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Time to relapse after epilepsy surgery in children: AED withdrawal policies are a contributing factor Volume 16, issue 3, September 2014

TEST YOURSELF


(1) When parents ask you whether it is safe to withdraw AEDs in their child who became seizure-free after
anticipated curative epilepsy surgery, how would you inform them on risks and benefits?


(2) Does postoperative AED withdrawal influence the “natural course” of the epilepsy?


(3) Is early postoperative withdrawal of AEDs unsafe in children?


Note:
Answers are based on two review papers (Braun & Schmidt, Curr Opin Neurol 2014;27:219-226; Ladino et al. Epil Res 2014;108:765-774), and on two research papers (Boshuisen et al. Lancet Neurol 2012;11:784-791, Boshuisen et al. Epileptic Disord 2014; 16: 305-11)

 

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Answers


(1)
- The overall relapse risk is less than one in three patients who start to reduce medication
- Recurrence rates from the literature are significantly higher in patients who remain on medication, which is explained by inherent differences between populations
- 75% of children who have a post-withdrawal relapse regain seizure-freedom after restart of medication
- In children, risk factors for post-withdrawal relapse are (among others): earlier start of withdrawal, incomplete resection, previous surgery, multifocal MRI lesions, and postoperative EEG abnormalities
- AED withdrawal significantly improves cognitive outcome measures in children
- Psychosocial consequences of relapse are less pronounced than in adults

 

(2)
- There is no proof that AED withdrawal increases recurrence risk, compared to continuing drugs
- There is no proof that AED withdrawal increases the risk of developing “de novo” refractory epilepsy
- Early withdrawal merely unmasks incomplete surgical success sooner, which is reflected by the strong relation between timing of AED reduction and time-to-relapse
- Early postoperative recurrences following AED withdrawal are not more difficult to treat than those that occur late

 

(3)
- Earlier start of reduction, and earlier complete discontinuation of AEDs, both slightly increase recurrence risk, with 2-3% per month. This is explained by shorter proof of surgical success.
- The chance to regain seizure-freedom after restart of AEDs following relapse is not influenced by timing of withdrawal
- Early withdrawal does not affect eventual seizure-freedom rates or “cure” (being seizure- and medication-free) in children.

 

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