Download - Orrin Devinsky, MD NYU Langone School of Medicineaz9194.vo.msecnd.net/pdfs/131202/30111A Devinsky Debate How Far … · Nonlesional Neocortical Epilepsy: Benefits v Risk December

Nonlesional Neocortical Epilepsy: Benefits v Risk

December 8, 2013

Orrin Devinsky, MD

NYU Langone School of Medicine

American Epilepsy Society | Annual Meeting

Disclosure

Name of Commercial Interest

None

American Epilepsy Society | 2013 Annual Meeting

Type of Financial Relationship

None

Learning Objectives

Better define risk:benefit of epilepsy surgery in nonlesional neocortical epilepsy surgery

Understand the range of treatment resistant epilepsy-associated morbidity and mortality


We are Fools at Understanding Risk

Loss aversion bias Losses may be twice as powerful as gains

Give up a $2 gain to avoid a $1 loss

Illusion of control

Yale students and dice

Status quo bias You get used to what youre used to, even if it stinks

Doctors, patients and parents get used to terrible epilepsy


9/11/2001: From Frying Pan to Fire

Four airlines hijacked 2,996 Americans died Over the next year many

Americans drove more Flew on airplanes less

Excess MVA accidents from 9.11.01 to 9.11.02

1,595 Americans died 4 flights/mo; 1 hijacked plane/mo risk of death: 1/540,000/yr MVA 1/7,000/yr Cancer 1/600/yr Heart disease 1/400/yr


9/11/2001: From Frying Pan to Fire (Gigerenzer, 2006)


9/11/2001: 2o Terror Proximity and Opportunity (Gaissmeier & Gigerenzer, Psychol Sci 2012;23:1449)


What are the Risks of Treatment-Resistant Epilepsy?

Sillanpaa & Shinnar, NEJM 2010;363:2522; Devinsky, NEJM 2011;365:1801

Death: ~ 6-9% per decade of SUDEP, all epilepsy-related death ~15% (MVA, suicide, accident, drowning, status..)

For a 20 year-old, over 3 decades, risk of dying from epilepsy > 40%

Cognitive morbidity, often progressive: Memory, attention, executive

Behavioral Depression rates approach 50% Anxiety >20% Psychosis >10%

Structural progressive atrophy


What are the Goals in Nonlesional Neocortical Surgery?

Set the goals: Cure would be wonderful, but often not likely

Palliation ok if team focuses on doing no harm

Epileptologists focus on seizure freedom

Oncologistst focus on cure as well as disease burden, survival, and quality of life

Should epileptologists adopt this?


How Much Brain Can be Safely Covered?


Risks of Invasive Electrodes & Epilepsy Surgery (Roth et al, Neurosurgery, 2013)

200 pediatric admissions 250 surgeries with resections 496 surgeries

No deaths No serious permanent neuro complications 2%/admission minor neuro complications 3%/admission hydrocephalus often hemispherectomy Major complications:

CNS or bone flap infections (1.5%/admission) Intracranial hemorrhage, CSF leak (0.5%/admission)


Risks of Invasive Electrodes Wellmer et al, Epilepsia 2012;53:1322

242 patients, ages 0-70 years


Benefits of Surgeries with Invasive Electrodes Wellmer et al, Epilepsia 2012;53:1322

242 patients, ages 0-70 years

For patients with > 24 mos followup

49.7% seizure freedom with surgery

6.3% without surgery

NET BENEFIT: 43.4% seizure free


Critical Factors to Decide

What is the risk of the assessment? Permanent neurological deficit is

What Happens if Primary Motor Cortex is Involved?

Do nothing never confuse invasive monitoring with need for action. All centers have probably hurt patients by removing nonlesional neocortex, but it can be avoided or minimized. Limit resection size and location to dysfunctional cortex Multiple subpial transections +/- resection 211 patients, meta-analysis (Spencer et al, Epilepsia 2002;43:141) MST + resection: Excellent outcome: > 95% seizure control Generalized seizures 87% CPS & SPS 68% MST alone: Excellent outcome: > 95% seizure control Generalized seizures 71% CPS & SPS 62.5% American Epilepsy Society | 2013 Annual Meeting

Proceed with Invasive Electrode Recording

Little risk if done at high volume center If no resectable focus is found, can do nothing or MST If one is found Chance of seizure freedom > ~30-40% Chance for >50% seizure reduction ~50-60% Chance for Responsive Neural Stimulation Status quo: risk of depression, anxiety, memory loss, psychosis, personality changes, death


Impact on Clinical Care and Practice

Dont fall victim to biases: risk aversion, illusion of control, and status quo (and many others)

Carefully consider risks and limits of epilepsy surgery

Carefully consider morbidity and mortality of treatment resistant epilepsy

Download - Orrin Devinsky, MD NYU Langone School of Medicineaz9194.vo.msecnd.net/pdfs/131202/30111A Devinsky Debate How Far … · Nonlesional Neocortical Epilepsy: Benefits v Risk December

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