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Saito Y, Sugai K, Iwasaki M, Atobe M, Sato N, Kakita A, Saito Y, Ohtsuki T, Sasaki M. Periodic cycles of seizure clustering and suppression in children with epilepsy strongly suggest focal cortical dysplasia. Dev Med Child Neurol 2023; 65:431-436. [PMID: 35871498 DOI: 10.1111/dmcn.15365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022]
Abstract
AIM We investigated characteristic seizure patterns in epilepsy caused by focal cortical dysplasia (FCD), which differ from epilepsy by other aetiologies in surgical cases with lesions on magnetic resonance imaging (MRI), then examined if these features were applicable to patients with epilepsy without any lesions on MRI. METHOD We retrospectively studied clinicopathological features in 291 (143 females) children with epilepsy who had undergone resective surgery after comprehensive evaluation, including 277 cases with lesions on MRI (136 females, age at resection 0-17 years [mean 6 years 10 months, SD 5 years 7 months]) and 14 cases without any lesions on MRI (seven females, age 0-16 years [mean 7 years 8 months, SD 4 years 8 months]). RESULTS Among 277 patients with lesions on MRI, 87 cases exhibited recurrent periodic cycles of seizure clustering (≥5 seizures/day for ≥1 week) and suppression (no seizures for ≥1 week); of these, 80 cases (92%) were pathologically diagnosed with FCD. Other pathologies included glial scar, hippocampal sclerosis, hemimegalencephaly, and cortical tuber in three, two, one, and one case respectively. All 14 patients without any lesions on MRI had significant recurrent periodic seizure cycles and FCD histopathologically. INTERPRETATION Periodic seizure cycles characterized by clustering and suppression in patients with epilepsy strongly suggest the presence of FCD regardless of MRI findings, and comprehensive evaluations for epilepsy surgery should be proceeded.
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Affiliation(s)
- Yoshihiko Saito
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kenji Sugai
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mahito Atobe
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Noriko Sato
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yuko Saito
- Department of Clinical Laboratory, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Taisuke Ohtsuki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan.,Epilepsy Hospital Bethel Japan, Miyagi, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
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Nandakumar N, Hsu D, Ahmed R, Venkataraman A. DeepEZ: A Graph Convolutional Network for Automated Epileptogenic Zone Localization from Resting-State fMRI Connectivity. IEEE Trans Biomed Eng 2022; 70:216-227. [PMID: 35776823 PMCID: PMC9841829 DOI: 10.1109/tbme.2022.3187942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Epileptogenic zone (EZ) localization is a crucial step during diagnostic work up and therapeutic planning in medication refractory epilepsy. In this paper, we present the first deep learning approach to localize the EZ based on resting-state fMRI (rs-fMRI) data. METHODS Our network, called DeepEZ, uses a cascade of graph convolutions that emphasize signal propagation along expected anatomical pathways. We also integrate domain-specific information, such as an asymmetry term on the predicted EZ and a learned subject-specific bias to mitigate environmental confounds. RESULTS We validate DeepEZ on rs-fMRI collected from 14 patients with focal epilepsy at the University of Wisconsin Madison. Using cross validation, we demonstrate that DeepEZ achieves consistently high EZ localization performance (Accuracy: 0.88 ± 0.03; AUC: 0.73 ± 0.03) that far outstripped any of the baseline methods. This performance is notable given the variability in EZ locations and scanner type across the cohort. CONCLUSION Our results highlight the promise of using DeepEZ as an accurate and noninvasive therapeutic planning tool for medication refractory epilepsy. SIGNIFICANCE While prior work in EZ localization focused on identifying localized aberrant signatures, there is growing evidence that epileptic seizures affect inter-regional connectivity in the brain. DeepEZ allows clinicians to harness this information from noninvasive imaging that can easily be integrated into the existing clinical workflow.
