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December 2009

Surgery Is the Best Option for Intractable Unilateral Mesial Temporal Epilepsy

Arch Neurol. 2009;66(12):1554-1556. doi:10.1001/archneurol.2009.276


Epilepsy Surgery for Pharmacoresistant Temporal Lobe Epilepsy: A Decision Analysis

Hyunmi Choi, MD, MS; Randall L. Sell, ScD; Leslie Lenert, MD, MS; Peter Muennig, MD, MPH; Robert R. Goodman, MD, PhD; Frank G. Gilliam, MD, MPH; John B. Wong, MD

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.

JAMA. 2008;300(21):2497-2505.