Resective surgery for intractable focal epilepsy in patients with low IQ: predictors for seizure control and outcome with respect to seizures and neuropsychological and psychosocial functioning

PURPOSE: To investigate possible predictive factors for seizure control in a group of children and adults with low IQs (IQ, < or =70) who underwent resective surgery for intractable focal epilepsy and to study outcome with respect to seizures and neuropsychological functioning. We also studied psychosocial outcome in the adult patients. METHODS: Thirty-one patients (eight children younger than 18 years) with a Wechsler Full Scale IQ of 70 or less underwent comprehensive neuropsychological assessments before and 2 years after surgery. Adults also completed the Washington Psychosocial Seizure Inventory (WPSI). Univariate analyses were used to identify variables differentiating between patients who became seizure free and those who did not. Pre- and postoperative test results were compared by t test for dependent samples. RESULTS: Forty-eight percent of the patients became seizure free, 52% of those with temporal lobe resection and 38% of those with extratemporal resection. Only one variable was predictive for seizure outcome: duration of epilepsy. In one third of the patients, who had the shortest duration of epilepsy (<12 years), 80% became seizure free. Significant improvement was seen regarding vocational adjustment in adults (WPSI). Seizure-free adults improved their Full Scale IQ scores. No cognitive changes were found in seizure-free children or in patients who did not become seizure free. CONCLUSIONS: A good seizure outcome was obtained after resective surgery in patients with intractable focal epilepsy and low IQ, provided that treatment was done relatively shortly after onset of epilepsy. No adverse effects were seen on cognitive and psychosocial functioning.     

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

PURPOSE: The goal of this study was to assess the patient-perceived costs and benefits associated with the longer-term outcomes of epilepsy surgery in patients who underwent anterior temporal lobectomy or selective amygdalohippocampectomy. METHODS: Surgery patients who were assessed in 1997 were reassessed in 2003. Demographic, clinical, and psychosocial details were collected using a validated self-completion questionnaire. Data were collected from 67 patients who had undergone surgery. RESULTS: Forty-five percent were seizure-free. There were significant differences (P<0.001) between the seizure-free (SF) and continuous seizure (CS) groups with respect to anxiety, depression, impact of epilepsy, self-esteem, mastery, stigma, affect balance, self-reported health, and quality of life. More SF patients were also employed and driving (P<0.001). Despite these differences there were no differences for regret over surgery but there were differences for satisfaction and success ratings. CONCLUSIONS: Patients who were not SF, in the longer term, had little regret undergoing surgery but were less likely to be satisfied and had a poorer psychosocial profile.     

Causal attributions for seizures: Relation to preoperative psychological adjustment and postoperative psychosocial function in temporal lobe epilepsy

In a sample of 65 epilepsy patients who were temporal lobectomy candidates, the links between causal attributions, learned resourcefulness, and preoperative psychosocial adjustment were explored. In addition, attributions as predictors of objective 2-year postoperative psychosocial outcomes were examined prospectively. With illness severity controlled for, attribution of seizures to stress factors and low learned resourcefulness were predictive of poor psychosocial adjustment preoperatively. Taking personal responsibility for seizure occurrence (self-blame) was associated with better psychosocial adjustment. At 2 years, patients were divided into three groups: (a) postoperative seizure-free (n = 21), (b) postoperative not seizure-free (n = 19), and (c) nonoperated controls (n = 25). Seizure-free outcome status was associated with better psychosocial outcome. Of greater interest was the predictive value of preoperative attributions. As expected, attributions involving personal responsibility were predictive of postoperative full-time employment and receipt of disability benefits. The data enhance understanding of the ways in which patients with epilepsy manage the challenges they face and enhance the psychometric prediction of psychosocial behavioral outcomes after epilepsy surgery.     

