Summary
Objective
Surgical volumes at large epilepsy centers are decreasing. Pediatric cohorts, however, show a trend toward more resections and superior outcome. Differences in pediatric and adult ...epilepsy surgery were investigated in our cohort.
Methods
The Bethel database between 1990 and 2014 was retrospectively analyzed.
Results
A total of 1916 adults and 1300 children underwent presurgical workup. The most common etiologies were medial temporal sclerosis (35.4%) in adults, and focal cortical dysplasias (21.1%) and diffuse hemispheric pathologies (14.7%) in children. Only 1.4% of the total cohort had normal histopathology. A total of 1357 adults (70.8%) and 751 children (57.8%) underwent resections. Surgery types for children were more diverse and showed a higher proportion of extratemporal resections (32.8%) and functional hemispherectomies (20.8%). Presurgical evaluations increased in both groups; surgical numbers remained stable for children, but decreased in the adult group from 2007 on. The patients’ decision against surgery in the adult nonoperated cohort increased over time (total = 44.9%, 27.4% in 1995‐1998 up to 53.2% in 2011‐2014; for comparison, in children, total = 22.1%, stable over time). Postsurgical follow‐up data were available for 1305 adults (96.2%) and 690 children (91.9%) 24 months after surgery. The seizure freedom rate was significantly higher in children than in adults (57.8% vs 47.5%, P < 0.001) and significantly improved over time (P = 0.016).
Significance
Pediatric epilepsy surgery has stable surgical volumes and renders more patients seizure‐free than epilepsy surgery in adults. A relative decrease in hippocampal sclerosis, the traditional substrate of epilepsy surgery, changes the focus of epilepsy surgery toward other pathologies.
Complaints pertaining to memory functioning are among the most often reported cognitive symptoms in patients with epilepsy. However, research suggests a considerable mismatch between patients' ...perception of memory functioning and the objective performance as measured with standardized neuropsychological tests. Depressive mood might be an important factor in explaining this discrepancy, though other variables have also occasionally been reported as relevant. There are mixed results as to which role these factors play in determining the overall quality of life of patients with epilepsy. The present study aimed to quantify the mismatch between subjective and objective memory functioning by taking into account the dynamic change of these factors as well as depressive symptoms after epilepsy surgery. Moreover, the influencing factors of subjective and objective memory change were investigated as well as their effects on the overall quality of life. Pre- and postoperative data from 78 patients with focal epilepsy were retrospectively analyzed. The results showed that (1) patients with clinically relevant postoperative depressive symptoms underestimate their actual memory performance; (2) for non-seizure-free patients, a postoperative decrease in depressive symptoms was associated with a tendency to underestimate memory decline; (3) the relationship between objective memory change and quality of life is mediated by the factors subjective memory change and depressive mood. Our data demonstrate a quantitative approximation of a pronounced depression-related negative biased self-perception of memory functioning of roughly 1 to 1.5 standard deviations. Moreover, it seems that when patients are relieved of having recurrent epileptic seizures, they may be less influenced by depressive symptoms when judging their memory change. Taken together, our study demonstrates the clinical relevance of incorporating subjective measures of memory functioning and mood that go beyond objective memory performance for the interpretation of how changes in memory functioning may affect patients' quality of life after epilepsy surgery.
Seizure outcome after extratemporal lobe epilepsy (exTLE) surgery has often been poorer than after temporal lobe epilepsy (TLE) surgery, but recent improvements in diagnostics and surgery may have ...changed this. Our aim was to analyze the changes in presurgical and surgical volumes and seizure outcome 2 years after surgery for patients with exTLE compared with those with TLE.
We performed a retrospective, single-center cohort study including patients from the Bethel presurgical-surgical-postsurgical database from 1990 to 2017. We used logistic regression to analyze factors influencing the odds for surgery and the odds for seizure freedom after surgery.
