Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Epilepsia. 2019 Feb;60(2):211-219. doi: 10.1111/epi.14641. Epub 2019 Jan 17.
Despite the obvious advantages of resective surgery in patients with drug-resistant focal epilepsy, namely high probability of seizure freedom, decreased mortality, and increased quality of life, referral rates from physicians and approval rates by patients for presurgical assessment remain constantly low.
In the outpatient clinics of a tertiary epilepsy center, checklists were implemented asking treating epileptologists whether they recommended presurgical evaluation with noninvasive video-electroencephalographic monitoring to adult patients with drug-resistant focal epilepsy and asking respective patients whether they followed this recommendation.
Of 185 eligible patients, 80 (43%) were recommended presurgical evaluation by their epileptologists, and 24 (30%) of these patients consented. Nineteen of all patients (10%) actually underwent noninvasive presurgical assessment, and nine of these eventually proceeded to resection. The most frequent reason for nonreferral by epileptologists was their subjective appraisal of seizure frequency as low (31%), whereas patients declined most often due to overall fear of brain surgery (50%). Variables independently associated with nonreferral by epileptologists comprised older age of patients at questioning (odds ratio [OR] = 1.03), no previous evaluation for epilepsy surgery (OR = 4.04), the presence of legal guardianship (OR = 4.29), and ≥11 years of professional experience by the treating epileptologist (OR = 4.62). Independent predictors for patients' rejection of presurgical evaluation were older age at questioning (OR = 1.08), lifetime number of antiepileptic drugs ≥ 5 (OR = 4.47), presence of focal aware seizures (OR = 4.37), and absence of focal seizures with impaired awareness (OR = 11.24).
In both epileptologists and patients with difficult-to-treat epilepsy, we found high decision rates against presurgical assessment. Some reasons given by physicians for not recommending presurgical evaluation to patients may be understandable; others need further exploration. On the patients' side, early and thorough counseling on risks and benefits of epilepsy surgery is necessary to increase understanding and acceptance.
尽管在耐药性局灶性癫痫患者中进行切除术具有明显优势，例如癫痫发作自由的可能性高、死亡率降低和生活质量提高，但医生的转诊率和患者对术前评估的接受率仍然很低。
在一家三级癫痫中心的门诊诊所，实施了检查表，询问治疗癫痫的医生是否建议对耐药性局灶性癫痫的成年患者进行非侵入性视频脑电图监测的术前评估，并询问各自的患者是否遵循这一建议。
在 185 名符合条件的患者中，80 名（43%）被他们的癫痫医生建议进行术前评估，其中 24 名（30%）患者同意。所有患者中有 19 名（10%）实际上接受了非侵入性术前评估，其中 9 名最终进行了切除。癫痫医生不推荐转诊的最常见原因是他们主观评估发作频率较低（31%），而患者拒绝的最常见原因是对脑部手术的总体恐惧（50%）。与癫痫医生不推荐转诊相关的独立变量包括患者接受询问时的年龄较大（优势比 [OR] = 1.03）、以前未接受癫痫手术评估（OR = 4.04）、存在法定监护（OR = 4.29）和治疗癫痫的医生的专业经验≥11 年（OR = 4.62）。患者拒绝术前评估的独立预测因素包括询问时的年龄较大（OR = 1.08）、一生服用的抗癫痫药物≥5 种（OR = 4.47）、存在局灶性意识清醒的发作（OR = 4.37）和缺乏意识受损的局灶性发作（OR = 11.24）。
在难治性癫痫的癫痫医生和患者中，我们发现大多数人反对进行术前评估。医生不建议患者进行术前评估的一些原因可能是可以理解的；其他原因需要进一步探讨。在患者方面，需要早期和彻底地就癫痫手术的风险和益处进行咨询，以提高理解和接受程度。
