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Seizure outcomes in nonresective epilepsy surgery: an update

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Abstract

In approximately 30 % of patients with epilepsy, seizures are refractory to medical therapy, leading to significant morbidity and increased mortality. Substantial evidence has demonstrated the benefit of surgical resection in patients with drug-resistant focal epilepsy, and in the present journal, we recently reviewed seizure outcomes in resective epilepsy surgery. However, not all patients are candidates for or amenable to open surgical resection for epilepsy. Fortunately, several nonresective surgical options are now available at various epilepsy centers, including novel therapies which have been pioneered in recent years. Ablative procedures such as stereotactic laser ablation and stereotactic radiosurgery offer minimally invasive alternatives to open surgery with relatively favorable seizure outcomes, particularly in patients with mesial temporal lobe epilepsy. For certain individuals who are not candidates for ablation or resection, palliative neuromodulation procedures such as vagus nerve stimulation, deep brain stimulation, or responsive neurostimulation may result in a significant decrease in seizure frequency and improved quality of life. Finally, disconnection procedures such as multiple subpial transections and corpus callosotomy continue to play a role in select patients with an eloquent epileptogenic zone or intractable atonic seizures, respectively. Overall, open surgical resection remains the gold standard treatment for drug-resistant epilepsy, although it is significantly underutilized. While nonresective epilepsy procedures have not replaced the need for resection, there is hope that these additional surgical options will increase the number of patients who receive treatment for this devastating disorder—particularly individuals who are not candidates for or who have failed resection.

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  1. Department of Neurological Surgery and UCSF Epilepsy Center, University of California, San Francisco, 505 Parnassus Avenue, Box 0112, M779, San Francisco, CA, 94143-0112, USA

    Dario J. Englot, Harjus Birk & Edward F. Chang

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Krasimir Minkin, Sofia, Bulgaria

Englot et al. review the current state of the art in nonresective epilepsy surgery. This paper has to be considered as continuation of the previous paper of the authors that focused on resective epilepsy surgery (1). The conclusions of these two reviews are that resective surgery provides more than 50 % complete seizure control while nonresective surgery has palliative goals and improve seizure control. This is particularly true for neuromodulation techniques (VNS, DBS, RNS) and disconnection surgeries (callosotomy and subpial transections). On the other hand, ablative surgeries (SLA, SRS) especially in temporal lobe epilepsy could achieve similar results than resective surgery. The full armamentarium of epilepsy surgery techniques is a prerequisite for adequate treatment of patients with drug-resistant epilepsies.

References

1. Englot DJ, Chang EF. Rates and predictors of seizure freedom in resective epilepsy surgery: an update. Neurosurg Rev 37(3):389–404

Dattatraya Muzumdar, Mumbai, India

Englot et al. have presented a literature review of seizure outcomes in nonresective epilepsy surgery. The gold standard in drug-resistant epilepsy is still appropriate presurgical evaluation of potential epilepsy surgery candidates in a tertiary comprehensive epilepsy care center and to subject them to appropriate surgical therapy. The seizure freedom rate of resective surgery is about 80 % in the literature. These patients can expect to be off medication in about 5 years from the date of surgery. The recent therapies like ablation and stimulation procedures may be appealing but there are caveats. They lack long-term outcome data analysis. Procedures like SRS take about 8 to 12 months for any tangible effect. The seizure freedom is still inferior to resective surgery. The long-term side effects are also not known. These procedures can be considered for patients who are averse to surgical resection, had a failed resective surgery, or at high risk due to major illnesses or advanced age. In these patients, palliation may be still worthwhile. In the current situation, even SLA and SRS may be unlikely to replace resection procedures. In resource-constraint countries, still cost effectiveness is an important variable. Resective or palliative surgical procedures (like multiple subpial transections and corpus callosotomy) are still cost effective than any nonresective modality. Large multicentric randomized double-blind studies are necessary and long-term outcome data will only decide their efficacy. The authors have presented a concise review, which is lucid, informative, and well referenced.

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Englot, D.J., Birk, H. & Chang, E.F. Seizure outcomes in nonresective epilepsy surgery: an update. Neurosurg Rev 40, 181–194 (2017). https://doi.org/10.1007/s10143-016-0725-8

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