Acute Postoperative Seizures as Predictors of Epilepsy Surgery Outcomes

Overview

This scoping review analyzed 21 studies involving 1,496 patients to evaluate whether acute postoperative seizures (APOS) can predict long-term seizure outcomes after epilepsy surgery. While APOS are strongly associated with seizure recurrence, up to 40% of patients with APOS achieve favorable long-term outcomes, highlighting the heterogeneity of postoperative seizure courses.

Background

Resective surgery is the preferred treatment for epilepsy but does not guarantee complete seizure remission, with approximately 56-61% of patients becoming seizure-free after temporal lobe surgery. Acute postoperative seizures, defined as seizures occurring within the first postoperative week, are linked to long-term seizure recurrence but can represent either a transient running-down phenomenon or a running-up pattern indicating persistent epileptogenic tissue. Differentiating these patterns early is critical to avoid unnecessary treatment escalation and to optimize patient management. However, predictors distinguishing these courses remain unclear due to complex pathophysiology and variable clinical presentations.

Data Highlights

Key Findings

• APOS occur within the first postoperative week and are strongly associated with long-term seizure recurrence.
• Up to 40% of patients with APOS experience a running-down seizure pattern leading to eventual remission.
• Running-down seizures are hypothesized to originate from epileptogenic tissue surrounding the resection site undergoing recovery.
• Running-up seizures may result from incomplete resection or emergence of new epileptogenic foci.
• Distinguishing running-down from running-up seizures is only possible retrospectively based on seizure recurrence.
• Early identification of running-down seizures can prevent unnecessary escalation of anti-seizure medication or reoperation.

Clinical Implications

Clinicians should recognize that not all acute postoperative seizures indicate poor prognosis; a subset represents a transient running-down phenomenon. Careful monitoring and delayed decision-making regarding treatment escalation may be warranted to avoid overtreatment. Improved understanding and identification of predictors for seizure course post-surgery can enhance patient counseling and optimize therapeutic strategies.

Conclusion

Acute postoperative seizures are a heterogeneous phenomenon with variable prognostic implications. Differentiating running-down from running-up seizure patterns remains challenging but is essential for guiding postoperative management and improving patient outcomes.

References

1. Giridharan et al. 2020 -- Meta-analysis on APOS and seizure outcomes
2. Rasmussen 1970s -- Theory on running-down seizures