Referral for Epilepsy Surgery Evaluation: Earlier Is Better in Most Cases, Expert Panel Says

Most patients up to age 70 with drug-resistant epilepsy should be offered surgical evaluation, and even those who are seizure-free on antiseizure medications with a resectable lesion might benefit from surgery by avoiding drug side effects. That’s the advice of the International League Against Epilepsy (ILAE) in a new consensus document published as a Special Report in Epilepsia designed to provide recommendations on the timing of referral for epilepsy surgery evaluation.

“Surgery for epilepsy offers patients the best chance of a cure, and delaying it in order to search for palliative options can lead to unnecessary consequences, including cognitive harm, poor psychosocial outcomes, and increased risk of morbidity and death,” says the document’s first and corresponding author, Lara Jehi, MD, an epilepsy specialist in Cleveland Clinic’s Epilepsy Center. Dr. Jehi led the work as Chair of the Surgical Therapies Commission for the ILAE, the highest authority in epilepsy care and research. “With these recommendations, we are hoping that more patients who could benefit will be more promptly offered this important option.”

Broad consensus in the absence of rigorous evidence

The recommendations from the ILAE are the result of a Delphi consensus process involving 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists and neuropsychologists from 28 countries with a median of 22 years in practice. The process involves a series of questions provided to the group, in which responses form the basis of the next round. Consensus was defined as 66% agreement, and three rounds were conducted to optimize agreement.

Such recommendations differ from clinical practice guidelines, which are based on rigorous systematic review of evidence. In contrast, consensus recommendations are used to provide guidance on controversial issues for which evidence is limited. “We met at least a dozen times over the course of 18 months to craft these recommendations,” notes Dr. Jehi. “Surgery is highly underutilized to treat epilepsy, and our team took care to consider all the possible scenarios that practicing neurologists struggle with as they determine whether or not to refer a patient for evaluation.”

Important takeaways

Dr. Jehi identifies the following as some of the document’s key recommendations.

1. Refer patients up to age 70 for surgical evaluation as soon as they are deemed drug resistant. This should be done for every patient who is cooperative with management, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type, localization and comorbidities.
2. Patients older than 70 should be considered for referral if they have no surgical contraindications.Patients should not be denied the possibility of treatment that can improve their quality of life simply because they are regarded as “too old.”
3. Consider referring children and adults who are seizure-free on one or two antiseizure medications with a lesion in noneloquent cortex. While the ILAE defines drug resistance as failure to achieve freedom from seizures after trials of two antiseizure medications, even those who do not meet this threshold may benefit from surgical intervention. “I see many patients who, although controlled on medications, suffer serious side effects from them,” Dr. Jehi says. “They should have the option of resection if they are appropriate candidates.”
4. Don’t delay referral for any of the following reasons: therapies other than antiseizure medications have not yet been tried, surgery is expected to be palliative only, or the patient has ongoing drug-resistant seizures despite a prior surgical resection.
5. Do not refer patients with active substance abuse or who are uncooperative with management. Because of possible increased anesthetic risk and the complexity of perioperative self-care, surgical referral is not recommended until substance abuse is under control and the patient is adherent with medical management. These were the only situations in which consensus was reached to withhold surgical referral.

Various controversies remain

Consensus was not reached for referring patients for surgical evaluation in some clinical scenarios. These included:

• Very young children who are seizure-free on antiseizure medications and have a lesion in noneloquent cortex
• Patients with ongoing seizures in the context of nonadherence to antiseizure medications without documented drug resistance
• Patients who did not achieve freedom from seizures after just one antiseizure medication

The authors note that such controversies point to potential areas for research.

A call for increasing patient options

The ILAE statement emphasizes that many patients and even clinicians commonly have misconceptions about epilepsy surgery, leading to underutilization or unnecessary delay of surgery. They note that risks of surgery are often overestimated and negative impacts of poorly controlled seizures are often underestimated.

Dr. Jehi adds that surgical evaluation may lead to consideration of previously unexplored options, such as laser interstitial thermal therapy or neuromodulation for patients who are unsuitable for surgery. Referral for surgery evaluation for patients with drug-resistant epilepsy, she notes, has been demonstrated to be cost-effective, whether or not the patient actually undergoes surgery.

“Patients should be counseled that referral for surgical evaluation is not in any way a commitment to undergo brain surgery,” says Dr. Jehi. “For those who are not surgical candidates, evaluation can lead to other benefits, such as improved diagnosis, better understanding of their condition and additional management strategies.”