Long-term Seizure-free Outcome Research Articles

Long-term Remission and Resolution of Epilepsy following Surgery for Drug Resistant Lesional Temporal Lobe Epilepsy. (P2-1.001)

<h3>Objective:</h3> To determine the long-term seizure freedom and resolution of epilepsy in patients with drug resistant Temporal Lobe Epilepsy (TLE) and a clear-cut MRI lesion. <h3>Background:</h3> The long-term seizure free outcomes following surgery for TLE varied widely from 41% – 80% following surgery for TLE. <h3>Design/Methods:</h3> In a retrospective, longitudinal cohort study, we analysed the presurgical, surgical and post-surgical parameters to determine the seizure freedom and resolution of epilepsy in patients with ‘drug resistant lesional TLE with at least 10 years or more of post-surgery follow-up. The Study period was from June 2001 to 2012 <h3>Results:</h3> Of the 259 patients who formed the study population, 46% were women. The duration of follow-up ranged from 10 to 21 years. The average age at surgery was 25.80 ± 11.32 yrs; 49% had an aura, 61% had only hypomotor seizures and 38% had psychiatric comorbidity. The commonest pathology was hippocampal sclerosis(70%) followed by tumoral lesions and focal cortical dysplasia; 9.8% had acute post-operative seizures. At latest follow-up 75.6% were seizure free of which 52% had resolution of epilepsy. Presence of an aura , hippocampal sclerosis and longer time to first post-operative seizure were strong predictors for resolution of epilepsy while acute post-operative seizures and an abnormal post-surgery EEG at 1 year were predictors of persistent seizures. On survival analysis, the time to first seizure was significantly early in patients with persistent seizures. Seizure freedom both at three and five years predicted seizure freedom at 10 years. <h3>Conclusions:</h3> Resective surgery for drug resistant lesional TLE was associated with higher rate of seizure-freedom in ~75% and resolution of epilepsy in 52.15% even at long term follow-up. Longer time to first seizure, presence of aura at presentation and hippocampal sclerosis are strong predictors for resolution of epilepsy. APOS and abnormal Post-Surgery inter-ictal EEG are predictors of unfavourable outcome. <b>Disclosure:</b> Dr. Sattaluri has nothing to disclose. Dr. Patil has nothing to disclose. Dr. Choudhary has nothing to disclose. Dr. Vooturi has nothing to disclose.

Treatment strategies for Lennox-Gastaut syndrome: outcomes of multimodal treatment approaches.

Background:Multimodal treatment approaches are often considered for patients with Lennox-Gastaut syndrome (LGS). Creating an algorithm that can guide healthcare providers in selecting treatment options for patients with LGS remains a challenge. Herein, we assessed the long-term seizure-free and neurodevelopmental outcomes of stepwise multimodal treatment in patients with LGS.Objective:Herein, we assess the long-term seizure-free and neurodevelopmental outcomes of stepwise multimodal treatment in patients with LGS.Methods:We retrospectively examined the data of 371 patients with LGS who underwent stepwise multimodal treatment, including antiseizure medication (ASM) therapy, dietary therapy (DT), resective epilepsy surgery (R-ES), and palliative epilepsy surgery (P-ES). The seizure-free outcome was considered to be the effect of the final treatment according to the treatment algorithm, and the percentage of patients who remained seizure-free in each treatment group was calculated. ASM treatment, DT, R-ES, and P-ES were applied to 371 (100%), 201 (54.2%), 112 (30.2%), and 115 (31.0%) patients with LGS, respectively. We evaluated the stepwise multimodal treatment outcomes in these patients.Results:One hundred sixty-eight patients (45.3%) remained seizure-free for at least 1 year (seizure-free-for-1-year group), 61 of whom (16.5%) remained seizure-free for more than 5 years (remained-seizure-free group). Among the patients treated with ASM therapy, DT, R-ES, and P-ES, 41 (11.1%), 53 (14.3%), 56 (15.1%), and 29 (7.8%), respectively, remained seizure-free for 1 year. In addition, 15 (4.1%), 15 (4.1%), 19 (5.1%), and 12 (3.2%) patients in the ASM, DT, R-ES, and P-ES treatment groups, respectively, remained seizure-free for more than 5 years. Both the seizure-free-for-1-year and remained-seizure-free groups showed significant improvement in electroencephalography findings and neurodevelopmental status following treatment.Conclusion:This study provides an update on the long-term seizure outcomes and neurodevelopmental improvements in a large cohort of patients with LGS following comprehensive multimodal treatment. We emphasize that the active combination of multiple ASMs, DT, and surgical treatment could provide long-term seizure-free outcomes and significant neurological benefits to patients with LGS.

