Designed to address guidelines for surgical treatment of epilepsy, the analysis urges tens of thousands of patients nationwide -- and their doctors -- to consider surgery for mesial temporal lobe epilepsy (MTLE) as a viable and desirable alternative to medication rather than a treatment of last resort. MTLE is the most common form of epilepsy.
"Our comprehensive review of a decade's worth of research findings shows that surgery as a treatment for disabling seizures caused by this form of epilepsy is clearly superior to medication, and the risks are at least comparable," said Dr. Jerome Engel, chairman of the review committee and professor of neurology and neurobiology at the David Geffen School of Medicine at UCLA.
"As many as 200,000 patients nationwide who are treating disabling seizures with antiepileptic drugs potentially could lead happier, more productive lives with surgical intervention," said Engel, who also directs the UCLA Seizure Disorder Center and holds the Jonathan Sinay Chair in Epilepsy. "Patients with MTLE who haven't responded to medication should seriously consider surgery as their treatment of choice."
The findings:
This evidence-based review considered the results of the only Class I randomized controlled clinical trial comparing surgical treatment for MTLE to medication therapy, and also the findings of 24 Class IV studies of surgical outcomes. The analysis identified three methodological deficiencies in the Class IV studies: 1) all but one was retrospective; 2) there was a lack of quantitative information about preoperative seizures; 3) seizure outcome assessment was not masked.
The Class I study showed that surgery left 64 percent of patients free of disabling seizures at the end of one year and 10 percent to 15 percent unimproved, while medication left just 8 percent free of seizures. The Class IV studies yielded essentially identical results, the researchers reported.
Among other findings:
- Patients who become free of disabling seizures have significantly better quality of life as early as one year after surgery. Employment status and activities of daily living improve, mortality decreases and medication regimens are reduced.
- Surgical morbidity and mortality is small. No surgery-related deaths were reported, but one patient treated medically in the Class I trial died. Surgical complications were reported in 11 percent of 556 patients from seven centers; 3 percent suffered permanent neurological deficits. Postoperative cognitive and behavioral difficulties were described in only three papers, where they occurred in 6 percent of patients. Half of these were permanent.
- The potential for achieving freedom from disabling seizures offered by surgical treatment, as opposed to continuing medication therapy, may reduce the risks of long-term morbidity. In addition, successful surgical intervention appears to reduce the risk of mortality from continuing epileptic seizures substantially. This reduction in death rate offsets the irreversible surgical complication rate.
Epilepsy primer:
More than 2.3 million Americans have epilepsy. The brain disorder causes seizures, or intermittent bursts of abnormal electrical activity in the brain, that may affect consciousness, movements or sensations. Seizures vary in severity and can last from a few seconds to several minutes.
Epilepsy can be traced to brain injuries, tumors, infections and genetic tendencies, and frequently affects children and young adults in the most critical years of their development. Mesial temporal lobe epilepsy is caused by an abnormality in the brain's hippocampus, a part of the brain's temporal lobe that is important to learning and memory.
Thirty percent of epilepsy patients suffer from intractable seizures, which do not respond to medication. Research shows that MTLE is often intractable and may be progressive in nature, especially in children and young adults, causing irreversible disturbances in psychological and social function if seizures are not controlled early.
An estimated 100,000 to 200,0000 patients with intractable epilepsy in the United States are potential surgical candidates, yet doctors perform only 2,000 to 3,000 surgical procedures for epilepsy each year.
According to findings published in Epilepsia, the estimated annual cost of epilepsy in the United States is $12.5 billion, with 80 percent of the cost attributed to patients with intractable epilepsy.
Online resources:
Journal
Neurology