Epilepsy Center, Cleveland Clinic, Cleveland, Ohio.
Quantitative Health Sciences, Cleveland, Ohio.
Epilepsia. 2020 Mar;61(3):465-478. doi: 10.1111/epi.16452. Epub 2020 Feb 27.
To analyze longitudinal seizure outcomes following epilepsy surgery, including reoperations, in patients with intractable focal epilepsy.
Clinicoradiological characteristics of patients who underwent epilepsy surgery from 1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing reoperations, the latest resection was considered the index surgery. The primary outcome was complete seizure freedom (Engel I) at last follow-up. Potentially significant outcome variables were first identified using univariate analyses and then fit in multivariate Cox proportional hazards models.
Of 898 patients fulfilling study criteria, 110 had reoperations; 92 had one resection prior to the index surgery and 18 patients had two or more prior resective surgeries. Two years after the index surgery, 69% of patients with no prior surgeries had an Engel score of I, as opposed to only 42% of those with one prior surgery, and 33% of those with two or more prior resections (P < .001). Among surgical outcome predictors, the number of prior epilepsy surgeries, female sex, lesional initial magnetic resonance imaging, no prior history of generalization, and pathology correlated with better seizure outcomes on univariate analysis. However, only sex (P = .011), history of generalization (P = .016), and number of prior surgeries (P = .002) remained statistically significant in the multivariate model.
Although long-term seizure control is possible in patients with failed prior epilepsy surgery, the chances of success diminish with every subsequent resection. Outcome is additionally determined by inherent biological markers (sex and secondary generalization tendency), rather than traditional outcome predictors, supporting a hypothesis of "surgical refractoriness."
分析 1995 年至 2016 年间因难治性局灶性癫痫行癫痫手术的患者的纵向癫痫发作结局，包括再次手术。
回顾了在 1995 年至 2016 年期间接受癫痫手术并随访时间≥1 年的患者的临床影像学特征。对接受再次手术的患者，将最新的切除视为索引手术。主要结局为末次随访时完全无癫痫发作（Engel I 级）。使用单变量分析初步确定有潜在意义的结局变量，然后将这些变量纳入多变量 Cox 比例风险模型中。
在 898 例符合研究标准的患者中，有 110 例患者接受了再次手术；92 例患者在索引手术前接受了一次切除术，18 例患者接受了两次或更多次切除术。在索引手术后 2 年，无既往手术的患者中有 69%的患者达到 Engel 评分 I 级，而仅接受一次手术的患者为 42%，接受两次或更多次切除术的患者为 33%（P<.001）。在手术结局预测因素中，既往癫痫手术次数、女性、初始磁共振成像有病变、无全身性发作病史和病理结果与单变量分析中的更好的癫痫发作结局相关。然而，只有性别（P=.011）、全身性发作病史（P=.016）和既往手术次数（P=.002）在多变量模型中仍具有统计学意义。
尽管先前癫痫手术失败的患者有获得长期癫痫控制的机会，但每次后续切除的成功率都会降低。结局还由内在的生物学标志物（性别和继发性发作倾向）决定，而不是传统的结局预测因素，这支持了“手术抵抗”的假说。
