Özge Vural, Ayse Serdaroglu, Aysegul Nese Citak Kurt, Tuğba Hirfanoğlu, , Gökhan Kurt

Dirençli epilepsili çocuklarda ilaç dışı tedavinin etkinliği

GİRİŞ ve AMAÇ: Epilepsi en yaygın kronik, nörolojik bozukluklardan biridir. Halen epilepsi tedavisinde eski ve yeni çok çeşitli antiepileptik ilaç kullanılmaktadır. Bu antiepileptik ilaçların kullanımına rağmen hastaların yaklaşık %20-30’u başarılı bir şekilde tedavi edilemez. Bu hasta grubuna ilaca dirençli epilepsi hastaları denir. Dirençli epilepsi hastalarında nöbetlerin sıklığı hastanın yaşam kalitesini ve bilişsel fonksiyonlarını olumsuz etkiler. Günümüzde epilepsi cerrahisi uygulamaları ile başarılı sonuçlar elde edilmektedir. Bu çalışmanın amacı; dirençli epilepsili çocuklarda epilepsi cerrahisinin (rezektif/vagal sinir stimülasyonu) etkinliğini değerlendirmekti. YÖNTEM ve GEREÇLER: Gazi Üniversitesi Tıp Fakültesi Çocuk Nöroloji Bilim Dalı Uzun Süreli Video EEG Monitorizasyon Ünitesinde epilepsi tanısı ile izlenen ve epilepsi cerrahi konseyi kararına göre epilepsi cerrahisi uygulanan 62 çocuk hastanın özellikleri incelendi. BULGULAR: Hastalardan 48’ine vagal sinir stimülasyonu (VSS), 14’üne rezektif cerrahi uygulandı, 31’i kız, 31’i erkek ve nöbet başlangıç yaşı 35,2 + 37,0 ay, cerrahi uygulanma yaşı 11,9 + 3,8 yaş, cerrahi öncesi izlem süresi 8,7 + 4,1 yıl idi. Rezektif cerrahi uygulanan hastalardan 12’si halen nöbetsiz iken, vagal sinir stimülasyonu yapılan hastalardan 3’ü nöbetsiz, 1 hastada %90’dan fazla, 7 hastada %75’den fazla, 19 hastada %50’den fazla nöbet kontrolü sağlanmıştır. TARTIŞMA ve SONUÇ: Sonuç olarak; gerek rezektif cerrahi gerekse VSS ilaca dirençli epilepsisi olan çocuk hastalarda uygulanan etkili tedavi yöntemleridir. VSS görece güvenli ve hafif yan etkileri olan bir yöntemdir. Erken dönemde, uygun hastalara uygulanan rezektif epilepsi cerrahisinin mortaliteyi azalttığı görülmüştür. Epilepsi hastalarında uygun cerrahi yöntem ve uygun hasta seçimi ile nöbet kontrolü büyük ölçüde sağlanabilmektedir. Uzun dönem izlenen seriler bize bu tedavi yöntemlerinin etkinliğini ve avantajlarını daha iyi gösterecektir. Daha etkili yöntemler bulunana kadar VSS ve rezektif cerrahi, ilaca dirençli epilepsi hastalarında cazip tedavi yöntemleri olmaya devam edecektir.

Anahtar Kelimeler:

Epilepsi, epilepsi cerrahisi, vagal sinir stimülasyonu

The efficacy of nonpharmacologic treatment in children with pharmacoresistant epilepsy

INTRODUCTION: Epilepsy is one of the most common chronic neurological disorders. Currently, a variety of older and newer AEDs are used in the treatment of epilepsy. Despite the use of these AEDs, about 20-30% of patients are not succesfully treated. This group of patients is called pharmacoresistant epilepsy patients. The frequency of seizures in patients with refractory epilepsy, adversely affects the quality of life and cognitive functions. Today, successful results are obtained from the epilepsy surgery. The purpose of this study was to evaluate the efficacy of epilepsy surgery (resective/VNS) in children with pharmacoresistant epilepsy. METHODS: This study was conducted among 62 children that were followed in Gazi University department of neurology long-term video EEG monitorization unit, with the diagnosis of epilepsy. They underwent the epilepsy surgery with the decision of the epilepsy surgery council. RESULTS: The study included 48 patients that underwent VNS treatment and 14 patients that underwent resective surgery. 31 patient were girls, 31 patients were boys, age at onset of seizures (range) was 35,2 + 37,0 months, age at epilepsy surgery was 11,9 + 3,8 years, time before epilepsy surgery was 8,7 + 4,1 years. 12 patients that underwent resective surgery were seizure free, 3 patients with VNS implantation were seizure free after surgery. Seizure reduction > %90 was achieved in 1 patient, > % 75 in 7 patients and > % 50 in 19 patients. DISCUSSION AND CONCLUSION: In conclusion resective surgery and VNS are effective treatment methods in children with pharmacoresistant epilepsy. VNS is relatively safe. In early period, resective epilepsy surgery for appropriate patients reduces the mortality. With appropriate patient and appropriate surgical method selection in patients with epilepsy, seizure control can be achieved largely. Until more effective therapies are developed, VNS and resective surgery will remain attractive alternatives for pharmacoresistant epilepsy.

