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Therapeutics in pediatric epilepsy, Part 2: Epilepsy surgery and vagus nerve stimulation
Jeffrey R Buchhalter1, Randa G Jarrar
1Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, Minn 55905, USA.
Insights
For children and adolescents with refractory epilepsy, invasive treatments like epilepsy surgery and vagus nerve stimulation offer effective seizure control when medications fail. These advanced therapies provide significant seizure reduction and improved quality of life.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Epileptology
Background:
- Antiepileptic drugs (AEDs) are the first line of treatment for epilepsy in children and adolescents.
- Refractory epilepsy, where seizures persist despite adequate AED trials, necessitates consideration of more invasive therapeutic options.
Purpose of the Study:
- To review the efficacy and safety of advanced invasive therapies for pediatric and adolescent epilepsy refractory to medical management.
- To provide an overview of surgical options including temporal lobectomy, extratemporal surgery, corpus callosotomy, hemispherectomy, and vagus nerve stimulation.
Main Methods:
- Review of existing literature on surgical and device-based treatments for refractory epilepsy in pediatric and adolescent populations.
- Analysis of outcomes, including seizure reduction rates and adverse effects, for various invasive epilepsy therapies.
Main Results:
- Temporal lobectomy achieves seizure freedom or rare seizures in at least 70% of pediatric cases, with common side effects including visual field defects and potential language difficulties.
- Extratemporal surgery shows variable success (20-80%), dependent on lesion identification. Corpus callosotomy offers palliative benefits for fall-related seizures in over 80% of patients.
- Hemispherectomy is effective in 60-80% of patients with hemispheric pathologies, carrying a 0-6% operative mortality risk. Vagus nerve stimulation reduces seizures by ≥50% in about one-third of patients without cognitive or systemic adverse effects.
Conclusions:
- Epilepsy surgery and vagus nerve stimulation are viable, effective options for pediatric and adolescent patients with refractory epilepsy.
- Treatment selection should be individualized based on seizure type, epilepsy origin, patient-specific factors, and potential risks and benefits of each modality.
Abstract:
When antiepileptic drugs fail to relieve seizures adequately in children and adolescents, more invasive therapies such as epilepsy surgery and an implanted device to stimulate the vagus nerve should be considered. Temporal lobectomy is an effective treatment of complex partial and secondarily generalized tonic-clonic seizures arising in the mesial structures or lateral temporal neocortex. Excellent outcomes (seizure free or rare, nondisabling seizures) are achieved in at least 70% of children. The most common adverse effect is a superior quadrant field cut that is usually asymptomatic. Transient and more long-lasting language difficulties have been reported when the surgery involves the dominant temporal lobe. The excellent outcome rate for extratemporal surgery ranges from approximately 20% to 80%, with better results seen in patients with an identifiable lesion. Potential morbidity is related to the region of resected neocortex. Corpus callosotomy is an excellent procedure for palliation but is not a cure for seizures that cause falls, with substantial improvement seen in more than 80% of patients. Potential adverse effects include more intense focal seizures and dysphasia, depending on the developmental level of the individual. Hemispherectomy provides seizure relief in 60% to 80% of patients with hemispherical pathologies such as Sturge-Weber or Rasmussen syndromes. Operative mortality has been reported in the range of 0% to 6%; other morbidities include infection and hydrocephalus. Stimulation of the vagus nerve has reduced partial seizures by 50% or more in approximately one third of patients. No adverse cognitive or systemic effects are associated with use of the implanted vagus nerve stimulator.