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Affiliation(s)
- Naresh Nandakumar
- Department of Electrical and Computer Engineering, Johns Hopkins University, USA
| | - David Hsu
- Department of Neurology, University of Wisconsin, USA
| | - Raheel Ahmed
- Department of Neurosurgery, University of Wisconsin, USA
| | - Archana Venkataraman
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218 USA
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Ostendorf AP, Ahrens SM, Lado FA, Arnold ST, Bai S, Bensalem Owen MK, Chapman KE, Clarke DF, Eisner M, Fountain NB, Gray JM, Hopp JL, Riker E, Schuele SU, Small BV, Herman ST. United States Epilepsy Center Characteristics: A Data Analysis From the National Association of Epilepsy Centers. Neurology 2021; 98:e449-e458. [PMID: 34880093 PMCID: PMC8826463 DOI: 10.1212/wnl.0000000000013130] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background and Objectives Patients with drug-resistant epilepsy (DRE) may benefit from specialized testing and treatments to better control seizures and improve quality of life. Most evaluations and procedures for DRE in the United States are performed at epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). On an annual basis, the NAEC collects data from accredited epilepsy centers on hospital-based epilepsy monitoring unit (EMU) size and admissions, diagnostic testing, surgeries, and other services. This article highlights trends in epilepsy center services from 2012 through 2019. Methods We analyzed data reported in 2012, 2016, and 2019 from all level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level and center population category. EMU beds, EMU admissions, epileptologists, and aggregate procedure volumes were also described using rates per population per year. Results During the period studied, the number of NAEC accredited centers increased from 161 to 256, with the largest increases in adult- and pediatric-only centers. Growth in EMU admissions (41%), EMU beds (26%), and epileptologists (109%) per population occurred. Access to specialized testing and services broadly expanded. The largest growth in procedure volumes occurred in laser interstitial thermal therapy (LiTT) (61%), responsive neurostimulation (RNS) implantations (114%), and intracranial monitoring without resection (152%) over the study period. Corpus callosotomies and vagus nerve stimulator (VNS) implantations decreased (−12.8% and −2.4%, respectively), while growth in temporal lobectomies (5.9%), extratemporal resections (11.9%), and hemispherectomies/otomies (13.1%) lagged center growth (59%), leading to a decrease in median volumes of these procedures per center. Discussion During the study period, the availability of specialty epilepsy care in the United States improved as the NAEC implemented its accreditation program. Surgical case complexity increased while aggregate surgical volume remained stable or declined across most procedure types, with a corresponding decline in cases per center. This article describes recent data trends and current state of resources and practice across NAEC member centers and identifies several future directions for driving systematic improvements in epilepsy care.
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Affiliation(s)
- Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Stephanie M Ahrens
- Department of Pediatrics, Nationwide Children's Hospital and Ohio State University, Columbus, OH
| | - Fred Alexander Lado
- Department of Neurology, Hofstra Northwell Comprehensive Epilepsy Center, Great Neck, NY
| | - Susan T Arnold
- Department of Pediatrics, Children's Medical Center, Dallas, TX
| | - Shasha Bai
- Pediatric Biostatistics Core, Emory University School of Medicine, Atlanta, GA
| | | | - Kevin E Chapman
- Department of Child Health, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Dave F Clarke
- Division of Pediatric Neurology, Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Mariah Eisner
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH
| | - Nathan B Fountain
- Department of Neurology, Comprehensive Epilepsy Program, University of Virginia, Charlottesville, Virginia
| | - Johanna M Gray
- National Association of Epilepsy Centers, Washington, DC
| | | | - Ellen Riker
- National Association of Epilepsy Centers, Washington, DC
| | - Stephan U Schuele
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Susan T Herman
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ
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Samanta D, Singh R, Gedela S, Scott Perry M, Arya R. Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers. Epilepsy Behav 2021; 117:107853. [PMID: 33678576 PMCID: PMC8035223 DOI: 10.1016/j.yebeh.2021.107853] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Rani Singh
- Department of Pediatrics, Atrium Health/Levine Children's Hospital, United States
| | - Satyanarayana Gedela
- Department of Pediatrics, Emory University College of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, United States
| | - M Scott Perry
- Cook Children's Medical Center, Fort Worth, TX, United States
