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Laxer KD, Elder CJ, Di Gennaro G, Ferrari L, Krauss GL, Pellinen J, Rosenfeld WE, Villanueva V. Presurgical Use of Cenobamate for Adult and Pediatric Patients Referred for Epilepsy Surgery: Expert Panel Recommendations. Neurol Ther 2024; 13:1337-1348. [PMID: 39154302 PMCID: PMC11393364 DOI: 10.1007/s40120-024-00651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024] Open
Abstract
Cenobamate has demonstrated efficacy in patients with treatment-resistant epilepsy, including patients who continued to have seizures after epilepsy surgery. This article provides recommendations for cenobamate use in patients referred for epilepsy surgery evaluation. A panel of six senior epileptologists from the United States and Europe with experience in presurgical evaluation of patients with epilepsy and in the use of antiseizure medications (ASMs) was convened to provide consensus recommendations for the use of cenobamate in patients referred for epilepsy surgery evaluation. Many patients referred for surgical evaluation may benefit from ASM optimization; both ASM and surgical treatment should be individualized. Based on previous clinical studies and the authors' clinical experience with cenobamate, a substantial proportion of patients with treatment-resistant epilepsy can become seizure-free with cenobamate. We recommend a cenobamate trial and ASM optimization in parallel with presurgical evaluations. Cenobamate can be started before phase two monitoring, especially in patients who are found to be suboptimal surgery candidates. As neurostimulation therapies are generally palliative, we recommend trying cenobamate before vagus nerve stimulation (VNS), deep brain stimulation, or responsive neurostimulation (RNS). In surgically remediable cases (mesial temporal sclerosis, benign discrete lesion in non-eloquent cortex, cavernous angioma, etc.), cenobamate use should not delay imminent surgery; however, a patient may decide to defer or even cancel surgery should they achieve sustained seizure freedom with cenobamate. This decision should be made on an individual, case-by-case basis based on seizure etiology, patient preferences, potential surgical risks (mortality and morbidity), and likely surgical outcome. The addition of cenobamate after unsuccessful surgery or palliative neuromodulation may also be associated with better outcomes.
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Affiliation(s)
- Kenneth D Laxer
- Sutter Pacific Epilepsy Program, California Pacific Medical Center, 1100 Van Ness Ave, 6th floor, San Francisco, CA, 94109, USA.
| | | | | | | | | | - Jacob Pellinen
- University of Colorado School of Medicine, Aurora, CO, USA
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, MO, USA
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
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Všianský V, Brázdil M, Rektor I, Doležalová I, Kočvarová J, Strýček O, Hemza J, Chrastina J, Brichtová E, Horák O, Mužlayová P, Hermanová M, Hendrych M, Pail M. Twenty-five years of epilepsy surgery at a Central European comprehensive epilepsy center-Trends in intervention delay and outcomes. Epilepsia Open 2023; 8:991-1001. [PMID: 37259787 PMCID: PMC10472383 DOI: 10.1002/epi4.12769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE We analyzed trends in patients' characteristics, outcomes, and waiting times over the last 25 years at our epilepsy surgery center situated in Central Europe to highlight possible areas of improvement in our care for patients with drug-resistant epilepsy. METHODS A total of 704 patients who underwent surgery at the Brno Epilepsy Center were included in the study, 71 of those were children. Patients were separated into three time periods, 1996-2000 (n = 95), 2001-2010 (n = 295) and 2011-2022 (n = 314) based on first evaluation at the center. RESULTS The average duration of epilepsy before surgery in adults remained high over the last 25 years (20.1 years from 1996 to 2000, 21.3 from 2001 to 2010, and 21.3 from 2011 to 2020, P = 0.718). There has been a decrease in rate of surgeries for temporal lobe epilepsy in the most recent time period (67%-70%-52%, P < 0.001). Correspondingly, extratemporal resections have become more frequent with a significant increase in surgeries for focal cortical dysplasia (2%-8%-19%, P < 0.001). For resections, better outcomes (ILAE scores 1a-2) have been achieved in extratemporal lesional (0%-21%-61%, P = 0.01, at least 2-year follow-up) patients. In temporal lesional patients, outcomes remained unchanged (at least 77% success rate). A longer duration of epilepsy predicted a less favorable outcome for resective procedures (P = 0.024) in patients with disease duration of less than 25 years. SIGNIFICANCE The spectrum of epilepsy surgery is shifting toward nonlesional and extratemporal cases. While success rates of extratemporal resections at our center are getting better, the average duration of epilepsy before surgical intervention is still very long and is not improving. This underscores the need for stronger collaboration between epileptologists and outpatient neurologists to ensure prompt and effective treatment for patients with drug-resistant epilepsy.
