 2012; 108:881-95. [PMID: 22939072 DOI: 10.1016/b978-0-444-52899-5.00034-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Jason S Hauptman
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
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Rathore C, Panda S, Sarma PS, Radhakrishnan K. How safe is it to withdraw antiepileptic drugs following successful surgery for mesial temporal lobe epilepsy? Epilepsia 2011; 52:627-35. [DOI: 10.1111/j.1528-1167.2010.02890.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hemb M, Velasco TR, Parnes MS, Wu JY, Lerner JT, Matsumoto JH, Yudovin S, Shields WD, Sankar R, Salamon N, Vinters HV, Mathern GW. Improved outcomes in pediatric epilepsy surgery: the UCLA experience, 1986-2008. Neurology 2010; 74:1768-75. [PMID: 20427752 DOI: 10.1212/wnl.0b013e3181e0f17a] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Epilepsy neurosurgery is a treatment option for children with refractory epilepsy. Our aim was to determine if outcomes improved over time. METHODS Pediatric epilepsy surgery patients operated in the first 11 years (1986-1997; pre-1997) were compared with the second 11 years (1998-2008; post-1997) for differences in presurgical and postsurgical variables. RESULTS Despite similarities in seizure frequency, age at seizure onset, and age at surgery, the post-1997 series had more lobar/focal and fewer multilobar resections, and more patients with tuberous sclerosis complex and fewer cases of nonspecific gliosis compared with the pre-1997 group. Fewer cases had intracranial EEG studies in the post-1997 (0.8%) compared with the pre-1997 group (9%). Compared with the pre-1997 group, the post-1997 series had more seizure-free patients at 0.5 (83%, +16%), 1 (81%, +18%), 2 (77%, +19%), and 5 (74%, +29%) years, and more seizure-free patients were on medications at 0.5 (97%, +6%), 1 (88%, +9%), and 2 (76%, +29%), but not 5 (64%, +8%) years after surgery. There were fewer complications and reoperations in the post-1997 series compared with the pre-1997 group. Logistic regression identified post-1997 series and less aggressive medication withdrawal as the main predictors of becoming seizure-free 2 years after surgery. CONCLUSIONS Improved technology and surgical procedures along with changes in clinical practice were likely factors linked with enhanced and sustained seizure-free outcomes in the post-1997 series. These findings support the general concept that clearer identification of lesions and complete resection are linked with better outcomes in pediatric epilepsy surgery patients.
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Affiliation(s)
- M Hemb
- Reed Neurological Research Center, 710 Westwood Plaza, Room 2123, Los Angeles, CA 90095-1769, USA
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Boshuisen K, Braams O, Jennekens-Schinkel A, Braun KP, Jansen FE, van Rijen PC, van Nieuwenhuizen O. Medication policy after epilepsy surgery. Pediatr Neurol 2009; 41:332-8. [PMID: 19818934 DOI: 10.1016/j.pediatrneurol.2009.04.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 04/22/2009] [Accepted: 04/27/2009] [Indexed: 11/28/2022]
Abstract
The postsurgical medication policy was reviewed for 109 children (age at surgery, 0-16 years) who had epilepsy surgery between 1991 and 2005. Intervals between surgery and both start (n = 84) and completion (n = 68) of withdrawal of antiepileptic drugs (AEDs) were calculated and analyzed in relation to demographic and epilepsy variables and to recurrent seizures. Postoperative seizure freedom was associated with completeness of surgical resection, defined as complete removal of the cortical region exhibiting ictal or interictal abnormalities on intracranial electroencephalography and lesion on magnetic resonance imaging (P = 0.008). Etiology seemed to be related, but numbers were too small for statistical analysis. In 24 children (22%), seizures recurred postoperatively, and in 19 of these 24 children the AEDs were never withdrawn. Two of the five children in whom seizures recurred after medication withdrawal regained seizure freedom. Mean interval from surgery to start of drug withdrawal was 1.71 years (n = 84), and 2.86 years (n = 68) from surgery to complete withdrawal. Seizure recurrence seemed not associated with withdrawal decisions. Timing of seizure relapse was identical in children still on AEDs and in those who stopped. Eight children with early discontinuation (0.6 years from surgery to start of withdrawal and 0.8 years to complete withdrawal) had no seizure recurrence. Long-term continuation of AEDs is probably not indicated in children with complete resection of the epileptogenic zone. The optimal timing needs to be further explored.