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Long-term outcomes after epilepsy surgery, a retrospective cohort study linking patient-reported outcomes and routine healthcare data. Epilepsy Behav 2020; 111:107196. [PMID: 32554230 DOI: 10.1016/j.yebeh.2020.107196] [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: 04/07/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of the study was to assess the long-term outcomes of epilepsy surgery between 1995 and 2015 in South Wales, UK, linking case note review, postal questionnaire, and routinely collected healthcare data. METHOD We identified patients from a departmental database and collected outcome data from patient case notes, a postal questionnaire, and the QOLIE-31-P and linked with Welsh routinely collected data in the Secure Anonymised Information Linkage (SAIL) databank. RESULTS Fifty-seven patients were included. Median age at surgery was 34 years (11-70), median: 24 years (2-56) after onset of habitual seizures. Median follow-up was 7 years (2-19). Twenty-eight (49%) patients were free from disabling seizures (Engel Class 1), 9 (16%) experienced rare disabling seizures (Class 2), 13 (23%) had worthwhile improvements (Class 3), and 7 (12%) had no improvement (Class 4). There was a 30% mean reduction in total antiepileptic drug (AED) load at five years postsurgery. Thirty-eight (66.7%) patients experienced tonic-clonic seizures presurgery verses 8 (14%) at last review. Seizure-free patients self-reported a greater overall quality of life (QOL; QOLIE-31-P) when compared with those not achieving seizure freedom. Seizure-free individuals scored a mean of 67.6/100 (100 is best), whereas those with continuing seizures scored 46.0/100 (p < 0.006). There was a significant decrease in the median rate of hospital admissions for any cause after epilepsy surgery (9.8 days per 1000 patient days before surgery compared with 3.9 after p < 0.005). SIGNIFICANCE Epilepsy surgery was associated with significant improvements in seizures, a reduced AED load, and an improved QOL that closely correlated with seizure outcomes and reduced hospital admission rates following surgery. Despite this, there was a long delay from onset of habitual seizures to surgery. The importance of long-term follow-up is emphasized in terms of evolving medical needs and health and social care outcomes.
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Yang X, Liu Q, Yang Q, Guo J, Guo Y, Mao C, Zhang Y, Dou W. Comparison of seizure outcomes and safety between anterior temporal lobotomy and lobectomy in patients with temporal lobe epilepsy. Neurol Res 2020; 42:164-169. [PMID: 31939712 DOI: 10.1080/01616412.2020.1711649] [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] [Indexed: 10/25/2022]
Abstract
Objectives: To compare the efficacy and safety of anterior temporal lobotomy (ATLo) and anterior temporal lobectomy (ATLe) in drug-resistant temporal lobe epilepsy.Methods: Patients diagnosed with pharmacoresistant temporal lobe epilepsy who underwent anterior temporal lobotomy (ATLo) or anterior temporal lobectomy (ATLe) performed by a single surgeon were retrospectively included. Every patient was followed up annually after surgery. The postoperative seizure outcome evaluation was based on the Engel and ILAE classifications. We compared postoperative complications and 2-year follow-up seizure outcomes between the ATLo group and the ATL group.Results: A total of 42 individuals (21 ATLo and 20 ATLe) were included. At the two-year follow-up, more patients in the ATLo group than the ATLe group had reached Engel class I (20 versus 14) and ILAE I (19 versus 13). However, these differences were not significant. One patient in the ATLo group had intraparenchymal hematoma and fully recovered. The two groups had similar incidences of other short-term complications, and no patients died or had any permanent complications.Discussion: ATLo is not inferior to ATLe for patients with drug-resistant temporal epilepsy. There was no significant difference in seizure outcomes or the rate of postoperative complications between the two groups. A large sample randomized control study is needed.
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Affiliation(s)
- Xiyue Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Qi Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Qiao Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Jinzhu Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Yi Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Chenhui Mao
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Yiwei Zhang
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Wanchen Dou
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
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Thuy Le MA, Fong SL, Lim KS, Gunadharma S, Sejahtera DP, Visudtibhan A, Chan D, Vorachit S, Chan S, Ohnmar, Chua AE, Cabral-Lim L, Yassin N, Le VT, Tan CT. Underutilization of epilepsy surgery in ASEAN countries. Seizure 2019; 69:51-56. [PMID: 30974407 DOI: 10.1016/j.seizure.2019.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE This survey was performed to determine the availability of epilepsy surgery, and understand the limiting factors to epilepsy surgery in ASEAN countries with total of 640 million population. METHOD A cross-sectional survey was completed by national representatives in all ASEAN countries (Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam). RESULTS Overall facilities for initial epilepsy pre-surgical evaluation are available in most countries, but further non-invasive and invasive investigations are limited. Three countries (Brunei, Cambodia, and East Timor) have no epilepsy center, and 2 countries (Laos, Myanmar) have level 2 centers doing tumor surgery only. Level-3 epilepsy centers are available in 6 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand, Vietnam); only 5 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand) has at least one level-4 epilepsy care facility. Indonesia with 261 million population only has one level 3 and another level 4 center. The costs of presurgical evaluation and brain surgery vary within and among the countries. The main barriers towards epilepsy surgery in ASEAN include lack of expertise, funding and facilities. CONCLUSIONS Epilepsy surgery is underutilized in ASEAN with low number of level 3 centers, and limited availability of advanced presurgical evaluation. Lack of expertise, facilities and funding may be the key factors contributing to the underutilization.
