Long-term outcome and determinants of quality of life after temporal lobe epilepsy surgery in adults

doi:10.1016/j.eplepsyres.2009.06.008

Epilepsy Research

Volume 86, Issues 2–3, October 2009, Pages 191-199

https://doi.org/10.1016/j.eplepsyres.2009.06.008 Get rights and content

Summary

Aim of the study

To find determinants of quality of life (QOL) in long-term follow-up after temporal lobe epilepsy (TLE) surgery in adults.

Methods

The QOLIE-31 questionnaire was sent to 400 of 524 patients who were operated on for refractory TLE between 1991 and 2003 in the Bethel Epilepsy Centre fulfilling the inclusion criteria of this study. Mainly patients with severe cognitive deficits and patients with progressive brain disorders were excluded. There were 222/400 patients who replied to the QOLIE-31 questionnaire and 147/222 of these patients replied to an additional questionnaire.

Results

Univariate analyses showed that seizure freedom, presence of auras, intake of antiepileptic drugs (AEDs), severity of AED side effects, and driving a car were significantly correlated with all subscales of QOLIE-31. Furthermore, employment status, psychiatric problems, tumors and hippocampus sclerosis pathology, the presence of a partner, age at reply, age at surgery and medical co-morbidities were significantly correlated with some subscales of the QOLIE-31. Multivariate analyses (stepwise regression analyses) revealed that especially the time since the last seizure and the severity of AED side effects had a strong impact on QOL. However, aura at last follow-up, psychiatric treatment and employment were seen in the multivariate analyses as significant predictors of some QOL subscales as well. Most subscales of QOL showed a steep, non-linear increase within the first years of seizure freedom and remained relatively stable except for cognitive function which showed continuous improvement parallel to seizure freedom. For patients who were seizure free since surgery, side effects of AED and/or psychiatric treatment were the strongest determinants of QOL.

Conclusion

Duration of seizure freedom and AED side effects have the strongest impact on QOL in the long-term follow-up. Therefore it is important not only to register intake of AEDs but also to assess side effects of AEDs. Persistence of auras also had an impact on different facets of QOL, but was significantly correlated with intake of AEDs. Apart from factors directly related to epilepsy QOL was dependent of psychosocial factors as employment status, psychiatric complications, and driving a car underlining the necessity of postoperative rehabilitation in this group.

Introduction

The importance of assessing the quality of life after epilepsy surgery is as old as the roots of modern epilepsy surgery. Penfield and Paine (1955) wrote, “It is not enough to know whether the surgery procedure has stopped attacks or not. We must know its effect upon the patient's ability to work, to hold a job, to study; the effect on physical and mental function, the effect on behavior and on the happiness of the patient and friends” (Penfield and Paine, 1955).

Studies focusing on short-term outcomes, including the only randomized clinical trial of surgery in temporal lobe epilepsy (TLE), have shown that epilepsy surgery significantly improves quality of life and health status (Wiebe et al., 2001).

Most epilepsy surgery patients report a positive overall impact of the procedure on their lives and a high willingness to undergo surgery again if that choice had to be made (Chin et al., 2006). The improvement of health-related quality of life (HRQOL) has been reported in short-term studies (Mikati et al., 2006), in studies concerning long-term outcome beyond 5 years (Lowe et al., 2004, Langfitt et al., 2007) and in studies with 10 years and more of follow-up (Tanriverdi et al., 2008). Even among non-seizure-free patients, improvement of HRQOL has been reported (Ahmad et al., 2007). Two reports have found that patients in remission for 3–5 years shifted to normalization of quality of life (Mikati et al., 2006, Spencer et al., 2007). Previous reports have aimed mainly to assess the changes of QOL after surgery (Spencer et al., 2007) and the main focus was on comparing seizure-free versus non-seizure-free patients (Stevanovic, 2007). Our center has already published the outcome of QOL in short-term follow-up (Thorbecke and Högter, 2008). The aim of this study was to evaluate the determinants of HRQOL in long-term follow-up in a large group of patients who underwent refractory TLE surgery at least 5 years prior to the study.

Section snippets

Patients

All adult patients (≥16 years when having TLR) who had undergone temporal lobe epilepsy surgery for refractory partial epilepsy between 1992 and 2003 in the Bethel Epilepsy Center, Bielefeld, Germany, were included in the study. We excluded patients with mental retardation, patients with Rasmussen encephalitis (progressive disease with special characters) and patients who were operated on for malignant tumors. Four hundred of 524 patients remained.

