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Jha R, Chua MMJ, Liu DD, Cosgrove GR, Tobochnik S, Rolston JD. Characterization of anti-seizure medication reduction and discontinuation rates following epilepsy surgery. Epilepsy Behav 2024; 158:109944. [PMID: 39002278 DOI: 10.1016/j.yebeh.2024.109944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 06/25/2024] [Accepted: 07/07/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE Many patients pursue epilepsy surgery with the hope of reducing or stopping anti-seizure medications (ASMs), in addition to reducing their seizure frequency and severity. While ASM decrease is primarily driven by surgical outcomes and patient preferences, preoperative estimates of meaningful ASM reduction or discontinuation are uncertain, especially when accounting for the various forking paths possible following intracranial EEG (iEEG), including resection, neuromodulation, or even the absence of further surgery. Here, we characterize in detail the ASM reduction in a large cohort of patients who underwent iEEG, facilitating proactive, early counseling for a complicated cohort considering surgical treatment. METHODS We identified a multi-institutional cohort of patients who underwent iEEG between 2001 and 2022, with a minimum of two years follow-up. The total number of ASMs prescribed immediately prior to surgery, choice of investigation modality, and subsequent surgical treatment were extracted for each patient. Primary endpoints included decreases in ASM counts from preoperative baseline to various follow-up intervals. RESULTS A total of 284 patients were followed for a median of 6.0 (range 2,22) years after iEEG surgery. Patients undergoing resection saw an average reduction of ∼ 0.5 ASMs. Patients undergoing neuromodulation saw no decrease and trended towards requiring increased ASM usage during long-term follow-up. Only patients undergoing resection were likely to completely discontinue all ASMs, with an increasing probability over time approaching ∼ 10 %. Up to half of resection patients saw ASM decreases, which was largely stable during long-term follow-up, whereas only a quarter of neuromodulation patients saw a reduction, though their ASM reduction decreased over time. CONCLUSIONS With the increasing use of stereotactic EEG and non-curative neuromodulation procedures, realistic estimates of ASM reduction and discontinuation should be considered preoperatively. Almost half of patients undergoing resective surgery can expect to reduce their ASMs, though only a tenth can expect to discontinue ASMs completely. If reduction is not seen early, it likely does not occur later during long-term follow-up. Less than a third of patients undergoing neuromodulation can expect ASM reduction, and instead most may require increased usage during long-term follow-up.
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Affiliation(s)
- Rohan Jha
- Harvard Medical School, Boston, MA, USA
| | - Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Garth R Cosgrove
- Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Rolston
- Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Brigo F, Zelano J, Abraira L, Bentes C, Ekdahl CT, Lattanzi S, Ingvar Lossius M, Redfors P, Rouhl RPW, Russo E, Sander JW, Vogrig A, Wickström R. Proceedings of the "International Congress on Structural Epilepsy & Symptomatic Seizures" (STESS, Gothenburg, Sweden, 29-31 March 2023). Epilepsy Behav 2024; 150:109538. [PMID: 38039602 DOI: 10.1016/j.yebeh.2023.109538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Laura Abraira
- Neurology Department, Epilepsy Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Carla Bentes
- Neurophysiological Monitoring Unit - EEG/Sleep Laboratory, Refractory Epilepsy Reference Centre (member of EpiCARE), Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Centro de Estudos Egas Moniz, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - Christine T Ekdahl
- Division of Clinical Neurophysiology and Department of Clinical Sciences, Lund University, Sweden; Lund Epilepsy Center, Department of Clinical Sciences, Lund University, Sweden
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Morten Ingvar Lossius
- National Centre for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Member of the ERN EpiCARE, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Petra Redfors
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Academic Centre for Epileptology Kempenhaeghe/MUMC+ Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Italy
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK; Centre for Epilepsy, Chalfont St Peter, Bucks., SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede 2103 SW, The Netherlands; Neurology Department, West of China Hospital, Sichuan University, Chengdu 610041, China
