RESUMO
OBJECTIVE: In the presurgical evaluation of patients with drug-resistant epilepsy (DRE), occasionally, patients do not experience spontaneous typical seizures (STS) during a stereo-electroencephalography (SEEG) study, which limits its effectiveness. We sought to identify risk factors for patients who did not have STS during SEEG and to analyze the clinical outcomes for this particular set of patients. METHODS: We conducted a retrospective analysis of all patients with DRE who underwent depth electrode implantation and SEEG recordings between January 2013 and December 2018. RESULTS: SEEG was performed in 155 cases during this period. 11 (7.2%) did not experience any clinical seizures (non-STS group), while 143 experienced at least one patient-typical seizure during admission (STS group). No significant differences were found between STS and non-STS groups in terms of patient demographics, lesional/non-lesional epilepsy ratio, pre-SEEG seizure frequency, number of ASMs used, electrographic seizures or postoperative seizure outcome in those who underwent resective surgery. Statistically significant differences were found in the average number of electrodes implanted (7.0 in the non-STS group vs. 10.2 in STS), days in Epilepsy Monitoring Unit (21.8 vs. 12.8 days) and the number of cases that underwent resective surgery following SEEG (27.3% vs. 60.8%), respectively. The three non-STS patients (30%) who underwent surgery, all had their typical seizures triggered during ECS studies. Three cases were found to have psychogenic non-epileptic seizures. None of the patients in the non-STS group were offered neurostimulation devices. Five of the non-STS patients experienced transient seizure improvement following SEEG. SIGNIFICANCE: We were unable to identify any factors that predicted lack of seizures during SEEG recordings. Resective surgery was only offered in cases where ECS studies replicated patient-typical seizures. Larger datasets are required to be able to identify factors that predict which patients will fail to develop seizures during SEEG.
Assuntos
Epilepsia Resistente a Medicamentos , Epilepsia , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Eletrodos Implantados/efeitos adversos , Convulsões/diagnóstico , Convulsões/cirurgia , Eletroencefalografia , Epilepsia/cirurgia , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/cirurgia , Técnicas EstereotáxicasRESUMO
OBJECTIVE: Epilepsy surgery for older adults is controversial owing to their longer duration of epilepsy and perceived higher surgical risk. However, because of an aging population and documented benefit of epilepsy surgery, surgery is considered more frequently for these patients. The authors' objective was to analyze the role of resective surgery in patients older than 60 years and to assess outcomes and safety. METHODS: The authors conducted a retrospective analysis of 595 patients who underwent resective epilepsy surgery at their center from 1999 to 2018. Thirty-one patients aged 60 years or older were identified. Sixty patients younger than 60 years were randomly selected as controls. Population characteristics, results of presurgical evaluations, outcomes, and complications were analyzed. RESULTS: No significant differences were found between the groups in terms of hemisphere dominance, side of surgery, presence of a lesion, and incidence of temporal lobe epilepsy. Epilepsy duration was greater in the older cohort (p = 0.019), and invasive EEG was more commonly employed in younger patients (p = 0.030). The rates of Engel class I outcome at 6 months, 1 year, and 2 years were 89.7%, 96.2%, and 94.7% for the older group and 75% (p = 0.159), 67.3% (p = 0.004), and 75.8% (p = 0.130) for the younger group, respectively. The proportion of seizure-free patients was greatest among those with temporal lobe epilepsy, particularly in the older group. Neurological complication rates did not differ significantly between groups, however medical and other minor complications occurred more frequently in the older group. CONCLUSIONS: Patients older than 60 years had equal or better outcomes at 1 year after epilepsy surgery than younger patients. A trend toward a greater proportion of patients with lesional temporal lobe epilepsy was found in the older group. These results suggest that good seizure outcomes can be obtained in older patients despite longer duration of epilepsy.
RESUMO
RESUMEN Las crisis epilépticas son una causa frecuente de consulta en la emergencia y en la atención ambulatoria. La evaluación de una primera crisis epiléptica reviste gran trascendencia en este contexto, ya que la ocurrencia de ésta no implica necesariamente el diagnóstico de epilepsia (dos o más crisis no provocadas separadas por más de 24 horas; una crisis única con alto riesgo de recurrencia (>60%); o la evidencia de un síndrome epiléptico - definición de la Liga Internacional para la Lucha Contra la Epilepsia, ILAE) y el tratamiento subsecuente. Por otro lado, no todo paciente con primera crisis debe ser dejado en observación sin recibir el manejo apropiado. Esta decisión está en función del riesgo de recurrencia de crisis. Para ello, la Academia Americana de Neurología (AAN de sus siglas en inglés) recomienda la clasificación de la primera crisis epiléptica en cinco grupos y dependiendo del riesgo de recurrencia de crisis establecido para cada uno de ellos, se tendrá una guía para proceder o no con el tratamiento antiepiléptico. Los grupos son: pacientes con crisis epiléptica provocadas; pacientes con crisis sintomáticas agudas; pacientes con crisis sintomática remotas; primera crisis asociada a síndromes epilépticos; primera crisis de causa desconocida. La guía publicada por AAN en el 2015 para el manejo de primera crisis, sugiere que los pacientes con crisis sintomáticas remotas (lesiones cerebrales pasadas no evolutivas), pacientes con anormalidades epileptiformes interictales; pacientes con estudios de imagen anormales (RMN y TC); y pacientes con crisis nocturnas, tienen un riesgo elevado para recurrencia de crisis (>60%) por lo que deben ser tratadas. La evidencia disponible a la fecha sugiere también que no hay diferencia significativa en el inicio precoz o diferido del tratamiento antiepiléptico para el control de las crisis a largo plazo.
SUMMARY Epileptic seizures are a common cause of medical consultation in the emergency room and in outpatient settings. The evaluation of the first epileptic seizure is of upmost importance as not all patients presenting with seizures have epilepsy (two or more unprovoked crises separated more than 24 hours; one single crisis with a high risk of recurrence (>60%); or evidence of an epileptic syndrome needing treatment based on the definition by the International League against Epilepsy). On the other hand, not every patient with a first episode should be just observed not offering proper treatment. This decision is based on the risk of recurrence. For that purpose, the American Academy of Neurology (AAN) recommends classifying the first seizures into five groups depending on the risk of recurrence, these groups are: patients with provoked seizures; patients with acute symptomatic seizures; patients with remote symptomatic seizures; first seizure associated with an epileptic syndrome, and first seizure of unknown origin. The AAN guidelines for the management of the first seizure published in 2015 suggests that patients with symptomatic remote seizures (non-evolutive and old cerebral lesions), patients with interictal epileptiform abnormalities, patients with abnormal findings on MRI or CT scan, and patients with nocturnal seizures had a high risk for recurrence (>60%) and should be treated. Current evidence suggests that there is no difference in early or delay treatment for controlling seizures at the long-term.