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Published on: May 20, 2016
Epilepsy Surgery in Young Children With Tuberous Sclerosis Complex: A Novel Hybrid Multimodal Surgical Approach
Vijay M Ravindra1,2, Patrick J Karas2, Tyler T Lazaro2
1Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
Insights
Surgery effectively treats drug-resistant epilepsy in children with tuberous sclerosis complex. A multimodal approach combining invasive monitoring and surgical options like open resection or laser therapy offers significant seizure freedom and developmental gains.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Epileptology
Background:
- Surgery is crucial for managing pediatric tuberous sclerosis complex (TSC)-related drug-resistant epilepsy (DRE).
- A multimodal strategy is essential for optimizing treatment outcomes in these complex cases.
Purpose of the Study:
- To evaluate a multimodal diagnostic and therapeutic approach for TSC-related DRE.
- To compare outcomes of open resection versus MRI-guided laser interstitial thermal therapy (LITT).
Main Methods:
- Prospective data collection on clinical and radiographic findings in pediatric patients with TSC-DRE.
- Invasive intracranial monitoring (stereo-EEG, grids) followed by surgical intervention (open resection or LITT).
- Assessment of seizure freedom, developmental progress, and Engel class.
Main Results:
- 87% of patients achieved >50% seizure freedom with the multimodal approach.
- Similar rates of seizure reduction (>50%) and developmental improvement were observed for both open resection and LITT.
- The median Engel class was II, with 55% of patients achieving Engel class I/II.
Conclusions:
- A hybrid surgical approach combining open and minimally invasive techniques is safe and effective for TSC-related DRE.
- Further clinical trials with longer follow-up are needed to refine optimal treatment strategies for individual patients.
Background:
Surgery has become integral in treating children with tuberous sclerosis complex (TSC)-related drug-resistant epilepsy (DRE).
Objective:
To describe outcomes of a multimodal diagnostic and therapeutic approach comprising invasive intracranial monitoring and surgical treatment and compare the complementary techniques of open resection and magnetic resonance-guided laser interstitial thermal therapy.
Methods:
Clinical and radiographic data were prospectively collected for pediatric patients undergoing surgical evaluation for TSC-related DRE at our tertiary academic hospital. Seizure freedom, developmental improvement, and Engel class were compared.
Results:
Thirty-eight patients (20 females) underwent treatment in January 2016 to April 2019. Thirty-five underwent phase II invasive monitoring with intracranial electrodes: 24 stereoencephalography, 9 craniotomy for grid/electrode placement, and 2 grids + stereoencephalography. With the multimodal approach, 33/38 patients (87%) achieved >50% seizure freedom of the targeted seizure type after initial treatment; 6/9 requiring secondary treatment and 2/2 requiring a third treatment achieved >50% freedom. The median Engel class was II at last follow-up (1.65 years), and 55% of patients were Engel class I/II. The mean age was lower for children undergoing open resection (2.4 vs 4.9 years, P = .04). Rates of >50% reduction in seizures (86% open resection vs 88% laser interstitial thermal therapy) and developmental improvement (86% open resection vs 83% magnetic resonance-guided laser interstitial thermal therapy) were similar.
Conclusion:
This hybrid approach of using both open surgical and minimally invasive techniques is safe and effective in treating DRE secondary to TSC. Clinical trials focused on treatment method with longer follow-up are needed to determine the optimal candidates for each approach and compare the treatment modalities more effectively.