Duration of follow-up ranged between 5 and 17

Seizure outcome

In our study, 167 patients (75.2%) had been seizure free for a period of at least 1 year before the last follow up, whereas 106 patients (47.7%) had been seizure free since surgery (best outcome group). The duration of seizure freedom in this study ranged from 0.08 to 16 years. There were 172 patients (77.5%) who were free of auras and 50 patients (22.5%) who had various types of auras in the year before the last follow-up. There were 22 patients (13.2%) who were seizure free but reported

Factors correlated with quality of life

Time since the last seizure (linear and non-linear), the presence of auras at the last follow-up, intake of antiepileptic drugs, the presence of AED side effects and driving a car were significantly correlated to HRQOL in all subscales of QOLIE-31 (Table 2 and Fig. 1). However, the side of surgery, age at surgery, age at reply, hippocampal sclerosis and tumor in pathology, the presence of a partner, employment, psychiatric treatment and the presence of co-morbidities were also slightly or

Discussion

Quality of life has been established as a cornerstone in the evaluation of surgery as a treatment for refractory temporal lobe epilepsy because of an increasing understanding of the complex impact of epilepsy on patient QOL (Raty and Wilde Larsson, 2007). This analysis shows that QOL in long-term follow-up depends on multiple factors and not only on seizure freedom, although seizure freedom has the strongest impact on QOL. Previous studies reported that seizures are not the sole criteria in

Limitation of the study

Admittedly, our study has limitations. The QOL data presented was for only 58% of the whole patient group with temporal epilepsy surgery, comparing between responder and non-responder for the QOLIE-31 were done at one point of follow-up. The study was done at only one point of follow-up. Nevertheless, our study offers new and valuable insights regarding QOL in a large group of temporal lobe surgery patients with long-term follow-up in one center.

Conclusions

Our results confirmed that the duration of seizure freedom and absence of AED side effects have the strongest impact on QOL in long-term follow-up. Most QOL subscales showed a steep, non-linear increase in the first 2 or 3 years of seizure freedom and then remained relatively stable or showed only a slight increase.

In view of the strong effects of side effects on QOL it seems important not only to register intake of AEDs but also to assess side effects of AEDs and their severity.

