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Drexler R, Ricklefs FL, Ben-Haim S, Rada A, Wörmann F, Cloppenborg T, Bien CG, Simon M, Kalbhenn T, Colon A, Rijkers K, Schijns O, Borger V, Surges R, Vatter H, Rizzi M, de Curtis M, Didato G, Castelli N, Carpentier A, Mathon B, Yasuda CL, Cendes F, Chandra PS, Tripathi M, Clusmann H, Delev D, Guenot M, Haegelen C, Catenoix H, Lang J, Hamer H, Brandner S, Walther K, Hauptmann JS, Jeffree RL, Kegele J, Weinbrenner E, Naros G, Velz J, Krayenbühl N, Onken J, Schneider UC, Holtkamp M, Rössler K, Spyrantis A, Strzelczyk A, Rosenow F, Stodieck S, Alonso-Vanegas MA, Wellmer J, Wehner T, Dührsen L, Gempt J, Sauvigny T. Defining benchmark outcomes for mesial temporal lobe epilepsy surgery: A global multicenter analysis of 1119 cases. Epilepsia 2024; 65:1333-1345. [PMID: 38400789 DOI: 10.1111/epi.17923] [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: 10/04/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Benchmarking has been proposed to reflect surgical quality and represents the highest standard reference values for desirable results. We sought to determine benchmark outcomes in patients after surgery for drug-resistant mesial temporal lobe epilepsy (MTLE). METHODS This retrospective multicenter study included patients who underwent MTLE surgery at 19 expert centers on five continents. Benchmarks were defined for 15 endpoints covering surgery and epilepsy outcome at discharge, 1 year after surgery, and the last available follow-up. Patients were risk-stratified by applying outcome-relevant comorbidities, and benchmarks were calculated for low-risk ("benchmark") cases. Respective measures were derived from the median value at each center, and the 75th percentile was considered the benchmark cutoff. RESULTS A total of 1119 patients with a mean age (range) of 36.7 (1-74) years and a male-to-female ratio of 1:1.1 were included. Most patients (59.2%) underwent anterior temporal lobe resection with amygdalohippocampectomy. The overall rate of complications or neurological deficits was 14.4%, with no in-hospital death. After risk stratification, 377 (33.7%) benchmark cases of 1119 patients were identified, representing 13.6%-72.9% of cases per center and leaving 742 patients in the high-risk cohort. Benchmark cutoffs for any complication, clinically apparent stroke, and reoperation rate at discharge were ≤24.6%, ≤.5%, and ≤3.9%, respectively. A favorable seizure outcome (defined as International League Against Epilepsy class I and II) was reached in 83.6% at 1 year and 79.0% at the last follow-up in benchmark cases, leading to benchmark cutoffs of ≥75.2% (1-year follow-up) and ≥69.5% (mean follow-up of 39.0 months). SIGNIFICANCE This study presents internationally applicable benchmark outcomes for the efficacy and safety of MTLE surgery. It may allow for comparison between centers, patient registries, and novel surgical and interventional techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sharona Ben-Haim
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
| | - Anna Rada
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Friedrich Wörmann
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Thomas Cloppenborg
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Matthias Simon
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Medical School, Bielefeld University, Bielefeld, Germany
| | - Thilo Kalbhenn
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Medical School, Bielefeld University, Bielefeld, Germany
| | - Albert Colon
- Department of Epileptology, Academic Center for Epileptology Kempenhaeghe, Heeze, the Netherlands
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kim Rijkers
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Neurosurgery, Academic Center for Epileptology UMC/Maastricht University Medical Center+, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Olaf Schijns
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Neurosurgery, Academic Center for Epileptology UMC/Maastricht University Medical Center+, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Michele Rizzi
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nicoló Castelli
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Bertrand Mathon
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery and Neurology, AIIMS, and MEG Resource Facility, New Delhi, India
| | - Manjari Tripathi
- Department of Neurosurgery and Neurology, AIIMS, and MEG Resource Facility, New Delhi, India
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Daniel Delev
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Marc Guenot
- Department of Functional Neurosurgery, Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Claire Haegelen
- Department of Functional Neurosurgery, Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Hélène Catenoix
- Department of Neurology, Hospices Civils de Lyon, Lyon, France
| | - Johannes Lang
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hajo Hamer
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Brandner
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Katrin Walther
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jason S Hauptmann
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Rosalind L Jeffree
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Eliane Weinbrenner
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Julia Onken
- Institute for Diagnostics of Epilepsy, Epilepsy Center Berlin-Brandenburg, Berlin, Germany
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Martin Holtkamp
- Institute for Diagnostics of Epilepsy, Epilepsy Center Berlin-Brandenburg, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Andrea Spyrantis
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Stefan Stodieck
- Department of Neurology and Epileptology, Hamburg Epilepsy Center, Protestant Hospital Alsterdorf, Hamburg, Germany
| | - Mario A Alonso-Vanegas
- National Institute of Neurology and Neurosurgery "Manuel Velasco Suarez", Mexico City, Mexico
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Hale AT, Chari A, Scott RC, Cross JH, Rozzelle CJ, Blount JP, Tisdall MM. Expedited epilepsy surgery prior to drug resistance in children: a frontier worth crossing? Brain 2022; 145:3755-3762. [PMID: 35883201 DOI: 10.1093/brain/awac275] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/18/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that, 1) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy associated tumours) will progress to drug-resistance, 2) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe, and 3) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to anti-seizure medications (ASM), which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Lastly, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rod C Scott
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Nemours Children's Hospital, Wilmington, DE, USA.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - J Helen Cross
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Martin M Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
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