Laxer Kenneth D, Elder Christopher J, Di Gennaro Giancarlo, Ferrari Louis, Krauss Gregory L, Pellinen Jacob, Rosenfeld William E, Villanueva Vicente
Sutter Pacific Epilepsy Program, California Pacific Medical Center, 1100 Van Ness Ave, 6th floor, San Francisco, CA, 94109, USA.
NYU Langone Health Comprehensive Epilepsy Center, New York, NY, USA.
Neurol Ther. 2024 Oct;13(5):1337-1348. doi: 10.1007/s40120-024-00651-4. Epub 2024 Aug 18.
Cenobamate has demonstrated efficacy in patients with treatment-resistant epilepsy, including patients who continued to have seizures after epilepsy surgery. This article provides recommendations for cenobamate use in patients referred for epilepsy surgery evaluation. A panel of six senior epileptologists from the United States and Europe with experience in presurgical evaluation of patients with epilepsy and in the use of antiseizure medications (ASMs) was convened to provide consensus recommendations for the use of cenobamate in patients referred for epilepsy surgery evaluation. Many patients referred for surgical evaluation may benefit from ASM optimization; both ASM and surgical treatment should be individualized. Based on previous clinical studies and the authors' clinical experience with cenobamate, a substantial proportion of patients with treatment-resistant epilepsy can become seizure-free with cenobamate. We recommend a cenobamate trial and ASM optimization in parallel with presurgical evaluations. Cenobamate can be started before phase two monitoring, especially in patients who are found to be suboptimal surgery candidates. As neurostimulation therapies are generally palliative, we recommend trying cenobamate before vagus nerve stimulation (VNS), deep brain stimulation, or responsive neurostimulation (RNS). In surgically remediable cases (mesial temporal sclerosis, benign discrete lesion in non-eloquent cortex, cavernous angioma, etc.), cenobamate use should not delay imminent surgery; however, a patient may decide to defer or even cancel surgery should they achieve sustained seizure freedom with cenobamate. This decision should be made on an individual, case-by-case basis based on seizure etiology, patient preferences, potential surgical risks (mortality and morbidity), and likely surgical outcome. The addition of cenobamate after unsuccessful surgery or palliative neuromodulation may also be associated with better outcomes.
司替戊醇已在难治性癫痫患者中显示出疗效，包括那些在癫痫手术后仍有发作的患者。本文为转诊进行癫痫手术评估的患者使用司替戊醇提供建议。召集了一个由来自美国和欧洲的六位资深癫痫专家组成的小组，他们在癫痫患者的术前评估和抗癫痫药物（ASM）使用方面具有经验，以就司替戊醇在转诊进行癫痫手术评估的患者中的使用提供共识性建议。许多转诊进行手术评估的患者可能会从ASM优化中受益；ASM和手术治疗都应个体化。根据先前的临床研究以及作者对司替戊醇的临床经验，相当一部分难治性癫痫患者使用司替戊醇后可实现无发作。我们建议在进行术前评估的同时进行司替戊醇试验和ASM优化。司替戊醇可以在第二阶段监测之前开始使用，尤其是在那些被发现不是最佳手术候选者的患者中。由于神经刺激疗法通常是姑息性的，我们建议在迷走神经刺激（VNS）、深部脑刺激或反应性神经刺激（RNS）之前尝试使用司替戊醇。在可通过手术治疗的病例（内侧颞叶硬化、非功能区皮质的良性离散病变、海绵状血管瘤等）中，使用司替戊醇不应延迟即将进行的手术；然而，如果患者使用司替戊醇实现了持续无发作，他们可能会决定推迟甚至取消手术。这一决定应根据癫痫病因、患者偏好、潜在手术风险（死亡率和发病率）以及可能的手术结果，逐案做出个体化决定。在手术失败或姑息性神经调节后添加司替戊醇也可能带来更好的结果。