| | - Alberto Vogrig
- Department of Medicine (DAME), University of Udine, Udine, Italy; Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Ronny Wickström
- Neuropediatric Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Athreya A, Matthews RE, Drane DL, Bonilha L, Willie JT, Gross RE, Karakis I. Withdrawal of antiseizure medications after MRI-Guided laser interstitial thermal therapy in extra-temporal lobe epilepsy. Seizure 2023; 110:86-92. [PMID: 37331198 DOI: 10.1016/j.seizure.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/16/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Abstract
PURPOSE This study investigated the success rate of antiseizure medications (ASMs) withdrawal following MRI Guided Laser Interstitial Thermal Therapy (MRg-LITT) for extra-temporal lobe epilepsy (ETLE), and identified predictors of seizure recurrence. METHODS We retrospectively assessed 27 patients who underwent MRg-LITT for ETLE. Patients' demographics, disease characteristics, and post-surgical outcomes were evaluated for their potential to predict seizure recurrence associated with ASMs withdrawal. RESULTS The median period of observation post MRg-LITT was 3 years (range 18 - 96 months) and the median period to initial ASMs reduction was 0.5 years (range 1-36 months). ASMs reduction was attempted in 17 patients (63%), 5 (29%) of whom had seizure recurrence after initial reduction. Nearly all patient who relapsed regained seizure control after reinstitution of their ASMs regimen. Pre-operative seizure frequency (p = 0.002) and occurrence of acute post-operative seizures (p = 0.01) were associated with increased risk for seizure recurrence post ASMs reduction. At the end of the observation period, 11% of patients were seizure free without drugs, 52% were seizure free with drugs and 37% still experienced seizures despite ASMs. Compared with pre-operative status, the number of ASMs was reduced in 41% of patients, unchanged in 55% of them and increased in only 4% of them. CONCLUSIONS Successful MRg-LITT for ETLE allows for ASMs reduction in a significant portion of patients and complete ASMs withdrawal in a subset of them. Patients with higher pre-operative seizure frequency or occurrence of acute post operative seizures exhibit higher chances relapse post ASMs reduction.
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Affiliation(s)
- Arjun Athreya
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca E Matthews
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, University of Washington, Seattle, WA, USA
| | - Leonardo Bonilha
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jon T Willie
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Athreya A, Fasano RE, Drane DL, Millis SR, Willie JT, Gross RE, Karakis I. Withdrawal of antiepileptic drugs after stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy. Epilepsy Res 2021; 176:106721. [PMID: 34273722 DOI: 10.1016/j.eplepsyres.2021.106721] [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: 04/12/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This retrospective study investigated the success rate of withdrawal of antiepileptic drugs (AEDs) following stereotactic laser amygdalohippocampotomy (SLAH) for mesial temporal lobe epilepsy (MTLE), and identified predictors of seizure recurrence. MATERIALS AND METHODS We retrospectively assessed 65 patients who underwent SLAH for MTLE (59 lesional). Patients' demographics, disease characteristics and post-surgical outcomes were evaluated for their potential to predict seizure recurrence associated with withdrawal of AEDs. RESULTS The mean period of observation post SLAH was 51 months (range 12-96 months) and the mean period to initial reduction of AEDs was 21 months (range 12-60 months). Reduction of AEDs was attempted in 37 patients (57 %) who were seizure free post SLAH and it was successful in approximately 2/3 of them. From the remainder 1/3 who relapsed, nearly all regained seizure control after reinstitution of their AEDs. The likelihood of relapse after reduction of AEDs was predicted only by pre-operative seizure frequency. At the end of the observation period, approximately 14 % of all SLAH patients were seizure free without AEDs and approximately 54 % remained seizure free on AEDs. Compared with preoperative status, the number of AEDs were reduced in 37 % of patients, unchanged in 51 % of them and increased in 12 % of them. CONCLUSIONS Successful SLAH for MTLE allows for reduction of AEDs in a significant portion of patients and complete withdrawal of AEDs in a subset of them. Patients with higher pre-operative seizure frequency exhibit a greater chance of relapse post reduction of AEDs.
