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Surgical Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review
Amy Y Tsou1, Sudha Kilaru Kessler2, Mingche Wu2
1From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine. amytsou@gmail.com.
Insights
Epilepsy surgery in young children (1-36 months) can lead to seizure freedom for some, with over half achieving favorable outcomes. Further research is needed to evaluate developmental and quality-of-life impacts.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Epileptology
Background:
- Early life epilepsies (1-36 months) are common and often drug-resistant.
- Surgical treatments are being explored for this vulnerable population.
- This review focuses on non-infantile spasm epilepsy cases.
Approach:
- Systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Library (1999-2021).
- Included studies with ≥10 patients undergoing surgical interventions or neurostimulation.
- Excluded infantile spasms and status epilepticus; focused on seizure freedom and harms.
Key Points:
- Low strength of evidence (SOE) indicates some infants achieve seizure freedom post-surgery.
- Hemispherectomy/hemispherotomy showed seizure freedom from 7-76% at 1 year.
- Non-hemispheric surgeries reported 40-70% seizure freedom.
- Over half of infants had favorable outcomes (>50% seizure reduction) after hemispherectomy/hemispherotomy.
- Surgical mortality and postoperative hydrocephalus were rare.
Conclusions:
- Despite sparse, low-quality evidence, epilepsy surgery offers potential seizure control for infants.
- Prospective studies are crucial to assess efficacy and long-term outcomes.
- Future research should include developmental, quality of life, and caregiver outcomes.
Background And Objectives:
Early life epilepsies (epilepsies in children 1-36 months old) are common and may be refractory to antiseizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1-36 months without infantile spasms.
Methods:
EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology, were reported together.
Results:
Eighteen studies (in 19 articles) met the inclusion criteria. Sixteen prestudies/poststudies reported on efficacy, and 12 studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For nonhemispheric surgeries, seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence (SOE) suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, International League Against Epilepsy I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations. Surgical mortality was rare for functional hemispherectomy/hemispherotomy and nonhemispheric resections. Low SOE suggests postoperative hydrocephalus is uncommon for infants undergoing nonhemispheric procedures for epilepsy.
Discussion:
Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL).
Trial Registration Information:
This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
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