Epilepsy Surgery: A Story of Diminishing Returns Over Time? Think Differently and Think Again

Beyond Seizure Freedom: Dissecting Long-Term Seizure Control After Surgical Resection for Drug-Resistant Epilepsy Hsieh JK, Pucci FG, Sundar SJ, Kondylis E, Sharma A, Sheikh SR, Vegh D, Moosa AN, Gupta A, Najm I, Rammo R, Bingaman W, Jehi L. Epilepsia. 2023;64(1):103-113. doi:10.1111/epi.17445 Objective: This study was undertaken to better understand the long-term palliative and disease-modifying effects of surgical resection beyond seizure freedom, including frequency reduction and both late recurrence and remission, in patients with drug-resistant epilepsy. Methods: This retrospective database-driven cohort study included all patients with >9 years of follow-up at a single high-volume epilepsy center. We included patients who underwent lobectomy, multilobar resection, or lesionectomies for drug-resistant epilepsy; we excluded patients who underwent hemispherectomies. Our main outcomes were (1) reduction in frequency of disabling seizures (at 6 months, each year up to 9 years postoperatively, and at last follow-up), (2) achievement of seizure remission (>6 months, >1 year, and longest duration), and (3) seizure freedom at last follow-up. Results: We included 251 patients; 234 (93.2%) achieved 6 months and 232 (92.4%) experienced 1 year of seizure freedom. Of these, the average period of seizure freedom was 10.3 years. A total of 182 (72.5%) patients were seizure-free at last follow-up (defined as >1 year without seizures), with a median 11.9 years since remission. For patients not completely seizure-free, the mean seizure frequency reduction at each time point was 76.2% and ranged from 66.6% to 85.0%. Patients decreased their number of antiseizure medications on average by.58, and 53 (21.2%) patients were on no antiseizure medication at last follow-up. Nearly half (47.1%) of those seizure-free at last follow-up were not seizure-free immediately postoperatively. Significance: Patients who continue to have seizures after resection often have considerable reductions in seizure frequency, and many are able to achieve seizure freedom in a delayed manner.