Epilepsy surgery trends in the United States, 1990-2008

UCSF Epilepsy Center, University of California, San Francisco, CA, USA.
Neurology (Impact Factor: 8.29). 03/2012; 78(16):1200-6. DOI: 10.1212/WNL.0b013e318250d7ea
Source: PubMed


To examine national time trends of resective surgery for the treatment of medically refractory epilepsy before and after Class I evidence demonstrating its efficacy and subsequent practice guidelines recommending early surgical evaluation.
We performed a population-based cohort study with time trends of patients admitted to US hospitals for medically refractory focal epilepsy between 1990 and 2008 who did or did not undergo lobectomy, as reported in the Nationwide Inpatient Sample.
Weighted data revealed 112,026 hospitalizations for medically refractory focal epilepsy and 6,653 resective surgeries (lobectomies and partial lobectomies) from 1990 to 2008. A trend of increasing hospitalizations over time was not accompanied by an increase in surgeries, producing an overall trend of decreasing surgery rates (F = 13.6, p < 0.01). Factors associated with this trend included a decrease in epilepsy hospitalizations at the highest-volume epilepsy centers, and increased hospitalizations to lower-volume hospitals that were found to be less likely to perform surgery. White patients were more likely to have surgery than racial minorities (relative risk [RR], 1.13; 95% confidence interval [CI], 1.10-1.17), and privately insured individuals were more likely to receive lobectomy than those with Medicaid or Medicare (RR, 1.28; 95% CI, 1.25-1.30).
Despite Class I evidence and subsequent practice guidelines, the utilization of lobectomy has not increased from 1990 to 2008. Surgery continues to be heavily underutilized as a treatment for epilepsy, with significant disparities by race and insurance coverage. Patients who are medically refractory after failing 2 antiepileptic medications should be referred to a comprehensive epilepsy center for surgical evaluation.

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Available from: Dario J. Englot, Sep 24, 2014
    • "Additional factors might include physician attitude and patient preference. Hospital characteristics revealed most ECoG cases occurring at urban teaching hospitals, which might have been anticipated, and is compatible with other trends in epilepsy surgery [8]. Similarly, hospital size also predicted ECoG, with larger hospitals more likely to provide the procedure. "
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    ABSTRACT: Invasive electrocorticography (ECoG) is used in patients when it is difficult to localize epileptogenic foci for potential surgical resection. As MR neuroimaging has improved over the past decade, we hypothesized the utilization of ECoG diminishing over time. Using the USA Nationwide Inpatient Sample, we collected demographic and complication data on patients receiving ECoG over the years 1988-2008 and compared this to patients with medically refractory epilepsy during the same time period. A total of 695 cases using extraoperative ECoG were identified, corresponding to 3528 cases nationwide and accounting for 1.1% of patients with refractory epilepsy from 1988-2008. African Americans were less likely to receive ECoG than whites, as were patients with government insurance in comparison to those with private insurance. Large, urban, and academic hospitals were significantly more likely to perform ECoG than smaller, rural, and private practice institutions. The most frequent complication was cerebrospinal fluid leak (11.7%) and only one death was reported from the entire cohort, corresponding to an estimated six patients nationally. Invasive ECoG is a relatively safe procedure offered to a growing number of patients with refractory epilepsy each year. However, these data suggest the presence of demographic disparities in those patients receiving ECoG, possibly reflecting barriers due to race and socioeconomic status. Among patients with nonlocalized seizures, ECoG often represents their only hope for surgical treatment. We therefore must further examine the indications and efficacy of ECoG, and more work must be done to understand if and why ECoG is preferentially performed in select socioeconomic groups. Copyright © 2014 Elsevier Ltd. All rights reserved.
    No preview · Article · Feb 2015 · Journal of Clinical Neuroscience
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    • "Two randomized controlled trails have established that in selected patients with drug-resistant epilepsies (DRE) surgical treatment is superior to continued medical treatment [1] [2]. Yet, epilepsy surgery (ES) not only remains one of the most underutilized of all accepted medical interventions [3], but there has also been a decrease in referrals for ES in recent years in high-income countries like Sweden [4], United States [5] and United Kingdom [6]. In contrast, in low-and middle-income countries (LAMIC), where 80% of people with epilepsy worldwide reside, the demand for ES far exceeds its availability [7]. "
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    ABSTRACT: Epilepsy surgery (ES) not only remains one of the most underutilized of all accepted medical interventions, but there has also been a decrease in referrals for ES in recent years in high-income countries. We undertook this study to determine the temporal trends of ES and its current state in India. We asked the directors of epilepsy centers across India to complete an online questionnaire about the number and type of ES procedures carried out from 1995 or commencement of the program till December 2012. During the 18-year period, a total of 4252 ES have been undertaken. On an average, 420 ES were being carried out each year in India. Three-fourths of resective surgeries involved the temporal lobe. Although majority of patients were selected for ES by noninvasive strategies, 13 centers had performed long-term invasive EEG monitoring to select complex cases. In between 1995-2000 and 2007-2012, the number of ES carried out in India registered an increase by three-fold. A steadily increasing number of eligible patients with drug-resistant epilepsy in India are undergoing ES in recent years. This temporal trend of ES in India is in contrast to the recent experience of high-income countries. Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
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    ABSTRACT: Radiosurgical treatment of intractable epilepsy has emerged as a noninvasive alternative to resection. Although gamma knife surgery (GKS) reportedly is effective when the radiation dose is sufficient to cause a destructive reaction in the targeted medial temporal lobe, the optimal target area and dose distribution are largely unknown. Some investigators have suggested that focused irradiation from a nondestructive dose is also effective. In this article the authors report two cases of medial temporal lobe epilepsy in which the patients underwent GKS performed using a 50% marginal dose of 18 Gy covering the amygdala. hippocampal head and body, and parahippocampal gyrus. In both cases this procedure failed to control seizures. Both patients became seizure free after undergoing anterior temporal lobectomy 30 and 16 months, respectively, after radiosurgery.
    Preview · Article · Dec 2001 · Journal of Neurosurgery
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