Short- and long-term seizure-free outcomes of dietary treatment in infants according to etiology

PurposeIt is important to determine whether specific etiology is more effective to dietary treatment so that the diet can be started earlier for infants. We evaluated etiology-specific, seizure-free outcomes of dietary treatment in infants <1 year of age. MethodsWe conducted a 10-year, retrospective, longitudinal observational study of 115 infants treated with ketogenic diet (KD) or modified Atkins diet (MAD). ResultsMost patients (70%) received classical KD; 30% received MAD. During follow-up, 90%, 73%, and 61% of the patients remained on the diet at 3, 6, and 12 months, respectively. Seizure-free outcomes were reported in 50%, 44%, and 50% of the patients at 3, 6, and 12 months, respectively. Long-term seizure-free outcomes over 12 months were reported in 43 (74%) of 58 infants who were seizure-free at 3 months. Etiologies were mostly symptomatic (structural brain abnormalities, genetic, or metabolic) in 83 (72%) of 115 patients. According to underlying etiology, long-term seizure-free outcomes were observed in 14 (33%) of 42 patients with structural brain abnormalities, 7 (33%) of 21 with genetic etiologies, 7 (35%) of 20 with metabolic etiologies, and 15 (47%) of 32 with unknown etiologies. There were no etiology-based differences with respect to long-term seizure-free outcomes (P = 0.63). ConclusionThe high rate of long-term seizure-free outcomes can be predicted based on the seizure freedom at 3 months regardless of etiology. Early dietary treatment is beneficial, even in infants <1 year of age with specific symptomatic etiologies such as genetic, structural brain abnormalities, and metabolic etiology.

Preoperative prediction of temporal lobe epilepsy surgery outcome

PurposeThere is controversy about relative contributions of ictal scalp video EEG recording (vEEG), routine scalp outpatient interictal EEG (rEEG), intracranial EEG (iEEG) and MRI for predicting seizure-free outcomes after temporal lobectomy. We reviewed NIH experience to determine contributions at specific time points as well as long-term predictive value of standard pre-surgical investigations. MethodsRaw data was obtained via retrospective chart review of 151 patients. After exclusions, 118 remained (median 5 years follow-up). MRI-proven mesial temporal sclerosis (MTSr) was considered a separate category for analysis. Logistic regression estimated odds ratios at 6-months, 1-year, and 2 years; proportional hazard models estimated long-term comparisons. Subset analysis of the proportional hazard model was performed including only patients with commonly encountered situations in each of the modalities, to maximize statistical inference. ResultsAny MRI finding, MRI proven MTS, rEEG, vEEG and iEEG did not predict two-year seizure-free outcome. MTSr was predictive at six months (OR=2.894, p=0. 0466), as were MRI and MTSr at one year (OR=10.4231, p=0. 0144 and OR=3.576, p=0. 0091). Correcting for rEEG and MRI, vEEG failed to predict outcome at 6 months, 1year and 2 years. Proportional hazard analysis including all available follow-up failed to achieve significance for any modality. In the subset analysis of 83 patients with commonly encountered results, vEEG modestly predicted long-term seizure-free outcomes with a proportional hazard ratio of 1.936 (p=0.0304). ConclusionsIn this study, presurgical tools did not provide unambiguous long-term outcome predictions. Multicenter prospective studies are needed to determine optimal presurgical epilepsy evaluation.

Long-term approach to patients with postsurgical seizures.

The main purpose of the study was to analyze the long-term outcomes and therapeutic approaches for patients with seizures within the first year after surgery. The secondary aim of the study was to evaluate the relationship between 1-year outcome and long-term outcome and choice of therapy. Our study was a retrospective investigation of the long-term outcomes of 95 patients (33.5% of all surgically treated patients) with seizure recurrence in the first year after surgery. The patients had follow-up visits for >5 years. At the 5-year follow-up visit (FU5), 28 (29.5%) of the 95 patients were completely seizure-free (International League Against Epilepsy (ILAE) class 1), 17 (17.9%) had auras only (ILAE class 2), and 21 (22.1%) were unimproved (ILAE classes 5 and 6). Statistically significant factors for these long-term outcomes were the focus localization of the epilepsy, preoperative MRI findings, and postoperative follow-up results in the first year. The patients with <3 seizure days in the first postoperative year (ILAE 3) represented 53.6% of the seizure-free patients at FU5; the patients with auras in the first year constituted 64.7% of the patients with only auras at FU5; and the patients unimproved in the first year represented 76.2% of the unimproved patients at FU5. Postoperative outcome depends to a certain extent on the outcome achieved in the first postoperative year. More than one third of the patients with postoperative seizures reached a long-term seizure-free outcome, and more than half of them did not experience disabling seizures in the last outcome year. The most therapeutic options were used in patients who were minimally influenced by the operation; the majority of patients with considerable improvement because of the operation do not use any other add-on antiepileptic drugs or other kinds of therapy.

