epilepsy surgery evaluation the perspective june 4, 2016 ... · pdf filelow frequency es in...
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Epilepsy Surgery EvaluationThe Epileptologist’s Perspective
June 4, 20165th Annual International Epilepsy SymposiumLexington, KY
Stephan Schuele, MD, MPH, FAAN, FACNS
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Stephan U. Schuele
Disclosures
Speaker Bureau: Eisai, Sunovion
No COI related to the content of this talk.
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Stephan U. Schuele
10 Questions you may get askedby your fellow July 1st
1. What’s your Concept of Epilepsy Surgery ?
2. What do you do with AED after Surgery ?
3. For what do you use Intraoperative ECoG ?
4. What do you with NL, dom, high funct. TLE ?
5. Why do you use SEEG
6. When do you offer RNS ?
7. Do you need a Social Worker for your Center ?
8. Who should treat PNES ?
9. How to counsel about Mortality and Surgery
10. What’s the future of Epilepsy Surgery ?
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Stephan U. Schuele
Q: Concept of Epilepsy Surgery
Symptomatogenic Zone/
Eloquent Cortex
Preoperative
Anatomy
Handedness
Neuropsychology
fMRI
Tractography
MEG
Wada
TMS
Intraoperative
Anatomy
SSEP
ECS
Awake Mapping
Irritative Zone
EEG
MEG
Intra-operative ECoG
Functional Deficit Zone/
Lesion
MRI
FDG PET
Neuropsychology
Ictal Onset Zone
Semiology
Scalp Video EEG
Ictal SPECT
Extra-operative ECoG
Stereo-EEG
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Sydney Cash, AES, 2015
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Epilepsy: Focus vs. Network
Pro Focus•Predictable
•Resectable
•Curative
Limitations• Secondary
epileptogenicity
•Poorer outcome in patients with secondarilygeneralized seizures
• Late relapses
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Stephan U. Schuele
Q: What do you do with AEDs after surgery
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Stephan U. Schuele
My Practice
No change for 6 months
6 months postop: 24 hour EEG
May stop meds causing side effects
Longterm:
Continue in nonlesional patients, FCD
Discontinue in lesional patients, complete resection after two years or later.
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Stephan U. Schuele
For what do you use Intraoperative ECoG
Not for Hippocampal Sclerosis
Lesional Cases: Extent of resection
Nonlesional (non-dominant) TLE: prognosis
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Stephan U. Schuele
What do you with non-lesional, (high functioning), dominant TLE
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Stephan U. Schuele
Hippocampal Transections
Koubeissi MZ et al. Epil Beh 2016. Multiple hippocampal transections
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Stephan U. Schuele
Low frequency ES in TLE
Koubeissi MZ et al. Ann Neurol 2013. Low-Frequency Electrical Stimulation
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Stephan U. Schuele
Laserablation
Kang JY et al. Epilepsia 2016. LiTT for mesial TLE.
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Stephan U. Schuele
Q: Why do you do SEEG ?
Gonzalez-Martinez J et al. Epilepsia 2013. SEEG in the difficult to localize refractory focal epilepsy.
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Periventricular nodular heterotopia
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Stephan U. Schuele
Reduced Morbidity
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Stephan U. Schuele
Q: When do you offer RNS ?
Bergey GK et al. Neurology 2015. Longterm treatment with RNS
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Stephan U. Schuele
RNS
In patients who were potential candidates for resection but were found to have localized seizure onset from eloquent cortex after an invasive evaluation
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Stephan U. Schuele
Secondary benefit of RNS
King-Stephens D et la. Epilepsia 2015. Lateralization of MTLE with chronic ambulatory ECOG
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Stephan U. Schuele
Why do you need a Social Worker ?
Psychosocial assessment and intervention
All Surgical Patients
Patient with psychiatric comorbidities
Pregnant women with epilepsy
Support
Patient Education
Crisis Intervention and Protective Services
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Stephan U. Schuele
Who should treat PNES ?
A multidisciplinary team
Including the Epileptologist
Focus on:
1/3 of patients who improve with diagnosis
1/3 of patients who are amenable to therapy
Caution: patient with pre-existing personality disorder
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Stephan U. Schuele
How do you counsel about mortality and surgery
Sperling MR et al. Neurology 2016. A reappraisal of mortality after epilepsy surgery.
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Stephan U. Schuele
What’s the future of Epilepsy Surgery ?