Abstracts

Rationale: Approximately 20% of patients with epilepsy have refractory epilepsy, and studies suggest that surgery should be considered early in the course of the disease. Most epilepsy surgical research focuses on those patients who have had a surgical resection. Few studies have examined the characteristics of patients who begin the lengthy and costly presurgical process, but do not have a resection. This study is an attempt to identify factors unique to this latter group of patients that might be used to predict that they would not ultimately have surgery.Methods: We reviewed all presurgical candidates in our Comprehensive Epilepsy Program from January, 1990 to December, 2006, eliminating patients who: 1. Were referred directly to an epilepsy surgeon without seeing an epileptologist, 2. Were referred for a second opinion, or 3. Had evolving lesions, thereby requiring resective surgery for other reasons. Medical records were reviewed to gather information related to completion of the standard parts of the presurgical evaluation process. For those individuals who did not ultimately have surgery, the furthest completion point of the evaluation pathway was identified, along with any stated reasons why subjects did not proceed further. Results: Of the 89 subjects who met our inclusion criteria, 44 had surgical resections and 45 did not. In looking at characteristics that distinguished the surgical completions from the nonsurgical subjects, there were a number of factors that proved to be the same between these two groups, as shown in Table 1. However, as seen in Table 2 in expanded form, while there was no significant difference in the prevalence of psychiatric disorders between the two groups, 15/45 of the nonsurgical patients had a history of previous psychiatric hospitalizations or suicide attempts, compared to 4/44 of the surgical subjects. In two-thirds of the non-surgical cases, the decision to avoid surgery was made by the patient, with 53% of this group stating that they felt that surgery (primarily involving standard resections or placement of invasive electrodes) was too risky. Conclusions: Of patients considering epilepsy surgery, a significant number chose not to complete the evaluation, fearing that brain surgery of any form was too risky. While patients in each group were equally likely to have had psychiatric diagnoses, subjects with a history of more severe antecedent psychiatric illness were less likely to complete the presurgical evaluation process. While presurgical candidates typically receive neuropsychiatric evaluations for competency and for assessment of emotional stability, our data suggests that this may not be enough for patients who have had suicide attempts or previous psychiatric hospitalizations. Perhaps beginning with a neuropsychiatric assessment and/or social work support at the start of the presurgical evaluation process may be of greater benefit to those individuals. Furthermore, identification of this risk factor is possible by history alone, before any testing is started, thereby making it a useful and practical stratagem to apply.