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Meta-Analysis
. 2022 Dec;63(12):3020-3036.
doi: 10.1111/epi.17413. Epub 2022 Oct 20.

Drug-resistant epilepsy and mortality-Why and when do neuromodulation and epilepsy surgery reduce overall mortality

Sylvain Rheims  1   2 , Mickael R Sperling  3 , Philippe Ryvlin  4
Affiliations
Meta-Analysis

Drug-resistant epilepsy and mortality-Why and when do neuromodulation and epilepsy surgery reduce overall mortality

Sylvain Rheims et al. Epilepsia. 2022 Dec.

Abstract

Patients with drug-resistant epilepsy have an increased mortality rate, with the majority of deaths being epilepsy related and 40% due to sudden unexpected death in epilepsy (SUDEP). The impact of epilepsy surgery on mortality has been investigated since the 1970s, with increased interest in this field during the past 15 years. We systematically reviewed studies investigating mortality rate in patients undergoing epilepsy surgery or neuromodulation therapies. The quality of available evidence proved heterogenous and often limited by significant methodological issues. Perioperative mortality following epilepsy surgery was found to be <1%. Meta-analysis of studies that directly compared patients who underwent surgery to those not operated following presurgical evaluation showed that the former have a two-fold lower risk of death and a three-fold lower risk of SUDEP compared to the latter (odds ratio [OR] 0.40, 95% confidence interval [CI]: 0.29-0.56; p < .0001 for overall mortality and OR 0.32, 95% CI: 0.18-0.57; p < .001 for SUDEP). Limited data are available regarding the risk of death and SUDEP in patients undergoing neuromodulation therapies, although some evidence indicates that vagus nerve stimulation might be associated with a lower risk of SUDEP. Several key questions remain to be addressed in future studies, considering the need to better inform patients about the long-term benefit-risk ratio of epilepsy surgery. Dedicated long-term prospective studies will thus be required to provide more personalized information on the impact of surgery and/or neuromodulation on the risk of death and SUDEP.

Keywords: SUDEP; deep brain stimulation; epilepsy; epilepsy surgery; mortality; vagus nerve stimulation.

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Conflict of interest statement

SSR has received speaker, consulting fees, or both, from UCB Pharma, EISAI, GW Pharma, Idiorsia, Livanova, and Arvelle Therapeutics/Angelini Pharma MRS has received compensation for speaking at CME programs from Medscape, Projects for Knowledge, International Medical Press, and Eisai. He has consulted for Medtronic, Neurelis, and Johnson & Johnson. He has received research support to Thomas Jefferson University from Eisai, Medtronic, Neurelis, SK Life Science, Takeda, Xenon, Cerevel, UCB Pharma, Janssen, Equilibre, and Engage Pharmaceuticals. He has received royalties from Oxford University Press and Cambridge University Press. PR has received speaker fees from Livanova, UCB Pharma, EISAI, and GW Pharma.

Figures

FIGURE 1
FIGURE 1
Flow diagrams of studies
FIGURE 2
FIGURE 2
Odds ratio for all causes of death in patients undergoing epilepsy surgery vs those who were not operated (control group). The analyses were performed using Mantel–Haenszel exact method (M‐H) without zero‐cell corrections for a stratified odds ratio (OR) and associated 95% confidence interval (CI). I 2, point estimates of Higgins I 2 with CI
FIGURE 3
FIGURE 3
Odds ratio (OR) for patients with sudden unexpected death in epilepsy (SUDEP) in patients undergoing epilepsy surgery vs those who were not operated (control group). The analyses were performed using Mantel–Haenszel exact method (M‐H) without zero‐cell corrections for a stratified OR and associated 95% confidence interval (CI). I 2, point estimates of Higgins I 2 with CI
FIGURE 4
FIGURE 4
Odds ratio (OR) for all causes of death (A) and sudden unexpected death in epilepsy (SUDEP) (B) in patients who were seizure‐free following epilepsy surgery vs those who were not seizure‐free. The analyses were performed using Mantel–Haenszel exact method (M‐H) without zero‐cell corrections for a stratified OR and associated 95% confidence interval (CI). I 2, point estimates of Higgins I 2 with CI
See this image and copyright information in PMC

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