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Affiliation(s)
- Minh-An Thuy Le
- Department of Neurology, Faculty of Medicine, University of Medicine and Pharmacy of Ho Chi Minh city, Ho Chi Minh City, Viet Nam
| | - Si-Lei Fong
- Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kheng-Seang Lim
- Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Suryani Gunadharma
- Faculty of Medicine, Padjadjaran University, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Desin Pambudi Sejahtera
- Department of neurology, Sardjito general hospital, Yogyakarta, Indonesia; Epilepsy subdivision, department of neurology, faculty of medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Anannit Visudtibhan
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Derrick Chan
- Division of Neurology, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Somchit Vorachit
- Faculty of Medicine, University of Health Sciences, Vientiane, Laos
| | - Samleng Chan
- University of Health Sciences, Phnom Penh, Cambodia
| | - Ohnmar
- Department of Neurology, University of Medicine 1, Yangon, Myanmar
| | - Annabell E Chua
- Department of Neurosciences, College of Medicine-Philippine General Hospital, The Health Sciences Center, University of the Philippines Manila, Manila, Philippines
| | - Leonor Cabral-Lim
- Department of Neurosciences, College of Medicine-Philippine General Hospital, The Health Sciences Center, University of the Philippines Manila, Manila, Philippines
| | - Norazieda Yassin
- Neurology Unit, Department of Internal Medicine. Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei; Brunei Neurosciences, Stroke and Rehabilitation Centre (BNSRC), Brunei
| | - Viet-Thang Le
- Department of Neurosurgery, Faculty of Medicine, University of Medicine and Pharmacy of Ho Chi Minh city, Ho Chi Minh city, Viet Nam
| | - Chong-Tin Tan
- Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Rosenow F, Bast T, Czech T, Feucht M, Hans VH, Helmstaedter C, Huppertz HJ, Noachtar S, Oltmanns F, Polster T, Seeck M, Trinka E, Wagner K, Strzelczyk A. Revised version of quality guidelines for presurgical epilepsy evaluation and surgical epilepsy therapy issued by the Austrian, German, and Swiss working group on presurgical epilepsy diagnosis and operative epilepsy treatment. Epilepsia 2016; 57:1215-20. [PMID: 27354263 DOI: 10.1111/epi.13449] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/29/2022]
Abstract
The definition of minimal standards remains pivotal as a basis for a high standard of care and as a basis for staff allocation or reimbursement. Only limited publications are available regarding the required staffing or methodologic expertise in epilepsy centers. The executive board of the working group (WG) on presurgical epilepsy diagnosis and operative epilepsy treatment published the first guidelines in 2000 for Austria, Germany, and Switzerland. In 2014, revised guidelines were published and the WG decided to publish an unaltered English translation in this report. Because epilepsy surgery is an elective procedure, quality standards are particularly high. As detailed in the first edition of these guidelines, quality control relates to seven different domains: (1) establishing centers with a sufficient number of sufficiently and specifically trained personnel, (2) minimum technical standards and equipment, (3) continuous medical education of employees, (4) surveillance by trained personnel during video electroencephalography (EEG) monitoring (VEM), (5) systematic acquisition of clinical and outcome data, (6) the minimum number of preoperative evaluations and epilepsy surgery procedures, and (7) the cooperation of epilepsy centers. These standards required the certification of the different professions involved and minimum numbers of procedures. In the subsequent decade, quite a number of colleagues were certified by the trinational WG; therefore, the executive board of the WG decided in 2013 to make these standards obligatory. This revised version is particularly relevant given that the German procedure classification explicitly refers to the guidelines of the WG with regard to noninvasive/invasive preoperative video-EEG monitoring and invasive intraoperative diagnostics in epilepsy.
