Epilepsy surgery effective also on patients older than 60

epilepsySurgery in older patients with epilepsy has the potential to improve overall health and quality of life, as well as provide a favorable seizure outcome, according to a study presented at the 67th Annual Meeting of the American Epilepsy Society.

Investigators at the University of California, Los Angeles (UCLA), reviewed the records of 10 patients who had undergone resective epilepsy surgery for medically refractory focal onset seizures at their institution between 1992 and 2012. Patients ages 60 and older (age range: 60 to 74) with a minimum follow-up of one year (range 1 to 7.5 years) were included in the study. Comorbidities at the time of surgery, including hypertension, hyperlipidemia, diabetes mellitus, hypothyroidism, osteoporosis, obstructive sleep apnea, depression, and falls, were noted. A modified Liverpool life satisfaction tool was administered postoperatively, with a maximum score of 40.

Patients’ mean age at surgery was 65.4. The mean duration of epilepsy before surgery was 27.8 years. At the time of surgery, 70% of patients had at least one medical comorbidity in addition to refractory seizures. No patients experienced any postsurgical complications.

The patients were followed for a mean of 3.2 years. At the time of final follow-up, 90% of patients had a good postsurgical outcome. Half of the patients were completely seizure free. Quality of life data were available for nine patients, whose mean modified Liverpool life satisfaction score was 30.4 after surgery. Of the nine patients with additional life satisfaction data, six reported excellent satisfaction with their surgery, and three reported postoperative improvements in their health.

Resective surgery is seldom used in epilepsy patients ages 60 and older despite its potential to offer seizure freedom. Older age may discourage referrals to specialized epilepsy centers, given concerns about increased surgical risk because of age and the presence of other health problems common in the elderly.

“Our data demonstrate that referral to a comprehensive epilepsy center for resective epilepsy surgery evaluation should not be negatively influenced by advancing age,” said Sandra Dewar, RN, Patient Care Coordinator at UCLA Health and the lead study author. “Consideration of surgery in older adults is important, since seizure freedom may increase safety, independence, and happiness later in life.”

Surgical Site May Influence Epilepsy Surgery’s Effect on Mood and Behavior in Children
Epilepsy surgery may improve mood and behavior among children, researchers reported at the 67th Annual Meeting of the American Epilepsy Society. The hemisphere on which surgeons operate may influence the effect of surgery.

Children with epilepsy are at high risk for depression, anxiety, and behavioral functioning disorders. Epilepsy surgery in children is associated with changes or improvements in mood and behavior, but research into the extent of the change has produced inconsistent results.

To examine changes in mood, anxiety, and behavioral functioning following epilepsy surgery, a collaborative team of investigators from the Cleveland Clinic and the University of Pittsburgh studied 101 children (ages 5 to 16) who underwent epilepsy surgery. The investigators analyzed the role of surgical site (ie, frontal or temporal) and hemisphere (ie, left or right) in the outcomes.

Children in the study completed the Children’s Depression Inventory (CDI) and the Revised Children’s Manifest Anxiety Scale (RCMAS) as part of comprehensive neuropsychologic evaluations conducted approximately 10 months apart. The children’s primary caregivers completed the Achenbach Child Behavior Checklist (CBCL) at both evaluations.

Among children who underwent left-sided surgeries, patients with frontal lobe epilepsy or their caregivers endorsed more symptoms on the Social Anxiety subscale of the RCMAS and on the Withdrawal subscale of the CBCL before surgery than patients with temporal lobe epilepsy. Patients with frontal lobe epilepsy also demonstrated notable improvement in anxiety or mood following surgery. The investigators found no significant two-way interactions among children who underwent right-sided surgeries.

In addition, 21% of all patients (ie, 15% of patients with temporal lobe epilepsy and 33% of patients with frontal lobe epilepsy) reported improvements in overall depression symptoms after surgery. About 38% of the cohort (ie, 27% of patients with temporal lobe epilepsy and 45% of patients with frontal lobe epilepsy) reported postoperative improvements in overall anxiety symptoms.

“We were pleased to discover that children generally experience improvements in mood and behavior following epilepsy surgery,” said Elizabeth Andresen, PhD, postdoctoral fellow in neuropsychology at the Cleveland Clinic and lead author of the study. “While children with frontal lobe epilepsy had greater symptoms of depression and anxiety before surgery than children with temporal lobe epilepsy, these symptoms improved significantly following surgery to levels comparable to or below [those of] the temporal lobe group. Interestingly, these relationships were most apparent in children who underwent left-sided surgeries.”

Rapid AED Withdrawal During vEEG Monitoring May Be Safe and Effective
Discontinuation of antiepileptic drug (AED) therapy during concurrent video and EEG monitoring (vEEG) may be safe for patients with epilepsy, according to research presented at the 67th Annual Meeting of the American Epilepsy Society.