Moderators of the effect of preoperative emotional adjustment on postoperative depression after surgery for temporal lobe epilepsy

PURPOSE: Other outcome measures besides seizure control must be considered when assessing the benefit of epilepsy surgery. We investigated the effect of preoperative psychosocial adjustment on postoperative depression in epilepsy patients followed up prospectively for 2 years after temporal lobectomy. METHODS: The Washington Psychosocial Seizure Inventory (WPSI) evaluated psychosocial functioning; the Centre for Epidemiological Studies Depression Scale (CES-D) measured depression. Both were completed at baseline and follow-up. RESULTS: Follow-up occurred in 39 temporal lobectomy patients at 2 years after surgery. Greatest improvement in depression scores was limited to patients with good seizure outcomes (seizure free, or marked reduction in seizure frequency), and seizure outcome was a significant predictor of postoperative depression. Despite this, preoperative scores on the emotional adjustment scale of the WPSI were most highly correlated with depression 2 years after surgery. To clarify this relation, moderated hierarchic regression suggested that good preoperative emotional adjustment (WPSI) was generally associated with less depression after surgery. Moreover, poorer preoperative adjustment combined with older age, generalized seizures, the finding of preoperative neurologic deficits, a family history of psychiatric illness, and/or a family history of seizures was related to higher depression scores 2 years after surgery. CONCLUSIONS: Depression after temporal lobectomy is dependent on a complex interaction of variables and can have a significant effect on indices of postoperative adjustment. The WPSI emotional adjustment scale may help to predict which patients are likely to be chronically depressed after surgery.     

Neuroticism in Temporal Lobe Epilepsy: Assessment and Implications for Pre- and Postoperative Psychosocial Adjustment and Health-Related Quality of Life

Summary: We assessed 77 candidates for epilepsy surgery to determine the association among neuroticism (a dimension of personality characterized by chronic negative emotions and behaviors), psychosocial adjustment as measured by the Washington Psychosocial Seizure Inventory (WPSI), and health-related quality of life (HRQOL) as measured by the Epilepsy Surgery Inventory 55 (ESI-55). Minnesota Multiphasic Personality Inventory 2 (MMPI-2) Neuroticism scale scores were significantly correlated with many domains of patient-perceived psychosocial adjustment and HRQOL regardless of frequency or type of seizures. We then followed 45 of the patients who subsequently underwent epilepsy surgery to determine the influence of neuroticism on postoperative functioning. Two-way analysis of variance (ANOVA) indicated that patients with high preoperative neuroticism had significantly poorer postoperative psychosocial adjustment and HRQOL scores than patients who had low or moderate preoperative neuroticism scores. These results support the validity of the MMPI-2 as a useful measure of neuroticism. Preoperative neuroticism has an important influence on postoperative psychosocial adjustment and HRQOL that is independent of postoperative seizure outcome. Understanding the influence of personality variables, such as neuroticism, on psychosocial functioning both before and after epilepsy surgery is essential in managing intractable seizures.     

Health-related quality of life using QOLIE-31: before and after epilepsy surgery a prospective study at a tertiary care center

Background: Outcome following epilepsy surgery has traditionally been measured in terms of relief of seizures. However, changes in health-related quality of life (HRQOL) after surgery for intractable epilepsy are also important to document. There are no studies on the Indian population which assess the outcome of epilepsy surgery in terms of HRQOL. Materials and Methods: We conducted a prospective study on the patients undergoing epilepsy surgery for intractable seizures, between February 2004 and May 2006 at our center. All patients cleared for epilepsy surgery by the epilepsy surgery team were taken up for study. All patients Results: Thirty-six patients satisfying the inclusion/exclusion criteria were included in the analysis. Twenty-nine of these (Group 1) had good seizure outcome (Engel 1 and 2), while seven patients (Group 2) had poor seizure outcome (Engel 3 and 4) at six months. Overall, 77% of all study patients were completely seizure-free at follow-up. There was no baseline difference in the seven domains of QOLIE-31 between the two groups. There was very significant improvement (P value> 0.005 using paired sample T test) in all the domains of QOLIE-31 in the good outcome group after surgery. Health-related quality of life improvement was seen in all the domains in the poor outcome group also, however, it was statistically significant only for the following parameters: seizure worry, overall QOL, emotional wellbeing, energy fatigue and social functioning domains. Improvement in seizure worry, overall QOL, emotional wellbeing and social functioning was significantly more in Group 1 as compared to Group 2. Conclusion: Complete seizure-free state after surgery is associated with very significant improvement in HRQOL parameters. Several, but not all parameters of HRQOL as assessed by QOLIE-31, improved after surgery even in the poor seizure outcome group. The improvement in domains of seizure worry, overall QOL, emotional wellbeing and social functioning is significantly more in those patients in whom complete seizure-free state is achieved.     

