Harvard Medical School, Boston, MA, USA.
Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Epilepsy Behav. 2024 Sep;158:109944. doi: 10.1016/j.yebeh.2024.109944. Epub 2024 Jul 13.
Many patients pursue epilepsy surgery with the hope of reducing or stopping anti-seizure medications (ASMs), in addition to reducing their seizure frequency and severity. While ASM decrease is primarily driven by surgical outcomes and patient preferences, preoperative estimates of meaningful ASM reduction or discontinuation are uncertain, especially when accounting for the various forking paths possible following intracranial EEG (iEEG), including resection, neuromodulation, or even the absence of further surgery. Here, we characterize in detail the ASM reduction in a large cohort of patients who underwent iEEG, facilitating proactive, early counseling for a complicated cohort considering surgical treatment.
We identified a multi-institutional cohort of patients who underwent iEEG between 2001 and 2022, with a minimum of two years follow-up. The total number of ASMs prescribed immediately prior to surgery, choice of investigation modality, and subsequent surgical treatment were extracted for each patient. Primary endpoints included decreases in ASM counts from preoperative baseline to various follow-up intervals.
A total of 284 patients were followed for a median of 6.0 (range 2,22) years after iEEG surgery. Patients undergoing resection saw an average reduction of ∼ 0.5 ASMs. Patients undergoing neuromodulation saw no decrease and trended towards requiring increased ASM usage during long-term follow-up. Only patients undergoing resection were likely to completely discontinue all ASMs, with an increasing probability over time approaching ∼ 10 %. Up to half of resection patients saw ASM decreases, which was largely stable during long-term follow-up, whereas only a quarter of neuromodulation patients saw a reduction, though their ASM reduction decreased over time.
With the increasing use of stereotactic EEG and non-curative neuromodulation procedures, realistic estimates of ASM reduction and discontinuation should be considered preoperatively. Almost half of patients undergoing resective surgery can expect to reduce their ASMs, though only a tenth can expect to discontinue ASMs completely. If reduction is not seen early, it likely does not occur later during long-term follow-up. Less than a third of patients undergoing neuromodulation can expect ASM reduction, and instead most may require increased usage during long-term follow-up.
许多患者希望通过手术减少或停止抗癫痫药物（ASM）的使用，以减轻癫痫发作频率和严重程度。ASM 的减少主要受手术效果和患者意愿的驱动，但术前对于有意义的 ASM 减少或停药的预测并不确定，尤其是在考虑颅内脑电图（iEEG）后的各种分叉路径时，包括切除、神经调节甚至不再进行手术。在此，我们详细描述了接受 iEEG 的大量患者的 ASM 减少情况，为考虑手术治疗的复杂患者提供了积极的早期咨询。
我们确定了一个 2001 年至 2022 年间接受 iEEG 的多机构队列患者，他们的随访时间至少为 2 年。从术前基线到各个随访间隔，提取每位患者的 ASM 处方总数、调查方式选择和随后的手术治疗。主要终点包括从术前基线到各种随访间隔 ASM 计数的减少。
共有 284 名患者在 iEEG 手术后平均随访 6.0 年（范围 2 至 22）。接受切除的患者平均减少约 0.5 种 ASM。接受神经调节的患者没有减少，并且在长期随访中倾向于增加 ASM 的使用。只有接受切除的患者可能完全停止所有 ASM，随着时间的推移，概率逐渐接近 10%。多达一半的切除患者出现 ASM 减少，且在长期随访中基本稳定，而只有四分之一的神经调节患者出现减少，尽管他们的 ASM 减少随着时间的推移而减少。
随着立体定向脑电图和非治疗性神经调节程序的广泛应用，术前应考虑到 ASM 减少和停药的实际预测。近一半接受切除术的患者可以期望减少他们的 ASM，但只有十分之一可以期望完全停止使用 ASM。如果早期没有看到减少，那么在长期随访中也不太可能出现。不到三分之一的接受神经调节的患者可以期望减少 ASM，而大多数患者可能需要在长期随访中增加使用。
