Authors :
Presenting Author: Steven Tobochnik, MD – VA Boston Healthcare System / Brigham and Women's Hospital
Gregory Head, RN – VA Boston Healthcare System; John Rolston, MD, PhD – Brigham and Women's Hospital; G. Rees Cosgrove, MD – Brigham and Women's Hospital; David McCarthy, MD – VA Boston Healthcare System
Rationale:
This aims to characterize the scope of epilepsy surgery for management of drug-resistant epilepsy (DRE) and potential barriers to intervention in surgical candidates at a Veterans Affairs (VA) Epilepsy Centers of Excellence (ECoE) site.
Methods:
A prospective cohort of Veterans with DRE treated at VA Boston Healthcare System (VABHS) between June 2020 and May 2023 was analyzed. DRE was defined as the failure of two or more anti-seizure medications at therapeutic doses to control seizures separately or in combination. Seizure control, discussion of potential surgical options, presurgical workup, and surgical outcomes were prospectively tracked as components of clinical care. Presurgical workup and postoperative follow-up were performed at VABHS. Surgical procedures were performed at the academic affiliate, Brigham and Women’s Hospital, and included stereo-electroencephalography (SEEG), resective surgery, laser ablation, vagus nerve stimulation (VNS), and responsive neurostimulation (RNS).
Results:
There were 52 patients with DRE (48 male, 4 female), including three who had previous surgical interventions. Epilepsy surgery was discussed as a potential treatment option with 44/52 (85%) patients, of whom 22 (50%) completed presurgical workup and had surgical intervention recommended as the best next treatment option by the treating epileptologist, and 13 (30%) were in the process of completing presurgical workup at the time of last follow-up. Of the patients for whom epilepsy surgery was not discussed, none had evidence of disabling seizures in the prior year. For those whom surgical intervention was recommended, 13/22 (59%) accepted and 12/13 completed surgery (four resection, four laser ablation, three RNS, and one VNS). SEEG was performed in 4/13 (31%). Mesial temporal laser ablations were performed in three patients, all of whom were >70 years old and were not interested in resective surgery. One-year Engel class I outcomes were achieved in 5/6 (83%) patients undergoing resective/ablative procedures. Patient preferences and logistical challenges in completing presurgical workup, primarily due to remote out-of-state residence, were the most common causes not to pursue surgery.
Conclusions:
Newer epilepsy surgery techniques (laser ablation and closed-loop neuromodulation) made up over half of procedures performed in this cohort of Veterans with DRE, reflecting advances in epilepsy surgery practices and the importance of ensuring access to specialized epilepsy care for patients with DRE who are not candidates or not interested in resective surgery. Older age should not be considered a barrier to epilepsy surgery. Strategies to optimize the presurgical evaluation for patients in remote locations are needed to improve access to the full range of surgical procedures and outcomes of DRE for a broader population.
Funding:
VA VISN-1 V1CDA2022-68 (ST)