Coagulation abnormalities in children undergoing epilepsy surgery
Donato Pacione1, Francine Blei, Orrin Devinsky
1Department of Neurosurgery, Division of Pediatric Neurosurgery, NYU Langone Medical Center, New York, NY, USA.
Insights
Preoperative screening for epilepsy surgery in children may miss coagulation issues. Platelet aggregation studies are recommended for children with tuberous sclerosis complex (TSC) to detect bleeding risks.
Area of Science:
- Pediatric Neurology
- Hematology
- Surgical Oncology
Background:
- Epilepsy surgery is a growing treatment for pediatric refractory epilepsy.
- Preoperative evaluation aims to identify bleeding risks not apparent through standard history and physical exams.
- Routine screening may not detect all underlying coagulation abnormalities.
Purpose of the Study:
- To evaluate the adequacy of standard preoperative screening for coagulation abnormalities in children undergoing epilepsy surgery.
- To identify specific patient factors associated with these abnormalities.
- To determine if enhanced testing, such as platelet aggregation studies, is warranted in certain pediatric epilepsy populations.
Main Methods:
- Prospective evaluation of 39 children undergoing pre-epilepsy surgery testing.
- Detailed hematological history and extensive laboratory panel including coagulation profiles and platelet aggregation studies.
- Analysis of patient variables: tuberous sclerosis complex (TSC), age, seizure characteristics, and medication use.
Main Results:
- 25.6% of children had coagulation or platelet function abnormalities.
- Platelet function abnormalities were linked to TSC (p=0.012), while coagulopathy was more common in non-TSC patients (p=0.041).
- Two TSC patients with normal standard screening had platelet aggregation abnormalities; one experienced significant intraoperative bleeding.
Conclusions:
- Standard preoperative screening and history are insufficient for detecting all coagulation issues in pediatric epilepsy surgery candidates.
- Platelet aggregation studies are crucial for patients with TSC to identify potential bleeding risks.
- Enhanced hematological evaluation may improve surgical safety in this population.
Object:
Surgery is increasingly used to treat children with refractory epilepsy. Before surgery, the authors routinely evaluated the coagulation profile to identify coagulation abnormalities not established by personal and family history, physical examination, and routine screening tests.
Methods:
Thirty-nine consecutive children undergoing testing prior to epilepsy surgery were prospectively evaluated. The authors evaluated a detailed hematological history and an elaborative hematological panel including complete blood count, hepatic panel, anticoagulant levels, coagulation profile (prothrombin time, partial thromboplastin time, international normalized ratio, fibrinogen, thrombin time, von Willebrand antigen, ristocetin cofactor, factor VIII, and individual factor assays when indicated) and platelet aggregation studies (in the presence of adenosine diphosphate, epinephrine, collagen, and ristocetin). Patient variables included tuberous sclerosis complex (TSC), age at epilepsy onset, age at surgery, seizure frequency, number and type of antiepileptic drugs, recent or present ketogenic diet, and use of selective serotonin reuptake inhibitors.
Results:
Ten children (25.6%) had either coagulation or platelet function abnormalities. Abnormal coagulation was identified in 5 children, and abnormal platelet function was discovered in 6. A diagnosis of TSC was associated with a platelet function abnormality (p = 0.012), whereas children without TSC had a higher rate of coagulopathy (p = 0.041). None of the other characteristics reached statistical significance. In 2 patients (5.1%) with TSC and platelet aggregation abnormalities, the authors noted normal standard screening laboratory studies and an uneventful detailed personal and family history. One of these 2 patients developed a significant intraoperative bleeding complication.
Conclusions:
A preoperative screening with standard laboratory studies and detailed history may not be adequate to fully examine underlying coagulation abnormalities in children with refractory epilepsy. Platelet aggregation studies should be considered in patients with TSC.
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