Management of Treatment-Resistant Epilepsy. Volume One. Evidence Report and Appendices. Evidence Report/Technology Assessment Number 77

摘要

This report, commissioned at the request of the Centers for Disease Control and Prevention and the Social Security Administration, addresses in an evidence-based fashion diagnosis of and interventions for treatment-resistant epilepsy (TRE). It addresses drug and surgical treatments, as well as service-related interventions. There is no widely used definition of TRE. Lack of high quality studies precludes an evidence-based determination of the most effective diagnostic for rediagnosing or reevaluating patients. Nevertheless, up to 35 percent of patients (but probably fewer) diagnosed with TRE may also have nonepileptic seizures, or not have epilepsy at all. Not all patients diagnosed with TRE receive optimized therapy, but the number of these patients cannot be determined. Initiation of sequential monotherapy appears to result in seizure increases in many patients, and whether sequential monotherapy causes any patients to become seizure- free is not clear. Polytherapy can reduce seizure frequency, but some patients experience intolerable adverse effects. Drug reduction may cause seizure increases without additional benefit. Results of the AED studies assessed in this report may not be generalizable to drugs not examined in the studies we included. Temporal lobe surgery eliminates seizures in many patients. Hemispherectomy and frontal lobe surgery eliminate seizures in an indeterminate number of patients. Corpus callosotomy reduces seizure frequency but generally does not eliminate seizures. Vagal nerve stimulation affords some seizure reduction. There was insufficient evidence to assess other treatments. Epilepsy is associated with increased all-cause mortality and death from drowning. The link between sudden death and seizure frequency is uncertain. Generalized tonic-clonic seizures seem associated with an increased risk of death.