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Surgical treatment of epilepsy in pediatric patients
1Department of Neurology, The Cleveland Clinic Foundation, Ohio 44195, USA.
Insights
Pediatric epilepsy surgery offers favorable seizure outcomes, with young age not negatively impacting results. Early surgical intervention may also aid developmental progression in children with intractable focal epilepsy.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Epileptology
Background:
- Epilepsy surgery is an established treatment for intractable focal epilepsy in adults.
- Increasingly, pediatric patients with intractable epilepsy are evaluated for surgical intervention.
- Surgical candidacy requires medically intractable focal epilepsy, a localized epileptogenic zone, and low risk of neurological deficits.
Observation:
- Common pediatric epilepsy etiologies include cortical malformations and low-grade tumors.
- Hippocampal sclerosis is another significant cause of epilepsy in pediatric surgical candidates.
- Seizure-free outcomes in pediatric epilepsy surgery range from 59% to 69%, comparable to adult series.
Findings:
- Young age does not adversely affect seizure outcomes post-epilepsy surgery.
- Infants, children, and adolescents show comparable seizure-free rates (60-69%) to adults (64%).
- Patients with hippocampal sclerosis or low-grade tumors often experience higher seizure-free rates.
Implications:
- Epilepsy surgery can potentially improve developmental trajectories in children.
- Optimal developmental outcomes are associated with earlier surgery and higher preoperative development.
- Careful presurgical evaluation is crucial to balance surgical risks and benefits for each child.
Abstract:
Surgery has become an accepted treatment modality for carefully selected adults with intractable focal epilepsy. More recently, increasing numbers of pediatric patients with intractable epilepsy are also being referred for surgical consideration. Key elements of surgical candidacy include medically intractable focal epilepsy, a localized epileptogenic zone, and a low risk for new postoperative neurologic deficits. The most common etiologies of the epilepsies in pediatric surgical candidates are malformation of cortical development and low grade tumor but some patients with childhood onset temporal lobe epilepsy due to hippocampal sclerosis also present for early surgery. Based on results from several recent pediatric surgical series, the chance for favorable seizure outcome after surgery is not adversely affected by young age, with seizure-free postoperative outcome reported for 60% to 65% of infants, 59% to 67% of children, and 69% of adolescents, compared to 64% reported in a large, predominantly adult series. Some subgroups of patients have higher percentages of seizure-free outcome, including those with hippocampal sclerosis or low grade tumor. In addition to seizures, developmental issues are also a major concern in children with intractable epilepsy. Few quantitative data are available, but some anecdotal experience suggests that surgical relief of catastrophic epilepsy may result in resumption of developmental progression after surgery, although the rate of development often remains abnormal. In one series, best developmental outcomes were seen in patients with earliest surgery and highest level of preoperative development. For each patient, the timing of surgery must be carefully considered, based on a full assessment of the relative risks and benefits, derived from a detailed presurgical evaluation.