Pediatric epilepsy surgery: could age be a predictor of outcomes?

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Like adults, many children suffering from intractable seizures benefit from surgical therapy. Although various reports indicate that early intervention may avoid severe developmental consequences often associated with intractable epilepsy, surgery is still considered a last option for many children. In this retrospective study, the authors aimed to determine whether pediatric epilepsy surgery, in particular during the first years of life, relates to measurable benefits.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Data from 78 patients (age range 5 months to 17 years) who underwent epilepsy surgery at the Geneva and Lausanne University Hospitals between 1997 and 2012 were reviewed retrospectively. Patients were dichotomized into 2 groups: infants (≤ 3 years of age, n = 19), and children/adolescents (4–17 years of age, n = 59). Compared with children/adolescents, infants more often had a diagnosis of dysplasia (37% vs 10%, respectively; p &lt; 0.05, chi-square test).</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The overall seizure-free rate was 76.9%, with 89.5% in infants and 72.9% in the children/adolescents group. Infants were 2.76 times as likely to achieve seizure-free status as children/adolescents. Postoperative antiepileptic medication was reduced in 67.9% of patients. Only 11.4% of the patients were taking more than 2 antiepileptic drugs after surgery, compared with 43% before surgery (p &lt; 0.0001). The overall complication rate was 15.1% (6.4% transient hemiparesis), and no major complications or deaths occurred.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The data show a high seizure-free rate in children ≤ 3 years of age, despite a higher occurrence of dysplastic, potentially ill-defined lesions. Pediatric patients undergoing epilepsy surgery can expect a significant reduction in their need for medication. Given the excellent results in the infant group, prospective studies are warranted to determine whether age ≤ 3 years is a predictor for excellent surgical outcome.</jats:p></jats:sec>

Preoperative evaluation and surgical management of infants and toddlers with drug-resistant epilepsy

“…In contrast to the typical etiologies of DRE in older children and adults, the etiologies of DRE predominating in very young children included hemispheric syndromes such as Sturge-Weber syndrome (SWS), Rasmussen encephalitis, and hemimegalencephaly; malformations of cortical development (MCD) such as focal cortical dysplasia (FCD), polymicrogyria, and heterotopias; vascular malformations or stroke; tuberous sclerosis complex (TSC); neoplasms such as ganglioglioma, dysembryoplastic neuroepithelial tumor (DNET), other low-grade tumors, and malignant tumors; gliosis; and prior infection such as encephalitis (Table 1). 30,35,40,44,45,50,51,69,70,73 Prevalence estimates of each etiology generally agreed with those reported by Harvey et al in children younger than 4 years with DRE in an international survey of epilepsy procedures. 34 Overall, only approximately 1% of infants and toddlers with DRE (4 of 444) harbored hippocampal sclerosis.…”

“…6,13,15,35,37,40,50,51,69,70,73 In general, patients with ETLE exhibit lower rates of seizure freedom (56%-68% Engel class I) than patients with TLE undergoing temporal lobectomy (60%-100%). 25,40 However, infants and toddlers experience a higher prevalence of ETLE and may respond better to resection, with seizure freedom rates as high as 82%. 25,40 Earlier surgical intervention increases the likelihood of success, as a meta-analysis has shown that preoperative epilepsy duration of 7 years or less represented a positive predictive factor for Engel class I outcome.…”

“…40 Reported rates of seizure freedom following epilepsy surgery in infants and toddlers range between 48% and 89.5%, including 65%-85% following hemispherotomy or hemispherectomy. 6,13,15,35,37,40,50,51,69,70,73 In general, patients with ETLE exhibit lower rates of seizure freedom (56%-68% Engel class I) than patients with TLE undergoing temporal lobectomy (60%-100%). 25,40 However, infants and toddlers experience a higher prevalence of ETLE and may respond better to resection, with seizure freedom rates as high as 82%.…”

“…25,40 However, infants and toddlers experience a higher prevalence of ETLE and may respond better to resection, with seizure freedom rates as high as 82%. 25,40 Earlier surgical intervention increases the likelihood of success, as a meta-analysis has shown that preoperative epilepsy duration of 7 years or less represented a positive predictive factor for Engel class I outcome. 25 Earlier surgical intervention also may foster improvements in global development and neuro-cognition by decreasing the disruptive effects of refractory seizures and interictal abnormalities.…”

Epilepsy Surgery Works – So Why the Wait?

“…These three randomized trials have clearly shown the superiority of surgery over medical therapy in children and adults with focal epilepsy be it temporal, extratemporal, hemispheric, or due to hypothalamic hamartoma. Jenny et al (4) noted seizure outcomes in children ≤3 years to be better than for chil-Surgery for Drug-Resistant Epilepsy in Children. Dwivedi BACKGROUND: Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but additional data are needed from randomized trials.…”