January 26, 2023

Associations Between Testing and Treatment Pathways in Lesional Temporal or Extratemporal Epilepsy: A Census Survey of National Association of Epilepsy Centers Center Directors

Abstract found on PubMed

Objective: The evaluation to determine candidacy and treatment for epilepsy surgery in persons with drug-resistant epilepsy (DRE) is not uniform. Many non-invasive and invasive tests are available to ascertain an appropriate treatment strategy. This study examines expert response to clinical vignettes of MRI-positive lesional focal cortical dysplasia in both temporal and extratemporal epilepsy to identify associations in evaluations and treatment choice.

Methods: We analyzed annual report data and a supplemental epilepsy practice survey reported in 2020 from 206 adult and 136 pediatric epilepsy center directors in the United States. Non-invasive and invasive testing and surgical treatment strategies were compiled for the two scenarios. We used chi-square tests to compare testing utilization between the two scenarios. Multivariable logistic regression modeling was performed to assess associations between variables.

Results: The supplemental survey response rate was 100% with 342 responses included in the analyses. Differing testing and treatment approaches were noted between the temporal and extratemporal scenarios such as chronic invasive monitoring selected in 60% of the temporal scenario versus 93% of the extratemporal scenario. Open resection was the most common treatment choice, however overall treatment choices varied significantly (p<0.001). Associations between non-invasive testing, invasive testing, and treatment choices were present in both scenarios. For example, in the temporal scenario SEEG was more commonly associated with FDG-PET (OR 1.85; 95% CI 1.06-3.29; p=0.033), MEG (OR 2.90; 95% CI 1.60-5.28; p = <0.001), HD EEG (OR 2.80; 95% CI 1.27-6.24; p = 0.011), fMRI (OR 2.17; 95% CI 1.19-4.10; p = 0.014) and Wada (OR 2.16; 95% CI 1.28-3.66; p = 0.004). In the extratemporal scenario, choosing SEEG was associated with increased odds of neuromodulation over open resection (OR 3.13; 95% CI 1.24-7.89; p=0.016).

Significance: In clinical vignettes of temporal and extratemporal lesional drug-resistant epilepsy, epilepsy center directors displayed varying patterns of non-invasive testing, invasive testing, and treatment choices. Differences in practice underscore the need for comparative trials for the surgical management of drug-resistant epilepsy.