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

Objective

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

Methods

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

Results

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

Significance

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

Long-term prognosis and psychosocial outcomes after surgery for MTLE

PURPOSE: To assess the seizure-freedom rates and self-perceived psychosocial changes associated with the long-term outcome of epilepsy surgery in patients with refractory medial temporal lobe epilepsy associated with hippocampal sclerosis. METHODS: A standard questionnaire was given to 183 patients who underwent surgery between 1988 and 2004, and 110 were completed. RESULTS: The mean duration of follow-up after surgery was 7 years, with a maximum of 17 years. The probability that patients were seizure-free after surgery was dependent on the definition of the seizure freedom. For the patients who were seizure-free since surgery (Engel's class Ia), the probability was 97.6% at 1 year after surgery, 85.2% at 2 years after surgery, 59.5% at 5 years after surgery, and 42.6% at 10 years after surgery. For the patients who still experienced rare disabling seizures after surgery but were seizure-free at least 1 year before the time of assessment, the probability was of 97.6% at 1 year after surgery, 95% at 2 years after surgery, 82.8% at 5 years after surgery, and 71.1% at 10 years after surgery. The psychosocial long-term outcome, as measured by indices of driving, employment, familial and social relationships, and marital status, was similar to the psychosocial short-term outcome. It did not depend on seizure freedom or on follow-up time interval and was not influenced statistically by seizure frequency in cases of persisting seizures. Most but not all patients noticed a substantial overall improvement in their psychosocial condition; 48% drove (increased by 7%), 47% improved (14% worsened) in their employment status, and 68% improved (5% worsened) in their familial and social relationships. Overall, 91% of patients were satisfied with the surgery, and 92% did not regret their decision. CONCLUSIONS: The results of this study suggest that temporal lobe surgery has real long-term benefits. Two specific conclusions emerge: (a) the long-term rates of freedom from seizure depend on how seizure freedom is defined, and (b) the psychosocial long-term outcome does not change dramatically over years and does not depend on seizure freedom.     

Cognitive, psychosocial, and family function one year after pediatric epilepsy surgery

PURPOSE: Assumptions regarding the benefits of seizure control after pediatric epilepsy surgery for cognitive, psychosocial, and family function were explored in a prospective study of 51 children with intractable epilepsy. METHODS: Thirty children who underwent surgery were studied before and 1 year after surgery, and a comparison group of 21 children with medically refractory seizures was examined at comparable times. RESULTS: One year after surgery, 57% of the surgical group was seizure free. Seizure status after surgery did not predict change over time in any of the areas measured. Cognitive and psychosocial status did not change over time in either group, and the strongest predictor of individual change in psychosocial status in the surgical group was baseline level of function. Within the surgical group, a trend toward an increase in independence promotion was noted in the family, but the children's satisfaction with the family declined. CONCLUSIONS: These findings challenge the assumption that elimination of seizures will result in improved cognitive, psychosocial, and family functioning, at least within the first year after surgery.     

