Chicago, IL ― A newly published clinical practice guideline from the American Epilepsy Society (AES) and Congress of Neurological Surgeons (CNS) provides updated, evidence-based recommendations for the surgical treatment of drug-resistant epilepsy in adults and children.
Published in Epilepsy Currents, the guideline is the first comprehensive update to epilepsy surgery recommendations in more than two decades, incorporating advances in surgical treatment since previous practice parameters were published in 2003.
The guideline addresses surgical treatment for mesial temporal lobe epilepsy, neocortical epilepsy, drop attacks in developmental and epileptic encephalopathies, and hypothalamic hamartomas. It incorporates newer and less-invasive approaches, including laser interstitial thermal therapy (LITT), as well as procedures commonly used in pediatric epilepsy that were not addressed in the previous guidance.
“People with drug-resistant epilepsy are often waiting far too long to be evaluated for treatments that could significantly improve seizure control and quality of life,” said Barbara C. Jobst, MD, Dr. med, FAES, of Dartmouth Health and Geisel School of Medicine at Dartmouth and guideline co-lead. “These recommendations give clinicians an updated framework for considering the full range of surgical options and, importantly, emphasize that people with drug-resistant epilepsy should have timely access to specialized epilepsy care including surgical procedures.”
The guideline comes at a time when epilepsy surgery remains substantially underused. In the United States, people wait an average of 10.1 years for a diagnosis of drug-resistant epilepsy and 16.7 years for referral for epilepsy surgery. An estimated 476,000 to 1.2 million of the 3.4 million people living with active epilepsy in the United States have drug-resistant epilepsy, yet only 1,508 temporal lobectomies and 877 extratemporal resections were performed across 256 U.S. epilepsy centers in 2019.
The guideline includes several key recommendations:
- Anterior temporal lobectomy (ATL) is strongly recommended over medical therapy for people with drug-resistant mesial temporal lobe epilepsy who are at low risk for cognitive decline. This recommendation is supported by moderate-certainty evidence. In patients with higher than low risk for cognitive decline a conditional recommendation is made for ATL, suggesting a through shared decision making process taking values and preferences of people with epilepsy into account.
- Selective amygdalo-hippocampectomy and LITT are conditionally recommended as surgical options for people with drug-resistant mesial temporal lobe epilepsy, with treatment decisions incorporating individual circumstances, risks, values and preferences.
- Resective or ablative surgery is conditionally recommended over medical therapy for people age 2 and older with drug-resistant neocortical epilepsy.
- Callosotomy is conditionally recommended over vagus nerve stimulation (VNS) for adults and children with drug-resistant drop attacks, Lennox-Gastaut Syndrome or developmental and epileptic encephalopathies, while recognizing that VNS may be preferred when lower procedural risk is prioritized.
- LITT is strongly recommended over open surgical resection for hypothalamic hamartomas, despite very low certainty of evidence, because of the greater potential harms associated with open surgery.
Importantly, the guideline goes beyond seizure outcomes to consider quality of life, mortality, cognitive and neuropsychological outcomes, mental health, social functioning and adverse events. Many recommendations are conditional due to available evidence being limited, underscoring the importance of shared decision-making that reflects each patient’s individual circumstances, values, and preferences.
The guideline also includes a good practice statement emphasizing that every person with drug-resistant epilepsy should have access to a tertiary epilepsy center for evaluation for epilepsy surgery.
Developed through a collaboration between AES and CNS, the multidisciplinary guideline panel included adult and pediatric epileptologists and neurologists, adult and pediatric neurosurgeons, a neuropsychologist, a neuroethicist, and a patient representative. The panel used the GRADE methodology to systematically assess available evidence and develop its recommendations.
“This guideline reflects an important collaboration between neurologists, neurosurgeons and other valuable members of the epilepsy care team around a shared goal: ensuring that people with drug-resistant epilepsy are thoroughly evaluated for the treatments most likely to improve their outcomes,” said Jorge Gonzalez-Martinez, MD, PhD, MCHM, of the University of Pittsburgh and guideline co-lead representing CNS.
The guideline was co-led by Dr. Jobst; Gregory Bergey, MD, of Johns Hopkins University School of Medicine; and Dr. Gonzalez-Martinez.
View the Full Guidelines