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Affiliation(s)
- Arjun Athreya
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca E Fasano
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, University of Washington, Seattle, WA, USA
| | - Scott R Millis
- Department of Neurology, Physical Medicine & Rehabilitation, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jon T Willie
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Thomas DL, Pierson CR. Neuropathology of Surgically Managed Epilepsy Specimens. Neurosurgery 2021; 88:1-14. [PMID: 33231262 DOI: 10.1093/neuros/nyaa366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Epilepsy is characterized as recurrent seizures, and it is one of the most prevalent disorders of the human nervous system. A large and diverse profile of different syndromes and conditions can cause perturbations in neural networks that are associated with epilepsy. Advances in neuroimaging and electrophysiological monitoring have enhanced our ability to localize the neuropathological lesions that alter the neural networks giving rise to epilepsy, whereas advances in surgical management have resulted in excellent seizure control in many patients following resections. Histopathologic study using a variety of special stains, molecular analysis, and functional studies of these resected tissues has facilitated the neuropathological characterization of these lesions. Here, we review the neuropathology of common structural lesions that cause epilepsy and are amenable to neurosurgical resection, such as hippocampal sclerosis, focal cortical dysplasia, and its associated principal lesions, including long-term epilepsy-associated tumors, as well as other malformations of cortical development and Rasmussen encephalitis.
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Affiliation(s)
- Diana L Thomas
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pathology, The Ohio State University, Columbus, Ohio
| | - Christopher R Pierson
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pathology, The Ohio State University, Columbus, Ohio.,Division of Anatomy, Department of Biomedical Education and Anatomy, The Ohio State University, Columbus, Ohio
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Uribe-San-Martín R, Di Giacomo R, Mai R, Gozzo F, Pelliccia V, Mariani V, Cardinale F, Ciampi E, Onofrj M, Tassi L. In Reply: Forecasting Seizure Freedom After Epilepsy Surgery Assessing Concordance Between Noninvasive and StereoEEG Findings. Neurosurgery 2021; 88:E290-E291. [PMID: 33370839 DOI: 10.1093/neuros/nyaa503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Reinaldo Uribe-San-Martín
- Neurology Department Pontificia Universidad Católica de Chile Neurology Service Complejo Asistencial Hospital Sótero del Río Puente Alto, Chile
| | - Roberta Di Giacomo
- Clinical Epileptology and Experimental Neurophysiology Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan, Italy
| | - Roberto Mai
- "Claudio Munari" Epilepsy Surgery Centre Niguarda Hospital Milan, Italy
| | - Francesca Gozzo
- "Claudio Munari" Epilepsy Surgery Centre Niguarda Hospital Milan, Italy
| | | | - Valeria Mariani
- "Claudio Munari" Epilepsy Surgery Centre Niguarda Hospital Milan, Italy
| | | | - Ethel Ciampi
- Neurology Department Pontificia Universidad Católica de Chile Neurology Service Complejo Asistencial Hospital Sótero del Río Puente Alto, Chile
| | - Marco Onofrj
- Department of Neuroscience Imaging and Clinical Sciences University G. D'Annunzio of Chieti-Pescara Chieti, Italy
| | - Laura Tassi
- "Claudio Munari" Epilepsy Surgery Centre Niguarda Hospital Milan, Italy
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Rathore C, Radhakrishnan K, Jeyaraj MK, Wattamwar PR, Baheti N, Sarma SP. Early versus late antiepileptic drug withdrawal following temporal lobectomy. Seizure 2020; 75:23-27. [DOI: 10.1016/j.seizure.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022] Open
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Abstract
PURPOSE OF REVIEW As the number of patients diagnosed with epilepsy continues to rise and the pharmacological and device-based treatment options for epilepsy increase, determining when to stop antiepileptic drug (AED) treatment continues to be an important issue for patient management and counseling. RECENT FINDINGS This review focuses on outcomes following AED withdrawal in seizure-free adults with epilepsy. Practical considerations are also discussed because, despite the importance of this topic, relatively little progress has been made in the past year regarding the identification of patients whose risk for recurrent seizures after AED withdrawal is no higher than that of the general population. SUMMARY Although articles in the past year have updated the debates about whether and when to discontinue AEDs in seizure-free adults and have suggested potential utility for electroencephalograms as a prognostic tool for AED reduction as well as for an AED withdrawal risk calculator, decisions about AED withdrawal should still be based on the known risks and consequences of seizure recurrence and be made following well documented discussions between doctor and patient/carer.