We included 3,822 patients with presurgical evaluation, 2,404 of whom had subsequently undergone surgery. The proportion of patients with exTLE in presurgical evaluation increased from 41% between 1990 and 1993 to 64% in 2014-2017. The odds for surgery decreased over time (2003-2011: odds ratio OR 0.50 95% CI 0.36-0.70; 2012-2017: OR 0.24 CI 0.17-0.35; reference: 1990-2002) and patients with exTLE had lower odds for surgery than patients with TLE, but this difference diminished over time (exTLE vs TLE 1990-2002: OR 0.14 CI 0.09-0.20; 2003-2011: OR 0.32 CI 0.24-0.44; 2012-2017: OR 0.46 CI 0.34-0.63). Etiology, the side of the epileptogenic lesion, and invasive recordings influenced the odds for surgery. The most frequent reasons for not undergoing surgery were missing identification of a circumscribed epileptogenic zone or an unacceptable risk of postsurgical deficits in patients with exTLE and the patient's decision in patients with TLE. Compared with patients with TLE, the odds for seizure freedom after surgery started lower for patients with exTLE in earlier years, but increased (≤2 lobes 1990-2002: OR 0.47 CI 0.33-0.68; 2003-2011: OR 0.62 CI 0.44-0.87; 2012-2017: OR 0.78 CI 0.53-1.15; ≥3 lobes 1990-2002: OR 0.37 CI 0.22-0.62; 2003-2011: OR 0.73 CI 0.43-1.23; 2012-2017: OR 1.46 CI 0.91-2.42). Etiology, age at surgery, and invasive recordings were further predictors for the odds for seizure freedom.
Over the past 28 years, the success of resective surgery for patients with exTLE has improved. At the same time, the number of patients with exTLE being evaluated for surgery increased, as well as their odds for undergoing surgery.
Objective
Identifying factors associated with surgical decision‐making is important to understand reasons for underutilization of epilepsy surgery. Neurologists' recommendations for surgery and ...patients' acceptance of these recommendations depend on clinical epilepsy variables, for example, lateralization and localization of seizure onset zones. Moreover, previous research shows associations with demographic factors, for example, age and sex. Here, we investigate the relevance of patients' psycho‐social profile for surgical decision‐making.
Methods
We prospectively studied 296 patients from two large German epilepsy centers. Multiple logistic regression analyses were used to investigate variables linked to neurologists' recommendations for and patients' acceptance of surgery or intracranial video‐electroencephalographic monitoring. Patients' psycho‐social profiles were assessed via self‐reports and controlled for various clinical–demographic variables. Model selection was performed using the Akaike information criterion.
Results
As expected, models for neurologists' surgery recommendations primarily revealed clinical factors such as lateralization and localization of the seizure onset zone, load with antiseizure medication (ASM), and site of the epilepsy‐center. For this outcome, employment was the only relevant psycho‐social aspect (odds ratio OR = .38, 95% confidence interval CI = .13–1.11). In contrast, three of the five relevant predictors for patients' acceptance were psycho‐social. Higher odds were found for those with more subjective ASM adverse events (OR = 1.04, 95% CI = .99–1.00), more subjective seizure severity (OR = 1.12, 95% CI = 1.01–1.24), and lower subjective cognitive impairment (OR = .98, 95% CI = .96–1.00).
Significance
We demonstrated the relevance of the patients' psycho‐social profile for decision‐making in epilepsy surgery, particularly for patients' decisions. Thus, in addition to clinical–demographic variables, patients' individual psycho‐social characteristics add to the understanding of surgical decision‐making. From a clinical perspective, this calls for individually tailored counseling to assist patients in finding the optimal treatment option.
People with epilepsy (PWE) not only suffer from seizures but also from various psycho-social issues containing facets such as social functioning, anxiety, depression or stigmatization, and ...consequently quality of life. (1) Assessing reliable change of these issues is crucial to evaluate their course and potential treatment effects. As most psycho-social self-report questionnaires have been validated in separate samples, their clinical-socio-demographic differences may limit the comparability and generalizability of the scales' internal consistency, which is important for the reliable change index (RCI). Using a co-normalized approach, we provide the internal consistency and RCIs for a large set of questionnaires targeting quality of life (QOLIE-31-P), depressive symptoms (NDDI-E), anxiety (GAD-7), seizure severity (LSSS), subjective antiseizure medication adverse events (LAEP), stigma, epilepsy-related fear, and restrictions in daily life (PESOS), and subjective cognition (FLei). As for some German versions of these measures, psychometric data is still missing, we also add important information for the German language area. (2) In addition, knowledge about intercorrelations of these constructs is needed to shape questionnaire usage and treatment approaches. We thus investigate associations of these scales and compare weighted and unweighted subscales of the QOLIE-31-P.
