Pauline Anderson

December 09, 2013

WASHINGTON, DC — Fewer patients are getting a temporal lobectomy, which is the treatment of choice for resistant temporal lobe epilepsy, possibly in part due to improved treatment of febrile seizures in children, researchers report. Meanwhile, surgeries in children with epilepsy are on the rise.

Neurologists discussed this changing landscape of epilepsy surgery during a Presidential Symposium at the American Epilepsy Society (AES) 67th annual meeting and shared their views with Medscape Medical News.

Jacqueline French, MD, AES president, and director of Clinical Trials Consortium, New York University Medical School and Comprehensive Epilepsy Center, revealed the results of a survey of centers with large epilepsy surgery programs. The survey, which collected data from 9 centers in the United States, Australia, and Germany, showed that the overall number of surgeries rose by over 20% from 1991 to 2001, but then dropped back by 20% from 2001 to 2011.

Rates for temporal lobectomies are going down "in a similar fashion," said Dr. French.

This drop was seen despite the publication of joint guidelines from the American Academy of Neurology and the AES recommending evaluation for surgery, said Dr. French.

Delayed Referrals

One factor contributing to the decline may be a delay in referral, said Dennis Spencer, MD, Harvey & Kate Cushing Professor and chairman, Yale University School of Medicine Department of Neurosurgery, New Haven, Connecticut. With a growing number of antiepileptic drugs now available, neurologists may be taking more time to try patients on these various agents before finally referring them for surgery, he said.

In the 1980s, patients referred for surgery at his center tended to be in their 20s but by the year 2000, they were in their 30s, said Dr. Spencer.

"This is a problem because patients are not getting their surgery early enough, and the longer you delay the surgery, the less the opportunity for controlling these patients, and giving them a better quality of life."

It's a matter of better education of doctors, he added. "They have to understand that there are evidence-based data" demonstrating the efficacy of surgery for temporal lobe epilepsy, said Dr. Spencer.

This surgery stops seizures in about 75% of well-selected cases, he said.

Another factor contributing to the decrease in temporal lobe surgeries is the waning of febrile seizures in childhood. At one time, febrile seizures in kids were a common cause of mesial temporal sclerosis, which used to be the most common cause of surgically remediable epilepsy in adults, said Dr. French. "It's even possible that some viral or infectious agent that was present 20 years ago, causing febrile seizures in children, is no longer as common."

Other possible explanations are that adult temporal lobe epilepsy is being better controlled with drugs today than it was 30 years ago, or that patients are just more reluctant to proceed to surgery now that they have a wider choice of antiepileptic drugs.

Over the years at his center, Dr. Spencer has noted that while temporal lobectomies have decreased, surgery for neocortex epilepsy has increased. In the late 1980s and early 1990s, 35% to 40% of surgeries were for temporal lobe epilepsy cases, and that has declined to under 20%. At the same time, the rate of surgeries for neocortex epilepsy has grown from under 20% to about 35% of cases.

Dr. Spencer's center carries out about 60 epilepsy-related surgeries every year.

Smaller Pool

It's possible that all those temporal lobe surgeries back in the 1980s lessened the pool of patients eligible for temporal lobectomies today, according to Jeffrey A. Loeb, MD, PhD, John S. Garvin Professor and head, Department of Neurology and Rehabilitation, University of Illinois, Chicago.

"Is the decline because we have had these factories that have been churning out these surgeries, so we've done them all?"

As well, neurologists may be referring only "straightforward" 1-stage temporal lobectomies, where epilepsy is easily identifiable in the left or right temporal lobe, but referring fewer more complex cases, said Dr. Loeb.

"Neurologists should rethink how they evaluate what they consider a surgical candidate; it can't just be is it left or right temporal lobe anymore," said Dr. Loeb. "We have to start doing more complex imaging, intracranial recordings, 2-stage surgeries — putting in electrodes followed by a second surgery to remove the epileptic tissues."

Although fewer adults with epilepsy are getting surgery, the situation is different for children, who are now being referred for surgery at a greater rate than in the past.

According to Howard L. Weiner, MD, NYU Langone Medical Center, neurologists are weighing additional factors when considering the risk-benefit equation for surgery in youngsters. Such factors include the effect of uncontrolled epilepsy on the developing brain and improved development and better quality of life due to surgery. He added that surgery in childhood is safe and can be cost-effective.

Dr. Spencer is encouraged by this increase in surgical referrals in children. "Pediatric neurologists have begun to refer patients earlier and earlier," he said. "That's very good news because we know that if you can control the seizures before the child enters high school their outcome or quality of life is going to be much improved."

Dr. French is also excited about the increase in surgery in children. "It means that parents are becoming more comfortable with this," she said, adding that there is now good evidence that surgery may prevent "catastrophic disruption" in brain development.

She pointed out that the benefits of surgery in children often outweigh the risks since their brains are more plastic.

Dr. French and Dr. Loeb have disclosed no relevant financial relationships.

American Epilepsy Society (AES) 67th Annual Meeting. Presidential Symposium: The Changing Landscape of Epilepsy Surgery, December 7, 2013.


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