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      Testing an online screening tool for epilepsy surgery evaluation Translated title: Testando uma ferramenta de triagem online para a avaliação de cirurgia de epilepsia

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          Abstract

          Background  Epilepsy surgery is recognized for its effectiveness in controlling seizures in a significant number of patients with drug-resistant epilepsy. Despite this, there remains a notable deficiency in referring these patients for video-electroencephalogram (EEG) monitoring and surgical evaluation. Addressing this gap, the Canadian Appropriateness of Epilepsy Surgery (CASES), an online tool for epilepsy surgery evaluation ( www.epilepsycases.com ), was developed to aid physicians in the referral process of patients with refractory epilepsy to surgical assessments.

          Objective  The present study aimed to evaluate the utility of CASES in identifying candidates for epilepsy surgery, thereby facilitating clinical decision-making for patients with drug-resistant epilepsy.

          Methods  A cross-sectional analysis was conducted using the CASES platform to assess surgical candidacy among individuals with epilepsy. Participants were selected among those receiving care at the Epilepsy Clinic of the Neurology Service, Hospital de Clínicas de Porto Alegre, Brazil, over a 3-month period. The study cohort included 211 patients. Data were systematically extracted from patient medical records or collected during clinical appointments.

          Results  Of the evaluated cohort, 59.6% were identified as potential candidates for video-EEG monitoring and subsequent surgical evaluation. Factors significantly associated with recommendations for video-EEG and surgical assessment included seizure frequency, the number of antiseizure medications (ASMs) trialed, and the occurrence of drug-related adverse effects.

          Conclusion  The CASES showed significant potential in guiding recommendations for video-EEG monitoring and facilitating referrals for epilepsy surgery. This tool may not only enhance patient treatments and outcomes but also contribute to cost savings in epilepsy management in both the short and long term.

          Resumo

          Antecedentes  A cirurgia de epilepsia é reconhecida por sua eficácia no controle de crises em um número significativo de pacientes com epilepsia resistente a medicamentos. Apesar disso, persiste uma deficiência notável na referência desses pacientes para monitoramento por vídeo-eletroencefalograma (EEG) e avaliação cirúrgica. Para avaliar essa lacuna, a Adequação Canadense da Cirurgia de Epilepsia (Canadian Appropriateness of Epilepsy Surgery CASES, na sigla em inglês) , uma ferramenta online para avaliação de cirurgia de epilepsia ( www.epilepsycases.com ), foi desenvolvida para auxiliar médicos no processo de selecionar pacientes com epilepsia refratária para avaliações cirúrgicas.

          Objetivo  Avaliar a utilidade da CASES na identificação de candidatos para cirurgia de epilepsia, facilitando assim os processos de decisão terapêutica para pacientes com epilepsia resistente a medicamentos.

          Métodos  Foi realizada uma análise transversal usando a plataforma CASES para estimar a necessidade de avaliação cirúrgica entre indivíduos com epilepsia. Os participantes foram selecionados dentre aqueles em atendimento na Clínica de Epilepsia do Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, durante um período de 3 meses. O estudo incluiu uma coorte de 211 pacientes. Os dados foram sistematicamente extraídos dos prontuários médicos dos pacientes ou coletados durante consultas clínicas.

          Resultados  Da coorte avaliada, 59,6% foram identificados como potenciais candidatos para monitoramento por vídeo-EEG e subsequente avaliação cirúrgica. Fatores significativamente associados com recomendações para vídeo-EEG e avaliação cirúrgica incluíram a frequência de crises, o número de drogas anticrise (DACs) testadas e a ocorrência de efeitos adversos relacionados aos medicamentos.

          Conclusão  A CASES mostrou um potencial significativo em orientar as recomendações para monitoramento por vídeo-EEG e facilitar o encaminhamento de pacientes para avaliação cirúrgica. Ferramentas como essas podem não apenas melhorar os tratamentos e resultados dos pacientes, mas também contribuir para economias de custo no manejo da epilepsia a curto e longo prazo.

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          Most cited references45

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          Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009.