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Affiliation(s)
- Kim Boshuisen
- Department of Child Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
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Kerling F, Pauli E, Lorber B, Blümcke I, Buchfelder M, Stefan H. Drug withdrawal after successful epilepsy surgery: how safe is it? Epilepsy Behav 2009; 15:476-80. [PMID: 19546031 DOI: 10.1016/j.yebeh.2009.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 05/29/2009] [Accepted: 05/31/2009] [Indexed: 10/20/2022]
Abstract
Discontinuation of antiepileptic drugs (AEDs) is one reason patients undergo epilepsy surgery, but little is known about the risk of seizure recurrence. We describe a prospective pilot study of withdrawal performed at our epilepsy center. Sixty completely seizure-free patients were included between 1997 and 2003. AED withdrawal was proposed 1 year after surgery after a detailed discussion of the risks and benefits. On the basis of their decision on withdrawal, patients were stratified into two cohorts (withdrawal group, N=34; control group, N=26). Discontinuation was carried out in small tapering steps over 1 year with yearly follow-up visits. Withdrawal was stopped when seizures recurred or the patients objected to further discontinuation. Twenty-six of 34 (76.5%) persons in the withdrawal group and 16 of 26 (61.5%) persons in the control group were seizure free 5 years after surgery. In this study, AED discontinuation 1 year after successful epilepsy surgery was not associated with a risk of seizure recurrence higher than that of controls.
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Affiliation(s)
- Frank Kerling
- Epilepsy Center (ZEE), Department of Neurology, University Hospital of Erlangen, Schwabachanlage 6, Erlangen, Germany.
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20
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Lachhwani DK, Loddenkemper T, Holland KD, Kotagal P, Mascha E, Bingaman W, Wyllie E. Discontinuation of medications after successful epilepsy surgery in children. Pediatr Neurol 2008; 38:340-4. [PMID: 18410850 DOI: 10.1016/j.pediatrneurol.2008.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 11/13/2007] [Accepted: 01/28/2008] [Indexed: 10/22/2022]
Abstract
To evaluate the need for antiepileptic drugs after successful epilepsy surgery in pediatric patients, we retrospectively reviewed patients who had epilepsy surgery and were seizure free or had rare nondisabling auras during the first 6 postoperative months. Association between drug discontinuation and seizure recurrence was evaluated using Cox proportional hazards multivariable survival analysis. Medications were withdrawn in 68 of 97 patients, seizure free (or with rare nondisabling auras) for >6 months after surgery; 57 of the 68 (84%) remained seizure free; the other 11 (16%) had seizure recurrence after 68 months (median). Seizure recurrence was controlled with medication in 7 of the 11 patients (3 have rare seizures, 1 frequent auras). Discontinuing medications at <6 mo, compared with later or no withdrawal, had significant risk for seizure recurrence (hazard ratio 5.8; 95% confidence interval 1.8, 17.5; P = 0.003). Of 29 patients who continued drugs, 28 (97%) remained seizure free after 37 months (median). Freedom from seizures 6 months after surgery predicted good outcome (95% seizure free, with or without medication). If discontinuation is offered after 6 months, the majority of patients (84%) can be expected to remain seizure free with no further need for medication. Although seizure breakthrough is possible in a smaller percentage, restarting drugs is likely to restore seizure control.