To determine the safety and long-term effects of AED withdrawal or discontinuation during this diagnostic procedure, investigators at the University of Saskatchewan in Saskatoon, Canada, conducted a prospective study of 150 patients with epilepsy admitted to their vEEG telemetry unit over a period of five years. Neurologists discontinued the patients’ medication therapy according to a standardized rapid AED withdrawal protocol. Rapid discontinuation was not performed for patients with a history of status epilepticus or phenobarbital exposure. The researchers then assessed the number of patients who had subsequent seizures, the safety of the withdrawal and telemetry procedures, and epilepsy surgery outcomes.

The group recorded seizures and nonepileptic events in 84.8% of the patients. This diagnostic yield was achieved over a mean monitoring duration of 4.53 days. The researchers found no benefit of longer monitoring. Habitual seizures were recorded in 107 patients to support a diagnosis of epilepsy. The investigators recorded nonepileptic events in 36 patients. The vEEG findings changed patient management for 93% of the cohort and likely improved quality of life by decreasing AED consumption and reducing seizure frequency.

Overall, 34% of the patients received epilepsy surgery. The probability of a good outcome (ie, Engel Class I or II) at 24 months was 78% among patients who underwent surgery and 40% among patients who did not. The overall complication rate of the surgery was 5.3%, and the most common complication was musculoskeletal pain secondary to clinical seizure activity. The investigators observed no mortality following surgery. In the first month following monitoring, 2.5% of patients were admitted to an emergency room for seizure clustering.

“VEEG telemetry monitoring with early cessation of AED therapy is safe and effective,” said Syed A. Rizvi, MD, a neurology resident at the University of Saskatchewan and lead author of the report. “Surgical outcomes are favorable and support the use of this technique under the supervision of a team comprising epileptologists, nurses, and EEG technologists.”

Prolonged Seizures During Childhood May Not Necessarily Damage the Brain
Childhood convulsive status epilepticus (CSE) may not damage the hippocampus unless it occurs years after the causative event, according to a study presented at the 67th Annual Meeting of the American Epilepsy Society. Prolonged febrile seizures also may not impair hippocampal growth in children.

Neurologists have long hypothesized that prolonged febrile seizures, the most common form of childhood CSE, cause mesial temporal sclerosis (MTS), which entails a loss of neurons and scarring of the hippocampus. Whether prolonged convulsions lead to long-term damage to the hippocampus or to MTS is uncertain.

A team of investigators from the United Kingdom and the United States used three-dimensional MRI imaging to measure hippocampal volume in 144 children. The cohort included 74 patients with seizures classified into four subgroups: prolonged febrile seizure, acute symptomatic (CSE at time of causative event such as meningitis or head injury), remote symptomatic (CSE months to years after causative event), and idiopathic or unclassified. The cohort also included 70 healthy controls.

Each hippocampal slice was measured independently by two investigators blind to clinical details. The hippocampal volume was measured on each side, and right–left asymmetry was calculated using asymmetry index. Volumetric images were taken at a mean follow up of 8.5 years (range 6.3 to 10 years) after the convulsive episode. The investigators also compared these measures across all patient groups.

The researchers found no significant corrected volumetric differences between the groups, except for the subgroup of children with remote symptomatic CSE, whose mean corrected hippocampal volume was 553 mm3 lower than that of controls. Asymmetry of the hippocampal structure also was significantly greater in the remote symptomatic subgroup, compared with the other groups. The investigators found no significant differences in asymmetry or corrected volume between the other CSE groups and healthy controls.

“On group analysis, hippocampal growth in children who had prolonged febrile seizures, acute symptomatic, and idiopathic or unclassified CSE was not impaired at a mean follow-up of 8.5 years post CSE,” said Suresh Pujar, MD, clinical research fellow in epilepsy at the Institute of Child Health, University College of London, and lead author of the study. “But children with remote symptomatic CSE have a significant reduction in hippocampal volume and increased asymmetry, compared with all the other groups in our study.”

The results of the study suggest that prolonged seizures, whether febrile or afebrile, may not have a lasting effect on hippocampal growth in children who were neurologically normal before CSE, according to the investigators.

Postsurgery Change in AEDs May Affect Seizure Recurrence, But Not Seizure Freedom
Late discontinuation of antiepileptic drugs (AEDs) following epilepsy surgery is associated with a lower rate of seizure recurrence, compared with early AED discontinuation, according to research presented at the 67th Annual Meeting of the American Epilepsy Society. The postsurgical timing of AED withdrawal may not influence the achievement of seizure freedom, however.

