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 language | English (US) |
|---|---|
| Pages (from-to) | 2491-2506 |
| Number of pages | 16 |
| Journal | Epilepsia |
| Volume | 63 |
| Issue number | 10 |
| DOIs | |
| State | Published - Oct 2022 |
Funding
We acknowledge the following Delphi process participants: Mario Alonso Vanegas (Mexico); Marjan Asadollahi (Iran); Fabrice Bartolomei (France); Gretchen Birbeck (USA); Kees Braun (The Netherlands); Sarat Chandra (India); Chun Kee Chung (South Korea); Youssef Comair (Lebanon); Thomas Czech (Austria); Olivier Delalande (France); Bertrand Devaux (France); Rei Enatsu (Japan); Ed Faught (USA); Martha Feucht (Austria); Stefano Francione (Italy); Dan Friedman (USA); William Gaillard (USA); Enrico Ghizoni (Brazil); Kensuke Kawai (Japan); Mark Keezer (Canada); Sonia Khan (Saudi Arabia); Nirmeen Kishk (Egypt); Vladimir Krylov (Russia); Katia Lin (Brazil); Pei Lin Lua (Malaysia); Kristina Malmgren (Sweden); Wirginia Maixner (Australia); Farrah Mateen (USA); Andrew McEvoy (United Kingdom); Zainal Muttaqin (Indonesia); Moosa Naduvil (USA); Jeff Ojemann (USA); Reda Ouazzani (Morocco); Cigdem Özkara (Turkey); Eliseu Paglioli (Brazil); Sally Rothemeyer (South Africa); John Rolston (USA); Felix Rosenow (Germany); Americo Sakamoto (Brazil); Laura Tassi (Italy); Sumeet Vadera (USA); Satsuki Watanbe (Japan); Natrujee Wiwattanadittakun (Thailand); Howard Weiner (USA); Lily Wong-Kiesel (USA); and Alice Yu (USA). Dr. Cendes reports personal fees from UCB Pharma, United Medical, Eurofarma, and Zodiac Pharma; and Institutional grants from Sao Paulo Research Foundation (FAPESP) and CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), outside the submitted work; and is a member of the editorial boards of the following journals: (1) (2) (3) (Associate Editor), and (4) (Specialty Chief Editor). CBJ has received unrestricted educational grants through UCB Canada Inc. and Eisai Inc. for work unrelated to this project. CBJ has received a Canadian Frailty Network Grant (Canadian Frailty Network: CAT2017‐19), which is supported by the Government of Canada through the Networks Centres of Excellence (NCE) program for work unrelated to this project. Michael Sperling has received compensation for speaking at CME programs from Medscape, Projects for Knowledge, International Medical Press, and Eisai. He has consulted for Medtronic, Neurelis, and Johnson & Johnson. He has received research support from Eisai, Medtronic, Neurelis, SK Life Science, Takeda, Xenon, Cerevel, UCB Pharma, Janssen, and Engage Pharmaceuticals. He has received royalties from Oxford University Press and Cambridge University Press. JHC has received compensation to her institution for serving as a study investigator for GW Pharmaceuticals, Marinius Pharmaceuticals, Inc, Vitaflow (International) Limited, Zogenix, and Stoke Therapeutics; and as a speaker and advisory board member for GW Pharmaceuticals, Nutricia, Biocodex, and Zogenix. She has received research support from the National Institute of Health Research Great Ormond Street Hospital Biomedical Research Centre; has received grants from the Engineering and Physical Sciences Research Council, Epilepsy Research UK, Great Ormond Street Hospital Charity, the National Institute of Health Research, and the Waterloo Foundation; and holds an endowed chair at the University College London Great Ormond Street Institute of Child Health. NJ receives grant funding paid to her institution for grants unrelated to this work from National Institute of Neurological Disorders and Stroke. (NINDS; National Institutes of Health [NIH] U24NS107201, NIH IU54NS100064, 3R01CA202911‐05S1, R21NS122389, and R01HL161847). She is the Bludhorn Professor of International Medicine. She receives an honorarium for her work as an Associate Editor of . NJ receives research funding from the NIH. The remaining authors have no conflicts to declare. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Neurology Epilepsy Research Epilepsia Frontiers in Neurology Epilepsia
Keywords
- drug-resistant epilepsy
- epilepsy surgery
- health care delivery
- neuromodulation
- public health
- treatment
ASJC Scopus subject areas
- Neurology
- Clinical Neurology