Quality control of elective surgery for drug-resistant epilepsy in a German reference centre—A long-term outcome study

PurposeResective epilepsy surgery is the recommended treatment for a well-defined group of patients with drug-resistant epilepsy. Long-term outcome studies are an appropriate quality control to assess the value of elective surgical procedures ethically and economically. This paper reports the long-term post-surgical follow-up of adult patients of the Kork Epilepsy Centre.MethodData collection was performed by means of a questionnaire to obtain updated information about postsurgical outcome, frequency and postsurgical seizure semiology in case of relapse, postsurgical use of antiepileptic drugs, social issues and satisfaction rates. We classified seizure outcome according to the ILAE surgery outcome scale (OC 1–OC 6).ResultsOutcome data of 340 adult patients were obtained. Mean post-operative follow-up was 6.7 years (range 1.0–21.6 years). Seizure remission was 67% if comprising patients with postoperative auras only (OC 1 + OC 2). Sixty-two per cent of patients were completely seizure free. The majority of patients (78%) underwent temporal lobe resections. Sixty-four per cent of these and 52% of the patients with extra-temporal resections became completely seizure-free (OC 1). Only 34% of the patients with negative MRI achieved complete seizure-freedom.ConclusionIn line with others our huge cohort sample that covers decades of experience with epilepsy surgery revealed satisfying long-term outcome results. Best results were obtained in lesional temporal lobe epilepsy, least favourable results in MRI-negative epilepsy.     

Quality of life one year after epilepsy surgery

BackgroundThe aim of surgery for medically intractable epilepsy was to achieve seizure freedom and improve overall quality of life (QOL) in patients. This investigation looked at changes in QOL one year after epilepsy surgery and the relationship of changes to mood, language, and seizure outcomes.MethodDepressive symptoms, QOL, and naming were measured in 25 patients with temporal lobe epilepsy before and one year after dominant temporal lobe resection. The Quality of Life in Epilepsy-89 (QOLIE-89), Beck Depression Inventory II (BDI-II), and Boston Naming Test (BNT) were used, respectively, and seizure outcome was reported according to the Engel classifications. Minimum clinically important differences (MCID) and reliable change indices (RCI) were used to assess the proportion of patients who achieved meaningful improvement or worsening in the respective areas of functioning, and the relationship between outcomes was evaluated. Changes on the 17 individual items of the QOLIE-89 were also assessed.ResultsOverall, there was a significant improvement in QOL, reduction in depressive symptoms, and decline in naming one year after surgery. Positive clinically important improvement in QOL was achieved in 76% of patients, meaningful reduction of depressive symptoms was achieved in 20%, and clinically important naming declines were observed in 48% of the cohort. Sixteen patients were seizure-free one year after surgery, but there was no significant correlation between changes in QOL and seizure outcome, depressive symptoms, or naming.ConclusionThe results in the reported cohort of patients showed that surgical treatment of temporal lobe epilepsy in the dominant hemisphere resulted in clinically meaningful improvement in overall QOL and declines in naming but no significant reduction of mood disturbance.     

Resection of Frontal Encephalomalacias for Intractable Epilepsy: Outcome and Prognostic Factors

Summary: Purpose: Because focal encephalomalacia is an important cause of medically intractable partial epilepsy and few studies have evaluated the efficacy and the safety of resecting focal encephalomalacias to improve seizure control, we studied a cohort of 17 consecutive patients who underwent resection of encephalomalacias in the frontal lobes as a treatment of their intractable epilepsy. Methods: We evaluated several factors for their value in predicting postsurgical seizure control. Pre- and postsurgical magnetic resonance imaging (MRI) scans were reviewed independently by 2 blinded investigators. Results: At a median of 3 years of follow-up (range 0.6–7.5 years), 12 patients (70%) were seizure-free or had only rare seizures. The presence of a focal fast frequency discharge (focal ictal β pattern) at the beginning of seizures on scalp EEG was predictive of seizure-free outcome (p = 0.017), even among patients who had complete resection of their encephalomalacias (p = 0.016). There was no significant differences in outcome with regard to age at the time of the injury that caused encephalomalacia, interval between injury and onset of seizures, duration of presurgical seizure history, presurgical seizure frequency, age at surgery, or the completeness of encephalomalacia resection. The analysis regarding completeness of encephalomalacia resection almost reached significance, suggesting that it may also be an important predictive factor (p = 0.051). Conclusions: We conclude that surgery is a very effective treatment for intractable frontal lobe epilepsy (FLE) secondary to encephalomalacias. Patients are more likely to become seizure-free if they have a focal ictal β discharge on their scalp EEG. Complete resection of the encephalomalacia should be attempted, since our results suggest that this may be a favorable predictive factor. Moreover, the operative strategy for our patients entailed, whenever possible, complete resection of the encephalomalacias and of the adjacent electrophysiologically abnormal tissues.     