          Anne T Berg, Samuel F. Berkovic, Martin J Brodie … (2010)
          The International League Against Epilepsy (ILAE) Commission on Classification and Terminology has revised concepts, terminology, and approaches for classifying seizures and forms of epilepsy. Generalized and focal are redefined for seizures as occurring in and rapidly engaging bilaterally distributed networks (generalized) and within networks limited to one hemisphere and either discretely localized or more widely distributed (focal). Classification of generalized seizures is simplified. No natural classification for focal seizures exists; focal seizures should be described according to their manifestations (e.g., dyscognitive, focal motor). The concepts of generalized and focal do not apply to electroclinical syndromes. Genetic, structural-metabolic, and unknown represent modified concepts to replace idiopathic, symptomatic, and cryptogenic. Not all epilepsies are recognized as electroclinical syndromes. Organization of forms of epilepsy is first by specificity: electroclinical syndromes, nonsyndromic epilepsies with structural-metabolic causes, and epilepsies of unknown cause. Further organization within these divisions can be accomplished in a flexible manner depending on purpose. Natural classes (e.g., specific underlying cause, age at onset, associated seizure type), or pragmatic groupings (e.g., epileptic encephalopathies, self-limited electroclinical syndromes) may serve as the basis for organizing knowledge about recognized forms of epilepsy and facilitate identification of new forms.
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            A randomized, controlled trial of surgery for temporal-lobe epilepsy.

            Samuel Wiebe, Warren Blume, John Girvin … (2001)
            Randomized trials of surgery for epilepsy have not been conducted, because of the difficulties involved in designing and implementing feasible studies. The lack of data supporting the therapeutic usefulness of surgery precludes making strong recommendations for patients with epilepsy. We conducted a randomized, controlled trial to assess the efficacy and safety of surgery for temporal-lobe epilepsy. Eighty patients with temporal-lobe epilepsy were randomly assigned to surgery (40 patients) or treatment with antiepileptic drugs for one year (40 patients). Optimal medical therapy and primary outcomes were assessed by epileptologists who were unaware of the patients' treatment assignments. The primary outcome was freedom from seizures that impair awareness of self and surroundings. Secondary outcomes were the frequency and severity of seizures, the quality of life, disability, and death. At one year, the cumulative proportion of patients who were free of seizures impairing awareness was 58 percent in the surgical group and 8 percent in the medical group (P<0.001). The patients in the surgical group had fewer seizures impairing awareness and a significantly better quality of life (P<0.001 for both comparisons) than the patients in the medical group. Four patients (10 percent) had adverse effects of surgery. One patient in the medical group died. In temporal-lobe epilepsy, surgery is superior to prolonged medical therapy. Randomized trials of surgery for epilepsy are feasible and appear to yield precise estimates of treatment effects.
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              Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial.