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Rathore C, Jeyaraj MK, Dash GK, Wattamwar P, Baheti N, Sarma SP, Radhakrishnan K. Outcome after seizure recurrence on antiepileptic drug withdrawal following temporal lobectomy. Neurology 2018; 91:e208-e216. [PMID: 29925547 DOI: 10.1212/wnl.0000000000005820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/10/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study the long-term outcome following seizure recurrence on antiepileptic drug (AED) withdrawal after anterior temporal lobectomy for mesial temporal lobe epilepsy. METHODS We retrospectively studied the AED profile of patients who had a minimum of 5 years of postoperative follow-up after anterior temporal lobectomy for mesial temporal lobe epilepsy. Only those patients with hippocampal sclerosis or normal MRI were included. AED withdrawal was initiated at 3 months in patients on ≥2 drugs and at 1 year for patients on a single drug. RESULTS Three hundred eighty-four patients with median postoperative follow-up of 12 years (range, 7-17 years) were included. Of them, 316 patients (82.3%) were seizure-free during the terminal 1 year. AED withdrawal was attempted in 326 patients (84.9%). At last follow-up, AEDs were discontinued in 207 patients (53.9%). Seizure recurrence occurred in 92 patients (28.2%) on attempted withdrawal. After a median postrecurrence follow-up of 7 years, 79 (86%) of them were seizure-free during the terminal 2 years. AEDs could be stopped in 17 patients (18.5%) and doses were reduced in another 57 patients (62%). Patients with febrile seizures, normal postoperative EEG at 1 year, and duration of epilepsy of <20 years (FND20 score) had 17% risk of seizure recurrence on attempted AED withdrawal. We also formulated a score to predict the chances of AED freedom for the whole cohort. CONCLUSION Patients with seizure recurrence on AED withdrawal have good outcome with 86% becoming seizure-free and 18% becoming drug-free after initial recurrence. A FND20 score helps in predicting recurrence on AED withdrawal.
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Affiliation(s)
- Chaturbhuj Rathore
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India.
| | - Malcolm K Jeyaraj
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
| | - Gopal K Dash
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
| | - Pandurang Wattamwar
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
| | - Neeraj Baheti
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
| | - Sankara P Sarma
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
| | - Kurupath Radhakrishnan
- From the R. Madhavan Nayar Center for Comprehensive Epilepsy Care (C.R., M.K.J., G.K.D., P.W., N.B., K.R.), Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala; Department of Neurology (C.R.), Smt. B.K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat; Department of Neurology (M.K.J.), Stanley Medical College, Chennai, Tamilnadu; Department of Neurology (G.K.D.), Narayana Hrudayalaya Hospital, Bengaluru, Karnataka; Department of Neurology (P.W.), United CIIGMA Hospital, Aurangabad, Maharashtra; Department of Neurology (N.B.), Central Institute of Medical Sciences, Nagpur, Maharashtra; Achutha Menon Center for Health Science Studies (S.P.S.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala; and Amrita Advanced Epilepsy Centre (K.R.), Department of Neurology, Kochi, Kerala, India
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Bartolini L, Majidi S, Koubeissi MZ. Uncertainties from a worldwide survey on antiepileptic drug withdrawal after seizure remission. Neurol Clin Pract 2018; 8:108-115. [PMID: 29708173 DOI: 10.1212/cpj.0000000000000441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022]
Abstract
Background We sought to determine differences in practice for discontinuation of antiepileptic drugs (AEDs) after seizure remission and stimulate the planning and conduction of withdrawal trials. Methods We utilized a worldwide electronic survey that included questions about AED discontinuation for 3 paradigmatic cases in remission: (1) focal epilepsy of unknown etiology, (2) temporal lobe epilepsy after surgery, and (3) juvenile myoclonic epilepsy. We analyzed 466 complete questionnaires from 53 countries, including the United States. Statistical analysis included χ2 and multivariate logistic regression. Results Case 1: responders in practice for <10 years were less likely to taper AEDs: odds ratio (OR) (95% confidence interval [CI]) 0.52 (0.32-0.85), p = 0.02. The likelihood of stopping AEDs was higher among doctors treating children: OR (95% CI): 11.41 (2.51-40.13), p = 0.002. Doctors treating children were also more likely to stop after 2 years or less of remission: OR (95% CI): 6.91 (2.62-19.31), p = 0.002, and the same was observed for US physicians: OR (95% CI): 1.61 (1.01-2.57), p = 0.0049. Case 2: responders treating children were more likely to taper after 1 year or less of postoperative remission, with the goal of discontinuing all medications: OR (95% CI): 1.91 (1.09-3.12), p = 0.015, and so were US-based responders: OR (95% CI): 1.73 (1.21-2.41), p = 0.003. Case 3: epileptologists were less likely to withdraw the medication: OR (95% CI): 0.56 (0.39-0.82), p = 0.003, and so were those in practice for 10 or more years: OR (95% CI): 0.54 (0.31-0.95), p = 0.025. Conclusions We observed several differences in practice for AED withdrawal after seizure remission that highlight global uncertainty. Trials of AED discontinuation are needed to provide evidence-based guidance.