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Affiliation(s)
- Vít Všianský
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Milan Brázdil
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Ivan Rektor
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Irena Doležalová
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Jitka Kočvarová
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Ondřej Strýček
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Jan Hemza
- Brno Epilepsy Center, Department of Neurosurgery, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Jan Chrastina
- Brno Epilepsy Center, Department of Neurosurgery, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Eva Brichtová
- Brno Epilepsy Center, Department of Neurosurgery, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Ondřej Horák
- Brno Epilepsy Center, Department of Pediatric Neurology, Brno University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Patrícia Mužlayová
- Brno Epilepsy Center, Department of Pediatric Neurology, Brno University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
| | - Markéta Hermanová
- Department of Pathology, St. Anne's University Hospital, Faculty of MedicineMasaryk UniversityBrnoCzech Republic
| | - Michal Hendrych
- Department of Pathology, St. Anne's University Hospital, Faculty of MedicineMasaryk UniversityBrnoCzech Republic
| | - Martin Pail
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of MedicineMasaryk University, Member of the ERN EpiCAREBrnoCzech Republic
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Feria-Romero IA, Reyes-Cuayahuitl A, Sosa-Maldonado J, Montes-Aparicio AV, Rayo-Mares D, Pérez-Pérez D, Grijalva-Otero I, Orozco-Suarez S. Study of genetic variants and their clinical significance in Mexican pediatric patients with epilepsy. Gene 2023:147565. [PMID: 37315635 DOI: 10.1016/j.gene.2023.147565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The use of novel and accurate techniques to identify genetic variants (with or without a record in the National Center for Biotechnology Information (NCBI) database) improves diagnosis, prognosis, and therapeutics for patients with epilepsy, especially in populations for whom such techniques exist. The aim of this study was to find a genetic profile in Mexican pediatric epilepsy patients by focusing on ten genes associated with drug-resistant epilepsy (DRE). METHODS This was a prospective, analytical, cross-sectional study of pediatric patients with epilepsy. Informed consent was granted by the patients' guardians or parents. Genomic DNA from the patients was sequenced using next-generation sequencing (NGS). For statistical analysis, Fisher's exact, Chi-square or Mann-Whitney U, and OR (95% CI) tests were performed, with significance values of p<0.05. RESULTS Fifty-five patients met the inclusion criteria (female 58.2%, ages 1-16 years); 32 patients had controlled epilepsy (CTR), and 23 had DRE. Four hundred twenty-two genetic variants were identified (71.3% with a known SNP registered in the NCBI database). A dominant genetic profile consisting of four haplotypes of the SCN1A, CYP2C9, and CYP2C19 genes was identified in most of the patients studied. When comparing the results between patients with DRE and CTR, the prevalence of polymorphisms in the SCN1A (rs10497275, rs10198801, and rs67636132), CYP2D6 (rs1065852), and CYP3A4 (rs2242480) genes showed statistical significance (p = 0.021). Finally, the number of missense genetic variants in patients in the nonstructural subgroup was significantly higher in DRE than in CTR (1 [0-2] vs. 3 [2-4]; p=0.014). CONCLUSIONS The Mexican pediatric epilepsy patients included in this cohort presented a characteristic genetic profile infrequent in the Mexican population. SNP rs1065852 (CYP2D6*10) is associated with DRE, especially with nonstructural damage. The presence of three genetic alterations affecting the CYP2B6, CYP2C9, and CYP2D6 cytochrome genes is associated with nonstructural DRE.
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Affiliation(s)
- Iris A Feria-Romero
- Unidad de Investigación Médica en Enfermedades Neurológicas, Hospital de Especialidades, "Dr. Bernardo Sepúlveda", Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Aracely Reyes-Cuayahuitl
- Servicio de Neurología Pediátrica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | | | - Alexia V Montes-Aparicio
- Programa de Maestría, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México, México
| | - Darío Rayo-Mares
- Servicio de Neurología Pediátrica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Daniel Pérez-Pérez
- Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilian University, Munich, Germany
| | - Israel Grijalva-Otero
- Unidad de Investigación Médica en Enfermedades Neurológicas, Hospital de Especialidades, "Dr. Bernardo Sepúlveda", Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Sandra Orozco-Suarez
- Servicio de Neurología Pediátrica, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
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Disparities in pediatric drug-resistant epilepsy care. Childs Nerv Syst 2023; 39:1611-1617. [PMID: 36797496 DOI: 10.1007/s00381-023-05854-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/14/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Epilepsy affects millions of children worldwide, with 20-40% experiencing drug-resistant epilepsy (DRE) who are recommended for epilepsy surgery evaluation and may benefit from surgical management. However, many patients live with DRE for multiple years prior to surgical epilepsy referral or treatment or are never referred at all. OBJECTIVE We aimed to describe factors associated with referral for epilepsy surgery in the USA, in order to identify disparities in DRE, characterize why they may exist, and recognize areas for improvement. METHODS Pediatric patients diagnosed with DRE between January 1, 2004 and December 31, 2020 were identified from the Pediatric Health Information System (PHIS) Database. Patients treated with antiseizure medications (ASMs) only, ASMs plus vagus nerve stimulation (VNS), and ASMs plus cranial epilepsy surgery were studied regarding access to epilepsy surgery and disparities in care. This study used chi-square tests to determine associations between treatment time and preoperative factors. Preoperative factors studied included epilepsy treatment type, age, sex, race/ethnicity, insurance type, geographic region, patient type, epilepsy type, and presence of pediatric complex chronic conditions (PCCCs). RESULTS A total of 18,292 patients were identified; 10,240 treated with ASMs, 5019 treated with ASMs + VNS, and 3033 treated with ASMs + cranial epilepsy surgery. Sex was not found to significantly vary among groups. There was significant variation in age, census region, race/ethnicity, patient type, presence of PCCCs, diagnosis, and insurance (p < 0.001). Those treated surgically, either with VNS or cranial epilepsy surgery, were 2 years older than those medically treated. Additionally, those medically treated were less likely to be living in the Midwest (25.46%), identified as non-Hispanic white (51.78%), have a focal/partial epilepsy diagnosis (8.74%), and be privately insured (35.82%). CONCLUSIONS We studied a large administrative US database examining variables associated with surgical epilepsy evaluation and management. We found significant variation in treatment associated with age, US census region, race/ethnicity, patient type, presence of PCCCs, diagnosis, and health insurance type. We believe that these disparities in care are related to access and social determinants of health, and we encourage focused outreach strategies to mitigate these disparities to broaden access and improve outcomes in children in the USA with DRE.
