Duke Epilepsy · Retrospective outcome analysis

Surgical Decision Support for Epilepsy Outcomes

I led the statistical analysis of whether the 5-SENSE focality score is associated with seizure freedom after resection or laser interstitial thermal therapy. The findings support the score as one part of a broader clinical assessment, not as a stand-alone threshold rule.

BiostatisticsEpilepsy surgeryModel evaluationSensitivity analysis

Clinical question

Does a focality score help explain postoperative seizure freedom?

The 5-SENSE score was developed to summarize focality from stereoelectroencephalography and related clinical evidence. We asked whether the continuous score is associated with Engel IA seizure freedom after resection or LITT, and why some patients with high scores do not achieve the expected outcome.

I led cohort reconciliation, the statistical analysis, sensitivity checks, and interpretation. Neuromodulation was analyzed separately because its responder endpoint is not equivalent to postoperative seizure freedom.

110Treated patients

→

88Resection or LITT

→

42Engel IA

46Not Engel IA

Distribution of 5-SENSE scores by Engel IA seizure-freedom outcome — **5-SENSE score by outcome.** Scores were higher among seizure-free patients in the primary surgery/LITT cohort. The continuous comparison supports an association, while the overlap between groups cautions against using the score alone.

ROC curve for the continuous 5-SENSE score — **Continuous-score discrimination.** The AUC was 0.71, with a bootstrap 95% confidence interval of 0.60 to 0.81. Discrimination was moderate rather than definitive.

AUC0.71Bootstrap 95% CI: 0.60 to 0.81

Per 10-point increase1.35×Higher odds of Engel IA

Threshold near 4195.2%Sensitivity

Threshold near 4130.4%Specificity

Threshold interpretation

A highly sensitive rule produced many false positives.

The threshold near 41 came from prior work on SEEG focality, not postoperative seizure freedom. In this cohort it retained nearly all favorable outcomes, but its low specificity means it should not be treated as a validated surgical cutoff.

The continuous score is more informative than a single transferred threshold. Its practical value is likely to depend on pathology, imaging concordance, treatment context, and other clinical evidence.

Failure analysis

Pathology helped explain why high-score outcomes diverged.

Among eligible high-score surgery cases, positive histology was present in 81.8% of true-positive cases and 42.9% of false-positive cases. The exact odds ratio was 5.77. This was the strongest explanatory difference in the updated analysis and remained visible in an exploratory model adjusted for SEEG.

The result supports combined interpretation. It does not establish pathology as a causal modifier, and the subset size limits precision.

Histology subtype counts among high-score true-positive and false-positive surgery cases — **Histology among high-score surgery cases.** Curated pathology showed more lesional findings among true-positive cases and more negative or no-lesion findings among false-positive cases.

Takeaway

Useful prognostic information, with clear limits.

The continuous 5-SENSE score was associated with Engel IA and had moderate discrimination. Its value lies in combination with pathology and other clinical evidence. Follow-up uncertainty, threshold transfer, and small treatment-specific subsets remain important limitations.

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