Elsevier

Pediatric Neurology

Volume 41, Issue 5, November 2009, Pages 332-338
Pediatric Neurology

Original Article
Medication Policy After Epilepsy Surgery

https://doi.org/10.1016/j.pediatrneurol.2009.04.025Get rights and content

The postsurgical medication policy was reviewed for 109 children (age at surgery, 0-16 years) who had epilepsy surgery between 1991 and 2005. Intervals between surgery and both start (n = 84) and completion (n = 68) of withdrawal of antiepileptic drugs (AEDs) were calculated and analyzed in relation to demographic and epilepsy variables and to recurrent seizures. Postoperative seizure freedom was associated with completeness of surgical resection, defined as complete removal of the cortical region exhibiting ictal or interictal abnormalities on intracranial electroencephalography and lesion on magnetic resonance imaging (P = 0.008). Etiology seemed to be related, but numbers were too small for statistical analysis. In 24 children (22%), seizures recurred postoperatively, and in 19 of these 24 children the AEDs were never withdrawn. Two of the five children in whom seizures recurred after medication withdrawal regained seizure freedom. Mean interval from surgery to start of drug withdrawal was 1.71 years (n = 84), and 2.86 years (n = 68) from surgery to complete withdrawal. Seizure recurrence seemed not associated with withdrawal decisions. Timing of seizure relapse was identical in children still on AEDs and in those who stopped. Eight children with early discontinuation (0.6 years from surgery to start of withdrawal and 0.8 years to complete withdrawal) had no seizure recurrence. Long-term continuation of AEDs is probably not indicated in children with complete resection of the epileptogenic zone. The optimal timing needs to be further explored.

Introduction

Surgery is a highly effective treatment for adults and children with pharmacoresistant focal epilepsy [1], [2], [3], [4]. After surgery, 64-70% of the patients are seizure-free while still using antiepileptic drugs (AEDs) [5]. The ultimate goal, however, is to achieve freedom from both seizures and AEDs. In adults, withdrawal of AEDs after epilepsy surgery appears to be associated with an increase of seizure recurrence [5]. Timing of AED withdrawal after surgery still has to be determined (and likewise the principles on which to base such decisions). In seizure-free, mainly adult patients, a reasonable time to attempt AED withdrawal appears to be 1 year postoperatively [6].

Recently, AED withdrawal policy after epilepsy surgery in children has been addressed. A low risk of seizure recurrence was found in children who had reduced or completely discontinued AEDs after a seizure-free period of at least 12 months after surgery [7]. Others found a significantly higher risk of breakthrough seizures in children who withdrew from AEDs within the first 6 months after surgery, compared with those who discontinued AEDs later or not at all [1]. In yet another study, however, 44% seizure recurrence was reported after AED withdrawal in children who were seizure-free for at least 1 year after surgery; these authors also found a higher recurrence rate after extratemporal surgery (55%) than after temporal surgery (32%) [8]. To date, the Dutch Collaborative Epilepsy Surgery Program has chosen to continue AEDs for at least 2 years after surgery. With the aim of contributing to an informed withdrawal policy, the present review evaluates postoperative AED withdrawal and analyzes the relation between seizure recurrence and the timing of withdrawal, as well as clinical and demographic variables.

Section snippets

Patients

A noncontrolled cohort study was conducted of all children who had resective epilepsy surgery in the University Medical Center Utrecht between 1991 and 2005, and whose postsurgical follow-up was at least 3 years. Information on sex, age at onset of epilepsy and at surgery, number of AEDs (also grouped as monotherapy vs polytherapy), affected hemisphere, type of surgery (hemispherectomy, temporal resection, extratemporal resection), pathological or anatomical diagnosis, and completeness of

Outcome

The cohort consisted of 109 children (Fig 1). The mean follow-up period was 8 years (range, 3-17 years). Of this cohort, 84 children started AED withdrawal, and 68 completed the withdrawal. Seizures recurred in 3 of these 68 children (in two of them immediately after completion of AED withdrawal and in one after 2 years). The remaining 65 children successfully completed medication withdrawal and were free of seizures and AEDs at time of the study. Of the original 84 children, 14 children

Discussion

In this retrospective study of AED withdrawal policy for a countrywide cohort of children who had epilepsy surgery between 1991 and 2005, 87 of 109 children (80%) were seizure-free after at least 3 years of follow-up. Of this surgical cohort, 65 of 109 (60%) achieved and maintained freedom from both seizures and AEDs. For seizure freedom postoperatively, etiology was conspicuous, although not statistically analyzable. Complete resection of the epileptogenic zone was significantly associated

References (12)

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Cited by (13)

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    The final expected outcome after surgery is to achieve a state of complete seizure freedom without the use of antiepileptic drugs (AEDs). Although early surgery offers the benefit of quicker seizure control, as well as possible reduction of associated comorbidities, the consensus is that surgery alone is unlikely to control seizures completely (Boshuisen et al., 2009; Kerling et al., 2009). Some reports have suggested that postoperative AED regimens influence seizure recurrence considering their possible neuroprotective or anti-epileptogenic effects (Pitkanen and Lukasiuk, 2011).

  • Management of antiepileptic drugs following epilepsy surgery: A meta-analysis

    2014, Epilepsy Research
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    Ziemba et al. (2011) reported that early tapering of AEDs (established as less than 9 months in their study) is a predictor of seizure recurrence in patients with nonlesional preoperative MRIs, but not in those with identified structural lesions. Additionally, most recurrences after pediatric (Boshuisen et al., 2009) and adult (Radhakrishnan et al., 2003; Jehi et al., 2010) ES occur during the first postoperative year; and having one seizure the first year had a six fold increase in likelihood of suffering continued seizure recurrences (Ramesha et al., 2011). Therefore, the available surveys of practice and our meta-analysis consider one year as the minimum time for beginning the AED discontinuation in carefully chosen patients.

  • Timing of antiepileptic drug withdrawal and long-term seizure outcome after paediatric epilepsy surgery (TimeToStop): A retrospective observational study

    2012, The Lancet Neurology
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    In adults who withdrew AEDs, seizure freedom rates were higher than in those who continued drug treatment, and seizures that recurred in patients who withdrew were more responsive to AEDs (63%) than those in patients who continued on AEDs (10%), suggesting that seizure reccurence during or after withdrawal might be regarded relatively benign.27 The rate of regaining seizure freedom (70%) in our study was comparable to previously published data.7,20,25–27 The effect of early withdrawal on recurrence risk is partly inherent to the present withdrawal policy in clinical practice; withdrawal of AEDs is generally considered only in patients who are seizure free after surgery.

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