Long-term outcomes of epilepsy surgery in Sweden

Objective:To investigate prospective, population-based long-term outcomes concerning seizures and antiepileptic drug (AED) treatment after resective epilepsy surgery in Sweden.Methods:Ten- and 5-year follow-ups were performed in 2005 to 2007 for 278/327 patients after resective epilepsy surgery from 1995 to 1997 and 2000 to 2002, respectively. All patients had been prospectively followed in the Swedish National Epilepsy Surgery Register. Ninety-three patients, who were presurgically evaluated but not operated, served as controls.Results:In the long term (mean 7.6 years), 62% of operated adults and 50% of operated children were seizure-free, compared to 14% of nonoperated adults (p < 0.001) and 38% of nonoperated children (not significant). Forty-one percent of operated adults and 44% of operated children had sustained seizure freedom since surgery, compared to none of the controls (p < 0.0005). Multivariate analysis identified ≥30 seizures/month at baseline and long epilepsy duration as negative predictors and positive MRI to be a positive predictor of long-term seizure-free outcome. Ten years after surgery, 86% of seizure-free children and 43% of seizure-free adults had stopped AEDs in the surgery groups compared to none of the controls (p < 0.0005).Conclusions:This population-based, prospective study shows good long-term seizure outcomes after resective epilepsy surgery. The majority of the patients who are seizure-free after 5 and 10 years have sustained seizure freedom since surgery. Many patients who gain seizure freedom can successfully discontinue AEDs, more often children than adults.Classification of evidence:This study provides Class III evidence that more patients are seizure-free and have stopped AED treatment in the long term after resective epilepsy surgery than nonoperated epilepsy patients.

Safety and Long-term Seizure-Free Outcomes of Subdural Grid Placement in Patients With a History of Prior Craniotomy

Patients who continue or begin to have seizures after brain surgery pose significant challenges and often require an invasive electroencephalographic evaluation before reoperation for drug-resistant epilepsy. The safety and seizure-free outcomes associated with subdural grid (SDG) implantation in patients with a prior craniotomy are important for both surgeon and patient to understand before pursuing further surgery. To evaluate the safety of SDG placement and subsequent resective surgery in patients with prior craniotomy and to characterize the seizure outcomes and their predictors after resective epilepsy surgery in this unique cohort. We retrospectively reviewed all intractable focal epilepsy patients with a history of craniotomy who underwent SDG insertion between 2000 and 2012 at our institution. A minimum follow-up of 6 months was required. End points analyzed included complications related to each surgery and Engel classification at the last follow-up. The mean age of seizure onset was 15.9 years, and the mean age for the initial surgery was 24.2 years. Only 3 patients began having seizures after the initial surgery. Seven patients (7%) had a complication associated with the SDG placement, and 15 (14%) had a complication after subsequent resection, which was equivalent to the initial procedure. Forty-eight patients (44%) were in Engel class I at the last follow-up. Freedom from seizures was predicted by ictal onset at the edge of the original surgical bed, particularly in patients with lesional epilepsy. Surgical intervention with SDG monitoring does not appear to be associated with increased risk of complications in epilepsy patients with a history of prior craniotomy, and rates of freedom from seizures in this challenging group are favorable.

Long-Term Outcome of the Ketogenic Diet for Intractable Childhood Epilepsy With Focal Malformation of Cortical Development

We evaluated the efficacy and long-term outcome of the ketogenic diet in patients with intractable childhood epilepsy as a result of focal malformation of cortical development. A retrospective analysis evaluated seizure outcomes of 47 patients who had intractable epilepsy from (and) surgically remediable focal malformation of cortical development and were first treated with the classic ketogenic diet, involving the 4:1 lipid/nonlipid ratio. The long-term prognosis of 21 patients, who became seizure-free 3 months after the ketogenic diet, was followed up with that of 22 patients who eventually underwent epilepsy surgery. Three months after diet initiation, 29 (61.7%) patients showed a reduction in seizure frequency of >50%, including 21 (44.7%) who became seizure-free. Of the 21 patients with complete seizure control at 3 months, 16 (76.2%) successfully completed the diet for 2 years without relapse, and 10 (47.6%) have remained seizure-free after cessation of the diet (mean follow-up for 3 years and 10 months), including 1 patient who remained seizure-free with additional medication after a relapse. Of the 22 patients who underwent epilepsy surgery, a seizure-free outcome was obtained for 13 (59.1%). The ketogenic diet should be considered to be an additional option even in patients with focal malformation of cortical development, and long-term seizure-free outcome can be expected for patients who become seizure-free 3 months after the diet.

Electro-clinical characteristics and postoperative outcome of medically refractory tumoral temporal lobe epilepsy

Very few studies have specifically addressed surgical treatment and outcome of patients with tumor-related temporal lobe epilepsy (TLE). To define the postoperative seizure outcome and the factors that influenced the outcome of patients with tumor-related TLE. We selected patients whose surgical pathology revealed a temporal lobe neoplasm and who had completed > 1 year of postoperative follow-up. We reviewed the clinical, EEG, radiological and pathological data, and the seizure outcome of these patients and assessed the factors that influenced the outcome. Out of the 409 patients who underwent surgery for refractory TLE during the 8-year study period, there were 34 (8.3%) patients with temporal lobe neoplasms. The median age at surgery was 20 years and the median duration of epilepsy prior to surgery was 9.0 years. MRI revealed tumor in the mesial location in 21 (61.8%) patients. Interictal and ictal epileptiform EEG abnormalities were localized to the side of th lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 27 (79%) patients were completely seizure-free. The only factor that predicted long-term seizure-free outcome was being seizure-free during the first two postoperative years. Our results emphasize the fact that in patients with tumoral TLE, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority.