NEW ORLEANS—Seizure freedom following resective epilepsy surgery is not influenced by a patient’s duration of epilepsy, according to George L. Morris III, MD. Thus, Dr. Morris advocates the use of resective epilepsy surgery at any point during a patient’s care—even if the duration of intractability has been substantial.

The average length of time since seizure onset in his study cohort was typically 20 years (range, 1 to 50), “and no significant differences were found between the seizure-free and non–seizure-free groups,” reported Dr. Morris at the 58th Annual Meeting of the American Epilepsy Society. “This study does not answer whether duration of epilepsy influences other types of outcome—such as quality of life—following an epilepsy surgery,” he added. Dr. Morris is the Medical Director of the Regional Epilepsy Center, St. Luke’s Medical Center, Milwaukee.

Other researchers have previously suggested that earlier intervention may lead to greater degrees of success with surgical intervention for epilepsy, but Dr. Morris does not share that view. “I believe, but don’t know for sure, that this comes from well-meaning physicians who hope for earlier patient interventions,” he told Neurology Reviews. “I do not believe I had seen that there was lost efficacy. So I looked at my rather large database from 10 years of surgeries to ask the question, Does the length of epilepsy before surgery reduce its value? The answer was no.”

EPILEPSY AND SURGERY

Dr. Morris and colleagues conducted their retrospective review of the database, which contained general demographic information regarding gender, age at onset, seizure types, evaluation information, and surgical outcomes. A total of 280 resections were performed during the 10-year period; complete data were found for 206 resections. The patients were assigned to one of two groups—those who were seizure-free and those who were not seizure-free at the end of six months. The relatively small number of patients who were not seizure-free was ultimately insufficient to support statistical analysis of each type of surgery, stated Dr. Morris.

For the group as a whole and for a subset of patients with temporal lobe epilepsy, statistical analysis subsequently revealed no relationship between duration of epilepsy and postoperative seizure status. “Issues such as quality of life were not assessed as a part of this study,” noted Dr. Morris. “The presence of seizure freedom may be less consequential when interventions are delayed. The long-term alterations in psychosocial status and cognitive impairment may prevent a substantial impact from seizure freedom when epilepsy surgery is delayed. Hence, duration would be significant in the treatment, but not for the purposes of producing seizure freedom.”

SURGERY NEVER RULED OUT

Dr. Morris emphasized that other factors affect patients who have continued seizures and that he and his colleagues are in the process of looking at quality-of-life scales for the patients with longer delays before surgery. “Many studies point to higher unemployment, injury, etc, so early is better for that reason,” he said. “But surgery is never not worth assessing.”

Dr. Morris added that he reminds physicians routinely that two drug trials that do not result in seizure freedom should be followed by a confirmation of disease, and subsequently a trial of a third drug. “If a localization-related epilepsy is found, state-of-the-art MRI with [fluid-attenuated inversion recovery] images and a complete surgical evaluation are warranted,” he said. “Surgery following a third drug failure must be presented to a patient as the best next option for a disease-free life. Surgery is difficult. But patients don’t ask us for easy; they ask us to fix the problem. If the patients say seizures are not a problem, then they may ask for other options. Despite the scary nature of brain surgery, they will be more satisfied. They can have surgery at any time, and physicians should not exclude surgery because of duration of illness or age.”

NR

—Colby Stong

Suggested Reading
Bauman JA, Feoli E, Romanelli P, et al. Multistage epilepsy surgery: safety, efficacy, and utility of a novel approach in pediatric extratemporal epilepsy. Neurosurgery. 2005:56:318-334.
Yoon HH, Kwon HL, Mattson RH, et al. Long-term seizure outcome in patients initially seizure-free after resective epilepsy surgery. Neurology. 2003;61:445-450.

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