Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy
Corresponding Author
Lara Jehi
Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Correspondence
Lara Jehi, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
Email: [email protected]
Search for more papers by this authorNathalie Jette
Department of Neurology and Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
Search for more papers by this authorChurl-Su Kwon
Departments of Neurology, Epidemiology, Neurosurgery and the Gertrude H. Sergievsky Center, Columbia University, New York, New York, USA
Search for more papers by this authorColin B. Josephson
Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorJorge G. Burneo
Department of Clinical Neurological Sciences and NeuroEpidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
Search for more papers by this authorFernando Cendes
Department of Neurology, University of Campinas, Campinas, Brazil
Search for more papers by this authorMichael R. Sperling
Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Search for more papers by this authorSallie Baxendale
Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
Search for more papers by this authorRobyn M. Busch
Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Search for more papers by this authorChahnez Charfi Triki
Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
Search for more papers by this authorJ. Helen Cross
UCL Great Ormond Street Institute of Child Health, London, UK
Search for more papers by this authorDana Ekstein
Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah Medical Organization, Jerusalem, Israel
Search for more papers by this authorDario J. Englot
Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Search for more papers by this authorGuoming Luan
Department of Neurosurgery, Comprehensive Epilepsy Center, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
Beijing Key Laboratory of Epilepsy, Beijing, China
Epilepsy Institution, Beijing, China
Search for more papers by this authorAndre Palmini
Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
Search for more papers by this authorLoreto Rios
Clínica Integral de Epilepsia, Campus Clínico Facultad de Medicina Universidad Finis Terrae, Santiago, Chile
Search for more papers by this authorXiongfei Wang
Department of Neurosurgery, Comprehensive Epilepsy Center, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
Beijing Key Laboratory of Epilepsy, Beijing, China
Epilepsy Institution, Beijing, China
Search for more papers by this authorKarl Roessler
Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
Search for more papers by this authorBertil Rydenhag
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Search for more papers by this authorGeorgia Ramantani
Department of Neuropediatrics, and University Children's Hospital Zurich, Switzerland, University of Zurich, Switzerland
Search for more papers by this authorStephan Schuele
Department of Neurology, Northwestern University, Chicago, Illinois, USA
Search for more papers by this authorJo M. Wilmshurst
Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
Institute of Neurosciences, University of Cape Town, Cape Town, South Africa
Search for more papers by this authorSarah Wilson
Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
Search for more papers by this authorSamuel Wiebe
Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorCorresponding Author
Lara Jehi
Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Correspondence
Lara Jehi, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
Email: [email protected]
Search for more papers by this authorNathalie Jette
Department of Neurology and Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
Search for more papers by this authorChurl-Su Kwon
Departments of Neurology, Epidemiology, Neurosurgery and the Gertrude H. Sergievsky Center, Columbia University, New York, New York, USA
Search for more papers by this authorColin B. Josephson
Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorJorge G. Burneo
Department of Clinical Neurological Sciences and NeuroEpidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
Search for more papers by this authorFernando Cendes
Department of Neurology, University of Campinas, Campinas, Brazil
Search for more papers by this authorMichael R. Sperling
Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Search for more papers by this authorSallie Baxendale
Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
Search for more papers by this authorRobyn M. Busch
Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Search for more papers by this authorChahnez Charfi Triki
Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
Search for more papers by this authorJ. Helen Cross
UCL Great Ormond Street Institute of Child Health, London, UK
Search for more papers by this authorDana Ekstein
Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah Medical Organization, Jerusalem, Israel
Search for more papers by this authorDario J. Englot
Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Search for more papers by this authorGuoming Luan
Department of Neurosurgery, Comprehensive Epilepsy Center, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
Beijing Key Laboratory of Epilepsy, Beijing, China
Epilepsy Institution, Beijing, China
Search for more papers by this authorAndre Palmini
Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
Search for more papers by this authorLoreto Rios
Clínica Integral de Epilepsia, Campus Clínico Facultad de Medicina Universidad Finis Terrae, Santiago, Chile
Search for more papers by this authorXiongfei Wang
Department of Neurosurgery, Comprehensive Epilepsy Center, Beijing Institute for Brain Disorders, Sanbo Brain Hospital, Capital Medical University, Beijing, China
Beijing Key Laboratory of Epilepsy, Beijing, China
Epilepsy Institution, Beijing, China
Search for more papers by this authorKarl Roessler
Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
Search for more papers by this authorBertil Rydenhag
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Search for more papers by this authorGeorgia Ramantani
Department of Neuropediatrics, and University Children's Hospital Zurich, Switzerland, University of Zurich, Switzerland
Search for more papers by this authorStephan Schuele
Department of Neurology, Northwestern University, Chicago, Illinois, USA
Search for more papers by this authorJo M. Wilmshurst
Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
Institute of Neurosciences, University of Cape Town, Cape Town, South Africa
Search for more papers by this authorSarah Wilson
Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
Search for more papers by this authorSamuel Wiebe
Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorChurl-Su Kwon and Colin B Josephson contributed equally to this study.