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Affiliation(s)
- Luca Bartolini
- Clinical Epilepsy Section (LB) and Stroke Diagnostics and Therapeutics Section (SM), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; and Department of Neurology (SM, MZK), George Washington University Hospital, Washington, DC
| | - Shahram Majidi
- Clinical Epilepsy Section (LB) and Stroke Diagnostics and Therapeutics Section (SM), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; and Department of Neurology (SM, MZK), George Washington University Hospital, Washington, DC
| | - Mohamad Z Koubeissi
- Clinical Epilepsy Section (LB) and Stroke Diagnostics and Therapeutics Section (SM), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; and Department of Neurology (SM, MZK), George Washington University Hospital, Washington, DC
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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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Sheng J, Liu S, Qin H, Li B, Zhang X. Drug-Resistant Epilepsy and Surgery. Curr Neuropharmacol 2018; 16:17-28. [PMID: 28474565 PMCID: PMC5771378 DOI: 10.2174/1570159x15666170504123316] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/23/2017] [Accepted: 04/25/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Epilepsy is a chronic brain disease that is caused by various factors and characterized by recurrent, episodic and temporary central nervous system dysfunction which results due to excessive discharge of brain neurons. In the past decades, despite the continuous development of antiepileptic drugs, there are still many patients with epilepsy progressing to drugresistant epilepsy. Currently, surgical treatment is one of important way to cure drug-resistant epilepsy. METHODS Data were collected from Web of Science, Medline, Pubmed, through searching of these keywords: "surgery" and "drug-resistant epilepsy". RESULTS An increasing number of studies have shown that surgery plays an important role in the treatment of drug-resistant epilepsy. Moreover, the comprehensive treatment mainly based on surgery can achieve the remission and even cure of drug-resistant epilepsy. CONCLUSION In this review, we discuss the pathogenesis of drug-resistant epilepsy and the comprehensive treatment mainly based on surgery; this review may provide a reference for the clinical treatment of drug-resistant epilepsy.
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Affiliation(s)
- Jiyao Sheng
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Shui Liu
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Hanjiao Qin
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Bingjin Li
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
| | - Xuewen Zhang
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, Second Hospital of Jilin University, Changchun130041, P.R. China
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Abstract
Epilepsy is one of the most common neurologic disorders, affecting about 50 million people worldwide. The disease is characterized by recurrent seizures, which are due to aberrant neuronal networks resulting in synchronous discharges. The term epilepsy encompasses a large spectrum of syndromes and diseases with different etiopathogenesis. The recent development of imaging and epilepsy surgery techniques is now enabling the identification of structural abnormalities that are part of the epileptic network, and the removal of these lesions may result in control of seizures. Access of this clinically well-characterized neurosurgical material has provided neuropathologists with the opportunity to study a variety of structural brain abnormalities associated with epilepsy, by combining traditional routine histopathologic methods with molecular genetics and functional analysis of the resected tissue. This approach has contributed greatly to a better diagnosis and classification of these structural lesions, and has provided important new insights into their pathogenesis and epileptogenesis. The present chapter provides a detailed description of the large spectrum of histopathologic findings encountered in epilepsy surgery patients, addressing in particular the nonneoplastic pathologies, including hippocampal sclerosis, malformations of cortical development, Sturge-Weber syndrome, and Rasmussen encephalitis, and reviews current knowledge regarding the underlying molecular pathomechanisms and cellular mechanisms mediating hyperexcitability.