Quality of life after extratemporal epilepsy surgery: a prospective clinical study

PURPOSE: The purpose of this prospective clinical study was to assess quality of life (QOL) and impact of seizure status on QOL in patients with extratemporal epilepsy after surgery. PATIENTS AND METHODS: Twenty-three consecutive patients who had been operated due to extratemporal epilepsy were included in this study. Quality of Life Inventory in Epilepsy-10 (QOLIE-10) questionnaire was completed by all patients before 6 months and 2 years after surgery. Results obtained from short- and long-term follow-up were compared to baseline. Furthermore, patients who were seizure-free since surgery and those who had seizure were also compared in terms of outcome in QOL after surgery. RESULTS: All patients showed significantly improved QOL in both short- and long-term follow-ups compared to preoperative status regardless of seizure status (p<0.001). Seizure-free patients showed better QOL than those of patients who continued to have seizure during postoperative period. Furthermore, improved QOL was correlated with seizure status and shorter duration of epilepsy (p=0.001). CONCLUSION: Our findings showed that improved QOL is related to postoperative seizure status. However, future clinical studies including larger population of patients with extratemporal epilepsy are required to elucidate the role of other factors.     

Psychosocial impact of epileptic seizures in a Dutch epilepsy population: a comparative Washington Psychosocial Seizure Inventory study

PURPOSE: The psychosocial functioning of epilepsy patients from the Netherlands was investigated and compared with results from other countries. The impact of epilepsy was also studied in two different groups of Dutch epilepsy patients, inpatients and outpatients. METHODS: The Washington Psychosocial Seizure Inventory (WPSI) was used to study the psychosocial problems of 134 Dutch outpatients and 181 Dutch inpatients. WPSI profiles were compared with those from the former German Democratic Republic (West Germany), Finland, Canada, the United States, Chile, and Japan. RESULTS: For the Dutch epilepsy patients, most of the psychosocial problems were experienced by inpatients; they had serious problems in emotional, interpersonal, and vocational adjustment, adjustment to seizures, and overall psychosocial functioning. Seizure-free outpatients, however, experienced significant problems only in the emotional adjustment area. Comparing the outcomes of various countries, Dutch outpatients and patients from West Germany and Finland experienced the least psychosocial difficulties, whereas epilepsy patients from Chile, Japan, and Canada have serious problems in most areas of psychosocial functioning. CONCLUSIONS: Patients with epilepsy experience psychosocial problems, although the amount of psychosocial difficulties depends on the seizure frequency and the culture that patients live in.     

