Epilepsy surgery is a very effective intervention for patients with treatment resistant epilepsy. The most successful and most common epilepsy surgery is temporal lobectomy, which produces seizure freedom in approximately two-thirds of patients. The strongest candidates for this type of surgery are those who have had treatment resistant epilepsy which includes 30-40 percent of all epilepsy cases. Even with this clear benefit, epilepsy specialists today reported at the Presidential Symposia during the American Epilepsy Society Annual Meeting, that the overall number of surgeries in adults, as well as the number of temporal lobectomies, has decreased from their peaks.
An American Academy of Neurology and American Epilepsy Society guideline recommends temporal lobectomy as the treatment of choice for treatment resistant temporal lobe epilepsy. Yet, in a survey of centers with large epilepsy surgery programs, the number of overall surgeries in adults, as well as the number of temporal lobectomies had decreased almost universally from their peaks. Moreover, surgeries for mesial temporal sclerosis have declined by half, whereas non-lesional cases have increased by a third.
"There is no reduction in the number of adults with treatment resistant epilepsy," says Jacqueline French, M.D., AES President and Director of Clinical Trials Consortium NYU Medical School and Comprehensive Epilepsy Center. "The research presented shows that there are several epidemiological reasons behind the reductions in adult surgery rates. This indicates the need to increase education about epilepsy surgery for patients and neurologists alike and the need to improve communication between epilepsy centers and neurologists."
In addition to better communication, the study presenters suggest that adult neurologists should continue efforts to find temporal lobe epilepsy patients (who most benefit from resective surgery) and promote early referral. There is also a need for better strategies for evaluating patients for surgery and to enhance basic research on non-temporal lobe epilepsy.
In contrast to the decrease in the rates of epilepsy surgery for adults, the rates of surgery in children is rising. This change in surgical landscape in children does not appear to be epidemiological but, rather, likely reflects a change in how neurologists are addressing the problem and are therefore referring more pediatric patients for surgery.
"In general neurologists are now weighing the risks-benefits of the current course of uncontrolled seizures vs. the risk of surgery. They are factoring in that uncontrolled epilepsy is bad for the developing brain and quality of life. They are also looking at life expectancy and that effective epilepsy surgery in children can improve development. Research has also shown that surgery in children is safe -- comparable to other aspects of pediatric neurosurgery and that it can be cost effective," says Howard L. Weiner, M.D., NYU Langone Medical Center.
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