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Affiliation(s)
- Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany.,Epilepsy Center Hessen, Philipps-University, Marburg, Germany
| | | | - Thomas Czech
- Department of Neurosurgery, MUW/AKH, Vienna, Austria
| | - Martha Feucht
- Department of Pediatrics and Adolescence Medicine, MUW/AKH, Vienna, Austria
| | - Volkmar H Hans
- Division of Neuropathology, Institute of Pathology, Ruhr University, Bochum, Germany
| | | | | | - Soheyl Noachtar
- Epilepsy Center Munich, Ludwig-Maximilians-University, Munich, Germany
| | | | | | - Margitta Seeck
- EEG and Epilepsy Unit, Geneva University Hospital, Geneva, Switzerland
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Kathrin Wagner
- Epilepsy Center Freiburg, Albert-Ludwigs-University, Freiburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany.,Epilepsy Center Hessen, Philipps-University, Marburg, Germany
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Mansouri A, Aldakkan A, Badhiwala JH, Taslimi S, Kondziolka D. A Practical Methodological Approach Towards Identifying Core Competencies in Medical Education Based on Literature Trends: A Feasibility Study Based on Vestibular Schwannoma Science. Neurosurgery 2016; 77:594-602; discussion 602-3. [PMID: 26308645 DOI: 10.1227/neu.0000000000000837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Competency-based medical education (CBME) is gaining momentum in postgraduate residency and fellowship training. While randomized trials, consensus statements, and practice guidelines can help delineate some of the core competencies for CBME, they are not applicable to all clinical scenarios. OBJECTIVE To propose and assess the feasibility of a practical methodology for addressing this issue using radiosurgery for vestibular schwannoma (VS) science as an example. METHODS The Web of Science electronic database was searched using relevant terms. A 3-step review of titles and abstracts was used. Studies were classified independently and in duplicate as either efficacy or effectiveness analyses. Cohen's kappa score was used to assess inter-rater agreement. RESULTS Overall, 1818 surgical and 943 radiosurgical publications were identified. The number of effectiveness studies surpassed that of efficacy studies in the late 1980s for surgical studies, and in the early-to-mid 1990s among radiosurgical studies. The publication rate was higher for radiosurgery in the mid 1990s, but it paralleled that of surgical studies beyond the early 2000s. Variations in this overall trend corresponded to the emergence of studies that assessed the role of endoscopy and the utility of dose reduction in radiosurgery. CONCLUSION We have confirmed the feasibility and accuracy of this objective methodological approach. By understanding how the peer-reviewed literature reflects actual practice interests, educators can tailor curricula to ensure that trainees remain current. While further validation studies are needed, this methodology can serve as a supplemental strategy for identifying additional core competencies in CBME.
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Affiliation(s)
- Alireza Mansouri
- *Division of Neurosurgery, University of Toronto, Toronto, Ontario; ‡Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; §Division of Neurosurgery, King Saud University, Riyadh, Saudi Arabia; ¶Departments of Neurosurgery and ‖Radiation Oncology, NYU Langone Medical Center, New York University, New York
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Katagiri M, Iida K, Kagawa K, Hashizume A, Ishikawa N, Hanaya R, Arita K, Kurisu K. Combined surgical intervention with vagus nerve stimulation following corpus callosotomy in patients with Lennox-Gastaut syndrome. Acta Neurochir (Wien) 2016; 158:1005-12. [PMID: 26979179 DOI: 10.1007/s00701-016-2765-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a drug-resistant pediatric epilepsy characterized by multiple seizure types, including drop attacks (DAs). Palliative procedures such as corpus callosotomy (CC) and vagus nerve stimulation (VNS) may be effective for adequate seizure control in LGS patients who are not candidates for resective surgery. We evaluated the efficacy of the combination of these two procedures for LGS-related seizures. METHOD Ten patients with LGS (age 3-30 years at VNS implantation) underwent CC and subsequent VNS. We evaluated surgical outcomes, particularly with respect to the efficacy of VNS on seizure reduction rates for different residual seizure types after CC. We compared clinical parameters, including sex, age, seizure duration, history, MRI findings, extent of CC, number of antiepileptic drugs, and neuropsychological states, between VNS responders and non-responders to predict satisfactory seizure outcomes with respect to residual seizures after CC. FINDINGS VNS was effective for residual seizures regardless of seizure type (except for DAs) after CC in patients with LGS. Six of ten (60%) patients had a satisfactory seizure outcome (≥50% seizure reduction) for all residual seizure types after VNS. Two of ten (20%) patients were seizure-free at 12 months post-VNS. Even those patients that were non-responders, with respect to all seizures including DAs, after prior CC showed favorable responses to subsequent VNS. Compared to VNS, excellent seizure outcomes for DAs were achieved after CC in seven of nine (77.8%) patients with DAs. Among the clinical parameters, only conversation ability before VNS was significantly different between responders and non-responders (p = 0.033). CONCLUSION Combined VNS and prior CC produced satisfactory seizure outcomes in LGS patients with different seizure types, including DAs. Even non-responders to prior CC responded to subsequent VNS for residual seizures, except for DAs. There is a greater likelihood that these procedures may be more feasible in patients who possess conversation ability prior to VNS.
