Elsevier

The Lancet Neurology

Volume 7, Issue 6, June 2008, Pages 525-537
The Lancet Neurology

Review
Outcomes of epilepsy surgery in adults and children

https://doi.org/10.1016/S1474-4422(08)70109-1Get rights and content

Summary

Surgery is widely accepted as an effective therapy for selected individuals with medically refractory epilepsy. Numerous studies in the past 20 years have reported seizure freedom for at least 1 year in 53–84% of patients after anteromesial temporal lobe resections for mesial temporal lobe sclerosis, in 66–100% of patients with dual pathology, in 36–76% of patients with localised neocortical epilepsy, and in 43–79% of patients after hemispherectomies. Reported rates for non-resective surgery have been less impressive in terms of seizure freedom; however, the benefit is more apparent when reported in terms of significant seizure reductions. In this Review, we consider the outcomes of surgery in adults and children with epilepsy and review studies of neurological and cognitive sequelae, psychiatric and behavioural outcomes, and overall health-related quality of life.

Introduction

Up to a third of all individuals with epilepsy are refractory to medical therapy.1 Epilepsy surgery is now widely accepted as an effective therapeutic option in a selected subset of these patients.2, 3, 4, 5, 6 Surgical procedures for epilepsy include resection (anteromedial temporal lobectomy, focal neocortical resection, lesional resection, and hemispherectomy) and disconnection procedures (corpus callosotomy and multiple subpial transections); the stimulation procedures (vagal nerve stimulation, responsive neurostimulation, thalamic stimulation, and transcranial stimulation) are not covered in this Review.

Epilepsy surgery in children is not simply an extension of adult procedures, and additional complicating factors must be considered, including different causes of epilepsy, the detrimental effects of seizures and antiepileptic drugs on the developing brain, and the capacity for functional plasticity in younger patients. Another challenge in children is that each age group—neonates, infants, children, and adolescents—has unique surgical considerations that can differ appreciably from one another, and from adults.

In both children and adults, seizure freedom, or improvement of seizure control, is the desired and most commonly reported outcome. However, other outcomes are important to consider and assess, including enhancement of developmental or cognitive potential, treatment of behavioural and psychosocial difficulties, and improvement of health-related quality of life for patients and their families. Many studies report notable successes, including seizure freedom and improvements in other neurological and cognitive measures, for surgery in appropriately selected patients.2, 3, 4 In this Review, we provide a current and comprehensive overview of these global and specific outcomes of epilepsy surgery in children and adults.

Section snippets

Seizure outcomes

Methods of reporting seizure outcome are heterogeneous among papers. Therefore, we used a well defined, widely applicable, and clinically useful criterion for success of surgery: namely, seizure freedom (with or without isolated auras) for at least 1 year at last follow-up regardless of antiepileptic medication status (Engel class 1a–c,7 ILAE classification8 class 1, 1a, and 2, seizure-frequency scoring system9 0–3). This method circumvents the difficulties of separating patients on or off

Outcome in adults

After anterior mesial temporal lobectomies, 0·4–4% of patients had partial hemianopsia, aphasia, motor deficit, sensory deficit, or cranial nerve palsy.2, 22, 30, 35, 39, 61 Older reports include 2–5% incidence of hemiparesis; however, this was not observed in recent studies, which might reflect refinement of selection of patients, modern neuroimaging techniques, and improvement in operative techniques and technology. In contrast to the high morbidity reported in older studies, more recent work

Outcome in adults

No deaths have been reported perioperatively or from complications of surgery, except for one death during a corpus callosotomy of which details were not given.105 Death after surgery was most common in individuals with continued seizures; there seems to be a decrease in relative death risk with surgery. The standard mortality ratio is high in poorly controlled epilepsy because of seizure-related trauma, status epilepticus, sudden unexplained death in epilepsy, and suicide, and might also be

Outcome in adults

Most cognitive changes after epilepsy surgery arise in patients who have anterior temporal lobectomies. The methods and timing of neuropsychological assessments documenting these changes are heterogeneous. Most studies describe significant decline in verbal memory after 19–50% of dominant temporal resections. This decline is related to intact preoperative memory, intact memory performance on the Wada test after injection contralateral to the seizure focus, an MRI lesion other than mesial

Outcome in adults

Psychiatric disorders are present in up to 50% of patients with epilepsy; the most common in adults are affective disorders such as depression, mania, and anxiety, and some patients have acute psychosis.143, 144, 145, 146, 147 Some studies, usually in patients with anterior temporal lobectomy, have tried to define the effect of surgery on psychiatric disturbances and the risk factors for sequelae, but most did not include presurgical and postsurgical assessments and so their results might not

Outcome in adults

The real effects of any intervention are seen in the patient's overall health goals. Health-related quality of life (HRQOL) includes multiple domains (physical, psychological, social, vocational, and economic). Although there is much published on this measure, the heterogeneity of HRQOL instruments and the timing of measurements limit comparisons. The most comprehensive and applicable inventory is the quality of life in epilepsy inventory-89 (QOLIE-89) developed from the epilepsy surgery

Conclusions

The low morbidity and benefit of epilepsy surgery for intractable seizures are well established for adults with medically refractory epilepsy. There is increasing interest in more global outcomes of surgery, which might lead to substantial improvements for patients. Seizure freedom seems to be the strongest and most consistent predictor for improvements in HRQOL and patients' perceived satisfaction, and therefore we should continue to aim for this goal and pursue procedures that allow seizures

Search strategy and selection criteria

We did a comprehensive literature search of MEDLINE and the Cochrane database with the key phrases “outcome of epilepsy surgery”, “outcome of paediatric epilepsy surgery”, “epilepsy surgery”, “paediatric epilepsy surgery”, “resection”, “multiple subpial transections”, “corpus callosotomy”, “hemispherectomies”, “epilepsy surgery” and “quality of life”, “epilepsy” and “quality of life”, “epilepsy surgery” and “psychiatric disorders”, “paediatric epilepsy surgery” and “quality of life”,

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