Keywords:

Epilepsy, epilepsy surgery,

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1. Dallas J, Englot DJ, Naftel RP. Neurosurgical approaches to pediatric epilepsy: Indications, techniques, and outcomes of common surgical procedures. Seizure. Seizure. 2018 Nov 16. pii: S1059-1311(18)30546-6.
2. Blumstein MD, Friedman MJ. Childhood seizures. Emerg Med Clin North Am 2007;25(4):1061-86.
3. Garcia Gracia, C., Yardi, R., Kattan, M.W., Nair, D., Gupta, A., Najm, I. et al, Seizure freedom score: a new simple method to predict success of epilepsy surgery. Epilepsia. 2015;56:359–65.
4. Jayakar, A., Bolton, J. Pediatric epilepsy surgery. Curr Neurol Neurosci Rep. 2015;15:1–8.
5. Spencer, S., Huh, L. Outcomes of epilepsy surgery in adults and children. Lancet Neurol. 2008;7:525–37.
6. Guerrini R. Epilepsy in children. Lancet 2006; 367: 499-524
7. Rosenow F, Luders H. Presurgical evaluation of epilepsy. Brain 2001; 124: 1683-700
8. Engel J Jr, Van Ness PC, Rasmussen TB, Ojemann LM. Outcome with respect to epileptic seizures. In: Engel J Jr (ed). Surgical Treatment of the Epilepsies. 2nd ed. Raven Press, New York,609-22;1993.
9. Lendt M, Helmstaedter C, Elger CE. Pre and postoperative socioeconomic development of 151 patients with focal epilepsies. Epilepsia 1997; 38: 1330-7.
10. Baaj AA, Benbadis SR, Tatum WO, Vale FL: Trends in the use of vagus nerve stimulation for epilepsy: analysis of a nationwide database. Neurosurg Focus 2008;25(3),10-15
11. Glauser T, Ben-Menachem E, Bourgeois B, et al. ILAE treatment guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 2006;47:1094-1120.
12. Nagarajan L, Walsh P, Gregory P, Lee M. VNS therapy in clinical practice in children with refractory epilepsy. Acta Neurol Scand 2002;105:13-17.
13. Uthman BM, Reichl AM, Dean JC, et al. Effectiveness of vagus nevre stimulation in epilepsy patients: a 12-year observation. Neurology 2004;63:1124-6.
14. Spanaki MV,Allen LS, Mueller WM, Morris GL. Vagus nevre stimulation therapy: 5-year or greater outcome at a university based epilepsy center. Seizure 2004;13:587-90.
15. Ardesch JJ, Buschman HPJ, Wagener-Schimmel LJJC, van der AaHE, Hageman G : Vagus nerve stimulation for medically refractory epilepsy : a long-term follow-up study. Seizure 16: 2007; 579-85.
16. Morrow JI, Bingham E, Craig JJ, Gray WJ : Vagal nerve stimulation in patients with refractory epilepsy. Effect on seizure frequency, severity and quality of life. Seizure 9: 2000; 442-5.
17. Schachter SC : Vagus nerve stimulation therapy summary : five years after FDA approval. Neurology 2002; 59: 15-20.
18. DeGiorgio CM, Schachter SC, Handforth A, Salinsky M, Thompson J, Uthman B, et al : Prospective long-term study of vagus nerve stimulation for the treatment of refractory seizures. Epilepsia 2000; 41: 1195-1200.
19. Morris GL 3rd, Muller WM : Long-term treatment with vagus nevre stimulation in patients with refractory epilepsy. The Vagus Nerve Stimulation Study Group E01-05. Neurology 1999; 53 : 1731-5.
20. George R, Salinski M, Kuzniecky R, Rosenfel W, Bergen D, Tarver WB, et al : Vagus nerve stimulation for treatment of partial seizures : long-term follow-up on first 67 patients exiting a controlled study.Epilepsia 1994; 35 : 637-43.
21. You SJ, Kang HC, Kim HD, Ko TS, Kim DS, Hwang YS, et al : Vagus nerve stimulation in intractable childhood epilepsy : a Korean Multicenter Experience. J Korean Med Sci 2007; 22 : 442-5.
22. Frost M, Gates J, Helmers SL, et al. Vagal nerve stimulation in children with refractory seizures associated with Lennox-Gastaut syndrome. Epilepsia 2001; 42:1148-52.
23. Davies KG, Weeks RD. Temporal lobectomy for intractable epilepsy : experience with 58 cases over 21 years. Br J Neurosurg 1993; 7:23–33.
24. Mathern GW, Giza CC, Yudovin S, Vinters HV, Peacock WJ, Shewmon DA, et al. Postoperative seizure control and antiepileptic drug use in pediatric epilepsy surgery patients : the UCLA experience, 1986-1997. Epilepsia 1999;40:1740–9.
25. Abou-Khalil B, Andermann E, Andermann F, Olivier A, Quesney LF. Temporal lobe epilepsy after prolonged febrile convulsions : excellent outcome after surgical treatment. Epilepsia 1993;34:878–83.
26. Berkovic SF, McIntosh AM, Kalnins RM, Jackson GD, Fabinyi GC, Brazenor GA, et al. Preoperative MRI predicts outcome of temporal lobectomy : an actuarial analysis. Neurology 1995;45:1358–63.
27. Janszky J, Janszky I, Schulz R, Hoppe M, Behne F, Pannek HW, et al. Temporal lobe epilepsy with hippocampal sclerosis : predictors for long-term surgical outcome. Brain 2005;128:395–404.
28. Myoung-Hee Lee, M.D., Eun-Ik Son, M.D., Ph.D. Comparison between Initial and Recent Surgical Outcome of 15-Year Series of Surgically Remediable Epilepsy J Korean Neurosurg Soc 2010;48: 230-5.