Antiepileptic drugs management and long-term seizure outcome in post surgical mesial temporal lobe epilepsy with hippocampal sclerosis
Introduction
Surgery is well recognized as the treatment of choice for refractory temporal lobe epilepsies (Wiebe et al., 2001), with short and long-term seizure remission rates higher than 85% (Pimentel et al., 2010), although with a better prognostic for medial temporal resections as compared to those in neocortical areas (Spencer et al., 2005). However, although the ultimate goal of surgery is the complete absence of seizures along with the total discontinuation of antiepileptic drugs (AEDs), the percentage of patients in this condition is not well known (Schmidt et al., 2004). Furthermore, somehow unexpectedly, seizure recurrence may occur in these elapsed periods of time. In what possible post surgery related factors are concerned, namely the role of AEDs strategy management, the literature is rather inconclusive (Schiller et al., 2003, Wieser and Häne, 2003, Wieser and Häne, 2004, Kim et al., 2005, Berg et al., 2006, Tanriverdi et al., 2008, Sperling et al., 2008, Kerling et al., 2009). One of the factors implicated may be due to their heterogeneity regarding the epileptogenic zone (EZ) location and type of pathology, rendering it difficult to achieve ultimate conclusions. Indeed, and to our best knowledge, only 4 of the studies of the last decade addressed exclusively the temporal lobe epilepsy (Schiller et al., 2003, Wieser and Häne, 2003, Wieser and Häne, 2004, Tanriverdi et al., 2008), and among them, only 1 (Wieser and Häne, 2004) addresses this issue with a homogeneous patient's population, respecting the aforementioned factors. Other related issues, such as the right time to start tapering AEDs, and the relation between tapering AEDs and seizure recurrence, remain controversial. Herein, with a different study design from the ones reported, we first aim to determine the long-term seizure outcome in a homogeneous population of post surgical epileptic patients and its relationship to AEDs tapering.
Section snippets
Materials and methods
Our Epilepsy Surgery Group of the Hospital de Santa Maria prospectively recruited and registered in a database a cohort of 164 surgical patients from 1998 to October 2009, in order to asses long-term seizure outcome. The great majority (127 patients) experienced temporal lobe resections. Among these, we included only those aged 18 years or older, who experienced selective amygdalohippocampectomies (AHE), either complete (non-dominant hemisphere) or of the anterior two-thirds (dominant
Results
Sixty-seven patients were eligible, 36 females and 31 males, with a mean (±S.D.) age of 43.6 ± 14.02 years (range 11.9–78.5 years; median 42.7) at the time of cross-section. Mean (±S.D.) time of post-surgery follow-up was 4.8 ± 2.9 years (range 1.1–13.2 years). At the time of the cross-section, 46.3% of the patients were tapering AEDs (31/67), 38.8% had not changed AEDs (26/67) and 14.9% had increased the dose of AEDs (10/67). Among the patients tapering AED, 32.2% had reached monotherapy (10/31)
Discussion
Our study addressed the role of the AEDs management strategy in the long term post surgery seizure outcome of a homogeneous adult patient population with HS who were seizure free for 1 year after surgery. It brings additional insights to the previously published data on the subject, generally addressing heterogeneous series regarding location of the EZ and type of pathology (Schiller et al., 2003, Wieser and Häne, 2003, Wieser and Häne, 2004, Kim et al., 2005, Berg et al., 2006, Tanriverdi et
Conclusions
Our study has some limitations. The sample was relatively small and we did not take into account potentially pre, intra and post surgery clinical and neurophysiological outcome factors in order to avoid too small subgroups. Also, dysplastic lesions associated with HS may have been included in the series of patients analysed. Furthermore, we may have misjudged some Engel classes’ subdivisions by using a telephone interview to collect patients’ data.
Despite these constraints, our study shows that
Disclosure
None of the authors has any conflict of interest to disclose.
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Seizure outcomes of large volume temporo-parieto-occipital and frontal surgery in children with drug-resistant epilepsy
2021, Epilepsy ResearchCitation Excerpt :Although posterior quadrant and hemispheric disconnective procedures have been shown to produce similar rates of seizure control to their corresponding anatomical resection surgeries (Lee et al., 2014; Yin et al., 2014), only few case studies have been published concerning frontal disconnections (Yin et al., 2016; Cossu et al., 2018). Finally, neither our analysis nor that of other authors account for the discontinuation of antiepileptic drugs (AEDs), which often does not follow a uniform strategy and may interfere with post-operative outcome (Pimentel et al., 2012; Kanchanatawan et al., 2014). At GOSH, for example, weaning of AEDs generally commences at 6 months post-surgery in children who are seizure-free.
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2021, Epilepsy ResearchCitation Excerpt :Nevertheless, 24/37 (64.86 %) of patients in our cohort remained seizure free after reduction of AEDs, suggesting that mitigation of the potential side effects and cost related with increased burden of AEDs is possible. The relapse rate of the remaining 13/37 (35.13 %) is comparable to open resections (Kim et al., 2005; Pimentel et al., 2012; Schmidt and Loscher, 2005). Most importantly, 12/13 (92.30 %) of our patients who relapsed after reduction of AEDs, regained seizure freedom after restoration of their AEDs, a rate also comparable to open resections (Pimentel et al., 2012; Rathore et al., 2011).
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2015, Epilepsy and BehaviorCitation Excerpt :Overall, the proportion of seizure freedom after discontinuation of AEDs postsurgery varied across studies [17,24–26]. In addition, we noted a significant reduction in the number of AEDs in those with favorable outcomes when compared to those with unfavorable outcomes as reported in other studies [11,27]. We found that 35% of patients drove before surgery for epilepsy and 51% drove postsurgery which was a statistically significant increase.
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2014, Epilepsy ResearchCitation Excerpt :In the 16 controlled studies the seizure recurrence was 18% (95% CI 16, 19.6) in patients with AED discontinuation and 76% (95% CI 70.7, 74.5) in patients with no discontinuation (p < 0.001). From the controlled studies, only five (Kim et al., 2005; Lachhwani et al., 2008; Pimentel et al., 2012; Schiller et al., 2000; Van Veelen et al., 2001) reported a higher seizure recurrence in the withdrawal group, 24% (95% CI 17.7, 30.4) vs. 7% (95% CI 1.02, 12.4). In the nine non-controlled studies the rate of seizure recurrence in the discontinuation group was 18% (95% CI 16, 19.7).