              Jerome Engel, Michael McDermott, Samuel Wiebe … (2012)
              Despite reported success, surgery for pharmacoresistant seizures is often seen as a last resort. Patients are typically referred for surgery after 20 years of seizures, often too late to avoid significant disability and premature death. We sought to determine whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management in controlling seizures and improving quality of life (QOL). The Early Randomized Surgical Epilepsy Trial (ERSET) is a multicenter, controlled, parallel-group clinical trial performed at 16 US epilepsy surgery centers. The 38 participants (18 men and 20 women; aged ≥12 years) had mesial temporal lobe epilepsy (MTLE) and disabling seizues for no more than 2 consecutive years following adequate trials of 2 brand-name AEDs. Eligibility for anteromesial temporal resection (AMTR) was based on a standardized presurgical evaluation protocol. Participants were randomized to continued AED treatment or AMTR 2003-2007, and observed for 2 years. Planned enrollment was 200, but the trial was halted prematurely due to slow accrual. Receipt of continued AED treatment (n = 23) or a standardized AMTR plus AED treatment (n = 15). In the medical group, 7 participants underwent AMTR prior to the end of follow-up and 1 participant in the surgical group never received surgery. The primary outcome variable was freedom from disabling seizures during year 2 of follow-up. Secondary outcome variables were health-related QOL (measured primarily by the 2-year change in the Quality of Life in Epilepsy 89 [QOLIE-89] overall T-score), cognitive function, and social adaptation. Zero of 23 participants in the medical group and 11 of 15 in the surgical group were seizure free during year 2 of follow-up (odds ratio = ∞; 95% CI, 11.8 to ∞; P < .001). In an intention-to-treat analysis, the mean improvement in QOLIE-89 overall T-score was higher in the surgical group than in the medical group but this difference was not statistically significant (12.6 vs 4.0 points; treatment effect = 8.5; 95% CI, -1.0 to 18.1; P = .08). When data obtained after surgery from participants in the medical group were excluded, the effect of surgery on QOL was significant (12.8 vs 2.8 points; treatment effect = 9.9; 95% CI, 2.2 to 17.7; P = .01). Memory decline (assessed using the Rey Auditory Verbal Learning Test) occurred in 4 participants (36%) after surgery, consistent with rates seen in the literature; but the sample was too small to permit definitive conclusions about treatment group differences in cognitive outcomes. Adverse events included a transient neurologic deficit attributed to a magnetic resonance imaging-identified postoperative stroke in a participant who had surgery and 3 cases of status epilepticus in the medical group. Among patients with newly intractable disabling MTLE, resective surgery plus AED treatment resulted in a lower probability of seizures during year 2 of follow-up than continued AED treatment alone. Given the premature termination of the trial, the results should be interpreted with appropriate caution. clinicaltrials.gov Identifier: NCT00040326.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Arq Neuropsiquiatr
                Journal ID (iso-abbrev): Arq Neuropsiquiatr
                Journal ID (doi): 10.1055/s-00054595
                Title: Arquivos de Neuro-Psiquiatria
                Publisher: Thieme Revinter Publicações Ltda. (Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil )
                ISSN (Print): 0004-282X
                ISSN (Electronic): 1678-4227
                Publication date (Electronic): 11 November 2024
                Publication date Collection: October 2024
                Publication date PMC-release: 1 November 2024
                Volume: 82
                Issue: 10
                Pages: 1-8
                Affiliations
                [1 ]Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Programa de Pós-Graduação em Medicina: Ciências Médicas, Porto Alegre RS, Brazil.
                [2 ]Hospital de Clínicas de Porto Alegre, Departamento de Neurologia, Porto Alegre RS, Brazil.
                [3 ]Hospital de Clínicas de Porto Alegre, Centro de Tratamento de Epilepsias Refratárias, Porto Alegre RS, Brazil.
                [4 ]Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Serviço de Neurocirurgia, Porto Alegre RS, Brazil.
                [5 ]Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Experimental, Laboratório Basic Research and Advanced Investigations in Neurosciences (BRAIN), Porto Alegre RS, Brazil.
                Author notes
                Address for correspondence Marino Muxfeldt Bianchin mbianchin@ 123456hcpa.edu.br
                Author information
                http://orcid.org/0009-0009-8511-5870
                http://orcid.org/0000-0002-8405-0966
                http://orcid.org/0000-0003-1952-9222
                http://orcid.org/0009-0000-8852-8990
                http://orcid.org/0000-0003-0562-9513
                http://orcid.org/0000-0002-4611-5562
                http://orcid.org/0000-0001-8345-6713
                Article
                Publisher ID: ANP-24-0040 Publisher ID: s00441791659
                DOI: 10.1055/s-0044-1791659
                PMC ID: 11555308
                PubMed ID: 39529325
                SO-VID: 1b409547-fe12-4e59-a9f6-bc5a431bbeba
                Copyright © The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ )
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 24 February 2024
                Date accepted : 20 July 2024
                Funding
                Support The authors declare that they have received financial support from Fundo de Incentivo à Pesquisa (FIPE), Hospital de Clínicas de Porto Alegre, to conduct the present study.
                Categories
                Subject: Original Article
                Series title: October

                Keywords: clinical decision-making,health care costs,electroencephalography,tomada de decisão clínica,custos de cuidados de saúde,eletroencefalografia
                Data availability:
                Keywords: clinical decision-making, health care costs, electroencephalography, tomada de decisão clínica, custos de cuidados de saúde, eletroencefalografia

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