A recently published study by researchers at Spectrum Health in Grand Rapids and Henry Ford Hospital in Detroit suggests that surgery may be an effective treatment for epilepsy in older patients, a finding Spectrum says runs counter to conventional treatment methods.
“Traditionally, there has been a tendency to exclude older patients from surgery for fear of increased risk of medical or surgical complications,” said Spectrum Health Medical Group neurosurgeon Sanjay Patra, lead author of the study published online in the British Journal of Neurosurgery. “This study provides evidence that surgery may instead be a viable and effective treatment option.”
The study was a retrospective review of data pertaining to 122 Henry Ford Hospital patients with medically refractory partial epilepsy who had been operated on in the past by physicians now employed at Spectrum Health. Medically refractory seizures are those that do not respond successfully to drug treatment. Partial epilepsy refers to a type of seizure that originates and remains in a limited area of the brain, such as the temporal lobe.
Researchers compared surgical outcomes of a group of patients age 50 and older with those of a younger group. The median follow-up time for both groups was 24 months. Results showed that 74 percent of patients in the older group remained free of disabling seizures, compared with 58 percent of patients in the younger group. Among patients age 60 and older, 91 percent remained seizure-free.
All patients underwent surgery between 1993 and 2008 at Henry Ford Hospital, and were operated on by Dr. Kost Elisevich, a neurosurgeon who is now co-chair of the department of clinical neurosciences and chief of neurosurgery, Spectrum Health Medical Group. Elisevich was the senior author of the study.
“Patients were distinguished by age and brain location of surgery to establish whether older patients experienced less optimal outcomes regarding seizure cessation, memory, cognition, likelihood of complications, and whether surgery location factored significantly in these outcome measures,” Elisevich said.
Epilepsy is the third most common neurological disorder in the United States after Alzheimer’s disease and stroke, affecting 2.2 million Americans, according to the Centers for Disease Control and Prevention. Older adults are among the fastest-growing segments of the population for new cases.
The majority of patients in the study underwent mesial temporal lobe surgery, which involves the removal of sections of the brain thought to be the source of seizures in mesial temporal lobe epilepsy syndrome.
“In most circumstances, we’re dealing with an invisible target that needs to be hunted out” within the brain, said Elisevich. That begins with studying images from MRIs and EEGs and functional studies involving the patient’s memory.
The remaining patients underwent surgery at other sites in the brain, although the results of the study reinforce the widely held opinion of the medical community that the efficacy of surgery for extratemporal epilepsy to date is inferior to that for temporal lobe epilepsy, regardless of age.
Complications from brain surgery can include nausea, depression, changes in personality, headaches, and difficulty speaking and remembering words. The overall complication rate in the study of 14.2 percent was similar in patients less than 50 (15.3 percent) and those 50 or older (11.4 percent). Verbal memory decline, however, was more notable in the older population and for those with epilepsy duration of greater than 20 years.
“This study demonstrates that epilepsy surgery in the older population has similar seizure-free outcomes and complications when compared with younger patients for both mesial temporal and extratemporal origins,” said Dr. Brien Smith. He was a co-author of the study and is co-chair of the department of clinical neurosciences, and chief of neurology, Spectrum Health Medical Group.
“Caution regarding postoperative memory decline in the older population, however, must be stressed,” added Smith.
Every patient’s situation is different, said Elisevich, and must be carefully evaluated by a team of physicians when surgery is being considered to stop continuing seizures “despite the fact that the patient may be on three or four anti-epileptic medications.”
Elisevich said quality of life is a consideration, when a patient is still having seizures and being restricted in capabilities, while “being slowed down by the medications that you’re taking, as well.”
The big question is, “Could your life be better without (the medications), ultimately?” he said.
When asked if he expects people to inquire about the surgery, Elisevich said, “Oh yes. They already are. This is something that has been a vexing issue for patients of all ages.”
He said that for many who have been diagnosed with epilepsy, it is an average of 20 years before surgery is a consideration, and during the 20 years, the patient had been using at least two types of medication to control their seizures.
He said there was a published report more than 10 years ago that said patients who have failed to respond to a second anti-epilepsy drug regimen “have only about a 3 or 4 percent chance of actually responding favorably to any other medication.”
Researchers suggest that postoperative memory decline in older patients may be due to less cognitive reserve, but also caution that larger studies with longer term follow-up will be needed to determine if the benefits of epilepsy surgery are sustained in the older population.
Additional and continuing epilepsy research is proceeding through Spectrum Health’s expanded epilepsy program. Spectrum Health announced the expansion of its inpatient epilepsy monitoring unit and epilepsy team in late 2012.
Spectrum Health is the first epilepsy program in West Michigan to receive a Level 4 designation by the National Association of Epilepsy Centers. Level 4 centers have the professional expertise and facilities to provide the highest level of medical and surgical epilepsy evaluation and treatment for patients with epilepsy.