Surgical evaluation in children <3 years of age with drug‐resistant epilepsy: Patient characteristics, diagnostic utilization, and potential for treatment delays

Abstract

Objective: Drug-resistant epilepsy (DRE) occurs at higher rates in children <3 years old. Epilepsy surgery is effective, but rarely utilized in young children despite developmental benefits of early seizure freedom. The present study aims to identify unique patient characteristics and evaluation strategies in children <3 years old who undergo epilepsy surgery evaluation as a means to assess contributors and potential solutions to health care disparities in this group. Methods:The Pediatric Epilepsy Research Consortium Epilepsy Surgery Database, a multicentered, cross-sectional collaboration of 21 US pediatric epilepsy centers, collects prospective data on children <18 years of age referred for epilepsy surgery evaluation. We compared patient characteristics, diagnostic utilization, and surgical treatment between children <3 years old and those older undergoing initial presurgical evaluation. We evaluated patient characteristics leading to delayed referral (>1 year) after DRE diagnosis in the very young. Results:The cohort included 437 children, of whom 71 (16%) were <3 years of age at referral. Children evaluated before the age of 3 years more commonly had abnormal neurological examinations (p = .002) and daily seizures (p = .001). At least one ancillary test was used in 44% of evaluations. Fifty-nine percent were seizure-free following surgery (n = 34), with 35% undergoing limited focal resections. Children with delayed referrals more often had focal aware (p < .001) seizures and recommendation for palliative surgeries (p < .001).Significance: There are relatively few studies of epilepsy surgery in the very young. Surgery is effective, but may be disproportionally offered to those with severe presentations. Relatively low utilization of ancillary testing may contribute to reduced surgical therapy for those without evident lesions on magnetic resonance imaging. Despite this, a sizeable portion of patients have favorable outcome after focal epilepsy surgery resections.

Surgical Treatments for Epilepsies in Children Aged 1–36 Months

“…A recent study (published subsequent to our search dates) reported of 34 children <3 undergoing epilepsy surgery since 2018, 59% were Engel I outcome at median follow-up of 21.9 months. 37 …”

Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

“…25 This "surgical treatment gap" has been steadily improving in the United States pediatric population but epilepsy surgery still remains underutilized. 13,26,27 The underutilization of pediatric epilepsy surgery is multifactorial and includes racial, ethnic, socioeconomic, and medical disparities. Although safe, effective, and recommended for all patients with DRE, there is a misconception amongst patients and health care providers that surgery remains a "last resort" and perceived as being experimental, ineffective, and high risk.…”

“…25 This “surgical treatment gap” has been steadily improving in the United States pediatric population but epilepsy surgery still remains underutilized. 13 26 27…”

Longitudinal neurological analysis of moderate and severe pediatric cerebral visual impairment

“…Additionally, the use of multiple antiseizure medications was also negatively associated with longitudinal CVI outcome, and suggests that Practically, it is important for the vision care provider to consider the number of seizure medications and whether if it may be affecting the child's performance during a CVI vision assessment. This would importantly pair up with the increasing tendency toward early aggressive seizure/epilepsy management among neurologists, including offering earlier curative or palliative epilepsy surgery options and few medication trials (Prideaux et al, 2018;Roth et al, 2021;Perry et al, 2022).…”