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Randhawa J, Hrazdil CT, McDonald PJ, Illes J. Strategic and principled approach to the ethical challenges of epilepsy monitoring unit triage. JOURNAL OF MEDICAL ETHICS 2023; 49:81-86. [PMID: 34497143 DOI: 10.1136/medethics-2020-107147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/27/2021] [Indexed: 06/13/2023]
Abstract
Electroencephalographic monitoring provides critical diagnostic and management information about patients with epilepsy and seizure mimics. Admission to an epilepsy monitoring unit (EMU) is the gold standard for such monitoring in major medical facilities worldwide. In many countries, access can be challenged by limited resources compared to need. Today, triaging admission to such units is generally approached by unwritten protocols that vary by institution. In the absence of explicit guidance, decisions can be ethically taxing and are easy to challenge. In an effort to address this gap, we propose a two-component approach to EMU triage that takes into account the unique landscape of epilepsy monitoring informed by triage literature from other areas of medicine. Through the strategic component, we focus on the EMU wait list management infrastructure at the institutional level. Through the principled component, we apply a combination of the ethical principles of prioritarianism, utilitarianism and justice to triage; and we use individual case examples to illustrate how they apply. The effective implementation of this approach to specific epilepsy centres will need to be customised to the nuances of different settings, including diverse practice patterns, patient populations and constraints on resource distribution, but the conceptual consolidation of its components can alleviate some of the pressures imposed by the complex decisions involved in EMU triage.
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Affiliation(s)
- Jason Randhawa
- Neuroethics Canada, Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Neurology, Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Chantelle T Hrazdil
- Division of Neurology, Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Patrick J McDonald
- Neuroethics Canada, Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Neurosurgery, Department of Surgery, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Neurology, Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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[ Delay time from diagnosis to surgery in drug-resistant epilepsy]. REVISTA DE LA FACULTAD DE CIENCIAS MÉDICAS 2022; 79:405-407. [PMID: 36542579 PMCID: PMC9987307 DOI: 10.31053/1853.0605.v79.n4.37485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/31/2022] [Indexed: 12/24/2022] Open
Abstract
Drug-resistant epilepsy, in a good number of cases, can benefit from surgery. It is essential to make a timely referral for the pre-surgical study. We retrospectively reviewed the clinical records of our center from 2011 to 2019. The patients who underwent temporal lobectomy were selected. After performing the data analysis, an average waiting time of 23 years was observed, similar to that observed in other countries of the American continent. There is an evident need to provide strategies to reduce the waiting time for epilepsy surgery in patients who benefit from the intervention.
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Hale AT, Chari A, Scott RC, Cross JH, Rozzelle CJ, Blount JP, Tisdall MM. Expedited epilepsy surgery prior to drug resistance in children: a frontier worth crossing? Brain 2022; 145:3755-3762. [PMID: 35883201 DOI: 10.1093/brain/awac275] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/18/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that, 1) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy associated tumours) will progress to drug-resistance, 2) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe, and 3) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to anti-seizure medications (ASM), which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Lastly, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rod C Scott
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Nemours Children's Hospital, Wilmington, DE, USA.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - J Helen Cross
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Martin M Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
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Khoo A, Martin L, Tisi JD, O’Keeffe AG, Sander JW, Duncan JS. Cost of pre-surgical evaluation for epilepsy surgery: A single-center experience. Epilepsy Res 2022; 182:106910. [DOI: 10.1016/j.eplepsyres.2022.106910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/24/2022] [Accepted: 03/13/2022] [Indexed: 11/03/2022]
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Penovich PE, Stern JM, Becker DA, Long L, Santilli N, McGuire L, Peck EY. Epilepsy Treatment Complacency in Patients, Caregivers, and Health Care Professionals. Neurol Clin Pract 2021; 11:377-384. [PMID: 34824892 PMCID: PMC8610521 DOI: 10.1212/cpj.0000000000001066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/27/2021] [Indexed: 11/22/2022]
Abstract
Objective To explore the perspectives of adult patients with epilepsy, caregivers, and health care professionals (HCPs) on treatment for seizures and treatment decisions, we developed and administered the STEP Survey (Seize the Truth of Epilepsy Perceptions). Methods Participants were recruited from online panel M3 and by Rare Patient Voice and completed the self-administered online STEP Survey. Analysis of variance and chi-square tests were used for group comparisons. Results The STEP Survey was completed by 400 adult patients, 201 caregivers, and 258 HCPs. Patients estimated reporting 45% of their seizures to their HCP, whereas caregivers estimated 83% and HCPs estimated 73% were reported. The most common reason for not reporting seizures was that the seizures were not serious enough to mention (patients 57%; caregivers 66%). A minority of patients (25%) and caregivers (30%) were very or extremely likely to ask their HCP about changing antiseizure medication (ASM) in the next 12 months. The HCP was most frequently selected by patients, caregivers, and HCPs as the person who initiates discussion of changing ASMs (patients 73%/caregivers 66%/HCPs 75%) and increasing ASM dosage (patients 77%/caregivers 68%/HCPs 81%). A majority of patients (65%) and caregivers (68%) somewhat or strongly agreed that they do not change ASMs due to fear of getting worse. HCPs perceive this fear less often, stating that 50% of their patients feel afraid when a second ASM was added. Conclusions Improved reporting of all seizures, discussion of treatment changes, and the impact of fear on treatment decisions provide opportunities to reduce complacency and optimize patient outcomes.
