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Nonlesional Neocortical Epilepsy: Benefits v Risk
December 8, 2013
Orrin Devinsky, MD
NYU Langone School of Medicine
American Epilepsy Society | Annual Meeting
Disclosure
Name of Commercial Interest
None
American Epilepsy Society | 2013 Annual Meeting
Type of Financial Relationship
None
Learning Objectives
Better define risk:benefit of epilepsy surgery in nonlesional neocortical epilepsy surgery
Understand the range of treatment resistant epilepsy-associated morbidity and mortality
American Epilepsy Society | 2013 Annual Meeting
We are Fools at Understanding Risk
Loss aversion bias Losses may be twice as powerful as gains
Give up a $2 gain to avoid a $1 loss
Illusion of control
Yale students and dice
Status quo bias You get used to what youre used to, even if it stinks
Doctors, patients and parents get used to terrible epilepsy
American Epilepsy Society | 2013 Annual Meeting
9/11/2001: From Frying Pan to Fire
Four airlines hijacked 2,996 Americans died Over the next year many
Americans drove more Flew on airplanes less
Excess MVA accidents from 9.11.01 to 9.11.02
1,595 Americans died 4 flights/mo; 1 hijacked plane/mo risk of death: 1/540,000/yr MVA 1/7,000/yr Cancer 1/600/yr Heart disease 1/400/yr
American Epilepsy Society | 2013 Annual Meeting
9/11/2001: From Frying Pan to Fire (Gigerenzer, 2006)
American Epilepsy Society | 2013 Annual Meeting
9/11/2001: 2o Terror Proximity and Opportunity (Gaissmeier & Gigerenzer, Psychol Sci 2012;23:1449)
American Epilepsy Society | 2013 Annual Meeting
What are the Risks of Treatment-Resistant Epilepsy?
Sillanpaa & Shinnar, NEJM 2010;363:2522; Devinsky, NEJM 2011;365:1801
Death: ~ 6-9% per decade of SUDEP, all epilepsy-related death ~15% (MVA, suicide, accident, drowning, status..)
For a 20 year-old, over 3 decades, risk of dying from epilepsy > 40%
Cognitive morbidity, often progressive: Memory, attention, executive
Behavioral Depression rates approach 50% Anxiety >20% Psychosis >10%
Structural progressive atrophy
American Epilepsy Society | 2013 Annual Meeting
What are the Goals in Nonlesional Neocortical Surgery?
Set the goals: Cure would be wonderful, but often not likely
Palliation ok if team focuses on doing no harm
Epileptologists focus on seizure freedom
Oncologistst focus on cure as well as disease burden, survival, and quality of life
Should epileptologists adopt this?
American Epilepsy Society | 2013 Annual Meeting
How Much Brain Can be Safely Covered?
American Epilepsy Society | 2013 Annual Meeting
Risks of Invasive Electrodes & Epilepsy Surgery (Roth et al, Neurosurgery, 2013)
200 pediatric admissions 250 surgeries with resections 496 surgeries
No deaths No serious permanent neuro complications 2%/admission minor neuro complications 3%/admission hydrocephalus often hemispherectomy Major complications:
CNS or bone flap infections (1.5%/admission) Intracranial hemorrhage, CSF leak (0.5%/admission)
American Epilepsy Society | 2013 Annual Meeting
Risks of Invasive Electrodes Wellmer et al, Epilepsia 2012;53:1322
242 patients, ages 0-70 years
American Epilepsy Society | 2013 Annual Meeting
Benefits of Surgeries with Invasive Electrodes Wellmer et al, Epilepsia 2012;53:1322
242 patients, ages 0-70 years
For patients with > 24 mos followup
49.7% seizure freedom with surgery
6.3% without surgery
NET BENEFIT: 43.4% seizure free
American Epilepsy Society | 2013 Annual Meeting
Critical Factors to Decide
What is the risk of the assessment? Permanent neurological deficit is
What Happens if Primary Motor Cortex is Involved?
Do nothing never confuse invasive monitoring with need for action. All centers have probably hurt patients by removing nonlesional neocortex, but it can be avoided or minimized. Limit resection size and location to dysfunctional cortex Multiple subpial transections +/- resection 211 patients, meta-analysis (Spencer et al, Epilepsia 2002;43:141) MST + resection: Excellent outcome: > 95% seizure control Generalized seizures 87% CPS & SPS 68% MST alone: Excellent outcome: > 95% seizure control Generalized seizures 71% CPS & SPS 62.5% American Epilepsy Society | 2013 Annual Meeting
Proceed with Invasive Electrode Recording
Little risk if done at high volume center If no resectable focus is found, can do nothing or MST If one is found Chance of seizure freedom > ~30-40% Chance for >50% seizure reduction ~50-60% Chance for Responsive Neural Stimulation Status quo: risk of depression, anxiety, memory loss, psychosis, personality changes, death
American Epilepsy Society | 2013 Annual Meeting
Impact on Clinical Care and Practice
Dont fall victim to biases: risk aversion, illusion of control, and status quo (and many others)
Carefully consider risks and limits of epilepsy surgery
Carefully consider morbidity and mortality of treatment resistant epilepsy