Ziemba Kristine S, Wellik Kay E, Hoffman-Snyder Charlene, Noe Katherine H, Demaerschalk Bart M, Wingerchuk Dean M
Department of Neurology, Mayo Clinic, Scottsdale, AZ 85255, USA.
Neurologist. 2011 May;17(3):176-8. doi: 10.1097/NRL.0b013e318217368e.
The ideal efficacy outcome after surgery for medically refractory epilepsy is seizure freedom without need for antiepileptic drug (AED) therapy but the appropriate timing of AED withdrawal and other prognostic factors remain unclear.
To critically evaluate current evidence regarding factors that influence the risk of seizure relapse after tapering AEDs in adult postepilepsy surgery patients.
The objective was addressed through the development of a structured, critically appraised topic. This included a clinical scenario, structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of epilepsy.
A structured literature search led to selection and appraisal of a retrospective cohort study. Of 147 patients who underwent AED tapering after epilepsy surgery, 61 (41.5%) ended up seizure-free off AEDs, 47 (32%) were seizure-free with AED continuation, and 39 (26.5%) continued to have seizures while on AEDs. Risk factors associated with seizure recurrence included: less time to AED reduction [<9 mo vs. ≥9 mo; P<0.001; hazard ratio (HR)=2.83; 95% confidence interval (CI)=1.62-4.94), seizure recurrence before AED reduction (P=0.002; HR=2.43; 95% CI=1.37-4.31], normal preoperative magnetic resonance imaging (P=0.01; HR=1.96; 95% CI=1.15-3.34), and longer epilepsy duration (>11 y vs. ≤11 y; P=0.02; HR=1.75; 95% CI=1.09-2.81). Cortical location of the epileptic focus was not associated with taper success.
In adults who have undergone neocortical resection surgery for medically refractory epilepsy, longer time from surgery to beginning AED taper (eg, greater than 9 months) is associated with a greater proportion of patients maintaining seizure freedom. Other risk factors associated with lower rate of seizure freedom after AED taper include longer duration of epilepsy, normal preoperative magnetic resonance imaging, and occurrence of postoperative seizures before initiation of AED withdrawal, but not cortical location of the epilepsy focus.
药物难治性癫痫手术后的理想疗效是无需抗癫痫药物（AED）治疗即可无癫痫发作，但AED撤药的合适时机及其他预后因素仍不明确。
严格评估有关影响成年癫痫手术后患者逐渐减少AED剂量后癫痫复发风险因素的现有证据。
通过制定结构化的严格评价主题来实现该目标。这包括一个临床病例、结构化问题、文献检索策略、严格评价、结果、证据总结、评论及最终结论。参与者包括顾问及住院神经内科医生、医学图书馆员、临床流行病学家以及癫痫领域的内容专家。
结构化文献检索导致对一项回顾性队列研究进行选择和评价。在147例癫痫手术后逐渐减少AED剂量的患者中，61例（41.5%）最终在停用AED后无癫痫发作，47例（32%）在继续使用AED时无癫痫发作，39例（26.5%）在使用AED期间仍有癫痫发作。与癫痫复发相关的危险因素包括：AED减量时间较短[<9个月与≥9个月；P<0.001；风险比（HR）=2.83；95%置信区间（CI）=1.62 - 4.94]、AED减量前癫痫复发（P=0.002；HR=2.43；95% CI=1.37 - 4.31）、术前磁共振成像正常（P=0.01；HR=1.96；95% CI=1.15 - 3.34）以及癫痫病程较长（>11年与≤11年；P=0.02；HR=1.75；95% CI=1.09 - 2.81）。癫痫病灶的皮质位置与减量成功无关。
在因药物难治性癫痫接受新皮质切除术的成年人中，从手术到开始逐渐减少AED剂量的时间较长（例如，大于9个月）与更多患者维持无癫痫发作相关。与逐渐减少AED剂量后无癫痫发作率较低相关的其他危险因素包括癫痫病程较长、术前磁共振成像正常以及在开始停用AED之前出现术后癫痫发作，但不包括癫痫病灶的皮质位置。