Abstract
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 nonsurgical 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. 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 with 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. After three rounds of Delphi surveys, evaluating 51 unique scenarios, 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 nonepileptic 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 antiseizure medications (ASMs) but have a brain lesion in noneloquent cortex; and (3) referral for surgery should not be offered to patients with active substance abuse who are noncooperative with management. We present the Delphi consensus results leading up to these Expert Consensus Recommendations and discuss the data supporting our conclusions. High level evidence will be required to permit creation of clinical practice guidelines.
CONFLICT OF INTEREST
Dr. Cendes reports personal fees from UCB Pharma, United Medical, Eurofarma, and Zodiac Pharma; and Institutional grants from Sao Paulo Research Foundation (FAPESP) and CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), outside the submitted work; and is a member of the editorial boards of the following journals: (1) Neurology (2) Epilepsy Research (3) Epilepsia (Associate Editor), and (4) Frontiers in Neurology (Specialty Chief Editor). CBJ has received unrestricted educational grants through UCB Canada Inc. and Eisai Inc. for work unrelated to this project. CBJ has received a Canadian Frailty Network Grant (Canadian Frailty Network: CAT2017-19), which is supported by the Government of Canada through the Networks Centres of Excellence (NCE) program for work unrelated to this project. Michael Sperling has received compensation for speaking at CME programs from Medscape, Projects for Knowledge, International Medical Press, and Eisai. He has consulted for Medtronic, Neurelis, and Johnson & Johnson. He has received research support from Eisai, Medtronic, Neurelis, SK Life Science, Takeda, Xenon, Cerevel, UCB Pharma, Janssen, and Engage Pharmaceuticals. He has received royalties from Oxford University Press and Cambridge University Press. JHC has received compensation to her institution for serving as a study investigator for GW Pharmaceuticals, Marinius Pharmaceuticals, Inc, Vitaflow (International) Limited, Zogenix, and Stoke Therapeutics; and as a speaker and advisory board member for GW Pharmaceuticals, Nutricia, Biocodex, and Zogenix. She has received research support from the National Institute of Health Research Great Ormond Street Hospital Biomedical Research Centre; has received grants from the Engineering and Physical Sciences Research Council, Epilepsy Research UK, Great Ormond Street Hospital Charity, the National Institute of Health Research, and the Waterloo Foundation; and holds an endowed chair at the University College London Great Ormond Street Institute of Child Health. NJ receives grant funding paid to her institution for grants unrelated to this work from National Institute of Neurological Disorders and Stroke. (NINDS; National Institutes of Health [NIH] U24NS107201, NIH IU54NS100064, 3R01CA202911-05S1, R21NS122389, and R01HL161847). She is the Bludhorn Professor of International Medicine. She receives an honorarium for her work as an Associate Editor of Epilepsia. NJ receives research funding from the NIH. The remaining authors have no conflicts to declare. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.
Supporting Information
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Table S1 |
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