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Surgical treatment of epilepsy in children
1Pediatric Epilepsy Program, The Cleveland Clinic Foundation, Ohio 44195, USA.
Insights
Pediatric epilepsy surgery can significantly reduce or eliminate intractable seizures in children. Early surgical evaluation is recommended for severe, intractable epilepsy to prevent long-term developmental issues.
Area of Science:
- Neurology
- Pediatric Epilepsy Surgery
Background:
- Intractable seizures in children and adults can be managed with cortical resection or hemispherectomy.
- Surgical candidacy requires intractable epilepsy, a localized epileptogenic zone, and minimal risk of new deficits.
Observation:
- Pediatric epilepsy presents unique challenges due to poorly localizing electroencephalographic features, extratemporal localization, and developmental pathology.
- Brain maturation and plasticity can influence surgical outcomes and the risk of postoperative deficits in children.
- Cognitive and psychosocial costs of untreated childhood epilepsy include developmental stagnation.
Findings:
- Pediatric epilepsy surgery yields seizure-free rates comparable to adult series.
- Delaying surgery for childhood-onset epilepsy into adulthood correlates with increased permanent psychosocial, behavioral, and educational problems.
- Children with severe intractable localization-related epilepsy should be considered for surgical evaluation at any age.
Implications:
- Careful risk/benefit assessment is crucial for each child undergoing epilepsy surgery evaluation.
- Specialized centers with pediatric epilepsy surgery expertise are vital for managing complex cases.
- Early surgical intervention in children may mitigate long-term developmental and psychosocial impairments.
Abstract:
In carefully selected children, as well as adults, intractable seizures may be eliminated or greatly reduced by cortical resection or hemispherectomy. Critical features of surgical candidacy include intractable disabling epilepsy, a localized epileptogenic zone, and a low risk of new postoperative deficits; however, the analysis may be complicated in children. Compared with adults, pediatric patients are especially likely to present with poorly localizing electroencephalographic features because of their high incidence of extratemporal localization and developmental pathology. Maturation factors may result in unusual epilepsy manifestations, for example, infantile spasms and hypsarrhythmia caused by a focal cortical lesion. The cognitive and psychosocial costs of continued frequent seizures during infancy and childhood must be assessed differently from those in adults and may include stagnation of developmental progression. The risk for new postoperative deficits may be modified if surgery is performed during stages of active brain maturation with developmental plasticity. For each individual child, the potential risk/benefit ratio for surgery must be carefully weighed on the basis of results of an extensive preoperative evaluation. Results from pediatric epilepsy surgery series are encouraging, with percentages of seizure-free patients similar to those in adult series. In some series, delaying surgery for childhood-onset epilepsy into adulthood was associated with greater permanent psychosocial, behavioral, and educational problems. The available data suggest that children should be considered for surgical evaluation at whatever age they present with severe intractable localization-related epilepsy. Complicated cases warrant referral to specialized centers with extensive pediatric epilepsy surgery experience.