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Abstract
The use of epilepsy surgery in various medically resistant epilepsies is well established. For patients with intractable pediatric epilepsy, the role of intracranial electrodes, resective surgery, hemispherectomy, corpus callosotomy, neurostimulation, and multiple subpial transections continues to be very effective in select cases. Newer treatment and diagnostic methods include laser thermal ablation, minimally invasive surgeries, stereo electroencephalography, electrocorticography, and other emerging techniques. This article will review the established and emerging surgical therapies for severe pediatric epilepsies, their respective indications and overall efficacy.
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López González FJ, Rodríguez Osorio X, Gil-Nagel Rein A, Carreño Martínez M, Serratosa Fernández J, Villanueva Haba V, Donaire Pedraza AJ, Mercadé Cerdá JM. Drug-resistant epilepsy: definition and treatment alternatives. Neurologia 2014; 30:439-46. [PMID: 24975343 DOI: 10.1016/j.nrl.2014.04.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 04/23/2014] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Drug-resistant epilepsy affects 25% of all epileptic patients, and quality of life decreases in these patients due to their seizures. Early detection is crucial in order to establish potential treatment alternatives and determine if the patient is a surgical candidate. DEVELOPMENT PubMed search for articles, recommendations published by major medical societies, and clinical practice guidelines for drug-resistant epilepsy and its medical and surgical treatment options. Evidence and recommendations are classified according to the criteria of the Oxford Centre for Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic actions. CONCLUSIONS Identifying patients with drug-resistant epilepsy is important for optimising drug therapy. Experts recommend rational polytherapy with antiepileptic drugs to find more effective combinations with fewer adverse effects. When adequate seizure control is not achieved, a presurgical evaluation in an epilepsy referral centre is recommended. These evaluations explore how to resect the epileptogenic zone without causing functional deficits in cases in which this is feasible. If resective surgery is not achievable, palliative surgery or neurostimulation systems (including vagus nerve, trigeminal nerve, or deep brain stimulation) may be an option. Other treatment alternatives such as ketogenic diet may also be considered in selected patients.
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Affiliation(s)
- F J López González
- Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, España.
| | - X Rodríguez Osorio
- Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, España
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Qualitätsleitlinien für prächirurgische Epilepsiediagnostik und operative Epilepsietherapie. DER NERVENARZT 2014; 85:753-6. [DOI: 10.1007/s00115-014-4070-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Stimulation of the brain for the treatment of epilepsy, indirectly via the vagus nerve and directly through intracranial targets, is feasible and has increased in use and complexity over the past 10 years. Vagus nerve stimulation is widely applied and the present indications and outcomes together with possible ways in which the treatment could be refined are reviewed. The application of stimulation to deep-brain targets is also reviewed along with present practice and results. Possible developments in the use of direct intracranial stimulation are also considered.
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Affiliation(s)
- Charles E Polkey
- King's College, London Academic Neurosciences Centre, Institute of Psychiatry, De Crespigney Park, Denmark Hill, London, SE5 8AF, UK.