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Affiliation(s)
- Eleonora Aronica
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands; Stichting Epilepsie Instellingen Nederland, the Netherlands.
| | - Angelika Mühlebner
- Department of Neuropathology, Academic Medical Center and Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands
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Bartolini L. Practice Current: When do you stop antiepileptic drugs in patients with genetic generalized epilepsies and in those with focal epilepsies? Neurol Clin Pract 2016; 6:530-537. [PMID: 29849245 DOI: 10.1212/cpj.0000000000000326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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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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18
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Zeng TF, An DM, Li JM, Li YH, Chen L, Hong Z, Lei D, Zhou D. Evaluation of different antiepileptic drug strategies in medically refractory epilepsy patients following epilepsy surgery. Epilepsy Res 2012; 101:14-21. [PMID: 22440744 DOI: 10.1016/j.eplepsyres.2012.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 02/05/2012] [Accepted: 02/12/2012] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aimed to explore the most appropriate antiepileptic drug strategies after successful epilepsy surgery. METHODS A total of 131 refractory epilepsy patients who underwent epilepsy surgery from January 2005 to December 2008 in the Department of Neurosurgery, West China Hospital, were retrospectively reviewed. Patients were divided into three groups (monotherapy, duotherapy, and polytherapy) according to drug combinations used immediately after epilepsy surgery. Seizure outcomes were followed up for more than 2 years. Engel classification was used to evaluate seizure outcomes. RESULTS The mean postoperative follow-up period was 3.7±1.0 years. Preoperative baseline data among the three groups were comparable. Seizure recurrence rate in monotherapy was obviously higher than in other groups (34.1% vs. 15.1%, 7.1%) at 6-month follow-up, which showed a statistically significant difference (p=0.02). Seizure outcomes for 2 years were assessed using Engel classification. In the duotherapy group, the rate of Engel class I was definitely higher than in the other two groups (69.9% vs. 47.7%, 57.1%, p=0.02). Seizure relapse rates at the 2-year follow-up, after planned reduction or withdrawal, were 46.4% for monotherapy, 16.9% for duotherapy, and 25.0% for polytherapy (p=0.01). CONCLUSIONS Monotherapy may be not sufficient enough to control seizures completely. It appears to have a higher risk for seizure relapse when considering drug reduction. It suggests that duotherapy may be more effective and safer than monotherapy. Even after successful epilepsy surgery, duotherapy seems preferable to monotherapy or polytherapy for control of residual seizures.
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Affiliation(s)
- Tian-fang Zeng
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
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AED discontinuation may not be dangerous in seizure-free patients. J Neural Transm (Vienna) 2010; 118:187-91. [DOI: 10.1007/s00702-010-0528-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 11/02/2010] [Indexed: 10/18/2022]
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Abstract
After a patient has initiated an antiepileptic drug (AED) and achieved a sustained period of seizure freedom, the bias towards continuing therapy indefinitely can be substantial. Studies show that the rate of seizure recurrence after AED withdrawal is about two to three times the rate in patients who continue AEDs, but there are many benefits to AED withdrawal that should be evaluated on an individualized basis. AED discontinuation may be considered in patients whose seizures have been completely controlled for a prolonged period, typically 1 to 2 years for children and 2 to 5 years for adults. For children, symptomatic epilepsy, adolescent onset, and a longer time to achieve seizure control are associated with a worse prognosis. In adults, factors such as a longer duration of epilepsy, an abnormal neurologic examination, an abnormal EEG, and certain epilepsy syndromes are known to increase the risk of recurrence. Even in patients with a favorable prognosis, however, the risk of relapse can be as high as 20% to 25%. Before withdrawing AEDs, patients should be counseled about their individual risk for relapse and the potential implications of a recurrent seizure, particularly for safety and driving.
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Affiliation(s)
- John D. Hixson
- University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143 USA
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