Surgery for Patients With Epilepsy Is Underused

LOS ANGELES—Surgical intervention for epilepsy is often seen as a last resort, even among patients with drug-resistant focal epilepsies, said Gregory D. Cascino, MD, a neurologist at Mayo Clinic in Rochester, Minnesota. One reason for this phenomenon may be concern about potential adverse effects. Research indicates, however, that clinical and functional outcomes of surgery significantly surpass those of treatment with antiepileptic drugs (AEDs) in selected patients with drug-resistant focal epilepsy.

“The three important goals of epilepsy treatment are no seizures, no adverse effects, and no lifestyle limitations. This is what patients want when they seek neurologic care,” said Dr. Cascino at the 70th Annual Meeting of the American Academy of Neurology. “Seizure freedom is important because of its beneficial effects on quality of life, which include the ability to drive, pursue an education, have a career, and live independently with no need for a caregiver. We need to consider the risk of any intervention, whether it is medical or surgical, against the natural history of the disease.” All patients with epilepsy, not just those with drug-resistant focal epilepsy, are at significant risk of mortality due to seizure complications, progressive cognitive disorder, mood disorders, and even sudden unexpected death in epilepsy, he noted.

Identifying Surgical Candidates

“As soon as a patient is diagnosed with drug-resistant focal epilepsy, the neurologist probably should begin to triage for alternative forms of treatment,” Dr. Cascino said. “That doesn’t mean that patients need surgery on the first visit. But perhaps physicians should consider them for inpatient epilepsy monitoring and carefully review a high-resolution MRI head seizure protocol.”

Research suggests that patients who tend to have the best outcomes are those who have neuroimaging abnormalities resulting from substrate-directed pathology (eg, tumor, vascular anomaly, malformation of cortical development, or mesial temporal sclerosis) and undergo a complete resection of the epileptogenic lesion and the site of seizure onset. “These patients have the highest likelihood of being seizure-free after surgery, although some will have to continue taking AEDs to remain seizure-free,” Dr. Cascino said. Approximately 75% of patients with a surgically remediable epileptic syndrome who undergo epilepsy surgery become seizure-free.