Sabine G. Uijl

A cross-sectional study of subjective complaints in patients with epilepsy who seem to be well-controlled with anti-epileptic drugs

OBJECTIVES Side-effects of anti-epileptic drugs (AEDs) may be overlooked in patients with epilepsy in everyday clinical practice. The aim of this study was to assess the prevalence and severity of subjective complaints in patients who were considered to be well-controlled and to assess whether these complaints are related to medication, personality traits, or other determinants. METHODS We included patients with epilepsy who were considered to be well-controlled in a cross-sectional study in seven hospitals in the Netherlands. Their medication had not been changed for six months and an apparent reason to change the medication was lacking at the time of enrolment. Subjective complaints were assessed with a 46-item questionnaire. Using multivariable linear regression modeling, we assessed whether patient characteristics, epilepsy characteristics, medication, quality of life (Qolie-10), and personality traits (SCL-90) explained the presence and severity of complaints. RESULTS Of 173 included patients, 67% reported moderate to severe subjective complaints on the questionnaire. Cognitive complaints were reported most frequently. Multivariate modeling showed that 61% of the variance in reported complaints could be explained by included determinants. The prevalence and severity of complaints was associated with AED polytherapy and higher scores on psycho neuroticism. CONCLUSIONS Patients who were considered to be well-controlled proved to report an unexpectedly high number of subjective complaints. Both medication and aspects of personality contributed to the level of complaints. Our study illustrates that subjective side-effects are easily overlooked in everyday clinical practice, possibly because in practice a generally phrased question is used to detect side-effects.

The Added Value of [18F]-Fluoro-D-deoxyglucose Positron Emission Tomography in Screening for Temporal Lobe Epilepsy Surgery

Purpose:[18F]‐Fluoro‐d‐deoxyglucose positron emission tomography (FDG‐PET) is an expensive, invasive, and not widely available technique used in the presurgical evaluation of temporal lobe epilepsy. We assessed its added value to the decision‐making process in relation to other commonly used tests.

Prognosis after temporal lobe epilepsy surgery: The value of combining predictors

Purpose: Although several independent predictors of seizure freedom after temporal lobe epilepsy surgery have been identified, their combined predictive value is largely unknown. Using a large database of operated patients, we assessed the combined predictive value of previously reported predictors included in a single multivariable model.

Adjustment of treatment increases quality of life in patients with epilepsy: a randomized controlled pragmatic trial

Background and purpose:  Complaints about side‐effects of antiepileptic drugs (AEDs) may be overlooked in clinical practice. We assessed the value and risks of an active intervention policy for reported complaints in a randomized controlled pragmatic trial.

Prognostic factors for medically intractable epilepsy: A systematic review

OBJECTIVE One third of all epilepsy patients have medically intractable epilepsy. Knowledge of prognostic factors that, in an early therapeutic stage of epilepsy, herald intractability could facilitate patient management. In this systematic review, we examined the evidence for independent prognostic factors of intractability in patients with epilepsy. METHODS MEDLINE and EMBASE were searched for cohort studies reporting on prognostic factors for medically intractable epilepsy. After selection of abstracts, full-text articles were obtained and their quality was assessed by two reviewers, using the QUIPS checklist. All independent prognostic factors in the individual studies were summarized. RESULTS Eleven cohort studies were included, of which ten hospital-based. Younger age at seizure onset, symptomatic etiology, high initial seizure frequency, medical history, epileptic EEG abnormalities, and failure of previous antiepileptic-drugs (AEDs) were documented as independent prognostic factors of intractability in at least 2 of the 11 studies; none of these factors was reported in all 11 studies. None of the studies considered genetic, neurobiological, or immunological factors. The studies were of moderate quality, mostly because they did not provide a conceptual model for the choice of predictors. Heterogeneity in study design, population, candidate prognostic factors, and outcome definitions precluded statistical pooling. CONCLUSIONS While potentially relevant prognosticators of medically intractable epilepsy have been identified, the evidence for these factors is not consistent. There is a need for well-designed prognostic population-based cohort studies that also include pharmacological, genetic, neurobiological, and immunological factors. A valid model for the early prediction of medically intractable epilepsy could improve patient management.