Although most patients with epilepsy become seizure-free after surgery, neurologists have no standard criteria for the timing of AED withdrawal following the procedure. In addition, the long-term effect of postoperative AED withdrawal is unclear.

Researchers at the Cleveland Clinic investigated the implications of AED withdrawal following surgery for drug-resistant temporal lobe epilepsy (TLE). The team reviewed data for all patients who underwent temporal lobectomy for drug-resistant TLE in their clinic from 1996 to 2011 and had at least six months of postoperative follow-up. Follow-up lasted as long as 16.7 years. The investigators noted patients’ clinical and imaging information; histopathological profiles; and dates of initiation, reduction, and termination of AEDs. Predictors of postoperative seizure outcome were defined using survival analyses and Cox-proportional hazard modeling.

More than 600 patients met the study criteria, including a patient cohort for whom medication was withdrawn and a second cohort for whom medication remained unchanged after surgery. The investigators used the latter group used as the control group. The researchers assessed the long-term recurrence of seizures following early and late withdrawal of AEDs postsurgery and compared those results with seizure recurrence when AEDs remained unchanged following surgery.

The number of AEDs per patient at the time of surgery ranged from 1 to 5, and the number of AEDs at last follow-up ranged from 0 to 5. At last follow-up, approximately 38% of patients had made no change in their baseline AEDs, about 21% of patients had stopped their AEDs, and approximately 42% had reduced their AEDs. The investigators found no relationship between AED management and the side of resection, MRI findings, baseline seizure-frequency, and presence or absence of convulsions. AEDs were more likely to be stopped in patients with tumors.

By the last follow-up, 55% of patients had seizure recurrence. Multivariate modeling indicated that higher baseline seizure frequency and history of generalization predicted seizure recurrence. For patients who stopped their AEDs, the mean timing of earliest AED change was shorter in patients with recurrent seizures (1.04 years), compared with patients who were seizure-free (1.44 years).

When the researchers analyzed patients who were seizure-free for at least six months postsurgery and compared seizure outcomes in the group with AED withdrawal to the cohort where AEDs were unchanged, they found no difference in long-term rates of seizure-freedom, regardless of etiology. The results of the large, retrospective, controlled cohort study need to be further evaluated in a well-designed, prospective, randomized trial, said the investigators.

Survey Indicates Positive Seizure and Psychosocial Outcomes of Epilepsy Surgery
Resective surgery may reduce seizures for the majority of patients with epilepsy, according to research presented at the 67th Annual Meeting of the American Epilepsy Society. The procedure may also improve patients’ daily functioning and social and emotional well-being.

To investigate the effect of epilepsy surgery on patients’ lives, researchers from the Comprehensive Epilepsy Program at the Henry Ford Hospital in Detroit conducted a long-term retrospective follow-up of surgical patients. The team correlated postsurgical psychosocial outcomes with seizure outcome and brain area that had been treated surgically.

The investigators conducted telephone interviews with more than half of all patients who had undergone epilepsy surgery at their center between 1993 and 2011. During the interviews, the researchers assessed current seizure frequency and psycho­social metrics such as driving, employment, and use of antidepressants. Of the respondents, 215 patients had undergone temporal lobe surgery and 38 had had surgery on other brain areas. The investigators recorded demographics, age at epilepsy onset and surgery, seizure frequency before surgery, and pathology.

Of the 253 patients surveyed, 32% were seizure-free and 75% had a favorable outcome (ie, Engel Class I or II). More than three-fourths of patients who had undergone temporal lobe surgery (78%) had a favorable outcome, and more than half of patients who had had extratemporal surgery (58%) had a similar outcome. In addition, almost all patients (92%) considered the surgery to have been worthwhile.

Half of the surgical patients (51%) were able to drive at the time of the survey, compared with 35% who were able to do so preoperatively. But after surgery, patients were less likely to be currently working full time, compared with before surgery (23% vs 42%). The difference in current full-time employment was significantly greater in patients with temporal resections, compared with patients with extratemporal resections (45% vs 26%).

More patients used antidepressants after surgery (30% vs 22%). Patients with a favorable surgical outcome were more likely than those with less favorable outcomes to be currently driving (65% vs 11%), more likely to be currently working (28% vs 8%), and less likely to be taking antidepressant medication (24% vs 47%).

“Resective epilepsy surgery not only yields favorable seizure outcomes, but [favorable] psychosocial outcomes as well,” said Vibhangini S. Wasade, MD, a neurologist at the Henry Ford Health System and lead author of the study. “Following surgery, more patients were able to drive, and those with favorable seizure outcomes were more likely to be employed full-time and less likely to be taking antidepressants. Overall, the great majority expressed satisfaction in having epilepsy surgery.”

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