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Affiliation(s)
- Patricia E Penovich
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - John M Stern
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - Danielle A Becker
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - Lucretia Long
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - Nancy Santilli
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - Lynanne McGuire
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
| | - Eugenia Y Peck
- Minnesota Epilepsy Group (PEP), Saint Paul; Department of Neurology (JMS), University of California at Los Angeles; Penn Epilepsy Center (DAB), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (LL), The Ohio State University Medical Center, Columbus; Human Care Systems Inc. (NS), San Francisco, CA; MedVal Scientific Information Services (LM), Princeton, NJ; and Health Division (EYP), Kantar Health, New York, NY
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Machine learning models for decision support in epilepsy management: A critical review. Epilepsy Behav 2021; 123:108273. [PMID: 34507093 DOI: 10.1016/j.yebeh.2021.108273] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE There remain major challenges for the clinician in managing patients with epilepsy effectively. Choosing anti-seizure medications (ASMs) is subject to trial and error. About one-third of patients have drug-resistant epilepsy (DRE). Surgery may be considered for selected patients, but time from diagnosis to surgery averages 20 years. We reviewed the potential use of machine learning (ML) predictive models as clinical decision support tools to help address some of these issues. METHODS We conducted a comprehensive search of Medline and Embase of studies that investigated the application of ML in epilepsy management in terms of predicting ASM responsiveness, predicting DRE, identifying surgical candidates, and predicting epilepsy surgery outcomes. Original articles addressing these 4 areas published in English between 2000 and 2020 were included. RESULTS We identified 24 relevant articles: 6 on ASM responsiveness, 3 on DRE prediction, 2 on identifying surgical candidates, and 13 on predicting surgical outcomes. A variety of potential predictors were used including clinical, neuropsychological, imaging, electroencephalography, and health system claims data. A number of different ML algorithms and approaches were used for prediction, but only one study utilized deep learning methods. Some models show promising performance with areas under the curve above 0.9. However, most were single setting studies (18 of 24) with small sample sizes (median number of patients 55), with the exception of 3 studies that utilized large databases and 3 studies that performed external validation. There was a lack of standardization in reporting model performance. None of the models reviewed have been prospectively evaluated for their clinical benefits. CONCLUSION The utility of ML models for clinical decision support in epilepsy management remains to be determined. Future research should be directed toward conducting larger studies with external validation, standardization of reporting, and prospective evaluation of the ML model on patient outcomes.
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Khoo A, de Tisi J, Mannan S, O'Keeffe AG, Sander JW, Duncan JS. Reasons for not having epilepsy surgery. Epilepsia 2021; 62:2909-2919. [PMID: 34558079 DOI: 10.1111/epi.17083] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study was undertaken to determine reasons for adults with drug-resistant focal epilepsy who undergo presurgical evaluation not proceeding with surgery, and to identify predictors of this course. METHODS We retrospectively analyzed data on 617 consecutive individuals evaluated for epilepsy surgery at a tertiary referral center between January 2015 and December 2019. We compared the characteristics of those in whom a decision not to proceed with surgical treatment was made with those who underwent definitive surgery in the same period. Multivariate logistic regression was performed to identify predictors of not proceeding with surgery. RESULTS A decision not to proceed with surgery was reached in 315 (51%) of 617 individuals evaluated. Common reasons for this were an inability to localize the epileptogenic zone (n = 104) and the presence of multifocal epilepsy (n = 74). An individual choice not to proceed with intracranial electroencephalography (icEEG; n = 50) or surgery (n = 39), risk of significant deficit (n = 33), declining noninvasive investigation (n = 12), and coexisting neurological comorbidity (n = 3) accounted for the remainder. Compared to 166 surgically treated patients, those who did not proceed to surgery were more likely to have a learning disability (odds ratio [OR] = 2.35, 95% confidence interval [CI] = 1.07-5.16), normal magnetic resonance imaging (OR = 4.48, 95% CI = 1.68-11.94), extratemporal epilepsy (OR = 2.93, 95% CI = 1.82-4.71), bilateral seizure onset zones (OR = 3.05, 95% CI = 1.41-6.61) and to live in more deprived socioeconomic areas (median deprivation decile = 40%-50% vs. 50%-60%, p < .05). SIGNIFICANCE Approximately half of those evaluated for surgical treatment of drug-resistant focal epilepsy do not proceed to surgery. Early consideration and discussion of the likelihood of surgical suitability or need for icEEG may help direct referral for presurgical evaluation.
