Where do we go from Here? December 7, 2013

Transcription

1 Where do we go from Here? December 7, 2013 Jacqueline A French MD Epilepsy Center NYU School of Medicine American Epilepsy Society Annual Meeting

2 Disclosure I have received grant funding from The Milken Foundation, the Epilepsy Therapy Project, and NINDS. I serve as the president of The Epilepsy Study Consortium, a non profit organization. NYU receives a fixed amount from the Epilepsy Study Consortium towards my salary. The money is for work performed by me on behalf of The Epilepsy Study Consortium, for consulting and clinical trial related activities. I receive no personal income for these activities. Within the past year, The Epilepsy Study Consortium received payments for research services from: Acorda, Eisai Medical Research, GlaxoSmithKline, Impax, Johnson & Johnson, Mapp Pharmaceuticals, Marinus, Novartis, Lundbeck, Pfizer, Sepracor, Sunovion, SK Life Science, Supernus Pharmaceuticals, UCB Inc/Schwarz Pharma, Upsher Smith, Vertex I am an investigator at NYU on studies for Eisai Medical Research, LCGH, Impax, Mapp Pharmaceuticals, Novartis, UCB Inc/Schwarz Pharma, Upsher Smith, Vertex. The HEP project receives research support from UCB, Pfizer and Lundbeck. The ASERT trial (completed) Received support from UCB, Supernus, Eisai, GSK, Lundbeck, J & J, Upsher-Smith, and Pfizer. American Epilepsy Society 2013 Annual Meeting

3 Learning Objectives Learn to provide optimal treatment, identify surgical candidates, and perform epilepsy surgery for those with syndromes other than temporal lobe epilepsy when indicated. American Epilepsy Society 2013 Annual Meeting

4 The changing landscape There are clear trends towards A reduction in surgery for mesial temporal lobectomy at major epilepsy centers A reduction in epilepsy surgery overall There are no clear trends towards A reduction in treatment resistant epilepsy patients overall 1 1. Brodie et a. Patterns of treatment response in newly diagnosed epilepsyl Neurology May 15;78(20):

5 The world as seen in 2000 Many patients with treatment resistant epilepsy, The majority with temporal lobe epilepsy Not enough surgical programs Conclusion: If we could increase the number of surgeries, we could make a serious dent in the number of treatment resistant patients

6 The world as seen in 2013 There are probably still a substantial number of patients who have not been referred for epilepsy surgery who are good candidates, however. The majority of treatment resistant epilepsy patients at most epilepsy centers Do not have clear surgically remediable epilepsy Do not have temporal lobe epilepsy

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8 What does this mean? We need to: Continue efforts to find TLE patients (who most benefit from resective surgery) and promote early referral Identify better methods of improving the lives of those who are not currently candidates for surgery Better strategies for evaluating patients who currently are considered poor surgical candidates Enhanced basic research on non-temporal lobe epilepsy Continued search for non-surgical effective therapies

9 FINDING TLE PATIENTS: EPILEPSY SURGERY GRADING SCALE Hypothesis: A simple instrument based upon seizure semiology, intelligence quotient (as a dichotomous variable), neuroimaging, and electroencephalographic findings will successfully predict patient that are likely to 1) progress to epilepsy surgery and 2) achieve seizure freedom following surgery. Could be used by neurologists to identify patients for early referral to surgical centers

10 Buiskool et al, Epilepsy Surgical Grading Scale (ESGS): Utilization in epilepsy surgery cohorts at two Centers in different countries 2013, Poster International Epilepsy Congress Montreal RESULTS OF GRADING SCALE NYU AUSTIN (MELBOURNE) 100% 80% 60% 40% 20% 0% 78% ESGS 1 ESGS 2 ESGS 3 72% ESGS 1 ESGS 2 ESGS 3 Seizure Free from Surgery

11 Better strategies for Extra-temporal lobe and non-lesional epilepsy Téllez Zenteno J et al, Surgical outcomes in lesional and non-lesional epilepsy: a systematic review and meta-analysis. Epilepsy Res May;89(2-3):310-8

12 Non-lesional treatment resistant patients are common MRI results in 93 treatment resistant patients enrolled in multicenter AED trials French et al,2013 unpublished data

13 What new strategies can we use? Ways to make non-lesional epilepsy lesional SISCOM Ictal Spect Measurement of cortical thickness PET MR spectroscopy

14 Conclusion The landscape IS changing Surgery for kids: Expanding Surgery for adults: Shrinking (for now) With better strategies, this can turn around It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change. -Darwin

15 Impact on Clinical Care and Practice New methods are needed to identify good candidates for surgery Patients with lesions and/or temporal lobe epilepsy should be referred early Neocortical (extratemporal) and non-lesional surgery is currently challenging