Abstract：
OBJECTIVE: Many patients pursue epilepsy surgery with the hope of reducing or stopping anti-seizure medications (ASMs), in addition to reducing their seizure frequency and severity. While ASM decrease is primarily driven by surgical outcomes and patient preferences, preoperative estimates of meaningful ASM reduction or discontinuation are uncertain, especially when accounting for the various forking paths possible following intracranial EEG (iEEG), including resection, neuromodulation, or even the absence of further surgery. Here, we characterize in detail the ASM reduction in a large cohort of patients who underwent iEEG, facilitating proactive, early counseling for a complicated cohort considering surgical treatment.
METHODS: We identified a multi-institutional cohort of patients who underwent iEEG between 2001 and 2022, with a minimum of two years follow-up. The total number of ASMs prescribed immediately prior to surgery, choice of investigation modality, and subsequent surgical treatment were extracted for each patient. Primary endpoints included decreases in ASM counts from preoperative baseline to various follow-up intervals.
RESULTS: A total of 284 patients were followed for a median of 6.0 (range 2,22) years after iEEG surgery. Patients undergoing resection saw an average reduction of ∼ 0.5 ASMs. Patients undergoing neuromodulation saw no decrease and trended towards requiring increased ASM usage during long-term follow-up. Only patients undergoing resection were likely to completely discontinue all ASMs, with an increasing probability over time approaching ∼ 10 %. Up to half of resection patients saw ASM decreases, which was largely stable during long-term follow-up, whereas only a quarter of neuromodulation patients saw a reduction, though their ASM reduction decreased over time.
CONCLUSIONS: With the increasing use of stereotactic EEG and non-curative neuromodulation procedures, realistic estimates of ASM reduction and discontinuation should be considered preoperatively. Almost half of patients undergoing resective surgery can expect to reduce their ASMs, though only a tenth can expect to discontinue ASMs completely. If reduction is not seen early, it likely does not occur later during long-term follow-up. Less than a third of patients undergoing neuromodulation can expect ASM reduction, and instead most may require increased usage during long-term follow-up.
METHODS: We identified a multi-institutional cohort of patients who underwent iEEG between 2001 and 2022, with a minimum of two years follow-up. The total number of ASMs prescribed immediately prior to surgery, choice of investigation modality, and subsequent surgical treatment were extracted for each patient. Primary endpoints included decreases in ASM counts from preoperative baseline to various follow-up intervals.
RESULTS: A total of 284 patients were followed for a median of 6.0 (range 2,22) years after iEEG surgery. Patients undergoing resection saw an average reduction of ∼ 0.5 ASMs. Patients undergoing neuromodulation saw no decrease and trended towards requiring increased ASM usage during long-term follow-up. Only patients undergoing resection were likely to completely discontinue all ASMs, with an increasing probability over time approaching ∼ 10 %. Up to half of resection patients saw ASM decreases, which was largely stable during long-term follow-up, whereas only a quarter of neuromodulation patients saw a reduction, though their ASM reduction decreased over time.
CONCLUSIONS: With the increasing use of stereotactic EEG and non-curative neuromodulation procedures, realistic estimates of ASM reduction and discontinuation should be considered preoperatively. Almost half of patients undergoing resective surgery can expect to reduce their ASMs, though only a tenth can expect to discontinue ASMs completely. If reduction is not seen early, it likely does not occur later during long-term follow-up. Less than a third of patients undergoing neuromodulation can expect ASM reduction, and instead most may require increased usage during long-term follow-up.
摘要：
目的：许多患者追求癫痫手术，希望减少或停止抗癫痫药物（ASM），除了降低他们的癫痫发作频率和严重程度。虽然ASM下降主要是由手术结果和患者偏好驱动的，术前估计有意义的ASM减少或中止是不确定的，尤其是在考虑颅内脑电图（iEEG）之后可能出现的各种分叉路径时，包括切除,神经调节,甚至没有进一步的手术。这里,我们详细描述了接受iEEG的大量患者的ASM减少，促进积极主动，考虑手术治疗的复杂队列的早期咨询。
方法：我们确定了2001年至2022年间接受iEEG治疗的多机构患者队列，至少随访两年。手术前立即处方的ASM总数，调查方式的选择，对每位患者进行手术治疗。主要终点包括ASM计数从术前基线到各种随访间隔的减少。
结果：总共284例患者在iEEG手术后中位随访6.0年（2,22年）。在长期随访期间，接受切除的患者平均减少了约0.5ASM。接受神经调节的患者没有减少，并且倾向于需要增加ASM的使用。只有接受切除术的患者才可能完全停止所有ASM，随着时间的推移，概率越来越高，接近10%。多达一半的切除患者看到ASM下降，在长期随访期间基本稳定，而只有四分之一的神经调节患者看到了减少，虽然他们的ASM减少随着时间的推移而减少。
结论：随着立体定向脑电图和非治疗性神经调节程序的使用越来越多，术前应考虑ASM减少和终止的实际估计。几乎一半接受切除手术的患者可以期望减少他们的ASM，虽然只有十分之一的人会完全停止ASM。如果没有及早看到减少，在长期随访过程中，它可能不会在以后发生。不到三分之一的接受神经调节的患者可以预期ASM减少，相反，大多数可能需要在长期随访期间增加使用量。
方法：我们确定了2001年至2022年间接受iEEG治疗的多机构患者队列，至少随访两年。手术前立即处方的ASM总数，调查方式的选择，对每位患者进行手术治疗。主要终点包括ASM计数从术前基线到各种随访间隔的减少。
结果：总共284例患者在iEEG手术后中位随访6.0年（2,22年）。在长期随访期间，接受切除的患者平均减少了约0.5ASM。接受神经调节的患者没有减少，并且倾向于需要增加ASM的使用。只有接受切除术的患者才可能完全停止所有ASM，随着时间的推移，概率越来越高，接近10%。多达一半的切除患者看到ASM下降，在长期随访期间基本稳定，而只有四分之一的神经调节患者看到了减少，虽然他们的ASM减少随着时间的推移而减少。
结论：随着立体定向脑电图和非治疗性神经调节程序的使用越来越多，术前应考虑ASM减少和终止的实际估计。几乎一半接受切除手术的患者可以期望减少他们的ASM，虽然只有十分之一的人会完全停止ASM。如果没有及早看到减少，在长期随访过程中，它可能不会在以后发生。不到三分之一的接受神经调节的患者可以预期ASM减少，相反，大多数可能需要在长期随访期间增加使用量。