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Affiliation(s)
- Anthony Khoo
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Jane de Tisi
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Shahidul Mannan
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | | | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK.,Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.,Department of Neurology, West China Hospital, and Institute of Brain Science and Brain-Inspired Technology, Sichuan University, Chengdu, China
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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Samanta D, Ostendorf AP, Willis E, Singh R, Gedela S, Arya R, Scott Perry M. Underutilization of epilepsy surgery: Part I: A scoping review of barriers. Epilepsy Behav 2021; 117:107837. [PMID: 33610461 PMCID: PMC8035287 DOI: 10.1016/j.yebeh.2021.107837] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/15/2021] [Accepted: 01/30/2021] [Indexed: 12/13/2022]
Abstract
One-third of persons with epilepsy have seizures despite appropriate medical therapy. Drug resistant epilepsy (DRE) is associated with neurocognitive and psychological decline, poor quality of life, increased risk of premature death, and greater economic burden. Epilepsy surgery is an effective and safe treatment for a subset of people with DRE but remains one of the most underutilized evidence-based treatments in modern medicine. The reasons for this quality gap are insufficiently understood. In this comprehensive review, we compile known significant barriers to epilepsy surgery, originating from both patient/family-related factors and physician/health system components. Important patient-related factors include individual and epilepsy characteristics which bias towards continued preferential use of poorly effective medications, as well as patient perspectives and misconceptions of surgical risks and benefits. Health system and physician-related barriers include demonstrable knowledge gaps among physicians, inadequate access to comprehensive epilepsy centers, complex presurgical evaluations, insufficient research, and socioeconomic bias when choosing appropriate surgical candidates.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Adam P Ostendorf
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Erin Willis
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rani Singh
- Department of Pediatrics, Atrium Health/Levine Children's Hospital, USA
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, USA
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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13
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Li Y, Tymchuk S, Barry J, Muppidi S, Le S. Antibody Prevalence in Epilepsy before Surgery (APES) in drug-resistant focal epilepsy. Epilepsia 2021; 62:720-728. [PMID: 33464599 DOI: 10.1111/epi.16820] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE There is a growing recognition of immune-mediated causes in patients with focal drug-resistant epilepsy (DRE); however, they are not systematically assessed in the pre-surgical diagnostic workup. Early diagnosis and initiation of immunotherapy is associated with a favorable outcome in immune-mediated seizures. Patients with refractory focal epilepsy with neuronal antibodies (Abs) tend to have a worse surgical prognosis when compared to other etiologies. METHODS We studied the prevalence of serum Abs in patients ≥18 years of age with DRE of unknown cause before surgery. We proposed and calculated a clinical APES (Antibody Prevalence in Epilepsy before Surgery) score for each subject, which was modified based on Dubey's previously published APE2 score. RESULTS`: A total of 335 patients were screened and 86 subjects were included in final analysis. The mean age at the time of recruitment was 44.84 ± 14.86 years, with age at seizure onset 30.89 ± 19.88 years. There were no significant differences among baseline clinical features between retrospective and prospective sub-cohorts. The prevalence of at least one positive Ab was 33.72%, and central nervous system (CNS)-specific Abs was 8.14%. APES score ≥4 showed slightly better overall prediction (area under the curve [AUC]: 0.84 vs 0.74) and higher sensitivity (100% vs 71.4%), with slightly lower but similar specificity (44.3% vs 49.4%), when compared to APE2 score ≥4. For subjects who had available positron emission tomography (PET) results and all components of APES score (n = 60), the sensitivity of APES score ≥4 yielded a similar prediction potential with an AUC of 0.80. SIGNIFICANCE Our findings provide persuasive evidence that a subset of patients with focal DRE have potentially immune-mediated causes. We propose an APES score to help identify patients who may benefit from a workup for immune etiologies during the pre-surgical evaluation for focal refractory epilepsy with unknown cause.
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Affiliation(s)
- Yi Li
- Stanford Comprehensive Epilepsy Center, Stanford University, Palo Alto, CA, USA
| | - Sarah Tymchuk
- Department of Psychiatry, University of Alberta Hospital, Alberta, Canada
| | - John Barry
- Stanford Department of Psychiatry, Stanford University, Palo Alto, CA, USA
| | - Srikanth Muppidi
- Stanford Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Scheherazade Le
- Stanford Comprehensive Epilepsy Center, Stanford University, Palo Alto, CA, USA
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Blank LJ, Acton EK, Thibault D, Willis AW. Neurodegenerative disease is associated with increased incidence of epilepsy: a population based study of older adults. Age Ageing 2021; 50:205-212. [PMID: 33030514 PMCID: PMC7946790 DOI: 10.1093/ageing/afaa194] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the incidence of epilepsy among Medicare beneficiaries with a new diagnosis of Alzheimer dementia (AD) or Parkinson disease (PD). METHODS Retrospective cohort study of Medicare beneficiaries with an incident diagnosis of AD or PD in the year 2009. The 5-year incidence of epilepsy was examined by sociodemographic characteristics, comorbidities and neurodegenerative disease status. Cox regression models examined the association of neurodegenerative disease with incident epilepsy, adjusting for demographic characteristics and medical comorbidities. RESULTS We identified 178,593 individuals with incident AD and 104,157 individuals with incident PD among 34,054,293 Medicare beneficiaries with complete data in 2009. Epilepsy was diagnosed in 4.45% (7,956) of AD patients and 4.81% (5,010) of PD patients between 2009 and 2014, approximately twice as frequently as in the control sample. Minority race/ethnicity was associated with increased risk of incident epilepsy. Among individuals with AD and PD, stroke was associated with increased epilepsy risk. Traumatic brain injury (TBI) was associated with increased epilepsy risk for individuals with PD. Depression was also associated with incident epilepsy (AD adjusted hazard ratio (AHR): 1.23 (1.17-1.29), PD AHR: 1.45 (1.37-1.54)). In PD only, a history of hip fracture (AHR, 1.35 (1.17-1.57)) and diabetes (AHR, 1.11 (1.05-1.18) were also associated with increased risk of epilepsy. CONCLUSION Incident epilepsy is more frequently diagnosed among neurodegenerative disease patients, particularly when preceded by a diagnosis of depression, TBI or stroke. Further studies into the differences in epilepsy risk between these two populations may help elucidate different mechanisms of epileptogenesis.
