Management of anti-epileptic treatment after epilepsy surgery

Although epilepsy surgery is a recognized treatment option for drug-resistant epilepsies since several decades and for many patients, the hope of AED discontinuation is one of the major aims for undergoing epilepsy surgery, the management of antiepileptic drugs (AEDs) after successful surgery still remains one of the most difficult and unsolved therapeutic challenges. Indeed,no systematic controlled trials have been specifically conducted so far and no consensus or standardized guidelines regarding postsurgical drug discontinuation policy and procedures are available. Several retrospective and very few prospective studies have explored the issue of AED tapering and discontinuation after successful surgery, attempting to establish in whom, when and how to proceed to drug withdrawal. The current data are far from providing conclusive evidence, however some information that can guide post-surgical AED management can be extrapolated from the literature:1) the rate of seizure recurrence appears to be higher in patients undergoing early (less than 6 months or 9 months according to different studies) AED withdrawal; 2) seizures that recur during AED tapering are easier to control than unprovoked postoperative seizure relapses; 3) no evidence exists showing negative long-term implications on seizure outcomes in patients who attempted AED withdrawal. Yet we lack information about who is the best candidate for AEDs discontinuation after successful surgery, which factors underlie continued remission or on the contrary predict a high risk of relapse after AED withdrawal, when to start AED tapering after surgery, which is the best protocol for AED discontinuation.Indeed, the recognition of epilepsy surgery as an effective treatment option in drug-refractory epilepsies has rendered studies of postsurgery AED treatment a timely issue. Hopefully, this will foster further research with carefully conducted and methodologically sound prospective studies which also report the proportion of patients with complete seizure freedom in order to appreciate how many patients can actually be considered for AED discontinuation. Ultimately randomized controlled trials in large samples are needed to identify the best candidates for AED discontinuation after successful surgery and how to correctly proceed with drug withdrawal.