A Randomized, Controlled Trial of Surgery for Temporal-Lobe Epilepsy

Wiebe, Samuel; Blume, Warren T.; Girvin, John P.; Eliasziw, Michael

doi:10.1056/nejm200108023450501

Cited by 3,058 publications

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“…One patient had transient neurological deficits in the surgical group (stroke), and three patients in the medical group experienced status epilepticus. In the Wiebe et al3 study, 58% of those in the surgical group (64% excluding those who did not have surgery) and 8% of those in the medical group were free of seizures impairing awareness at 1 year (those free of all seizures were 42% excluding those who did not have surgery vs. 3% in the medical arm). QOL and employment or school attendance was significantly higher in the surgical compared to the medical group.…”

Section: The Evidence For Resective Surgerymentioning

confidence: 96%

“…3, 4, 23, 24, 25, 26, 27 Every RCT was carried out in adults with drug‐resistant temporal lobe epilepsy (TLE), though a few also targeted teenagers3, 4, 26, 27 and children,26 according to their eligibility criteria, in addition to adults. Follow‐up ranged from 6 months to 2 years.…”

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

“…Two RCTs compared the safety and efficacy of medical versus surgical treatment in patients with TLE. These include the RCT by Wiebe et al3 the most highly cited epilepsy surgery RCT, and, most recently, the ERSET (Early Randomized Surgical Epilepsy Trial) study by Engel et al4 in patients with new‐onset drug‐resistant epilepsy (within 2 years of becoming drug‐resistant). Four RCTs compared small to larger surgical resections, including temporal lobectomy with or without sparing of the superior temporal gyrus,23 2.5‐ versus 3.5‐cm temporal resection,24 temporal lobectomy with partial versus complete hippocampectomy25 and temporal lobectomy with or without anterior corpus callosotomy in patients with developmental delay only 26.…”

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

“…It is imperative to identify and refine effective therapies. Resective epilepsy surgery, in appropriately selected patients, is the accepted treatment of choice for DRE as supported by two randomized clinical trials,3, 4 multiple retrospective cohort series, and a practice parameter issued by the American Academy of Neurology recommending a surgical evaluation for any patient with uncontrolled disabling complex partial seizures 5. Similarly, a plethora of nonresective yet surgical DRE treatments have flourished recently, including various neuromodulation procedures6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and thermal‐based19 and radiation‐based neurosurgeries 20.…”

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confidence: 99%

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Not all that glitters is gold: A guide to surgical trials in epilepsy

Jehi

2016

Epilepsia Open

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SummaryEpilepsy surgery is often the only effective treatment in appropriately selected patients with drug‐resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). Abstracts were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra‐TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.

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Section: The Evidence For Resective Surgerymentioning

confidence: 96%

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

mentioning

confidence: 99%

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Not all that glitters is gold: A guide to surgical trials in epilepsy

Jehi

2016

Epilepsia Open

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“…Refractory temporal lobe epilepsy (TLE) with hippocampal sclerosis (HS) is the most common medically intractable epilepsy condition 1. Temporal lobe surgery may render between 38 and 60% patients seizure free, depending on the time to postoperative follow‐up and definition of seizure freedom 2, 3, 4, 5. Quantitative magnetic resonance imaging (MRI) techniques provide sensitive surrogate markers of HS 6.…”

Section: Introductionmentioning

confidence: 99%

Hippocampal subfield segmentation in temporal lobe epilepsy: Relation to outcomes

et al. 2018

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ObjectiveTo investigate the clinical and surgical outcome correlates of preoperative hippocampal subfield volumes in patients with refractory temporal lobe epilepsy (TLE) using a new magnetic resonance imaging (MRI) multisequence segmentation technique.MethodsWe recruited 106 patients with TLE and hippocampal sclerosis (HS) who underwent conventional T1‐weighted and T2 short TI inversion recovery MRI. An automated hippocampal segmentation algorithm was used to identify twelve subfields in each hippocampus. A total of 76 patients underwent amygdalohippocampectomy and postoperative seizure outcome assessment using the standardized ILAE classification. Semiquantitative hippocampal internal architecture (HIA) ratings were correlated with hippocampal subfield volumes.ResultsPatients with left TLE had smaller volumes of the contralateral presubiculum and hippocampus‐amygdala transition area compared to those with right TLE. Patients with right TLE had reduced contralateral hippocampal tail volumes and improved outcomes. In all patients, there were no significant relationships between hippocampal subfield volumes and clinical variables such as duration and age at onset of epilepsy. There were no significant differences in any hippocampal subfield volumes between patients who were rendered seizure free and those with persistent postoperative seizure symptoms. Ipsilateral but not contralateral HIA ratings were significantly correlated with gross hippocampal and subfield volumes.ConclusionsOur results suggest that ipsilateral hippocampal subfield volumes are not related to the chronicity/severity of TLE. We did not find any hippocampal subfield volume or HIA rating differences in patients with optimal and unfavorable outcomes. In patients with TLE and HS, sophisticated analysis of hippocampal architecture on MRI may have limited value for prediction of postoperative outcome.

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The Early Identification of Candidates for Epilepsy Surgery

Dlugos¹

2001

Arch Neurol

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The effectiveness of resective surgery for the treatment of carefully selected patients with medically intractable, localization-related epilepsy is clear. Seizure-free rates following temporal lobectomy are consistently 65% to 70% in adults and 68% to 78% in children. Extratemporal resections less commonly lead to a seizure-free outcome, although one recent childhood series reported a seizure-free rate of 62% following extratemporal epilepsy surgery. With both temporal and extratemporal resections, additional patients have a reduction in seizures following surgery but are not completely seizure free. The identification of favorable surgical candidates has been the subject of extensive research, and many investigators have examined predictors of outcome following epilepsy surgery. However, the early identification of the potential epilepsy surgery candidate and the optimal timing of surgery have only occasionally been addressed in the literature. This issue is methodologically challenging to study since studies require large numbers of patients with new-onset partial epilepsy who are followed over time. The purpose of this article is to review the current ability for early prediction of medical intractability in patients with surgically remediable epilepsy. Emphasis will be placed on the early prediction of intractable temporal lobe epilepsy in children and adolescents, since temporal lobectomy remains the prototype epilepsy surgery, and early surgery may improve psychosocial outcome in younger patients.

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A Randomized, Controlled Trial of Surgery for Temporal-Lobe Epilepsy

Abstract: In temporal-lobe epilepsy, surgery is superior to prolonged medical therapy. Randomized trials of surgery for epilepsy are feasible and appear to yield precise estimates of treatment effects.

Cited by 3,058 publications

References 34 publications

Not all that glitters is gold: A guide to surgical trials in epilepsy

Not all that glitters is gold: A guide to surgical trials in epilepsy

Hippocampal subfield segmentation in temporal lobe epilepsy: Relation to outcomes

The Early Identification of Candidates for Epilepsy Surgery

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