Krucoff Max O, Chan Alvin Y, Harward Stephen C, Rahimpour Shervin, Rolston John D, Muh Carrie, Englot Dario J
Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, U.S.A.
Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.
Epilepsia. 2017 Dec;58(12):2133-2142. doi: 10.1111/epi.13920. Epub 2017 Oct 10.
Medically refractory epilepsy is a debilitating disorder that is particularly challenging to treat in patients who have already failed a surgical resection. Evidence regarding outcomes of further epilepsy surgery is limited to small case series and reviews. Therefore, our group performed the first quantitative meta-analysis of the literature from the past 30 years to assess for rates and predictors of successful reoperations.
A PubMed search was conducted for studies reporting outcomes of repeat epilepsy surgery. Studies were excluded if they reported fewer than five eligible patients or had average follow-ups < 1 year, and patients were excluded from analysis if they received a nonresective intervention. Outcomes were stratified by each variable of interest, and quantitative meta-analysis was performed to generate odds ratios (ORs) and 95% confidence intervals (CIs).
Seven hundred eighty-two patients who received repeat resective epilepsy surgery from 36 studies were included. Engel I outcome was observed in 47% (n = 369) of patients. Significant predictors of seizure freedom included congruent over noncongruent electrophysiology data (OR = 3.6, 95% CI = 1.6-8.2), lesional over nonlesional epilepsy (OR = 3.2, 95% CI = 1.9-5.3), and surgical limitations over disease-related factors associated with failure of the first surgery (OR = 2.6, 95% CI = 1.3-5.3). Among patients with at least one of these predictors, seizure freedom was achieved in 58%. Conversely, the use of invasive monitoring was associated with worse outcome (OR = 0.4, 95% CI = 0.2-0.9). Temporal lobe over extratemporal/multilobe resection (OR = 1.5, 95% CI = 0.8-3.0) and abnormal over normal preoperative magnetic resonance imaging (OR = 1.9, 95% CI = 0.6-5.4) showed nonsignificant trends toward seizure freedom.
This analysis supports considering further resection in patients with intractable epilepsy who continue to have debilitating seizures after an initial surgery, especially in the context of factors predictive of a favorable outcome.
药物难治性癫痫是一种使人衰弱的疾病，对于已经接受过手术切除但治疗失败的患者而言，治疗起来尤其具有挑战性。关于进一步癫痫手术结果的证据仅限于小型病例系列和综述。因此，我们团队对过去30年的文献进行了首次定量荟萃分析，以评估再次手术成功的发生率和预测因素。
在PubMed上搜索报告重复癫痫手术结果的研究。如果研究报告的符合条件的患者少于5例或平均随访时间<1年，则将其排除；如果患者接受的是非切除性干预，则将其排除在分析之外。按每个感兴趣的变量对结果进行分层，并进行定量荟萃分析以生成比值比（OR）和95%置信区间（CI）。
纳入了来自36项研究的782例接受重复切除性癫痫手术的患者。47%（n = 369）的患者达到Engel I级结果。癫痫发作缓解的显著预测因素包括电生理数据一致而非不一致（OR = 3.6，95% CI = 1.6 - 8.2）、病灶性癫痫而非非病灶性癫痫（OR = 3.2，95% CI = 1.9 - 5.3）以及手术局限性而非与首次手术失败相关的疾病因素（OR = 2.6，95% CI = 1.3 - 5.3）。在具有这些预测因素中至少一项的患者中，58%实现了癫痫发作缓解。相反，使用侵入性监测与较差的结果相关（OR = 0.4，95% CI = 0.2 - 0.9）。颞叶切除而非颞外/多叶切除（OR = 1.5，95% CI = 0.8 - 3.0）以及术前磁共振成像异常而非正常（OR = 1.9，95% CI = 0.6 - 5.4）显示出癫痫发作缓解的趋势不显著。
该分析支持对那些在初次手术后仍有使人衰弱的癫痫发作的难治性癫痫患者考虑进一步切除手术，特别是在存在预后良好预测因素的情况下。