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Affiliation(s)
- Deepak K Lachhwani
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Sinclair DB, Jurasek L, Wheatley M, Datta A, Gross D, Ahmed N, Quigley D, Snyder T, Aronyk K, McKean J. Discontinuation of antiepileptic drugs after pediatric epilepsy surgery. Pediatr Neurol 2007; 37:200-2. [PMID: 17765808 DOI: 10.1016/j.pediatrneurol.2007.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 01/18/2007] [Accepted: 05/07/2007] [Indexed: 10/22/2022]
Abstract
In children with medically intractable seizures, epilepsy surgery is now a widely accepted option. Successful discontinuation of antiepileptic drugs after epilepsy surgery has been reported in adults, but rarely in children. Surgical outcome and need for antiepileptic drugs after temporal and extratemporal lobe resection were retrospectively reviewed for 80 pediatric patients from the Comprehensive Epilepsy Program at the University of Alberta. For 1 year after surgery, children were maintained on at least one antiepileptic drug. Antiepileptic drug discontinuation was attempted in all patients with a nonepileptic electroencephalogram after 1 year seizure-free. Less than half of the patients (44%) eventually relapsed without antiepileptic drugs. Of the 40 patients in the temporal lobe group, 13 (32%) relapsed without antiepileptic drugs, as did 22 of the 40 extratemporal lobe resection patients (55%). Success rates for antiepileptic drug discontinuation after surgery were higher in the temporal lobe than in the extratemporal lobe group. Long-term antiepileptic drugs are not necessary in all cases, and for many children medication can be withdrawn after epilepsy surgery.
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Affiliation(s)
- D Barry Sinclair
- Comprehensive Epilepsy Program, University of Alberta, Edmonton, Alberta, Canada.
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Shorvon S. The treatment of chronic epilepsy: a review of recent studies of clinical efficacy and side effects. Curr Opin Neurol 2007; 20:159-63. [PMID: 17351485 DOI: 10.1097/wco.0b013e3280555186] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Al-Kaylani M, Konrad P, Lazenby B, Blumenkopf B, Abou-Khalil B. Seizure freedom off antiepileptic drugs after temporal lobe epilepsy surgery. Seizure 2007; 16:95-8. [PMID: 17239628 DOI: 10.1016/j.seizure.2006.10.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2006] [Revised: 10/19/2006] [Accepted: 10/25/2006] [Indexed: 11/19/2022] Open
Abstract
Data are limited on seizure recurrence after antiepileptic drug (AED) discontinuation in operated seizure-free patients. We reviewed seizure outcome in patients who came off AEDs after being seizure-free for 2 years following temporal lobe surgery in our center. Thirty-nine (68%) of 57 patients who discontinued AED therapy remained seizure-free. They had a younger age at surgery than the group with seizure recurrence (p=0.01). Earlier surgery may be a favorable predictor for seizure freedom after AED discontinuation.
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Affiliation(s)
- Muhammad Al-Kaylani
- Department of Neurology, Vanderbilt University Medical Center, 2311 Pierce Avenue, Nashville, TN 37232, USA
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25
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Martinez CC, Pyzik PL, Kossoff EH. Discontinuing the Ketogenic Diet in Seizure-Free Children: Recurrence and Risk Factors. Epilepsia 2007; 48:187-90. [PMID: 17241227 DOI: 10.1111/j.1528-1167.2006.00911.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
About 10% of children become seizure-free after initiation of the ketogenic diet, and typically stop the diet after 2 yr. A retrospective chart review was performed of all children who became seizure-free on the ketogenic diet at our institution since 1993 and then discontinued the diet. Of 557 children started on the diet since 1993, 66 (12%) discontinued the diet after a median of 2.1 yr due to seizure freedom; 92% were also medication-free. Thirteen (20%) had recurrence of their seizures at a median of 2.4 yr (range: 0-5.5 yr) after the diet was stopped. Seven (58%) became seizure-free a second time, four with anticonvulsant therapy. Four patients (6%) continue to have daily seizures despite both medication and dietary therapies. The presence of recent EEG epileptiform activity, abnormal MRI, lower initial seizure frequency, and tuberous sclerosis complex all significantly increased the likelihood of recurrence.
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Affiliation(s)
- Celina C Martinez
- School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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