Nonlesional Neocortical Epilepsy: Benefits v Risk December 8, 2013

Transcription

1 Nonlesional Neocortical Epilepsy: Benefits v Risk December 8, 2013 Orrin Devinsky, MD NYU Langone School of Medicine American Epilepsy Society Annual Meeting

2 Disclosure Name of Commercial Interest None Type of Financial Relationship None

3 Learning Objectives Better define risk:benefit of epilepsy surgery in nonlesional neocortical epilepsy surgery Understand the range of treatment resistant epilepsy-associated morbidity and mortality

4 We are Fools at Understanding Risk Loss aversion bias Losses may be twice as powerful as gains Give up a $2 gain to avoid a $1 loss Illusion of control Yale students and dice Status quo bias You get used to what you re used to, even if it stinks Doctors, patients and parents get used to terrible epilepsy

5 9/11/2001: From Frying Pan to Fire Four airlines hijacked 2,996 Americans died Over the next year many Americans drove more Flew on airplanes less Excess MVA accidents from to ,595 Americans died 4 flights/mo; 1 hijacked plane/mo risk of death: 1/540,000/yr MVA 1/7,000/yr Cancer 1/600/yr Heart disease 1/400/yr

6 9/11/2001: From Frying Pan to Fire (Gigerenzer, 2006)

7 9/11/2001: 2 o Terror Proximity and Opportunity (Gaissmeier & Gigerenzer, Psychol Sci 2012;23:1449)

8 What are the Risks of Treatment- Resistant Epilepsy? Sillanpaa & Shinnar, NEJM 2010;363:2522; Devinsky, NEJM 2011;365:1801 Death: ~ 6-9% per decade of SUDEP, all epilepsy-related death ~15% (MVA, suicide, accident, drowning, status..) For a 20 year-old, over 3 decades, risk of dying from epilepsy > 40% Cognitive morbidity, often progressive: Memory, attention, executive Behavioral Depression rates approach 50% Anxiety >20% Psychosis >10% Structural progressive atrophy

9 What are the Goals in Nonlesional Set the goals: Neocortical Surgery? Cure would be wonderful, but often not likely Palliation ok if team focuses on doing no harm Epileptologists focus on seizure freedom Oncologistst focus on cure as well as disease burden, survival, and quality of life Should epileptologists adopt this?

10 How Much Brain Can be Safely Covered?

11 Risks of Invasive Electrodes & Epilepsy Surgery (Roth et al, Neurosurgery, 2013) 200 pediatric admissions 250 surgeries with resections 496 surgeries No deaths No serious permanent neuro complications 2%/admission minor neuro complications 3%/admission hydrocephalus often hemispherectomy Major complications: CNS or bone flap infections (1.5%/admission) Intracranial hemorrhage, CSF leak (0.5%/admission)

12 Risks of Invasive Electrodes Wellmer et al, Epilepsia 2012;53: patients, ages 0-70 years

13 Benefits of Surgeries with Invasive Electrodes Wellmer et al, Epilepsia 2012;53: patients, ages 0-70 years For patients with > 24 mos followup 49.7% seizure freedom with surgery 6.3% without surgery NET BENEFIT: 43.4% seizure free

14 Critical Factors to Decide What is the risk of the assessment? Permanent neurological deficit is <1% Complication impacts patients life transiently ~5% Death: invasive electrodes and resective surgery ~ 1/ seizure types: 1 without motor features, 1? L UE automatisms before clonic; 1 TCSz without aura. Ictal & II-EEG: R central-parietal focus. 1 o sensori-motor cortex involved near onset?? Right-handed and lateralization of language

15 What Happens if Primary Motor Cortex is Involved? Do nothing never confuse invasive monitoring with need for action. All centers have probably hurt patients by removing nonlesional neocortex, but it can be avoided or minimized. Limit resection size and location to dysfunctional cortex Multiple subpial transections +/- resection 211 patients, meta-analysis (Spencer et al, Epilepsia 2002;43:141) MST + resection: Excellent outcome: > 95% seizure control Generalized seizures 87% CPS & SPS 68% MST alone: Excellent outcome: > 95% seizure control Generalized seizures 71% CPS & SPS 62.5%

16 Proceed with Invasive Electrode Recording Little risk if done at high volume center If no resectable focus is found, can do nothing or MST If one is found Chance of seizure freedom > ~30-40% Chance for >50% seizure reduction ~50-60% Chance for Responsive Neural Stimulation Status quo: risk of depression, anxiety, memory loss, psychosis, personality changes, death

17 Impact on Clinical Care and Practice Don t fall victim to biases: risk aversion, illusion of control, and status quo (and many others) Carefully consider risks and limits of epilepsy surgery Carefully consider morbidity and mortality of treatment resistant epilepsy