Antiepileptic drugs control seizures in 60%-70% of people with epilepsy. The remaining 30%-40% resort to other therapies, such as the vagus nerve stimulator (VNS); responsive neurostimulation (RNS); deep brain stimulation (DBS), which is approved in Europe but not in the United States; ketogenic and Atkins diets; alternative and complementary therapies; and epilepsy surgery. Seizure control is essential, because the potential consequences of chronic epilepsy include psychological dysfunction, social stigma, inability to drive, lower rates of employment, reduced quality of life, and physical injury, as well as increased mortality from drowning and other accidents, status epilepticus, and sudden unexpected death in epilepsy (SUDEP).
Although VNS, RNS, and DBS can reduce the number and severity of seizures, they rarely stop seizures completely.Diets are difficult to follow and tend to be used primarily in children with severe seizures and developmental disability. Alternative and complementary therapies lack proven safety or efficacy. The remaining option is epilepsy surgery, which has proved to be superior to medical treatment in 2 randomized trials.[3,4] Despite its effectiveness, epilepsy surgery remains underutilized.
Who Should Consider Epilepsy Surgery?
Candidates for surgery must have “drug-resistant epilepsy,” defined “as a failure of adequate trials of 2 (or more) tolerated, appropriately chosen, and appropriately used antiepileptic drug regimens (whether administered as monotherapies or in combination) to achieve freedom from seizures.” Once patients fall into this category, it is uncommon for them to become seizure-free with continued medical management. For example, in a randomized trial of patients who were surgical candidates, 58% became seizure-free after temporal lobe surgery compared with only 8% who received continued medical therapy.
Benefits of Epilepsy Surgery
In the 58% of patients who became seizure-free in a randomized trial, quality of life, employment status and school attendance improved. There were no deaths, although 1 patient in the control group died of SUDEP.
Risks of Epilepsy Surgery
In the trial by Wiebe and colleagues, 5% of patients had postoperative difficulties with memory. Depression occurred at a similar rate as in the medically treated group. Hemiparesis or death did not occur. In general, the serious complication rate of temporal lobectomy is < 5%.
Freedom from seizures after surgery does not occur in all patients. This outcome depends on the type of epilepsy surgery and the particulars of the patient. Even in those who become seizure-free immediately after surgery, seizures may recur over time.
A recently published study from Sweden, where all epilepsy surgery procedures are recorded in the Swedish National Epilepsy Surgery Register, addressed the important question of durability of seizure control after epilepsy surgery. Long-term follow-up revealed that 87% of adults and children who were seizure-free 2 years after surgery were also seizure-free at 5- or 10-year follow-up. Many patients are keen to discontinue antiepileptic drug treatment, and this was possible in 54% of patients who were seizure-free at 10 years. The best results were achieved for temporal lobe surgery; 44% of adults had sustained seizure freedom and 55% of children. However, an increase in seizures occurred in 3% of adults and 8% of children.
Drug-resistant epilepsy affects 30%-40% of people with epilepsy and is associated with significant morbidity and mortality. In the prospective Swedish study, only 13% of patients who were seizure-free at 2 years were no longer seizure free at 5-10 years, indicating that seizure control from epilepsy surgery is durable in most patients. More than one half of the seizure-free patients were relieved of their daily pharmacotherapy burden.
Epilepsy surgery can successfully eliminate seizures in many drug-resistant patients over the long-term and should be considered when patients continue to have seizures despite optimal medical therapy.