Investigatory pathway and principles of patient selection for epilepsy surgery candidates: a systematic review

Ghaffari-Rafi, Arash; Leon-Rojas, Jose

doi:10.1186/s12883-020-01680-w

Cited by 13 publications

(7 citation statements)

References 45 publications

(65 reference statements)

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“…We expect our cost findings to be similar to those of the other pediatric epilepsy surgery centers in Ontario and other provinces in Canada because surgical practices and the health care systems are similar across Canada. While some variations in diagnostic tests for presurgical evaluation exist in pediatric epilepsy centers across Canada, the United States, and other countries, 45 surgical care and postsurgical follow-up are relatively similar. Furthermore, seizure outcomes after epilepsy surgery in our center 46 have been shown to be comparable to published outcomes from other pediatric epilepsy centers in the United States and other countries.…”

Section: Discussionmentioning

confidence: 99%

Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario

et al. 2022

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Background and ObjectivesImprovement in seizure control after epilepsy surgery could lead to lower health care resource use and costs, but it is uncertain whether this could offset the high costs related to surgery. This study aimed to evaluate phase-specific and cumulative long-term health care costs of surgery compared to medical therapy in children with drug-resistant epilepsy from the health care payer perspective.MethodsChildren who were evaluated for epilepsy surgery and treated with surgery or medical therapy from 2003 to 2018 at the Hospital for Sick Children in Toronto were identified from chart review and linked to their health administrative databases in Ontario, Canada. Inverse probability of treatment weighting with stabilized weights was used to balance the baseline covariates between the 2 groups. Patients were assigned to presurgery, surgery, short-term (first 2 years), intermediate-term (2–5 years), and long-term (>5 years) postsurgery care phases on the basis of treatment trajectory. Phase-specific and cumulative long-term health care costs were evaluated. Costs were converted from Canadian to US dollars year 2018 value.ResultsThere were 372 surgical and 258 medical patients. Costs were higher in surgical than medical patients for presurgery (3 and 39 weeks), surgery, and short-term care phase, and the attributable costs of surgery per 7 patient-days were $1,602 (95% CI $1,438–$1,785), $172 (95% CI $147–$185), $19,819 (95% CI $18,822–$20,932), and $28 (95% CI $22–$32), respectively. Costs were lower in surgical patients for intermediate- and long-term care phase, and the attributable costs were −$72 (95% CI −$124 to −$35) and −$94 (95% CI −$129 to −$63), respectively. In surgical patients, costs were highest for surgery followed by presurgery care phase, with hospitalizations accounting for the highest cost component. In medical patients, costs increased gradually from presurgery to long-term care phase. Cumulative costs were higher for surgical than medical patients in the first 7 years after surgery, but from 8 years on, costs were lower for surgical patients.DiscussionThis study demonstrated the long-term economic benefits of epilepsy surgery compared to medical therapy for the health care system with the use of real-world data, which would justify the high costs of surgery. The results will support future economic evaluation comparing minimally invasive treatment such as laser therapy to surgery.

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Section: Discussionmentioning

confidence: 99%

Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario

et al. 2022

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“…During pre-surgical workup, MRI scans form a vital basis for the localization of structural lesions associated with epilepsy. 1 , 4 , 15 , 16 Patients with a clearly defined MRI lesion are two to three times more likely to achieve postoperative seizure freedom than patients without structural abnormalities on MRI. 1 But not all epileptogenic pathologies are readily visible on structural MRI scans.…”

Section: Introductionmentioning

confidence: 99%

The spatial relationship between the MRI lesion and intraoperative electrocorticography in focal epilepsy surgery

