Resective epilepsy surgery involving eloquent cortex in the age of responsive neurostimulation: A value-based decision-making framework

Abstract

Resective epilepsy surgery has endured as the most effective way to render patients with seizure-free intractable localization-related epilepsy. Under conditions where the seizure focus is in close proximity to eloquent cortex, a postoperative deficit may be expected. Patients often accept the risk or certainty of these deficits for the possibility of seizure freedom. Recently, responsive neurostimulation (RNS) has emerged as an alterative to resective epilepsy surgery. This cranially implanted closed-loop neurostimulation system records brain activity and interrupts seizure propagation, thereby decreasing seizure frequency. The introduction of RNS to clinical practice raises several challenges to clinicians and patients alike. Despite a dearth of long-term data, should this be considered as a safer and potentially reversible option for patients who would otherwise be candidates for resective surgery in eloquent cortex? In the current report, we analyze the complex bioethical implications of presenting a new, "safer" technology, alongside a well-established, "more effective" treatment. We present an adapted value-based decision-making model to guide patients and help clinicians navigate the tradition of resective epilepsy surgery in eloquent cortex in the nascent age of RNS.

Keywords: Decision-making; Drug-resistant epilepsy; Ethics; Resective surgery; Responsive neurostimulation.