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Taimouri V, Akhondi-Asl A, Tomas-Fernandez X, Peters JM, Prabhu SP, Poduri A, Takeoka M, Loddenkemper T, Bergin AMR, Harini C, Madsen JR, Warfield SK. Electrode localization for planning surgical resection of the epileptogenic zone in pediatric epilepsy. Int J Comput Assist Radiol Surg 2013; 9:91-105. [PMID: 23793723 DOI: 10.1007/s11548-013-0915-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE In planning for a potentially curative resection of the epileptogenic zone in patients with pediatric epilepsy, invasive monitoring with intracranial EEG is often used to localize the seizure onset zone and eloquent cortex. A precise understanding of the location of subdural strip and grid electrodes on the brain surface, and of depth electrodes in the brain in relationship to eloquent areas is expected to facilitate pre-surgical planning. METHODS We developed a novel algorithm for the alignment of intracranial electrodes, extracted from post-operative CT, with pre-operative MRI. Our goal was to develop a method of achieving highly accurate localization of subdural and depth electrodes, in order to facilitate surgical planning. Specifically, we created a patient-specific 3D geometric model of the cortical surface from automatic segmentation of a pre-operative MRI, automatically segmented electrodes from post-operative CT, and projected each set of electrodes onto the brain surface after alignment of the CT to the MRI. Also, we produced critical visualization of anatomical landmarks, e.g., vasculature, gyri, sulci, lesions, or eloquent cortical areas, which enables the epilepsy surgery team to accurately estimate the distance between the electrodes and the anatomical landmarks, which might help for better assessment of risks and benefits of surgical resection. RESULTS Electrode localization accuracy was measured using knowledge of the position of placement from 2D intra-operative photographs in ten consecutive subjects who underwent intracranial EEG for pediatric epilepsy. Average spatial accuracy of localization was 1.31 ± 0.69 mm for all 385 visible electrodes in the photos. CONCLUSIONS In comparison with previously reported approaches, our algorithm is able to achieve more accurate alignment of strip and grid electrodes with minimal user input. Unlike manual alignment procedures, our algorithm achieves excellent alignment without time-consuming and difficult judgements from an operator.
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Affiliation(s)
- Manuel G Campos
- Department of Neurosurgery, Clinica Las Condes, Santiago, Chile.
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Lee KK, Salamon N. [18F] fluorodeoxyglucose-positron-emission tomography and MR imaging coregistration for presurgical evaluation of medically refractory epilepsy. AJNR Am J Neuroradiol 2009; 30:1811-6. [PMID: 19628624 DOI: 10.3174/ajnr.a1637] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Epilepsy is a chronic disorder affecting approximately 1% of the population of the world. Approximately one third of patients with epilepsy remain refractory to medical therapy. For these patients, surgery is a curative option. In order for surgery to be considered, precise localization of the structural abnormality is needed. When MR imaging findings are normal, more sensitive techniques such as positron-emission tomography (PET) can help find the abnormality. Combining MR imaging and PET information increases the sensitivity of the presurgical evaluation. In this review, we discuss the clinical applications of coregistration of [(18)F] fluorodeoxyglucose (FDG)-PET with MR imaging for medically refractory epilepsy. Because FDG-PET/MR imaging coregistration has been a routine component of the presurgical evaluation for patients with epilepsy at our institution since 2004, we also included cases from our data base that exemplify the utility of this technology to obtain better postsurgical outcomes.
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Affiliation(s)
- K K Lee
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Baldy-Moulinier M, Gelisse P, Crespel A. Quelle organisation de soins pour améliorer la qualité de la prise en charge des patients avec une épilepsie partielle pharmaco-résistante ? Rev Neurol (Paris) 2004. [DOI: 10.1016/s0035-3787(04)71215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE To review systematically the available evidence with regard to the current status of epilepsy surgery in the management of patients with epilepsy. METHODS A careful search of published literature, including Medline, published reviews, chapters, and cross-references thereof. RESULTS With medical treatment of epilepsy being unsuccessful in many cases, the importance of surgical approaches cannot be underscored. Early surgery is the treatment of choice for patients with clear-cut mesial temporal sclerosis and results in significant clinical improvement in up to 80% of cases, provided the EEG, neuropsychological, and neuropsychiatric results are in concordance with this approach. In patients with poorly defined, widespread, or dual pathology, however, invasive recordings may be necessary, and while this is performed in major centres, the outcome is rather more variable in this group. Improved surgical techniques, and the use of stereotactic approaches and image guidance procedures, have resulted in surgical resections becoming more selective. With isolated structural lesions such as dysembryoplastic tumours, low-grade astrocytomas, or focal vascular abnormalities, total macroscopic and radiological evidence of lesional excision is associated with excellent seizure-free outcome. The first randomised controlled trial of epilepsy surgery has demonstrated clearly the efficacy of these techniques, and the risk of complications. DISCUSSION Increasing sophistication of noninvasive presurgical evaluation enables surgical candidates to be identified at an earlier stage and presents a realistic alternative to medical treatment in many cases. The introduction of minimally invasive techniques has had a significant impact on surgical practice and its associated morbidity. The future of epilepsy surgery lies with continued basic science research and its application to clinical medicine.
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Affiliation(s)
- Shahzad Shaefi
- Department of Neurosurgery, National Hospital for Neurosurgery and Neurology, London, United Kingdom
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