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Affiliation(s)
- Leah J Blank
- Department of Neurology, Division of Health Outcomes and Knowledge Translational Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K Acton
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dylan Thibault
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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15
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Blank LJ, Acton EK, Willis AW. Predictors of Mortality in Older Adults With Epilepsy: Implications for Learning Health Systems. Neurology 2021; 96:e93-e101. [PMID: 33087496 PMCID: PMC7884975 DOI: 10.1212/wnl.0000000000011079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the incidence of epilepsy and subsequent 5-year mortality among older adults, as well as characteristics associated with mortality. METHODS This was a retrospective cohort study of Medicare beneficiaries age 65 or above with at least 2 years enrollment before January 2009. Incident epilepsy cases were identified in 2009 using ICD-9-CM code-based algorithms; death was assessed through 2014. Cox regression models examined the association between 5-year mortality and incident epilepsy, and whether mortality differed by sociodemographic characteristics or comorbid disorders. RESULTS Among the 99,990 of 33,615,037 beneficiaries who developed epilepsy, most were White (79.7%), female (57.3%), urban (80.5%), and without Medicaid (71.3%). The 5-year mortality rate for incident epilepsy was 62.8% (62,838 deaths). In multivariable models, lower mortality was associated with female sex (adjusted hazards ratio [AHR] 0.85, 95% confidence interval [CI] 0.84-0.87), Asian race (AHR 0.82, 95% CI 0.76-0.88), and Hispanic ethnicity (AHR 0.81, 95% CI 0.76-0.84). Hazard of death increased with comorbid disease burden (per 1-point increase: AHR 1.27, 95% CI 1.26-1.27) and Medicaid coinsurance (AHR 1.17, 95% CI 1.14-1.19). Incident epilepsy was particularly associated with higher mortality when diagnosed after another neurologic condition: Parkinson disease (AHR 1.29, 95% CI 1.21-1.38), multiple sclerosis (AHR 2.13, 95% CI 1.79-2.59), dementia (AHR 1.33, 95% CI 1.31-1.36), traumatic brain injury (AHR 1.55, 95% CI 1.45-1.66), and stroke/TIA (AHR 1.20, 95% CI 1.18-1.21). CONCLUSIONS Newly diagnosed epilepsy is associated with high 5-year mortality among Medicare beneficiaries. Future studies that parse the interplay of effects from underlying disease, race, sex, and poverty on mortality will be critical in the design of learning health care systems to reduce premature deaths.
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Affiliation(s)
- Leah J Blank
- From the Department of Neurology, Division of Health Outcomes and Knowledge Translational Research (L.J.B.), and Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Center for Clinical Epidemiology and Biostatistics (E.K.A., A.W.W.), Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research (E.K.A., A.W.W.), Department of Neurology (A.W.W.), Department of Biostatistics, Epidemiology and Informatics (A.W.W.), and Leonard Davis Institute of Health Economics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia.
| | - Emily K Acton
- From the Department of Neurology, Division of Health Outcomes and Knowledge Translational Research (L.J.B.), and Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Center for Clinical Epidemiology and Biostatistics (E.K.A., A.W.W.), Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research (E.K.A., A.W.W.), Department of Neurology (A.W.W.), Department of Biostatistics, Epidemiology and Informatics (A.W.W.), and Leonard Davis Institute of Health Economics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison W Willis
- From the Department of Neurology, Division of Health Outcomes and Knowledge Translational Research (L.J.B.), and Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Center for Clinical Epidemiology and Biostatistics (E.K.A., A.W.W.), Department of Neurology Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research (E.K.A., A.W.W.), Department of Neurology (A.W.W.), Department of Biostatistics, Epidemiology and Informatics (A.W.W.), and Leonard Davis Institute of Health Economics (A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia
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16
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Solli E, Colwell NA, Say I, Houston R, Johal AS, Pak J, Tomycz L. Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review. Epilepsia 2020; 61:1352-1364. [PMID: 32558937 DOI: 10.1111/epi.16572] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.
