根據八月二日The New England Journal of Medicine上的一份研究報告指出，在與鎮痙攣藥物相較，外科手術在治療顳葉頑固型癲癇上更為有效。研究人員覺得，即使手術極為有效，但在治療顳葉癲癇使用上卻相當少；顳葉癲癇是種包含單一與復合暫時發作，會引起實體觸感的喪失、幻覺、或不自主的動作，如嘴唇發出聲響，咬食衣服等。
Surgery Shows Dramatic Results in Refractory Epilepsy
Question Is "When" Not "Whether," Say Experts
By Laurie Barclay, MD
WebMD Medical News
Reviewed by Aman Shah, MD
Aug. 1, 2001 -- Surgery is a significantly more effective treatment for refractory temporal lobe epilepsy than anticonvulsants, according to a report in the Aug. 2 issue of TheNew England Journal of Medicine. The researchers feel that surgery, despite its effectiveness, is underused in the treatment of temporal lobe epilepsy, a form of epilepsy that is characterized by simple or complex partial seizures and may involve losing touch with reality, hallucinations, or automatic movements like lip smacking or picking at clothing.
"Physicians should be aware that the effect of surgery for temporal lobe epilepsy is impressive, and it should not be considered as a treatment of last resort. We still can't answer the question of when is the appropriate time to consider surgery, which is being addressed by an ongoing multicenter trial," lead author Samuel Wiebe, MD, tells WebMD.
"While this study was done in those over age 16, there is no reason to believe the findings would not apply to children, especially since plasticity is better in the developing brain," he says. "The earlier the surgery is done, the less likely seizures are to impair psychosocial function in the formative years. ... It's futile to continue trying many different drugs for many years."
"If you're in an area where there are competent neurosurgeons with appropriate experience, surgery should be considered early on in the treatment of temporal lobe epilepsy. Adverse effects of surgery can be serious, although they were not in this study," adds co-author Warren T. Blume, MD. Both Wiebe and Blume are clinical neuroscientists at the University of Western Ontario in London.
The researchers randomized 80 patients with temporal lobe epilepsy to surgery or continued drug treatment. All patients underwent a battery of neuropsychological and radiological testing and, for more than a year, had recurrent seizures that were poorly controlled by two or more anticonvulsants.
The surgical procedure involved extensive testing using sophisticated EEG techniques to identify the origins and characteristics of the seizure as well as testing of memory function at the site of the seizure, followed by resection of the anterior lateral nondominant temporal lobe or the dominant temporal lobe accompanied by resections in the amygdala and hippocampus.
One year later, 58% of those who had surgery were free of seizures impairing awareness, compared to 8% of those who did not. The surgical group also had fewer seizures overall and a better quality of life.
Four surgical patients had adverse effects -- one patient had a small symptomatic thalamic infarct, two had verbal memory impairments, and one had a wound infection. All patients in the medical group had their anticonvulsants switched or increased in dosage, compared to just 22% of the surgical group. One patient in the medical group died of unknown reasons.
"This is the first time anyone has been able to complete a randomized, controlled trial of epilepsy surgery. The results unequivocally demonstrate that the results reported in the literature from retrospective studies over the last two decades (approximately two-thirds seizure-free) are valid," accompanying editorial author Jerome Engel Jr., MD, PhD, tells WebMD.
"The results also confirm results of pharmacotherapy trials which indicate that seizure freedom with continued drug treatment in this patient population is extremely rare. Early surgery would avoid the development of irreversible psychological and social consequences of disabling epilepsy," says Engel, a professor of neurology at UCLA. "The next question is whether surgery should be considered the treatment of choice and, if so, when in the course of the disorder."
"Uncontrolled epilepsy poses a risk for death, injury, and impaired quality of life and can eventually cause brain damage," Kimford J. Meador, MD, a professor of neurology at the Medical College of Georgia, in Augusta, tells WebMD after reviewing the study. However, many patients with uncontrolled seizures wait up to 20 years to have surgery because of unfounded fears that make surgery a last resort. "Hopefully, these findings will encourage consideration of this treatment earlier," says Meador.
"The surgery is not to be taken lightly," Blume says. "The brain is so complex that you need to have it done by a neurosurgeon who appreciates that complexity, in a center with extensive experience and expertise."
"Except in extreme cases, patients will not become deaf, mute, or paralyzed when proper evaluations and surgery are performed," says Stephan Eisenschenk, MD, an assistant professor of neurology at the University of Florida, in Gainesville, who also reviewed the study for WebMD.
Thanks to remarkable advances in diagnosis and treatment at academic centers, including sophisticated techniques to view brain structure and function, surgical outcome is much better in selected patients, according to Eisenschenk.