Surgical Risk Complications And Benefits

Unfortunately, many patients receive misinformation about the dangers of epilepsy surgery, dissuading them from seeking evaluation. In actuality, the death rate from epilepsy surgery is about 1%, with anterior temporal lobectomy having a lower mortality (< 1%) than hemispherectomy [95]. In a recent report by Engel et al. [77], 2 out of 556 patients (0.4%) from seven centres died within a month of surgery, but deaths were unrelated to the surgical procedure. The risk of death related to surgery is likely to be lower than that related to sudden unexpected death in epilepsy (SUDEP), which is estimated to be 0.35 to 4.5 per 1000 patient years, depending on patient profile [96]. One could therefore argue that the risk of surgery is less than the risk of continued, medically refractory epilepsy. Beyond overt mortality, continued seizures have been associated with cognitive decline over time in TLE [97].

Potential surgical complications include infection, cerebral haemorrhage, subdural haematoma and neurological deficits. There is also evidence that epilepsy surgery can precipitate psychiatric disturbances and worsen anxiety and depression in some patients [77]. However, other contradictory findings have documented a post-operative improvement in depression, suggesting that more research in this area is needed [42]. One large literature review was performed by the Quality Standards Subcommittee of the American Academy of Neurology in 2003 [77], and assessed the overall outcome of epilepsy surgery. Surgical complications were tallied in a total of 556 patients from seven centres. A total of 6% of patients experienced neurological deficits (3% transient and 3% permanent) [77]. Postoperative infections were documented in 5% of patients, and hydrocephalus was described in three cases of large resections. A separate series of three papers which included 219 patients discussed post-operative cognitive and behavioural changes [77, 98-100]. Disturbances were described in 6% of patients and were transient in at least 3% and predominantly related to persistence of seizures [77, 98-100]. Ultimately, the risk of morbidity in epilepsy surgery depends on the specifics of the particular surgery planned for each patient. Risks cannot be realistically estimated until the results of EEG monitoring, neuroimaging and neuropsychological testing are known.

In chronically refractory patients who do not undergo surgery, only 5-14% will achieve seizure remission [101]. Epilepsy surgery offers a better chance of obtaining seizure freedom in many cases, and in the aforementioned Engel et al. study [77] seizure reduction correlated with improved quality of life. In one Class I trial, patients who underwent surgery had improved quality of life after 1 year compared with patients who were treated with medication alone [77]. A trend towards better social function was also seen in patients in the Class I trial, and in several Class IV trials (evidence from uncontrolled studies, case series, case reports or expert opinion), with improvement in employment and activities of daily living [77]. Lastly, there is an overall reduction of long-term medical costs for patients who undergo epilepsy surgery [102].

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