- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children’s Hospital, Houston, Texas,
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children’s Hospital, Chicago, IL, USA.
Sandi K. Lam
Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children’s Hospital, Chicago, IL, USA.
DOI:10.25259/SNI_417_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nisha Gadgil, Melissa A. LoPresti, Matthew Muir, Jeffrey M. Treiber, Marc Prablek, Patrick J. Karas, Sandi K. Lam. An update on pediatric surgical epilepsy: Part I. 27-Dec-2019;10:257
How to cite this URL: Nisha Gadgil, Melissa A. LoPresti, Matthew Muir, Jeffrey M. Treiber, Marc Prablek, Patrick J. Karas, Sandi K. Lam. An update on pediatric surgical epilepsy: Part I. 27-Dec-2019;10:257. Available from: https://surgicalneurologyint.com/surgicalint-articles/9821/
Epilepsy affects many children worldwide, with drug-resistant epilepsy affecting 20–40% of all children with epilepsy. This carries a significant burden for patients and their families and is strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. For this reason, we sought to explore the role of pediatric epilepsy surgery and provide an overview of the factors contributing to epilepsy surgery planning and execution. We review the necessary preoperative evaluations, surgical indications, planning considerations, and surgical options to provide a clear pathway in the evaluation and planning of pediatric epilepsy surgery.
Keywords: Drug-resistant epilepsy, Epilepsy surgery, Pediatric
Epilepsy is estimated to affect 10.5 million children worldwide.[
Surgical treatment of DRE has been shown to be safer and more efficacious compared to medical management.[
With advances in technology, there are now multiple indications for the different types of surgery to address pediatric epilepsy. We describe, in Part I, practices and advances in diagnostic workup and surgical strategies.
Surgical indications have evolved overtime to encompass a wider variety of epilepsy types, applying epilepsy surgery to more patients.
Presurgical evaluation identifies the EZ, correlating it with function. Stepwise evaluation should include a detailed clinical history, interictal scalp electroencephalography (EEG), long-term video EEG, high-resolution structural magnetic resonance imaging (MRI), and neuropsychological/ neuropsychiatric assessment[
Where the EZ cannot be characterized with noninvasive testing, or noninvasive testing yields contradictory results, Phase 2 assessment utilizing intracranial EEG monitoring may be pursued. Implantation of subdural grids and depth electrodes allows more accurate localization of the EZ than scalp EEG. Functional zones may be identified through cortical stimulation mapping. However, invasive electrocorticography may carry a complication rate of up to 20% (e.g., intracranial hematoma).[
For those who are not candidates or have failed surgery, vagus nerve stimulation may palliatively reduce seizures by 50–75%.[
Several surgical options exist based on the seizure type, lesion type, size and location, and EZ characteristics. Lesionectomy is favored for singular cortical-based lesions and can be curative. Lobectomy is used for more focal lesions and proven superior in cases of temporal lobe epilepsy over medical management (Class I evidence).[
Pediatric epilepsy is more diverse in etiology and semiology with migrational disorders, congenital epileptic syndromes, and extratemporal epileptogenic foci more common in children. Therefore, cortical excisions and hemispherectomies are perhaps more common than temporal lobectomies in the pediatric population versus adults. In addition, DRE impacts neurodevelopment in children. Early surgical intervention limits the time on intolerable medications, minimizes cognitive delays and learning disabilities, and improves psychomotor development.[
It is critical to identify the best candidates for epilepsy surgery. The goals include cure or palliation and may warrant a variety of open versus stereotactic techniques [
Despite the growing appreciation for the deleterious developmental and psychosocial effects of pediatric DRE, there are too few surgical referrals,[
Here, we reviewed, summarized, and synthesized important practices and advances in diagnostic workup and surgical strategies of epilepsy surgery. Future increased awareness of the role of epilepsy surgery in children with DRE is critical to increase the breadth of impact.
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