Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy

Abstract

Epilepsy surgery is the treatment of choice for patients with drug-resistant seizures. A timely evaluation for surgical candidacy can be life-saving for patients who are identified as appropriate surgical candidates, and may also enhance the care of nonsurgical candidates through improvement in diagnosis, optimization of therapy, and treatment of comorbidities. Yet, referral for surgical evaluations is often delayed while palliative options are pursued, with significant adverse consequences due to increased morbidity and mortality associated with intractable epilepsy. The Surgical Therapies Commission of the International League Against Epilepsy (ILAE) sought to address these clinical gaps and clarify when to initiate a surgical evaluation. We conducted a Delphi consensus process with 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. After three rounds of Delphi surveys, evaluating 51 unique scenarios, we reached the following Expert Consensus Recommendations: (1) Referral for a surgical evaluation should be offered to every patient with drug-resistant epilepsy (up to 70 years of age), as soon as drug resistance is ascertained, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type (including epileptic encephalopathies), localization, and comorbidities (including severe psychiatric comorbidity like psychogenic nonepileptic seizures [PNES] or substance abuse) if patients are cooperative with management; (2) A surgical referral should be considered for older patients with drug-resistant epilepsy who have no surgical contraindication, and for patients (adults and children) who are seizure-free on 1-2 antiseizure medications (ASMs) but have a brain lesion in noneloquent cortex; and (3) referral for surgery should not be offered to patients with active substance abuse who are noncooperative with management. We present the Delphi consensus results leading up to these Expert Consensus Recommendations and discuss the data supporting our conclusions. High level evidence will be required to permit creation of clinical practice guidelines.

Keywords: drug-resistant epilepsy; epilepsy surgery; health care delivery; neuromodulation; public health; treatment.

Figure 1

legend: Delphi summary of 51 ratings based on A)-demographic factors, B) clinical factors, and C) treatment factors. Dark blue shades are for proportions where response was to always ro likely refer for presurgical evaluation; light blue for unsure, and green for never or unlikely. SES= Socioeconomic status; ASM= antiseizure medication; DRE= drug resistant epilepsy; PNES= psychogenic non-epileptic seizures; Rx= Treatment. *seizure free on 1–2 ASMs, lesion in non-eloquent cortex ⁺and no surgical contraindications.

Figure 1

legend: Delphi summary of 51 ratings based on A)-demographic factors, B) clinical factors, and C) treatment factors. Dark blue shades are for proportions where response was to always ro likely refer for presurgical evaluation; light blue for unsure, and green for never or unlikely. SES= Socioeconomic status; ASM= antiseizure medication; DRE= drug resistant epilepsy; PNES= psychogenic non-epileptic seizures; Rx= Treatment. *seizure free on 1–2 ASMs, lesion in non-eloquent cortex ⁺and no surgical contraindications.

Figure 1

legend: Delphi summary of 51 ratings based on A)-demographic factors, B) clinical factors, and C) treatment factors. Dark blue shades are for proportions where response was to always ro likely refer for presurgical evaluation; light blue for unsure, and green for never or unlikely. SES= Socioeconomic status; ASM= antiseizure medication; DRE= drug resistant epilepsy; PNES= psychogenic non-epileptic seizures; Rx= Treatment. *seizure free on 1–2 ASMs, lesion in non-eloquent cortex ⁺and no surgical contraindications.

Figure 1

legend: Delphi summary of 51 ratings based on A)-demographic factors, B) clinical factors, and C) treatment factors. Dark blue shades are for proportions where response was to always ro likely refer for presurgical evaluation; light blue for unsure, and green for never or unlikely. SES= Socioeconomic status; ASM= antiseizure medication; DRE= drug resistant epilepsy; PNES= psychogenic non-epileptic seizures; Rx= Treatment. *seizure free on 1–2 ASMs, lesion in non-eloquent cortex ⁺and no surgical contraindications.