title: Reducing versus stopping antiepileptic medications after temporal lobe surgery.
abstract: OBJECTIVE
  To study the safety of antiepileptic drug (AED) withdrawal after temporal lobe epilepsy (TLE) surgery.
  
  
  METHODS
  We reviewed patients who underwent TLE surgery from 1995 to 2011, collecting data on doses, dates of AED initiation, reduction, and discontinuation. Predictors of seizure outcome were defined using Cox-proportional hazard modeling and adjusted for, while comparing longitudinal seizure-freedom in patients for whom AEDs were unchanged after resection as opposed to reduced or stopped.
  
  
  RESULTS
  A total of 609 patients (86% adults) were analyzed. Follow-up ranged from 0.5 to 16.7 years. Most (64%) had hippocampal sclerosis. Overall, 229 patients had remained on their same baseline AEDs, while 380 patients stopped (127 cases) or reduced (253 cases) their AEDs. Mean timing of the earliest AED change was shorter in patients with recurrent seizures (1.04 years) compared to those seizure-free at last follow-up (1.44 years; P-value 0.03). Whether AEDs were withdrawn 12 or 24 months after surgery, there was a 10-25% higher risk of breakthrough seizures within the subsequent 2 years. However, 70% of patients with seizure recurrence after AED discontinuation reachieved remission, as opposed to 50% of those whose seizures recurred while reducing AEDs (P = 0.0001). Long-term remission rates were similar in both AED discontinuation and "unchanged" groups (82% remission for AEDs withdrawn after 1 year and 90% for AEDs withdrawn after 2 years), while only 65% of patients whose recurrences started during AED reduction achieved a 2-year remission by last follow-up.
  
  
  CONCLUSIONS
  AED withdrawal increases the short-term risk of breakthrough seizures after TLE surgery, and may alter the long-term disease course in some patients.
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Ruta
authors.initials: R
authors.lastname: Yardi
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Anna
authors.initials: A
authors.lastname: Irwin
authors.affiliation: The Children's Mercy Hospital, University of Missouri Kansas, Missouri.
authors.forename: Husam
authors.initials: H
authors.lastname: Kayyali
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Ajay
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Dileep
authors.initials: D
authors.lastname: Nair
authors.affiliation: Department of Neurosurgery, Cleveland Clinic Cleveland, Ohio.
authors.forename: Jorge
authors.initials: J
authors.lastname: Gonzalez-Martinez
authors.affiliation: Department of Neurosurgery, Cleveland Clinic Cleveland, Ohio.
authors.forename: William
authors.initials: W
authors.lastname: Bingaman
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Imad M
authors.initials: IM
authors.lastname: Najm
authors.affiliation: Epilepsy Center, Neurological Institute, Cleveland Clinic Cleveland, Ohio.
authors.forename: Lara E
authors.initials: LE
authors.lastname: Jehi