Surgical versus medical treatment for refractory epilepsy: Outcomes beyond seizure control

Abstract

SUMMARYNearly one third of patients with epilepsy become medically intractable, and the likelihood of achieving seizure freedom decreases with each additional medication trial. For appropriately chosen patients, epilepsy surgery affords the opportunity to achieve seizure freedom and potentially wean off medications. Epilepsy surgery, as with medical management, is not without adverse effects; to counsel patients wisely, practitioners need to understand the advantages and disadvantages of both. Randomized controlled trials in temporal lobe epilepsy reveal that epilepsy surgery achieves superior outcome compared to continued medical management. Although seizure freedom is the ultimate goal of any therapy, it represents a single outcome measure among a variety of other domains that affect patient welfare. It is imperative that providers understand the patient variables that affect these outcome measures and how these measures impact each other. Because the data comparing surgical therapy versus medical management for refractory epilepsy are limited, we review the available evidence comparing outcomes beyond seizure freedom including quality of life, cognition, psychosocial function, mortality, and financial costs.

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

“…Other studies do not provide information on allocation concealment 25, 26. Other challenges include the significant heterogeneity that exists among patients in regard to age of onset, epilepsy duration, and epilepsy etiology 29. The five resective epilepsy surgery RCTs also have limited generalizability because they include only patients with TLE, often mesial TLE only, as in the Schramm et al and the ERSET studies 4, 24.…”

“…Beyond adult patients with TLE, all data driving surgical decision making are strictly observational. No surgical RCTs specifically address children 29. Other striking challenges in need of rigorous research include: …”

Review of Epilepsy - Etiology, Diagnostic Evaluation and Treatment

“…Medically intractable or refractory epilepsy is defined as the failure of adequate trials of two tolerated and appropriately chosen antiepileptic medication schedules with adequate doses [9]. Patients with intractable epilepsy experience a significantly increased risk of injuries and premature death, as well as negative consequences upon their quality of life, cognition, and mood [4,5,[10][11][12][13][14][15][16][17][18][19]. Patients with epilepsy suffer from lower socioeconomic status and lower quality of life compared to other general population in validated quality of life in epilepsy questionnaire (QOLIE).…”

“…Patients with epilepsy suffer from lower socioeconomic status and lower quality of life compared to other general population in validated quality of life in epilepsy questionnaire (QOLIE). Fewer epilepsy patients married or had children, higher education or achievement in later life than the general population [4,5,10,14,15]. Also, patients with poorly controlled epilepsy experience decline in memory and cognition [10,12,14,15,17].…”

“…Fewer epilepsy patients married or had children, higher education or achievement in later life than the general population [4,5,10,14,15]. Also, patients with poorly controlled epilepsy experience decline in memory and cognition [10,12,14,15,17]. Co-morbid mood disorders such as depression and anxiety are common and more prevalent in patients with epilepsy compared to the general population [15,19].…”