Clinical Scorecard: Can Acute Postoperative Seizures Serve as Predictors for Outcomes in Epilepsy Surgery? A Scoping Review

At a Glance

Key Highlights

• Approximately 56-61% of patients achieve seizure freedom after temporal lobe resective surgery.
• APOS occur within the first postoperative week and are strongly linked to long-term seizure recurrence, but up to 40% with APOS may still have favorable outcomes.
• Distinguishing running-down seizures (RDS) from running-up seizures (RUS) is only possible retrospectively and is critical to avoid unnecessary treatment escalation.

Guideline-Based Recommendations

Diagnosis

• Define APOS as seizures occurring within the first postoperative week.
• Classify postoperative seizures into habitual, non-habitual, and neighborhood seizures based on semiology and pathophysiology.
• Recognize that differentiation between RDS and RUS requires longitudinal follow-up.

Management

• Avoid premature escalation of anti-seizure medications or reoperation without clear evidence of seizure recurrence trajectory.
• Consider the possibility of running-down seizures when postoperative seizures decrease gradually and remit within 2 years.
• Tailor therapeutic interventions based on seizure course to reduce treatment burden.

Monitoring & Follow-up

• Long-term follow-up is essential to distinguish RDS from RUS, as classification depends on eventual seizure recurrence.
• Monitor seizure frequency and characteristics closely during the first 2 years post-surgery.
• Use clinical counseling to manage caregiver uncertainty regarding postoperative seizures.

Risks

• Incomplete resection or maturation of new epileptogenic foci may lead to running-up seizures and seizure recurrence.
• Misclassification of postoperative seizures may lead to unnecessary treatment escalation or reoperation.
• Postoperative inflammation can cause neighborhood seizures, which are typically focal and non-disabling.

Patient & Prescribing Data

Surgically treated epilepsy patients exhibiting acute or early postoperative seizures

Up to 40% of patients with APOS may achieve long-term seizure remission, indicating that not all early postoperative seizures require aggressive treatment escalation.

Clinical Best Practices

• Recognize the heterogeneity of postoperative seizures and their underlying mechanisms.
• Provide clear counseling to patients and caregivers about the potential for running-down seizures and the uncertainty in early postoperative seizure prognosis.
• Implement careful and prolonged postoperative monitoring to guide treatment decisions.
• Avoid premature changes in anti-seizure medication based solely on early postoperative seizures without longitudinal evidence.

References

• Giridharan et al. Meta-analysis on APOS and seizure freedom
• Rasmussen's theory on running-down seizures
• PRISMA 2020 guidelines