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Published on: August 16, 2024
Epilepsy surgery in the first six months of life: A systematic review and meta-analysis
Konstantin L Makridis1, Deniz A Atalay2, Ulrich-Wilhelm Thomale3
1Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany; Center for Chronically Sick Children, Augustenburger Platz 1, Berlin, Germany; Charité - Universitätsmedizin Berlin, Institute of Cell- and Neurobiology, Charitéplatz 1, Berlin 10117, Germany.
Insights
Epilepsy surgery in infants under six months offers excellent seizure control, with many reducing or stopping anti-seizure medication. Achieving seizure freedom is key for potential cognitive gains, and surgery should occur in specialized centers.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Epileptology
Background:
- Drug-resistant epilepsy affects nearly one-third of infants.
- Epilepsy surgery is effective but may be delayed in infants due to surgical challenges.
- Infants under six months present unique surgical and anesthesiologic considerations.
Purpose of the Study:
- To evaluate the outcomes of epilepsy surgery in infants operated on within the first six months of life.
- To assess the seizure control and complication rates associated with early epilepsy surgery.
- To investigate the impact of early surgery on anti-seizure medication use and cognitive development.
Main Methods:
- A meta-analysis and systematic review were conducted.
- Data from 158 infants undergoing epilepsy surgery at ≤ six months of age were analyzed.
- Outcomes included seizure freedom, complication rates, medication changes, and cognitive function.
Main Results:
- Overall seizure freedom was 65.6%, with hemispherotomy (71%) yielding higher rates than focal surgery (58%).
- Complications occurred in 27.7% of patients, most commonly hydrocephalus (14.71%).
- Postoperative anti-seizure medication reduction or discontinuation was observed in a significant proportion of patients; cognitive gains were primarily seen in seizure-free infants.
Conclusions:
- Epilepsy surgery in the first six months of life can achieve excellent seizure control and reduce anti-seizure medication dependence.
- While cognitive outcomes are promising, seizure freedom is the primary goal for cognitive improvement.
- Due to surgical complexities, early epilepsy surgery should be performed exclusively in specialized epilepsy centers.
Introduction:
Nearly one-third of all infants with epilepsy develop drug-resistant epilepsy. Although epilepsy surgery is a well-established therapy across all age groups, there might be a reluctance to operate on infants in the first six months of life due to unique surgical and anesthesiologic difficulties.
Methods:
We performed a meta-analysis and systematic review to assess the outcome and complication rate of epilepsy surgery in infants operated on ≤ six months of life.
Results:
158 infants underwent epilepsy surgery, most frequently a hemispherotomy rather than focal surgery. Overall seizure freedom after surgery was 65.6% [CI: 0.5785; 0.7261], with higher seizure-free rates following hemispherotomy (71%) than after focal surgery (58%). Complications occurred in 27.7% [0.1794; 0.4004] of patients. Most prevalently, a hydrocephalus developed in 20 out of 136 cases (14.71%). Anti-seizure medication (ASM) was discontinued in 21.5% [0.1431; 0.3100] and reduced in 85.9% [0.515; 0.9721] of 93 patients postoperatively. 84.6% of infants displayed cognitive impairment (development quotient (DQ) <85) preoperatively. After surgery, there was a trend toward a cognitive gain. However, cognitive gain was seen almost exclusively in seizure-free patients.
Discussion:
Excellent seizure control can be achieved with epilepsy surgery in the first six months of life, a large proportion of patients are able to reduce or discontinue ASM. Data regarding cognitive outcome are promising, but also show that the primary goal should be to achieve seizure freedom. Given the more difficult surgical conditions, epilepsy surgery in the first six months of life should only be performed in specialized epilepsy centers.
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