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Affiliation(s)
- Elena Solli
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nicole A Colwell
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Irene Say
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rebecca Houston
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anmol S Johal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jayoung Pak
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Luke Tomycz
- New Jersey Neuroscience Institute, Morristown, NJ, USA
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17
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Mahabadi SM, Fehr C, Wu A, Hernandez-Ronquillo L, Rizvi SA, Tellez-Zenteno JF. Evaluation of wait times for assessment and epilepsy surgery according the geographic area of residence in the province of Saskatchewan, Canada. Seizure 2020; 79:80-85. [PMID: 32438310 DOI: 10.1016/j.seizure.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/17/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The aim of this study was to determine and compare the waiting times for surgical assessment, neuropsychological testing and epilepsy surgery between people with epilepsy who live in cities with available neurologists vs not. METHODS We reviewed all cases referred for epilepsy surgery between 2007 and 2017 at the Saskatchewan Epilepsy Program Royal University Hospital (SEP) (n = 98; Saskatchewan, Canada). Mann-Whitney U test was used to compare wait times from first diagnosis of epilepsy to epilepsy surgery between patients who live in cities with neurologists (mainly urban areas) vs cities without neurologists (mainly rural areas). RESULTS The mean age of patients who enrolled in SEP was 37.8 ± 12.8 years. The median wait time from date of epilepsy diagnosis to referral was 9.5 years in Saskatoon and Regina (cities with available neurologists) and 14 years in other areas of Saskatchewan (small cities and rural areas with no available neurologists) (p = 0.03). The median wait time from date of epilepsy diagnosis to first consult with the epileptologist was 10 years in Saskatoon and Regina and 15.5 years in other areas of Saskatchewan (p = 0.03). The median wait time from date of first diagnosis to epilepsy surgery was 13.2 years in Saskatoon and Regina and 18.2 years in other areas of Saskatchewan (p = 0.05). CONCLUSION A notable difference was observed in surgical wait times between patients who live in cities with available neurologists compared with people living in rural areas and cities with no neurologists. This suggests that delayed surgical treatment for epilepsy is related with the availability of neurologists.
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Affiliation(s)
- Sareh Miranzadeh Mahabadi
- Saskatchewan Epilepsy Program, Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Cassie Fehr
- Saskatchewan Epilepsy Program, Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Adam Wu
- Saskatchewan Epilepsy Program. Department of Surgery, Division of Neurosurgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - Lizbeth Hernandez-Ronquillo
- Saskatchewan Epilepsy Program, Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Syed Ali Rizvi
- Saskatchewan Epilepsy Program, Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jose F Tellez-Zenteno
- Saskatchewan Epilepsy Program, Department of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, SK, Canada.
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18
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Rampp S, Stefan H, Wu X, Kaltenhäuser M, Maess B, Schmitt FC, Wolters CH, Hamer H, Kasper BS, Schwab S, Doerfler A, Blümcke I, Rössler K, Buchfelder M. Magnetoencephalography for epileptic focus localization in a series of 1000 cases. Brain 2019; 142:3059-3071. [PMID: 31373622 DOI: 10.1093/brain/awz231] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 02/05/2023] Open
Abstract
Abstract
The aim of epilepsy surgery in patients with focal, pharmacoresistant epilepsies is to remove the complete epileptogenic zone to achieve long-term seizure freedom. In addition to a spectrum of diagnostic methods, magnetoencephalography focus localization is used for planning of epilepsy surgery. We present results from a retrospective observational cohort study of 1000 patients, evaluated using magnetoencephalography at the University Hospital Erlangen over the time span of 28 years. One thousand consecutive cases were included in the study, evaluated at the University Hospital Erlangen between 1990 and 2018. All patients underwent magnetoencephalography as part of clinical workup for epilepsy surgery. Of these, 405 underwent epilepsy surgery after magnetoencephalography, with postsurgical follow-ups of up to 20 years. Sensitivity for interictal epileptic activity was evaluated, in addition to concordance of localization with the consensus of presurgical workup on a lobar level. We evaluate magnetoencephalography characteristics of patients who underwent epilepsy surgery versus patients who did not proceed to surgery. In operated patients, resection of magnetoencephalography localizations were related to postsurgical seizure outcomes, including long-term results after several years. In comparison, association of lesionectomy with seizure outcomes was analysed. Measures of diagnostic accuracy were calculated for magnetoencephalography resection and lesionectomy. Sensitivity for interictal epileptic activity was 72% with significant differences between temporal and extra-temporal lobe epilepsy. Magnetoencephalography was concordant with the presurgical consensus in 51% and showed additional or more focal involvement in an additional 32%. Patients who proceeded to surgery showed a significantly higher percentage of monofocal magnetoencephalography results. Complete magnetoencephalography resection was associated with significantly higher chances to achieve seizure freedom in the short and long-term. Diagnostic accuracy was significant in temporal and extra-temporal lobe cases, but was significantly higher in extra-temporal lobe epilepsy (diagnostic odds ratios of 4.4 and 41.6). Odds ratios were also higher in non-lesional versus lesional cases (42.0 versus 6.2). The results show that magnetoencephalography provides non-redundant information, which significantly contributes to patient selection, focus localization and ultimately long-term seizure freedom after epilepsy surgery. Specifically in extra-temporal lobe epilepsy and non-lesional cases, magnetoencephalography provides excellent accuracy.