Straumann

Schaft

Noordmans

et al. 2022

Brain Communications

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MRI and intraoperative electrocorticography are often used in tandem to delineate epileptogenic tissue in resective surgery for focal epilepsy. Both the resection of the MRI lesion and tissue with high rates of electrographic discharges on electrocorticography, e.g. spikes and high-frequency oscillations (80-500 Hz), leads to a better surgical outcome. How MRI and electrographic markers are related, however, is currently unknown. The aim of this study was to find the spatial relationship between MRI lesions and spikes/high-frequency oscillations. We retrospectively included 33 pediatric and adult patients with lesional neocortical epilepsy who underwent electrocorticography-tailored surgery (14 female, median age = 13.4 years, range = 0.6-47.0 years). Mesiotemporal lesions were excluded. We used univariable linear regression to find correlations between pre-resection spike/high-frequency oscillation rates on an electrode and its distance to the MRI lesion. We tested straight lines to the centre and the edge of the MRI lesion, and the distance along the cortical surface to determine which of these distances best reflects the occurrence of spikes/high-frequency oscillations. We conducted a moderator analysis to investigate the influence of the underlying pathology type and lesion volume on our results. We found spike and high-frequency oscillation rates to be spatially linked to the edge of the MRI lesion. The underlying pathology type influenced the spatial relationship between spike/high-frequency oscillation rates and the MRI lesion (pspikes < 0.0001, pripples < 0.0001), while lesion volume did not (pspikes = 0.64, pripples = 0.89). A higher spike rate was associated with a shorter distance to the edge of the lesion for cavernomas (F(1,64)=-1.37, p < 0.0001, η2 = 0.22), focal cortical dysplasias (F(1,570)=-0.25, p < 0.0001, η2 = 0.05), and pleomorphic xanthoastrocytomas (F(1,66)=-0.18, p = 0.01, η2 = 0.09). In focal cortical dysplasias, a higher ripple rate was associated with a shorter distance (F(1,570)=-0.35, p < 0.0001, η2 = 0.05). Conversely, low-grade gliomas showed a positive correlation; the further an electrode was away from the lesion, the higher the rate of spikes (F(1,75) = 0.65, p < 0.0001, η2 = 0.37) and ripples (F(1,75) = 2.67, p < 0.0001, η2 = 0.22). Pathophysiological processes specific to certain pathology types determine the spatial relationship between the MRI lesion and electrocorticography results. In our analyses, non-tumorous lesions (focal cortical dysplasias, cavernomas) seemed to intrinsically generate spikes and high-frequency oscillations, particularly at the border of the lesion. This advocates for a resection of this tissue. Low-grade gliomas caused epileptogenicity in the peritumoral tissue. Whether a resection of this tissue leads to a better outcome is unclear. Our results suggest that the underlying pathology type should be considered when intraoperative electrocorticography is interpreted.

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“… 15,16 Therefore, a thorough pre-operative work-up should be performed, in order to properly demarcate the area to be excised and the associated eloquent areas that should be respected during surgery, by using multiple modalities such as scalp EEG, video EEG, fMRI, tractography, among others. 17 …”

Section: Introductionmentioning

confidence: 99%

The role of preoperative diffusion tensor imaging in predicting and improving functional outcome in pediatric patients undergoing epilepsy surgery: a systematic review

et al. 2021

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Objective: Diffusion tensor imaging (DTI) is a useful neuroimaging technique for surgical planning in adult patients. However, no systematic review has been conducted to determine its utility for pre-operative analysis and planning of Pediatric Epilepsy surgery. We sought to determine the benefit of pre-operative DTI in predicting and improving neurological functional outcome after epilepsy surgery in children with intractable epilepsy. Methods: A systematic review of articles in English using PubMed, EMBASE and Scopus databases, from inception to January 10, 2020 was conducted. All studies that used DTI as either predictor or direct influencer of functional neurological outcome (motor, sensory, language and/or visual) in pediatric epilepsy surgical candidates were included. Data extraction was performed by two blinded reviewers. Risk of bias of each study was determined using the QUADAS 2 Scoring System. Results: 13 studies were included (6 case reports/series, 5 retrospective cohorts, and 2 prospective cohorts) with a total of 229 patients. Seven studies reported motor outcome; three reported motor outcome prediction with a sensitivity and specificity ranging from 80 to 85.7 and 69.6 to 100%, respectively; four studies reported visual outcome. In general, the use of DTI was associated with a high degree of favorable neurological outcomes after epilepsy surgery. Conclusion: Multiple studies show that DTI helps to create a tailored plan that results in improved functional outcome. However, more studies are required in order to fully assess its utility in pediatric patients. This is a desirable field of study because DTI offers a non-invasive technique more suitable for children. Advances in knowledge: This systematic review analyses, exclusively, studies of pediatric patients with drug-resistant epilepsy and provides an update of the evidence regarding the role of DTI, as part of the pre-operative armamentarium, in improving post-surgical neurological sequels and its potential for outcome prediction.

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Investigatory pathway and principles of patient selection for epilepsy surgery candidates: a systematic review

Cited by 13 publications

References 45 publications

Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario

Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario

The spatial relationship between the MRI lesion and intraoperative electrocorticography in focal epilepsy surgery

The role of preoperative diffusion tensor imaging in predicting and improving functional outcome in pediatric patients undergoing epilepsy surgery: a systematic review

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