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Treatment of Refractory Mesial Temporal Lobe Epilepsy

Treatment of Refractory Mesial Temporal Lobe Epilepsy To the Editor: The efficacy of epilepsy surgery (73% seizure-free) in the best-possible surgical candidates was corroborated by Dr Engel and colleagues.1 Their trial also showed that surgery can cause irreversible deficits because a statistically reliable decline in performance on memory tests was more frequent in the surgical group (36% in delayed recall and 55% in naming) than in the medical group (0% and 7%, respectively).1 Other aspects of the trial might deserve some clarification. The reported incidence of visual field defects is between 68% and 100% after anterior temporal lobectomy, and in 25% to 46% of patients it may be severe enough to fail driver's license tests.2 However, I could not find any mention of this subject in the study by Engel et al.1 No patient achieved seizure freedom in the medical group, which is surprising given that the patients had failed only 2 AED trials and had a whole year to attempt new trials.1 In a previous study that compared epilepsy surgery with continued pharmacotherapy, 8% of the medical group became seizure-free even though this sample had previously failed 6 AED trials and had just 1 month to adjust to treatment.3 Moreover, a retrospective study found that 21% of surgical candidates excluded for surgery after presurgical evaluation subsequently achieved seizure freedom with medical therapy.4 As shown by a prospective observational study, after the failure of 2 AED trials, approximately 17% of patients could be expected to become seizure-free following each of the next 3 AED trials.5 Engel et al1 provided the number of AEDs used by their patients at baseline and at the end of the study, but it would be important to know the mean number (and range) of AED trials performed in the medical group before randomization and during the subsequent year. The trial by Engel et al1 was atypical in that the patients included were low in number and highly selected, almost one-third of the patients in the medical group received surgery, and the trial was stopped prematurely. Consequently, this trial will be insufficient “to determine whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management” in early focal refractory epilepsy. Perhaps a large, prospective observational, multicenter study that reflects clinical practice, with identical standardized outcome measures for any intervention, would better inform patients about their preferred treatment option at any time in the course of AED resistance. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving honoraria for lectures or for participation on advisory panels, or both, from Eisai, GlaxoSmithKline, and UCB Pharma; and receiving reimbursement for travel expenses from Eisai, GlaxoSmithKline, UCB Pharma, and Novartis. References 1. Engel J Jr, McDermott MP, Wiebe S, et al; Early Randomized Surgical Epilepsy Trial (ERSET) Study Group. Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA. 2012;307(9):922-93022396514PubMedGoogle ScholarCrossref 2. Yogarajah M, Focke NK, Bonelli S, et al. Defining Meyer's loop-temporal lobe resections, visual field deficits and diffusion tensor tractography. Brain. 2009;132(pt 6):1656-166819460796PubMedGoogle ScholarCrossref 3. Wiebe S, Blume WT, Girvin JP, Eliasziw M.Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311-31811484687PubMedGoogle ScholarCrossref 4. Selwa LM, Schmidt SL, Malow BA, Beydoun A. Long-term outcome of nonsurgical candidates with medically refractory localization-related epilepsy. Epilepsia. 2003;44(12):1568-157214636329PubMedGoogle ScholarCrossref 5. Schiller Y, Najjar Y. Quantifying the response to antiepileptic drugs: effect of past treatment history. Neurology. 2008;70(1):54-6518166707PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Treatment of Refractory Mesial Temporal Lobe Epilepsy

JAMA , Volume 307 (23) – Jun 20, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2012.4987
Publisher site
See Article on Publisher Site

Abstract

To the Editor: The efficacy of epilepsy surgery (73% seizure-free) in the best-possible surgical candidates was corroborated by Dr Engel and colleagues.1 Their trial also showed that surgery can cause irreversible deficits because a statistically reliable decline in performance on memory tests was more frequent in the surgical group (36% in delayed recall and 55% in naming) than in the medical group (0% and 7%, respectively).1 Other aspects of the trial might deserve some clarification. The reported incidence of visual field defects is between 68% and 100% after anterior temporal lobectomy, and in 25% to 46% of patients it may be severe enough to fail driver's license tests.2 However, I could not find any mention of this subject in the study by Engel et al.1 No patient achieved seizure freedom in the medical group, which is surprising given that the patients had failed only 2 AED trials and had a whole year to attempt new trials.1 In a previous study that compared epilepsy surgery with continued pharmacotherapy, 8% of the medical group became seizure-free even though this sample had previously failed 6 AED trials and had just 1 month to adjust to treatment.3 Moreover, a retrospective study found that 21% of surgical candidates excluded for surgery after presurgical evaluation subsequently achieved seizure freedom with medical therapy.4 As shown by a prospective observational study, after the failure of 2 AED trials, approximately 17% of patients could be expected to become seizure-free following each of the next 3 AED trials.5 Engel et al1 provided the number of AEDs used by their patients at baseline and at the end of the study, but it would be important to know the mean number (and range) of AED trials performed in the medical group before randomization and during the subsequent year. The trial by Engel et al1 was atypical in that the patients included were low in number and highly selected, almost one-third of the patients in the medical group received surgery, and the trial was stopped prematurely. Consequently, this trial will be insufficient “to determine whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management” in early focal refractory epilepsy. Perhaps a large, prospective observational, multicenter study that reflects clinical practice, with identical standardized outcome measures for any intervention, would better inform patients about their preferred treatment option at any time in the course of AED resistance. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving honoraria for lectures or for participation on advisory panels, or both, from Eisai, GlaxoSmithKline, and UCB Pharma; and receiving reimbursement for travel expenses from Eisai, GlaxoSmithKline, UCB Pharma, and Novartis. References 1. Engel J Jr, McDermott MP, Wiebe S, et al; Early Randomized Surgical Epilepsy Trial (ERSET) Study Group. Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA. 2012;307(9):922-93022396514PubMedGoogle ScholarCrossref 2. Yogarajah M, Focke NK, Bonelli S, et al. Defining Meyer's loop-temporal lobe resections, visual field deficits and diffusion tensor tractography. Brain. 2009;132(pt 6):1656-166819460796PubMedGoogle ScholarCrossref 3. Wiebe S, Blume WT, Girvin JP, Eliasziw M.Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311-31811484687PubMedGoogle ScholarCrossref 4. Selwa LM, Schmidt SL, Malow BA, Beydoun A. Long-term outcome of nonsurgical candidates with medically refractory localization-related epilepsy. Epilepsia. 2003;44(12):1568-157214636329PubMedGoogle ScholarCrossref 5. Schiller Y, Najjar Y. Quantifying the response to antiepileptic drugs: effect of past treatment history. Neurology. 2008;70(1):54-6518166707PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Jun 20, 2012

References