Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy

Lara Jehi*, Nathalie Jette, Churl Su Kwon, Colin B. Josephson, Jorge G. Burneo, Fernando Cendes, Michael R. Sperling, Sallie Baxendale, Robyn M. Busch, Chahnez Charfi Triki, J. Helen Cross, Dana Ekstein, Dario J. Englot, Guoming Luan, Andre Palmini, Loreto Rios, Xiongfei Wang, Karl Roessler, Bertil Rydenhag, Georgia RamantaniStephan Schuele, Jo M. Wilmshurst, Sarah Wilson, Samuel Wiebe

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations

Abstract

Epilepsy surgery is the treatment of choice for patients with drug-resistant seizures. A timely evaluation for surgical candidacy can be life-saving for patients who are identified as appropriate surgical candidates, and may also enhance the care of nonsurgical candidates through improvement in diagnosis, optimization of therapy, and treatment of comorbidities. Yet, referral for surgical evaluations is often delayed while palliative options are pursued, with significant adverse consequences due to increased morbidity and mortality associated with intractable epilepsy. The Surgical Therapies Commission of the International League Against Epilepsy (ILAE) sought to address these clinical gaps and clarify when to initiate a surgical evaluation. We conducted a Delphi consensus process with 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. After three rounds of Delphi surveys, evaluating 51 unique scenarios, we reached the following Expert Consensus Recommendations: (1) Referral for a surgical evaluation should be offered to every patient with drug-resistant epilepsy (up to 70 years of age), as soon as drug resistance is ascertained, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type (including epileptic encephalopathies), localization, and comorbidities (including severe psychiatric comorbidity like psychogenic nonepileptic seizures [PNES] or substance abuse) if patients are cooperative with management; (2) A surgical referral should be considered for older patients with drug-resistant epilepsy who have no surgical contraindication, and for patients (adults and children) who are seizure-free on 1–2 antiseizure medications (ASMs) but have a brain lesion in noneloquent cortex; and (3) referral for surgery should not be offered to patients with active substance abuse who are noncooperative with management. We present the Delphi consensus results leading up to these Expert Consensus Recommendations and discuss the data supporting our conclusions. High level evidence will be required to permit creation of clinical practice guidelines.

Original languageEnglish (US)
Pages (from-to)2491-2506
Number of pages16
JournalEpilepsia
Volume63
Issue number10
DOIs
StatePublished - Oct 2022

Keywords

  • drug-resistant epilepsy
  • epilepsy surgery
  • health care delivery
  • neuromodulation
  • public health
  • treatment

ASJC Scopus subject areas

  • Neurology
  • Clinical Neurology

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