Ethical considerations in the surgical and neuromodulatory treatment of epilepsy

Hofmann

Keating

et al. 2023

J of Inher Metab Disea

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Glutaric aciduria type 1 (GA1) is an autosomal recessive disease frequently leading to dystonia. Deep brain stimulation (DBS), intrathecal baclofen (ITB), and intraventricular baclofen (IVB) are the current interventional treatment options for refractory dystonia. We performed a scoping review, individual patient data (IPD) analysis, and clinical trials review to summarize the existing literature on these interventions in this population, characterize outcomes, and suggest directions for future investigation. PubMed, Embase, and Scopus were searched following PRISMA guidelines. IPD were extracted from studies providing IPD for GA1 patients. http://clinicaltrials.gov was reviewed. Of 139 articles, 7 studies with 10 patients were included. In study‐level data, 2/4 (50.0%) DBS studies found no improvement in dystonia and 3/3 (100%) on baclofen found decreased dystonia and enteral medication regimen. In the IPD analysis, four studies with 5 patients (2 IVB, 2 DBS, 1 ITB) were included. The average percent reduction in dystonia was 29.9% ± 32.5% (median:18%, IQR:18%–29.2%). Function improved in 4 (80.0%) patients. All patients with reported changes in enteral dystonia‐related medication regimen (3/3, 100%) reported reduction in medication usage. No patients (0%) had perioperative complications. Mean follow‐up length was 14.8 ± 12.2 months. No interventional clinical trials were found. ITB, IVB, and DBS represent present neuromodulatory approaches for the treatment of GA1. ITB and IVB reduce dystonia, while DBS has a heterogeneous effect. ITB and IVB improved function and reduced enteral medication regimens. These findings must be viewed with caution considering limited data and a serious risk of bias. Further large‐scale studies are necessary to determine indications for ITB, IVB, and DBS and elucidate treatment algorithms.

Section: Discussionmentioning

confidence: 99%

Section: Implications For Clinical Decisionmaking and Patient Educationmentioning

confidence: 99%

See 1 more Smart Citation

Deep brain stimulation and intrathecal/intraventricular baclofen for glutaric aciduria type 1: A scoping review, individual patient data analysis, and clinical trials review

Hofmann

Keating

et al. 2023

J of Inher Metab Disea

Self Cite

“…Authors have proposed a three-tiered approach for the surgical treatment of people with epilepsy: (1) gathering information and assessing risks and benefits of treatment options, (2) clear communication with patients/caregivers based on patient values and barriers, and (3) long-term decision maintenance through continued identification of gaps in understanding or misconceptions and information provision. 45 Most patients with LGS may not have decision-making capacity because they are unable to appreciate the treatment options and their risks and benefits because of young age or cognitive impairment. 46 The focus of clinical decision making and education is generally on caregivers.…”

Section: Implications For Clinical Decision Making and Patient Educationmentioning

confidence: 99%

Deep Brain Stimulation of the Centromedian Nucleus of the Thalamus for Lennox-Gastaut Syndrome: A Systematic Review and Individual Patient Data Analysis

Hofmann

et al. 2022

Neurosurgery

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BACKGROUND: Lennox-Gastaut syndrome (LGS) is a severe childhood-onset pharmacoresistant epilepsy. Deep brain stimulation (DBS) of the centromedian nucleus of the thalamus (CMN) has been utilized. OBJECTIVE: To conduct a systematic review and individual patient data (IPD) analysis to characterize outcomes of DBS of CMN in LGS. METHODS: PubMed, Embase, and Scopus were searched per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Articles were screened by title/abstract then full text. Included articles were reviewed for bibliographic, demographic, and outcome data. IPD were extracted from studies providing IPD for all patients. RESULTS: Of 72 resultant articles, 10 studies (114 patients) were included. Six of 7 studies reporting the outcome of ≥50% seizure reduction indicated that ≥50% of patients achieved this, with improved functional ability. Seizure freedom rate was generally <10%. Six studies with 47 patients provided IPD. The mean ages at epilepsy onset and CMN DBS were 3.9 ± 4.5 years and 17.4 ± 8.8 years, respectively. Nineteen of 41 (46.3%) patients had positive MRI findings. Seizure types included atypical absence in 39 (83.0%) patients, generalized tonic-clonic in 32 (68.1%), tonic in 22 (46.8%), and atonic in 20 (42.6%). Thirty-eight (80.9%) patients experienced ≥50% reduction in seizure frequency, and only 3 (6.4%) experienced seizure freedom. The mean seizure reduction was 62.9% ± 31.2% overall. Quality of life improved in 30/34 (88.2%) and was unchanged in the remainder (11.8%). The complication rate was 2/41 (4.9%). The mean length of follow-up was 19.8 ± 26.1 months (IQR: 4-18 months). CONCLUSION: Limited data indicate that DBS of the CMN may be effective and safe for people with LGS.

“…14,15 Here, 2 additional sub-principles are useful in weighing treatment decisions—proportionality and subsidiarity. 16,17 Proportionality involves ensuring comparable risks and benefits for individual patients. Any surgical intervention for stroke must have the potential to benefit the patient when assuming a reasonable level of risk.…”

Section: Ethical Principles In Health Carementioning

confidence: 99%

Ethical Considerations in Surgical Decompression for Stroke

Clark

Campbell

et al. 2022

Stroke

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Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.