WASHINGTON, DC—Neurologists are considering resective surgery as a treatment for children with epilepsy more often than they have in the past, according to research presented at the 67th Annual Meeting of the American Epilepsy Society. “The change in surgical landscape in kids does not appear to be epidemiologic, but rather reflects a change in us and [in] how we look at the problem,” said Howard L. Weiner, MD.
Neurologists’ understanding of pediatric epilepsy surgery has changed during the past 20 years. The treatment had long been limited to children with brain lesions, focal cortical dysplasias, epilepsy-associated tumors, cavernous malformations, and hemispheric pathology. But neurologists are now performing surgery on children with more challenging types of epilepsy such as bilateral polymicrogyria and tuberous sclerosis.
A New Analysis of Surgery’s Risks and Benefits for Children
Neurologists’ perception of pediatric epilepsy surgery’s risk–benefit profile has evolved, “tilting the balance toward favoring surgery,” said Dr. Weiner, Professor of Neurosurgery at the New York University Langone Medical Center. Researchers have concluded that uncontrolled epilepsy is harmful for the developing brain, for the child’s and the family’s quality of life, and for the child’s life expectancy. Evidence indicates that successful epilepsy surgery can improve brain development and children’s quality of life. Other research suggests that pediatric epilepsy surgery is safe and can be cost-effective.
After conducting a prospective study of 198 children in 2012, investigators concluded that “uncontrolled seizures impair cognitive function, with effects being most severe in infancy and lessening with increasing age at onset.” The results underscored “the need for early, aggressive treatment and seizure control in infants and young children,” they added.
Overall mortality in children with epilepsy is double that of children in the general population because of sudden and seizure-related deaths, said Dr. Weiner. The rate of sudden unexpected death in epilepsy is similar to or higher than the rate of sudden infant death syndrome, “which gets a tremendous amount of attention in the pediatric world,” he added.
Other data suggest that pediatric epilepsy surgery affects children’s development. In one investigation, children’s seizure frequency and developmental quotient improved after surgery. Developmental status before surgery predicted developmental function after surgery, which suggests that neurologists should treat children before their development regresses, said Dr. Weiner. Another trial suggested that children with epileptic spasms who underwent surgery at a younger age had the largest increase in developmental quotient after surgery, compared with children who underwent surgery later. These data call the conventional thinking about pediatric epilepsy surgery into question, said Dr. Weiner.
Surgery Is Safe and May Be Cost Effective
The complication rate of pediatric epilepsy surgery is similar to that of other types of pediatric neurosurgery. Dr. Weiner and colleagues analyzed data for resective surgeries performed on children at the New York University Langone Medical Center during a 12-year period. The researchers observed no mortality. The number of complications was significantly lower during the second half of the study period, compared with the first half, although the patient population did not change significantly. “Perhaps there was a learning curve,” said Dr. Weiner.
Other studies indicate that epilepsy surgery can be cost-effective. Investigators in Toronto found that surgical treatment resulted in a greater reduction in seizure frequency, compared with medical therapy, and was a cost-effective treatment option in children with intractable epilepsy. Researchers at the Cleveland Clinic found that patients’ hospitalization rates and emergency room visits decreased significantly after surgery.
An Expanding Pool of Surgical Candidates
Recent research has enabled neurologists to consider surgery for children who previously would not have been considered candidates for surgery. Physicians at the Cleveland Clinic successfully performed surgery on patients for epilepsy that resulted from early brain lesions. The patients had generalized EEG findings, which usually are a contraindication for surgery, said Dr. Weiner. The investigators found that focal epilepsy surgery may be successful for certain children with a congenital or early-acquired brain lesion, despite abundant generalized or bilateral epileptiform discharges on EEG.
Other studies have focused new attention on children with tuberous sclerosis. “Multiple or bilateral seizure foci are not necessarily a contraindication to surgery, and children within this larger population may be candidates for focal surgery,” said Dr. Weiner.
Improved preoperative diagnostic evaluations are a major reason for the expanding pool of surgical candidates. MRI, PET, magnetoencephalography, single-photon emission computed tomography, and fMRI have “gotten better over the last 20 years, and now we can see the surgical substrate much better,” said Dr. Weiner. For example, 7-T MRI with high field strength has revealed previously uncharacterized brain lesions in patients with tuberous sclerosis complex.