Dataset Information

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

ABSTRACT:

Objective

To perform a systematic review and individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Tuberous Sclerosis Complex undergoing resective epilepsy surgery.

Data sources

Electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science), archives of major epilepsy and neurosurgery meetings, and bibliographies of relevant articles, with no language or date restrictions.

Study selection

We included case-control or cohort studies of consecutive participants undergoing resective epilepsy surgery that reported seizure outcomes. We performed title and abstract and full text screening independently and in duplicate. We resolved disagreements through discussion.

Data extraction

One author performed data extraction which was verified by a second author using predefined data fields including study quality assessment using a risk of bias instrument we developed. We recorded all preoperative factors that may plausibly predict seizure outcomes.

Data synthesis

To identify predictors of a good seizure outcome (i.e. Engel Class I or II) we used logistic regression adjusting for length of follow-up for each preoperative variable.

Results

Of 9863 citations, 20 articles reporting on 181 participants were eligible. Good seizure outcomes were observed in 126 (69%) participants (Engel Class I: 102(56%); Engel class II: 24(13%)). In univariable analyses, absence of generalized seizure semiology (OR = 3.1, 95%CI = 1.2-8.2, p = 0.022), no or mild developmental delay (OR = 7.3, 95%CI = 2.1-24.7, p = 0.001), unifocal ictal scalp electroencephalographic (EEG) abnormality (OR = 3.2, 95%CI = 1.4-7.6, p = 0.008) and EEG/Magnetic resonance imaging concordance (OR = 4.9, 95%CI = 1.8-13.5, p = 0.002) were associated with a good postoperative seizure outcome.

Conclusions

Small retrospective cohort studies are inherently prone to bias, some of which are overcome using individual participant data. The best available evidence suggests four preoperative factors predictive of good seizure outcomes following resective epilepsy surgery. Large long-term prospective multicenter observational studies are required to further evaluate the risk factors identified in this review.

SUBMITTER: Fallah A

PROVIDER: S-EPMC3566144 | biostudies-literature | 2013

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

Fallah Aria A Guyatt Gordon H GH Snead O Carter OC Ebrahim Shanil S Ibrahim George M GM Mansouri Alireza A Reddy Deven D Walter Stephen D SD Kulkarni Abhaya V AV Bhandari Mohit M Banfield Laura L Bhatnagar Neera N Liang Shuli S Teutonico Federica F Liao Jianxiang J Rutka James T JT

PloS one 20130206 2

<h4>Objective</h4>To perform a systematic review and individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Tuberous Sclerosis Complex undergoing resective epilepsy surgery.<h4>Data sources</h4>Electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science), archives of major epilepsy and neurosurgery meetings, and bibliographies of relevant articles, with no language or date restrictions.<h4>Study selection</h4>We inc ...[more]

PMID: 23405072

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Project description:Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.

Project description:18F-FDG PET is an important tool for the presurgical assessment of children with drug-resistant epilepsy. Standard assessment is performed visually and is often subjective and highly user-dependent. Voxelwise statistics can be used to remove user-dependent biases by automatically identifying areas of significant hypo- or hypermetabolism associated with the epileptogenic area. In the clinical setting, this analysis is performed using commercially available software. These software packages suffer from two main limitations when applied to pediatric PET data: pediatric scans are spatially normalized to an adult standard template, and statistical comparisons use an adult control dataset. The aim of this work was to provide a reliable observer-independent pipeline for the analysis of pediatric 18F-FDG PET scans, as part of presurgical planning in epilepsy. Methods: A pseudocontrol dataset (19 subjects 6-9 y old, and 93 subjects 10-20 y old) was used to create two age-specific 18F-FDG PET pediatric templates in standard pediatric space. The 18F-FDG PET scans of 46 epilepsy patients (16 patients 6-9 y old, and 30 patients 10-17 y old) were retrospectively collated and analyzed using voxelwise statistics. This procedure was implemented with the standard pipeline available in the commercial software Scenium and an in-house Statistical Parametric Mapping, version 8 (SPM8), pipeline (including age-specific pediatric templates and reference database). A ?-test was used to assess the level of agreement between the findings of voxelwise analyses and the clinical diagnosis of each patient. The SPM8 pipeline was further validated using postsurgical seizure-free patients. Results: Improved agreement with the clinical diagnosis was reported using SPM8, in terms of focus localization, especially for the younger patient group: ? = 0.489 for Scenium versus 0.826 for SPM. The proposed pipeline also showed a sensitivity of about 70% in both age ranges for the localization of hypometabolic areas on pediatric 18F-FDG PET scans in postsurgical seizure-free patients. Conclusion: We showed that by creating age-specific templates and using pediatric control databases, our pipeline provides an accurate and sensitive semiquantitative method for assessing the 18F-FDG PET scans of patients under 18 y old.

Dataset Information

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

Objective

Data sources

Study selection

Data extraction

Data synthesis

Results

Conclusions

Publications

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

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