In our prospective study, 202 adult in-patients of the Epilepsy-Center Berlin-Brandenburg with a reliable diagnosis of epilepsy filled out a set of self-report questionnaires between 03/2018 and 03/2021. We calculated Cronbach's α, RCIs, and bivariate intercorrelations and compared the respective correlations of weighted and unweighted scales of the QOLIE-31-P.
For most of the scales, good to excellent internal consistency was identified. Furthermore, we found intercorrelations in the expected directions with strong links between scales assessing similar constructs (e.g., QOLIE-31-P Cognition and FLei), but weak relationships between measures for different constructs (e.g., QOLIE-31-P Seizure worry and FLei). The QOLIE-31-P Total score was highly correlated with most of the other scales. Some differences regarding their correlational patterns for weighted and unweighted QOLIE-31-P scales were identified.
Psycho-social constructs share a large amount of common variance, but still can be separated from each other. The QOLIE-31-P Total score represents an adequate measure of general psycho-social burden.
The amygdala might support an attentional bias for emotional faces. However, whether and how selective attention toward a specific valence modulates this bias is not fully understood. Likewise, it is ...unclear whether amygdala and cortical signals respond to emotion and attention in a similar way. We recorded gamma‐band activity (GBA, > 30 Hz) intracranially in the amygdalae of 11 patients with epilepsy and collected scalp recordings from 19 healthy participants. We presented angry, neutral, and happy faces randomly, and we denoted one valence as the target. Participants detected happy targets most quickly and accurately. In the amygdala, during attention to negative faces, low gamma‐band activity (LGBA, < 90 Hz) increased for angry compared with happy faces from 160 ms. From 220 ms onward, amygdala high gamma‐band activity (HGBA, > 90 Hz) was higher for angry and neutral faces than for happy ones. Monitoring neutral faces increased amygdala HGBA for emotions compared with neutral faces from 40 ms. Expressions were not differentiated in GBA while monitoring positive faces. On the scalp, only threat monitoring resulted in expression differentiation. Here, posterior LGBA was increased selectively for angry targets from 60 ms. The data show that GBA differentiation of emotional expressions is modulated by attention to valence: Top‐down‐controlled threat vigilance coordinates widespread GBA in favor of angry faces. Stimulus‐driven emotion differentiation in amygdala GBA occurs during a neutral attentional focus. These findings align with a multi‐pathway model of emotion processing and specify the role of GBA in this process.
Our research challenges the idea of inherent automatic processing of emotional expressions in the amygdala. Instead, the differentiation of facial expressions in gamma‐band activity is modulated by valence monitoring. Threat monitoring facilitates top‐down, not bottom‐up, guidance of widespread gamma oscillations. Automatic attentional shifts toward emotion in the amygdala appear to occur only during a neutral focus.
Despite the success of epilepsy surgery, recent reports suggest a decline in surgical numbers. We tested these trends in our cohort to elucidate potential reasons.
Presurgical, surgical and ...postsurgical data of all patients undergoing presurgical evaluation in between 1990 and 2013 were retrospectively analysed. Patients were grouped according to the underlying pathology.
A total of 3060 patients were presurgically studied, and resective surgery was performed in 66.8% (n=2044) of them: medial temporal sclerosis (MTS): n=675, 33.0%; benign tumour (BT): n=408, 20.0%; and focal cortical dysplasia (FCD): n=284, 13.9%. Of these, 1929 patients (94.4%) had a follow-up of 2 years, and 50.8% were completely seizure free (Engel IA). Seizure freedom rate slightly improved over time. Presurgical evaluations continuously increased, whereas surgical interventions did not. Numbers for MTS, BT and temporal lobe resections decreased since 2009. The number of non-lesional patients and the need for intracranial recordings increased. More evaluated patients did not undergo surgery (more than 50% in 2010-2013) because patients were not suitable (mainly due to missing hypothesis: 4.5% in 1990-1993 up to 21.1% in 2010-2013, total 13.4%) or declined from surgery (maximum 21.0% in 2010-2013, total 10.9%). One potential reason may be that increasingly detailed information on chances and risks were given over time.
The increasing volume of the presurgical programme largely compensates for decreasing numbers of surgically remediable syndromes and a growing rate of informed choice against epilepsy surgery. Although comprehensive diagnostic evaluation is offered to a larger group of epilepsy patients, surgical numbers remain stable.
PDF