Drug-resistant epilepsy in children with partial onset epilepsy treated with carbamazepine

Objective: To evaluate the outcome, including drug-resistant epilepsy (DRE) in children with newly diagnosed partial onset epilepsy treated with carbamazepine (CBZ). Methods: A retrospective medical records review and telephone questionnaire were undertaken on a total of 100 subjects. Results: Long-term follow-up was obtained on 79 children with a mean duration of 7.1 years from CBZ initiation. A total of 66 (83.5%) subjects achieved 2-year seizure remission, 48 (72.7%) subjects did so with CBZ monotherapy. Seven (10.6%) had seizure recurrence after 2-year seizure remission. DRE was diagnosed in seven (8.9%) subjects and five subjects had epilepsy surgery. The mean duration from seizure onset to epilepsy surgery was 5.3 (±2.1) years. Contributing factors for the prolonged duration from seizure onset to epilepsy surgery were identified including: relapsing–remitting course of seizure, family reluctance for epilepsy surgery and uncontrolled psychological problems. Conclusions: Over 80% of children with newly diagnosed partial onset epilepsy who were initially treated with CBZ achieved 2-year seizure remission, and more than 70% of this group did so with CBZ monotherapy. The majority of these patients maintained seizure remission overtime. However, 8.9% of this population met the criteria for DRE and most of them had epilepsy surgery. The duration from seizure onset to epilepsy surgery is an important potential area for improvement in DRE patient care.     

Discontinuation of antiepileptic drugs after successful epilepsy surgery

OBJECTIVE: To evaluate the frequency and risk factors for seizure recurrence subsequent to antiepileptic drug (AED) withdrawal in patients who underwent surgical treatment for intractable partial epilepsy and were rendered seizure-free. METHODS: The outcome of discontinuation of AED medication was studied retrospectively in 210 consecutive patients who were rendered seizure-free after epilepsy surgery performed between 1989 and 1993. RESULTS: Medical therapy was reduced in 96 patients and discontinued in 84 patients. The seizure recurrence rate after complete AED withdrawal was 14% and 36% at 2 and 5 years. In contrast, only 3% and 7% of the 30 patients who did not alter AED treatment after surgery had recurrent seizures in the same time intervals. After AED discontinuation, seizures tended to recur more often in patients with normal preoperative MRI studies compared with those with focal pathology. However, this difference did not reach significance. Intraoperative electrocorticography, extent of surgical resection, postoperative EEG, and seizure-free duration after surgery were not predictive of seizure outcome after AED withdrawal. CONCLUSIONS: AED withdrawal was associated with seizure recurrence in a significant portion of patients rendered seizure-free by epilepsy surgery. Patients with a normal preoperative MRI study showed a tendency for higher seizure recurrence, whereas the duration of seizure-free postoperative AED treatment interval did not significantly influence the seizure recurrence rate. These results will prove useful in counseling patients about discontinuing AED treatment after successful epilepsy surgery.     

Presurgical neuropsychological testing predicts cognitive and seizure outcomes after anterior temporal lobectomy

We sought to determine significant predictors of seizure and cognitive outcome following surgery for epilepsy. Participants included 41 patients who had undergone anterior temporal lobectomy (ATL). Higher presurgical verbal/language scores and lower nonverbal memory scores were predictive of seizure-free status following ATL. Overall, the presurgical predictors were 93% accurate in discriminating between seizure-free and non-seizure-free patients postsurgery. Surgery in the nondominant-for-language hemisphere was predictive of higher postsurgical verbal/language and verbal memory scores. Higher presurgical visual/construction, nonverbal memory, and verbal/language scores were predictive of better postsurgical verbal/language functioning. Better presurgical verbal/language functioning was predictive of the same skills postsurgically as well as visual/construction outcomes. Exploratory analyses in a subset of participants (n = 25) revealed that dominant and nondominant intracarotid amobarbital (Wada) memory scores added unique variance only for predicting nonverbal memory following ATL. Presurgical neuropsychological testing provides significant and unique information regarding postsurgical seizure freedom and cognitive outcome in patients who have undergone ATL.     

