primary outcome:
Surgery for epilepsy
(See also summary of findings Table for the main comparison.)At one year, in Wiebe 2001, 23 of 40 (58%) participants in the surgery group were free from seizures impairing awareness compared to 3 of 40 (8%) in the medical treatment group (risk ratio (RR) 7.67, 95% confidence interval (CI) 2.50 to 23.51; P = 0.0004; Analysis 1.1), and in Dwivedi 2017, 44 of 57 (77%) participants in the surgery group were free from seizures (ILAE Class 1) compared to 4 of 59 (7%) in the medical treatment group (RR 11.33, 95% CI 4.37 to 29.64; P < 0.00001; Analysis 1.1). Pooling of data from the two studies showed that the RR of seizure freedom in the surgery group compared to the medical group was 9.78 (95% CI 4.73 to 20.21; P < 0.00001; Analysis 1.1; low‐certainty evidence). No heterogeneity was present between studies (I² = 0%).Also at one year in Wiebe 2001, 15 of 40 (38%) participants in the surgery group were free from all seizures including auras compared to 1 of 40 (3%) in the medical treatment group (RR 15.00, 95% CI 2.08 to 108.23; P = 0.007; Analysis 1.2; very low‐certainty evidence). The median percentage improvement in monthly seizure frequency impairing awareness was 100% in the surgery group compared to 34% in the medical treatment group.(See also summary of findings Table 2.)In Alonso‐Vanegas 2018, at one year, 11 out of 14 (79%) participants in the parahippocampectomy (PHC) group, 13 out of 14 (93%) in the anterior temporal lobectomy (ATL) group and 14 of 15 (93%) in the selective amygdalohippocampectomy (SAH) group had a good outcome according to Engel Class Scale 1 and 6 out of 14 (43%) participants in the PHC group, 10 out of 14 (71%) in the ATL group and 9 of 15 (60%) in the SAH group were seizure free according to Engel Class Scale 1A.At 5 years, 50%, 64% and 67% of participants in the PHC, ATL and SAH groups respectively were seizure free according to Engel Class Scale 1 and 29%, 50% and 53% of participants in the PHC, ATL and SAH groups respectively were seizure free according to Engel Class Scale 1A. There were no statistically significant differences between any of the pairs of treatments at 1 year or at 5 years, or according to either definition of the Engel Class Scale (low‐certainty evidence, Analysis 2.1, Analysis 2.2, Analysis 2.3).In Barbaro 2018, between 25 and 36 months, 16 out of 31 (52%) participants in the stereotactic radiosurgery group achieved remission of seizures (at least Engel Class IB) which was statistically significantly less compared to 21 out of 27 (78%) participants in the ATL group (RR 0.66, 95% CI 0.45 to 0.99; P = 0.04; low‐certainty evidence; Analysis 2.4).In Ding 2016, at one year, 17 of 23 (74%) participants in the resection with CCT group were free from seizures (Engel Class 1) compared to 13 of 20 (65%) in the resection only group (RR 1.14, 95% CI 0.76 to 1.70; P = 0.53; low‐certainty evidence; Analysis 2.5). The RR of seizure freedom for the resection with CCT group compared to the resection only group at three years was 1.19 (95% CI 0.72 to 1.95; P = 0.50; intention to treat approach; Analysis 2.5), and at five years was 1.09 (95% CI 0.53 to 2.21; P = 0.82; intention‐to‐treat approach; Analysis 2.5).In Liang 2010, at two years, 18 of 30 (60%) participants in the ATL group were free from seizures (Engel Class 1) compared to 22 of 30 (73%) participants in the aCCT group (RR 1.22, 95% CI 0.85 to 1.76; P = 0.28; moderate‐certainty evidence; Analysis 2.6).In Vogt 2018, at 1 year, 13 out of 22 (59%) participants in the subtemporal SAH group were free from all seizures including auras (ILAE 1a) compared to 16 out of 25 (64%) participants in the transsylvian group (RR 0.92, 95% CI 0.59 to 1.46; P = 0.73; low‐certainty evidence; Analysis 2.7).In Wyler 1995, at one year, 25 of 36 (69%) participants in the total hippocampectomy group were free from all seizures including auras compared to 13 of 34 (32%) participants in the partial hippocampectomy group (RR 1.82, 95% CI 1.12 to 2.93; P = 0.01; low‐certainty evidence; Analysis 2.8). Wyler 1995 also reported time to first seizure: seizure recurrence occurred earlier in the partial hippocampectomy group than in the total hippocampectomy group (at 1.3 vs 1.9 years, respectively).In Schramm 2011, at one year, 77 of 104 (74%) participants in the 2.5‐cm resection group were free from seizures (Engel Class 1) compared to 75 of 103 (73%) participants in the 3.5‐cm resection group (RR 1.02, 95% CI 0.86 to 1.20; P = 0.84; moderate‐certainty evidence; Analysis 2.9).