Epilepsy surgery should not be a “last-resort.” Epilepsy surgery is a proven method to improve and potentially completely control seizures in selected patients. Epilepsy surgery is considered in patients who have not had control of their seizures despite trials with 2 or more antiepileptic drugs (AEDs). Epilepsy surgery can dramatically change a patient’s life. The chance of complete seizure control can be > 70% for some patients.
Despite a proven track record, it is typically many years from the time the patient starts having seizures to the time they finally have epilepsy surgery. Studies suggest that patients are finally referred for epilepsy surgery after 20 years of seizure activity. There is mounting data that performing epilepsy surgery sooner rather later may be helpful. Surely, it does not take 20 years to see if 2 or 3 seizure medications are going to control the seizures! Please note- if a patient has not had his or her seizures controlled after trying 2 AEDs, the chances of having AEDs completely control the seizures is quite low. That is why epilepsy surgery is considered in those who have tried 2 AEDs.
Of course, epilepsy surgery has risks. Remember, the surgery involves having the surgeon remove a piece of the skull and removing a piece of brain tissue. This brain tissue is the area of the brain that the seizures were starting. By removing this abnormal tissue, the seizures can be controlled. Risks include stroke, infection or memory problems. With careful evaluation, these risks can be minimized.
A recent article has been published entitled “Early Surgical Therapy for Drug-Resistant Temporal Lobe Epilepsy.” (Engel, JAMA, 2012). The goal of the study was to compare: 1) epilepsy surgery to 2) continued AED therapy without epilepsy surgery. The study looked at the effect of surgery on seizure control and the effect on quality of life. The patients in the study had tried 2 AEDs and were still having seizures. The seizures had to be disabling for no more than 2 consecutive years. This is important—this is the “early” part of the study. Rather than waiting for many many years, the study sought to evaluate those who had seizures for only a short period of time (< 2 years).
A total of 38 patients (18 men and 20 women) with temporal lobe epilepsy were included in the study. 15 patients were randomized to the surgery group and 23 patients were randomized to the medical group (medical group – treated with AED only, did not have surgery). It should be noted, the surgery patients did continue their AEDs.
- Surgery group: 11 of 15 patients were seizure free.
- Medical group: 0 of 23 patients were seizure free. (P < 0.001)
- Quality of life scores were better in the surgery group, but the findings did not reach statistical significance (p=0.08).
- Surgery group adverse events: 1 patient had a postoperative stroke. Neurologic symptoms resolved.
- Medical group adverse events: 3 patients went into status epilepticus (prolonged and potentially dangerous seizure activity).
The authors concluded that early surgery is superior to AED treatment alone for controlling seizures in patients with temporal lobe epilepsy. This study clearly supports the idea that you should not wait years and years for surgery. If a patient is not responding to AEDs, then surgery should be considered sooner rather than later.
The study suggested that quality of life was also better in the surgery group, but the small number of patients resulted in a non-significant finding. It should be noted that the study was stopped early because it was a challenge to recruit patients that met the inclusion criteria. The actual study had a total of 38 patients—the goal was 200. Because of the small numbers, the results need to be interpreted with appropriate caution.
This study supports the recommendation of the American Academy of Neurology: if a patient’s seizures are not controlled by 2 AEDs, then evaluation for possible epilepsy surgery should be considered. This should happen sooner rather than later!
Engel J, McDermott M, Wiebe S, et al. Early surgical therapy for drug-resistant temporal lobe epilepsy. JAMA 2012;307:922-930.