Furthermore,

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Citation Excerpt :
Elsharkawy et al (2009), found that the QOL in those seizure free improved between 6 months to 2 years after surgery and remained relatively stable thereafter [34]. Studies have also found similar findings of improved QOL post-resection [33,34] with one study suggesting this could be sustained after 26 years in eighty percent of patients [31]. However, Elsharkawy et al observed this improvement in QOL may not endure after the initial 2–3 years post resection [34].
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Patients who underwent iEEG between 1999 and 2016 were identified. Patients were retrospectively assessed between 2014 and 2017 by specialist clinic record review and telephone survey with standardized validated questionnaires for: 1) seizure freedom using the Engel classification; 2) Mood using the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E); 3) Quality-of-life outcomes using the QOLIE-10 questionnaire. Summary statistics and univariate analysis were performed to investigate variables for significance.
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Insular epilepsy is increasingly recognized in epilepsy surgery centers. Recent studies suggest that resection of an epileptogenic zone that involves the insula as a treatment for drug-resistant seizures is associated with good outcomes in terms of seizure control. However, despite the existing evidence of a role of the insula in emotions and affective information processing, the long-term psychological outcome of patients undergoing these surgeries remain poorly documented. A group of 27 adults (18 women) who underwent an insulo-opercular resection (in combination with a part of the temporal lobe in 10, and of the frontal lobe in 5) as part of epilepsy surgery at our center between 2004 and 2019 completed psychometric questionnaires to assess depression (Beck Depression Inventory – 2nd edition; BDI-II), anxiety (State-Trait Anxiety Inventory, Trait Version; STAI-T), and quality of life (Patient Weighted Quality of Life In Epilepsy; QOLIE-10-P). Scores were compared to those of patients who had standard temporal lobe epilepsy (TLE) surgery with similar socio-demographic and disease characteristics. Seizure control after insular epilepsy surgery was comparable to that observed after TLE surgery, with a majority of patients reporting being seizure free (insular: 63.0%; temporal: 63.2%) or having rare disabling seizures (insular: 7.4%; temporal: 18.4%) at the time of questionnaire completion. Statistical comparisons revealed no significant group difference on scores of depression, anxiety, or quality of life. Hemisphere or extent of insular resection had no significant effect on the studied variables. In the total sample, employment status and seizure control, but not location of surgery, significantly predicted quality of life. Self-reported long-term psychological status after insulo-opercular resection as part of epilepsy surgery thus appears to be similar to that observed after TLE surgery, which is commonly performed in epilepsy surgery centers.
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The study included 229 adults, of whom 178 had complete follow-up with data from all three time points. Following surgery, scores on Quality of life in epilepsy inventory (QOLIE-10), Patient health questionnaire (PHQ-9), and General anxiety disorder (GAD-7) improved significantly with time. After adjusting for gender, age, marital status, and type of surgery using linear modeling, the mean QOLIE-10 score decreased by 1.157 points/year, mean PHQ-9 score by 0.331 points/year, and mean GAD-7 score by 0.299 points/year. Improvement in QOL continued to be observed throughout the follow-up duration, whereas both depression and anxiety improved the most within the first postoperative year and then stabilized. Seizure freedom was strongly correlated with improved QOL (p = 0.001), while depressive symptoms showed a nonstatistically significant correlation with worse QOL (p = 0.07). Patients who underwent frontal resection had significantly superior QOL and depression symptom improvement compared with temporal resections during full data analysis (QOLIE-10, p = 0.024; PHQ-9, p = 0.027), but only significant depression symptom improvement on secondary analysis of complete follow-up patients only (PHQ, p = 0.040; QOL, p = 0.104).
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Individuals with temporal lobe epilepsy (TLE) often experience diminished quality of life (QoL). Although comorbid depression is one of the most recognized predictors of poor QoL in TLE, impairments in verbal memory (VM) and executive functioning (EF), have also been identified as risk factors, independent of other biological and psychosocial factors. In this study, we examine the contribution of depression, VM, and EF to QoL in 52 well-characterized medically-refractory TLE patients.
Quality of life was assessed with the Quality of Life in Epilepsy (QOLIE-31) questionnaire and depression symptomatology was evaluated with the Beck Depression Inventory-II (BDI-II). Tests of VM included the California Verbal Learning Test-Second Edition and the Wechsler Memory Scale-Third Edition, Logical Memory and Verbal Paired Associates subtests. Tests of EF included the D-KEFS Category Switching and Color Word Interference Tests, and the Trail Making Test. Using these measures, a principal component (PC) was derived for VM and for EF. Hierarchical multiple linear regression analysis was used to evaluate the unique contributions of BDI-II Score, VM PC, and EF PC to the QOLIE-31 Total Score, while controlling for important clinical and demographic variables. Post-hoc analyses were also performed to examine the contribution of each variable to specific QOLIE subscales.
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Long-term outcome and determinants of quality of life after temporal lobe epilepsy surgery in adults

Summary

Aim of the study

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Seizure outcome

Factors correlated with quality of life

Discussion

Limitation of the study

Conclusions

J. Clin. Neurosci.

Epilepsy Behav.

Neurochirurgie

Epilepsy Res.

Epilepsy Behav.

Epilepsy Behav.

Epilepsy Behav.

Epilepsy Behav.

Epilepsy Behav.

Seizure

Epilepsy Behav.

Epilepsy Res.

Health-related quality of life using QOLIE-31: before and after epilepsy surgery a prospective study at a tertiary care center

Neurol. India

Psychiatric outcome after temporal lobectomy: a predictive study

Epilepsia

Psychosocial difficulties and outcome after temporal lobectomy

Epilepsia

Marital status after epilepsy surgery

Epilepsia

Improving quality of life with epilepsy surgery: the seizure outcome is the key to success

Neurology

Patient-perceived impact of resective epilepsy surgery

Neurology

Statistical Power for the Behavioral Sciences

Moderators of the effect of preoperative emotional adjustment on postoperative depression after surgery for temporal lobe epilepsy

Epilepsia

Psychiatric comorbidity in patients with epilepsy. implications for diagnosis and treatment

Epilepsy Behav.