Decision-making in temporal lobe epilepsy surgery: The contribution of basic non-invasive tests

PURPOSE We studied the extent to which the widely used diagnostic tests contribute to the decision whether or not to perform temporal lobe epilepsy (TLE) surgery in The Netherlands. METHODS This nation-wide, retrospective study included 201 consecutive patients referred for TLE surgery screening. The individual and combined contribution of nine index tests to the consensus decision to perform surgery was investigated. The contribution of each test was quantified using multivariable logistic regression and ROC curves. RESULTS Surgery was performed in 119 patients (59%). Patient history and routine EEG findings were hardly contributory to decision-making, whereas a convergence of MRI with long-term interictal and ictal EEG findings correctly identified the candidates considered eligible for surgery (25% of total). Videotaped seizure semiology contributed less to the results. The area under the ROC curve of the combination of basic tests was 0.75. Ineligibility was never accurately predicted with any test combination. CONCLUSIONS In the Dutch presurgical work-up, when MRI and long-term EEG findings were concordant, a decision for TLE surgery could be reached without further ancillary tests. Videotaped seizure semiology contributed less than expected to the final clinical decision. In our study, basic test findings alone were insufficient to exclude patients from surgery.

What is the current evidence on decision-making after referral for temporal lobe epilepsy surgery?: A review of the literature

OBJECTIVES Many patients thought to have temporal lobe epilepsy, are evaluated for surgical treatment. Decision-making in epilepsy surgery is a multidisciplinary, phased process involving complex diagnostic tests. This study reviews the literature on the value of different tests to decide on whether to operate. METHODS Articles were selected when based on the consensus decision whether to perform temporal lobe surgery, or on the consensus localization or lateralization of the epileptic focus. The articles were scrutinized for sources of bias as formulated in methodological guidelines for diagnostic studies (STARD). RESULTS Most studies did not fulfill the criteria, largely because they addressed prognostic factors in operated patients only. Ten articles met our inclusion criteria. In most articles, a single test was studied; SPECT accounted for five papers. Unbiased comparison of the results was not possible. CONCLUSION Surprisingly little research in epilepsy surgery has focused on the decision-making process as a whole. Future studies of the added value of consecutive tests are needed to avoid redundant testing, enable future cost-efficiency analyses, and provide guidelines for diagnostic strategies after referral for temporal lobe epilepsy surgery.

Epilepsy surgery can help many more adult patients with intractable seizures

PURPOSE To quantify underreferral for epilepsy surgery in The Netherlands, and reveal its causes. METHODS Cross-sectional sample of medical files of epilepsy patients from eight general hospitals and two tertiary care epilepsy centers. We selected patients, not seizure free despite 3 or more anti-epileptic drugs. Medical records were judged by an expert panel whether referral should have been done according to published Dutch guidelines. The treating neurologists were confronted with the panels judgement. KEY FINDINGS In a sample of 1424 patients, 69 had been referred; another 265 were intractable and not referred; 139 of these 265 patients should have been according to the panel. In 89 of 139 patients, the neurologist gave additional arguments for not referring, mainly the physicians estimate of (low) seizure burden or the patients psychological condition. In 66 of 89 cases, this could not convince the panel. Attitudes were similar in secondary and tertiary treatment centers. Multivariable data analysis showed independent predictors of incorrectly, versus correctly, not referred patients. SIGNIFICANCE Substantial underreferral exists in The Netherlands, withholding refractory patients seizure freedom. Adherence to existing guidelines, better prioritizing of surgical work-up, and unprejudiced discussion of surgical treatment with the patient, could lead to 2-2.5 times more referrals.

Anti-epileptic drug changes and quality of life in the community.

Changes in anti‐epileptic drug (AED) regimens may indicate unsatisfactory treatment results such as insufficient seizure control or adverse effects. This inference underlies epilepsy management and research, yet current studies often do not account for AED changes. We assessed AED change patterns and their association with quality of life (QoL), as main outcome measure, in a community‐based setting.

The intracarotid amobarbital or Wada test: unilateral or bilateral?

Objective –  In the Netherlands, presurgical screening for temporal lobe epilepsy (TLE) includes the intracarotid amobarbital procedure (IAP), consisting of two consecutive injections of amobarbital, ipsilateral and contralateral to the epileptic focus. We studied whether a bilateral IAP has added value to a unilateral, ipsilateral IAP.