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Strategies for reoperation after comprehensive epilepsy surgery
1Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA. tschwartz1@nyc.rr.com
Journal of Neurosurgery
|October 13, 2001
Summary
Reoperation for epilepsy after initial surgery yields lower seizure freedom rates than previously reported, especially with comprehensive evaluations. Palliative surgery, like vagus nerve stimulator (VNS) placement, may offer significant seizure reduction when curative resections fail.
Area of Science:
- Neurosurgery
- Epileptology
- Medical Imaging
Background:
- Previous studies reported favorable seizure control after reoperation for epilepsy surgery.
- These earlier reports involved patients from before the widespread use of magnetic resonance (MR) imaging and often lacked intracranial monitoring or utilized subtotal resections.
Purpose of the Study:
- To test the hypothesis that reoperation for recurrent seizures, following a more thorough initial diagnostic workup and surgical intervention, would not achieve the previously reported high success rates.
- To evaluate the efficacy of reoperation for medically intractable epilepsy in the contemporary surgical era.
Main Methods:
- A consecutive series of 27 patients undergoing a second surgery for medically intractable epilepsy at Yale-New Haven Hospital were reviewed, with a minimum 1-year follow-up post-second surgery.
- All patients underwent a standardized protocol including preoperative MR imaging, a low threshold for invasive monitoring, and, when indicated, radical amygdalohippocampectomy.
- Six patients (22%) received palliative surgery (corpus callostomy or vagus nerve stimulator [VNS] placement); the remaining 21 underwent resective surgery.
Main Results:
- Only four of the 21 patients (19%) who underwent resective reoperation achieved seizure freedom.
- Common reasons for treatment failure included dual pathology, recurrent tumors, limited resection for functional preservation, extensive developmental abnormalities, and electrographic sampling errors.
- Successful outcomes were associated with recurrent tumor removal, completion hemispherectomy, or correction of sampling errors through repeated invasive monitoring.
- Five of six (83%) palliative surgeries resulted in >50% seizure frequency reduction.
Conclusions:
- Reoperation for recurrent seizures after epilepsy surgery has a significantly lower likelihood of cure than previously suggested, particularly when aggressive preoperative evaluation and resection are employed.
- Intentionally palliative surgical options, such as vagus nerve stimulator (VNS) implantation, should be considered for patients who do not achieve seizure reduction after initial epilepsy surgery.