Retention rate of pregabalin in drug-resistant epilepsy: 1-year follow-up, single-centre observation in 105 consecutive, adult patients

ObjectivesPregabalin (PGB) is a newer antiepileptic drug (AED) licensed as add-on treatment for partial epilepsy in adults. Efficacy and safety have been proven in several controlled clinical studies. These trials, however, only partially reflect clinical practice. Retention rate has been established as a marker for efficacy and safety of AEDs in long-term follow-up studies.MethodsWe evaluated the data of the first 105 patients treated with PGB at Bethel Epilepsy Centre, a tertiary referral centre for epilepsy. The patients were interviewed after 3, 6 and 12 months.Results105 adult patients (aged 38 ± 13 years) were treated with PGB, on average in combination with 2.1 AEDs (mean observation period 232 days). 76.2% had focal epilepsy, 19.0 multifocal epilepsy, and 3.8% epilepsy with both focal and generalised seizures. 40% continued PGB with the following outcome: 5.7% seizure-free for at least 1 month (4.8% for at least 3 months, 2.4% for at least 6 months; one of the seizure-free patients, however, had had epilepsy surgery during the observational period), 17.1% responders (≥50% reduction of seizure frequency but not seizure-free), 13.3% with unchanged or increased seizure frequency. Reasons for withdrawal were lack of efficacy (47.6%) or side-effects (12.7%).ConclusionsPGB is a new therapeutic option as add-on therapy for patients with highly refractory focal epilepsies although the therapeutic success that can be expected in this group of patients is limited.     

Control de las crisis epilépticas con la hemisferectomía cerebral en adultos: revisión sistemática y metaanálisis con datos de pacientes individuales

ObjectiveThe objective of our study was to determine the seizure control rate of cerebral hemispherectomies in adult patients with drug-resistant epilepsy.Materials and methodsA systematic review and individual patient data meta-analysis was carried out. Seven international databases and scientific meeting proceedings were reviewed. Individual patient data were analysed to establish potential factors associated with postoperative seizure control.ResultsEight articles that satisfied the pre-established selection criteria were identified.After a median follow-up of 70 months (interquartile range, 29-175.5), 79.4% of patients remained seizure-free. There were no statistically significant differences in age at onset of epilepsy, duration of epilepsy, age at surgery, time of follow-up, gender, surgical-laterality, aetiology and ictal EEG abnormalities between seizure-free patients and those with recurrences.ConclusionsCerebral hemispherectomy has a high seizure control rate in adult patients with drug-resistant epilepsy. None of the variables analysed in the present study were associated with surgical success.     

Prognosis after temporal lobe epilepsy surgery: the value of combining predictors

Purpose: Although several independent predictors of seizure freedom after temporal lobe epilepsy surgery have been identified, their combined predictive value is largely unknown. Using a large database of operated patients, we assessed the combined predictive value of previously reported predictors included in a single multivariable model.
Methods: The database comprised a cohort of 484 patients who underwent temporal lobe surgery for drug-resistant epilepsy. Good outcome was defined as Engel class 1, one year after surgery. Previously reported independent predictors were tested in this cohort. To be included in our final prediction model, predictors had to show a multivariable p-value of <0.20.
Results: The final multivariable model included predictors obtained from the patient's history (absence of tonic–clonic seizures, absence of status epilepticus), magnetic resonance imaging [MRI; ipsilateral mesial temporal sclerosis (MTS), space occupying lesion], video electroencephalography (EEG; absence of ictal dystonic posturing, concordance between MRI and ictal EEG), and fluorodeoxyglucose positron emission tomography (FDG-PET; unilateral temporal abnormalities), that were related to seizure freedom in our data. The model showed an expected receiver-operating characteristic curve (ROC) area of 0.63 [95% confidence interval (CI) 0.57–0.68] for new patient populations. Intracranial monitoring and surgery-related parameters (including histology) were not important predictors of seizure freedom. Among patients with a high probability of seizure freedom, 85% were seizure-free one year after surgery; however, among patients with a high risk of not becoming seizure-free, still 40% were seizure-free one year after surgery.
Conclusion: We could only moderately predict seizure freedom after temporal lobe epilepsy surgery. It is particularly difficult to predict who will not become seizure-free after surgery.