Jehi Lara, Jetté Nathalie
Epilepsy Center Cleveland Clinic Neurological Institute Cleveland Ohio U.S.A.
Department of Clinical Neurosciences and Hotchkiss Brain Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada.
Epilepsia Open. 2016 Jul 27;1(1-2):22-36. doi: 10.1002/epi4.4. eCollection 2016 Sep.
Epilepsy surgery is often the only effective treatment in appropriately selected patients with drug-resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). Abstracts were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra-TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.
癫痫手术通常是经适当选择的药物难治性癫痫患者的唯一有效治疗方法，这种疾病影响着约30%的癫痫患者。我们回顾了支持癫痫手术应用的证据，重点关注随机对照试验（RCT）。其次，我们确定了在癫痫手术对某些人群的益处、手术选择个体化的挑战以及我们对手术结果机制缺乏了解等方面的知识空白。我们于2016年3月2日进行了检索（MEDLINE、Embase、Cochrane、Clinicaltrials.gov），以识别癫痫手术RCT、系统评价或卫生技术评估（HTA）。对摘要进行筛选，以识别切除性、姑息性（如胼胝体切开术、多处软膜下横切术[MST]）、消融性（如激光间质热疗法[LITT]、伽玛刀放射外科手术[RS]）和神经调节性（如小脑刺激[CS]、海马刺激[HS]、重复经颅磁刺激[rTMS]、反应性神经刺激[RNS]、丘脑刺激[TS]、三叉神经刺激[TNS]和迷走神经刺激[VNS]）RCT。提取研究特征和结果。识别知识空白。在1205篇摘要中，识别出20项RCT（切除性手术包括胼胝体切开术[n = 7]、MST[n = 0]、RS[n = 1，3篇论文]、LITT[n = 0]、CS[n = 1]、HS[n = 2]、RNS[n = 1]、rTMS[n = 1]、TNS[n = 1]、TS[n = 1]和VNS[n = 5]）。大多数研究针对颞叶癫痫（TLE）患者，没有一项研究考察切除性手术治疗颞叶外癫痫（ETLE）患者或除内侧颞叶硬化以外有特定病变患者的有效性。除VNS外，未识别出儿科手术RCT。很少有RCT探讨癫痫手术的有效性，且大多数的普遍性有限。未来需要开展研究以比较不同手术策略的有效性，更好地理解手术结果的机制，并确定理想的手术方法，特别是对于认知功能高或非常低、影像学正常或ETLE的患者。
