Timing of Referral to Evaluate for Epilepsy Surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy
Abstract number :
2.366
Submission category :
15. Practice Resources
Year :
2022
Submission ID :
2204482
Source :
www.aesnet.org
Presentation date :
12/4/2022 12:00:00 PM
Published date :
Nov 22, 2022, 05:25 AM
Authors :
Lara Jehi, MD, MHCDS – Cleveland Clinic; Nathalie Jette, MD – Mount Sinai; Churl-Su Kwon, MD – Columbia University; Colin Josephson, MD – University of Calgary; Jorge Burneo, MD – Western University, London; Fernando Cendes, MD, PhD – University of Campinas; Michael Sperling, MD – Thomas Jefferson University; Sallie Baxendale, PhD – University College London Queen Square; Robyn Busch, PhD – Cleveland Clinic; Chahnez Triki, MD – Hedi Chaker Hospital; Helen Cross, MD – UCL Great Ormond Street Institute of Child Health; Dana Ekstein, MD – Hadassah Medical Organization; Dario Englot, MD – Vanderbilt University; Guoming Luan, MD – Sanbo Brain Hospital; Andre Palmini, MD, PhD – Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS); Loreto Rios, MD – Campus Clínico Facultad de Medicina Universidad Finis Terrae; Xiongfei wang, MD – Sanbo Brain Hospital; Karl Roessler, MD – Medical University of Vienna; Bertil Rydenhag, MD – University of Gothenburg; georgia ramantani, MD – University of Zurich; Stephan Schuele, MD – Northwestern University; Jo Wilmhurst, MD – University of Cape Town; Sarah Wilson, PhD – University of Melbourne; samuel wiebe, MD – University of Calgary
Rationale: Epilepsy surgery is the treatment of choice for patients with drug-resistant seizures. A timely evaluation for surgical candidacy can be life-saving for patients who are identified as appropriate surgical candidates, and may also enhance the care of non-surgical candidates through improvement in diagnosis, optimization of therapy, and treatment of comorbidities. Yet, referral for surgical evaluations is often delayed while palliative options are pursued, with significant adverse consequences due to increased morbidity and mortality associated with intractable epilepsy.
Methods: The Surgical Therapies Commission of the International League Against Epilepsy (ILAE) sought to address these clinical gaps and clarify when to initiate a surgical evaluation. We conducted a Delphi consensus process evaluating 51 unique patient scenarios considering criteria that may influence the decision to refer for an epilepsy surgery evaluation (e.g., sociodemographic, clinical history, therapies, EEG, imaging findings). Response options are shown in Table 1. The survey responses were converted into expert consensus recommendations as follows:_x000D_
1 – Consensus reached in the category of “always/likely to refer” = referral for a surgical evaluation “should be offered”_x000D_
2 – Consensus reached in the category of “unlikely or never to refer” = referral for surgical evaluation “should not be offered”_x000D_
3 – Consensus not reached but ≥50% answered “always” or “very likely” to refer = referral for surgical evaluation “should be considered”_x000D_
4 – Consensus not reached and < 50% agreement = “further research is needed”
Results: Survey participation was global: 61 epileptologists, epilepsy neurosurgeons, neurologists, neuro-psychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. Three rounds of Delphi surveys were necessary. Detailed results are shown in Figure 1.
Conclusions: We reached the following expert consensus recommendations: (1) Referral for a surgical evaluation should be offered to every patient with drug-resistant epilepsy (up to 70 years of age), as soon as drug-resistance is ascertained, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type (including epileptic encephalopathies), localization, and comorbidities [including severe psychiatric comorbidity like psychogenic non-epileptic seizures (PNES) or substance abuse] if patients are cooperative with management; (2) A surgical referral should be considered for older patients with drug-resistant epilepsy who have no surgical contraindication, and for patients (adults and children) who are seizure-free on 1-2 anti-seizure medications (ASM)s but have a brain lesion in non-eloquent cortex; and (3) Referral for surgery should not be offered to patients with active substance abuse who are non-cooperative with management. High level evidence will be required to permit creation of clinical practice guidelines.
Funding: None
Practice Resources