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Original Contribution
December 3, 2008

Epilepsy Surgery for Pharmacoresistant Temporal Lobe Epilepsy: A Decision Analysis

Author Affiliations

Author Affiliations: Departments of Neurology (Drs Choi and Gilliam) and Neurological Surgery (Dr Goodman), Columbia University, and Department of Health Policy and Management (Dr Muennig), Columbia University Mailman School of Public Health, New York, New York; Department of Community Health and Prevention, Drexel University School of Public Health, Philadelphia, Pennsylvania (Dr Sell); National Center for Public Health Informatics, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lenert); and Department of Medicine, Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts (Dr Wong). Dr Gilliam is now with the Department of Neurology, Weill Cornell Medical College, New York, NY.

JAMA. 2008;300(21):2497-2505. doi:10.1001/jama.2008.771

Context Patients with pharmacoresistant epilepsy have increased mortality compared with the general population, but patients with pharmacoresistant temporal lobe epilepsy who meet criteria for surgery and who become seizure-free after anterior temporal lobe resection have reduced excess mortality vs those with persistent seizures.

Objective To quantify the potential survival benefit of anterior temporal lobe resection for patients with pharmacoresistant temporal lobe epilepsy vs continued medical management.

Design Monte Carlo simulation model that incorporates possible surgical complications and seizure status, with 10 000 runs. The model was populated with health-related quality-of-life data obtained directly from patients and data from the medical literature. Insufficient data were available to assess gamma-knife radiosurgery or vagal nerve stimulation.

Main Outcome Measures Life expectancy and quality-adjusted life expectancy.

Results Compared with medical management, anterior temporal lobe resection for a 35-year-old patient with an epileptogenic zone identified in the anterior temporal lobe would increase survival by 5.0 years (95% CI, 2.1-9.2) with surgery preferred in 100% of the simulations. Anterior temporal lobe resection would increase quality-adjusted life expectancy by 7.5 quality-adjusted life-years (95%, CI, −0.8 to 17.4) with surgery preferred in 96.5% of the simulations, primarily due to increased years spent without disabling seizures, thereby reducing seizure-related excess mortality and improving quality of life. The results were robust to sensitivity analyses.

Conclusion The decision analysis model suggests that on average anterior temporal lobe resection should provide substantial gains in life expectancy and quality-adjusted life expectancy for surgically eligible patients with pharmacoresistant temporal lobe epilepsy compared with medical management.