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Affiliation(s)
- Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Germany
- Department of Neurosurgery, University Hospital Halle (Saale), Germany
| | - Hermann Stefan
- Department of Neurology, University Hospital Erlangen, Germany
| | - Xintong Wu
- Department of Neurosurgery, University Hospital Erlangen, Germany
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | | | - Burkhard Maess
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | | | - Carsten H Wolters
- Institute for Biomagnetism and Biosignalanalysis, University Münster, Germany
| | - Hajo Hamer
- Department of Neurology, Epilepsy Center, University Hospital Erlangen, Germany
| | - Burkhard S Kasper
- Department of Neurology, Epilepsy Center, University Hospital Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Germany
| | - Arndt Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Ingmar Blümcke
- Department of Neuropathology, University Hospital Erlangen, Germany
| | - Karl Rössler
- Department of Neurosurgery, University Hospital Erlangen, Germany
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Mumford V, Rapport F, Shih P, Mitchell R, Bleasel A, Nikpour A, Herkes G, MacRae A, Bartley M, Vagholkar S, Braithwaite J. Promoting faster pathways to surgery: a clinical audit of patients with refractory epilepsy. BMC Neurol 2019; 19:29. [PMID: 30782132 PMCID: PMC6381714 DOI: 10.1186/s12883-019-1255-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Background Individuals with epilepsy who cannot be adequately controlled with anti-epileptic drugs, refractory epilepsy, may be suitable for surgical treatment following detailed assessment. This is a complex process and there are concerns over delays in referring refractory epilepsy patients for surgery and subsequent treatment. The aim of this study was to explore the different patient pathways, referral and surgical timeframes, and surgical and medical treatment options for refractory epilepsy patients referred to two Tertiary Epilepsy Clinics in New South Wales, Australia. Methods Clinical records were reviewed for 50 patients attending the two clinics, in two large teaching hospitals (25 in Clinic 1; 25 in Clinic 2. A purpose-designed audit tool collected detailed aspects of outpatient consultations and treatment. Patients with refractory epilepsy with their first appointment in 2014 were reviewed for up to six visits until the end of 2016. Data collection included: patient demographics, type of epilepsy, drug management, and assessment for surgery. Outcomes included: decisions regarding surgical and/or medical management, and seizure status following surgery. Patient-reported outcome measures to assess anxiety and depression were collected in Clinic 1 only. Results Patient mean age was 38.3 years (SD 13.4), the mean years since diagnosis was 17.3 years (SD 9.8), and 88.0% of patients had a main diagnosis of focal epilepsy. Patients were taking an average of 2.3 (SD 0.9) anti-epileptic drugs at the first clinic visit. A total of 17 (34.0%) patients were referred to the surgical team and 11 (22.0%) underwent a neuro-surgical procedure. The average waiting time between visit 1 to surgical referral was 38.8 weeks (SD 25.1), and between visit 1 and the first post-operative visit was 55.8 weeks (SD 25.0). Conclusion The findings confirm international data showing significant waiting times between diagnosis of epilepsy and referral to specialist clinics for surgical assessment and highlight different approaches in each clinic in terms of visit numbers and recorded activities. A standardised pathway and data collection, including patient-reported outcome measures, would provide better evidence for whether promoting earlier referral and assessment for surgery improves the lives of this disease group. Electronic supplementary material The online version of this article (10.1186/s12883-019-1255-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Virginia Mumford
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
| | - Frances Rapport
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Patti Shih
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Andrew Bleasel
- University of Sydney, Sydney, Australia.,Westmead Hospital, Westmead, Australia
| | - Armin Nikpour
- University of Sydney, Sydney, Australia.,Royal Prince Alfred Hospital, Sydney, Australia
| | - Geoffrey Herkes
- University of Sydney, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Amy MacRae
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Sanjyot Vagholkar
- Primary Care & Wellbeing, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Leading up to saying "yes": A qualitative study on the experience of patients with refractory epilepsy regarding presurgical investigation for resective surgery. Epilepsy Behav 2018; 83:36-43. [PMID: 29649672 DOI: 10.1016/j.yebeh.2018.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/02/2018] [Accepted: 03/18/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Adult patients with refractory epilepsy who are potential candidates for resective surgery undergo a period of presurgical investigation in tertiary epilepsy centers (TECs), where they engage extensively with healthcare professionals and receive a range of treatment-related information. This qualitative study aimed to examine the experiences of adult patients with refractory epilepsy leading up to and during presurgical investigation and how their perceptions of resective surgery are shaped. METHODS In-depth interviews with 12 patients and six epilepsy specialist clinicians and 12 observations of routine patient-clinician consultations took place at two TECs in Sydney, Australia. Data were thematically analyzed via group work. RESULTS Patients reflected on prior experiences of poor seizure control and inadequate antiepileptic drug management and a lack of clarity about their condition before referral to tertiary care. Poor continuity of care and disrupted care transitions affected patients from regional locations. Tertiary referral increased engagement with personalized information about refractory epilepsy, which intensified during presurgical assessments with additional hospital visits and consultations. Experiential information, such as testimonials of other patients, influenced perceptions of surgery and fostered more trust and confidence towards healthcare professionals. CONCLUSION Qualitative inquiry detailed multifaceted effects of information on patients' overall treatment trajectory and experience of healthcare. Earlier patient identification for surgical assessments should be accompanied by access to good quality information at primary and community care levels and strengthened referral processes.
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Sadanand V. Epilepsy: A Call for Help. Brain Sci 2018; 8:E22. [PMID: 29382091 PMCID: PMC5836041 DOI: 10.3390/brainsci8020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is a considerable individual and social economic burden. In properly selected patients, epilepsy surgery can provide significant relief from disease, including remission. However, the surgical treatment of epilepsy lags in terms of knowledge and technology. The problem arises due to its slow adaptation and dissemination. This article explores this issue of a wide treatment gap and its causes. It develops a framework for a rational decision-making process that is appropriate for extant circumstances and will result in the speedy delivery of surgical care for suitable patients with medically intractable epilepsy.
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