Changing profiles of pediatric epilepsy surgery candidates over time: A nationwide single‐center experience from 1990 to 2011

SUMMARYObjective: Since 2008, we have changed our presurgical diagnostic imaging evaluation for medically refractory focal epilepsy to include high-resolution epilepsy protocol on 3 T magnetic resonance imaging (MRI), and combined magnetoencephalography and 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) in selected patients with normal or subtle changes on MRI or discordant diagnostic tests. The aim of this study was to evaluate the effectiveness of the change in imaging practice on epilepsy surgery outcome in a tertiary pediatric epilepsy surgery center. Methods: The change in practice occurred in early 2008, and patients were classified based on old or new practice. The patient characteristics, surgical variables, and seizure-free surgical outcome were compared, and the trend in seizure-free outcome over time was assessed. Results: There was a trend for increased abnormal MRI (92% vs. 86%, respectively, p = 0.062), and increased utilization of FDG-PET (34% vs. 3% respectively, p < 0.001) with new relative to old practice. There were no statistically significant differences in invasive monitoring, location, and type of surgery and histology between the two periods (all p > 0.05). During the old practice, there was no statistically significant change in yearly trend of seizure-free outcome (odds ratio [OR] 0.960, 95% confidence interval [CI] 0.875-1.053, p = 0.386). The change in practice in 2008 was associated with a significant improvement in seizure-free outcome (OR 1.535, 95% CI 1.100-2.142, p = 0.012). During the new practice, there was a significant positive trend in yearly seizure-free outcome (OR 1.219, 95% CI 1.053-1.411, p = 0.008), after adjusting for age at seizure onset, invasive monitoring, location and type of surgery, histology, MRI, magnetoencephalography, and FDG-PET. Significance: We have found an improvement in seizure-free surgical outcome following the change in imaging practice. This study highlights the importance of optimizing and improving presurgical diagnostic imaging evaluation to improve surgical outcome. KEY WORDS: Seizure-free outcome, Magnetic resonance imaging, 18-Fluorodeoxyglucose-positron emission tomography, Magnetoencephalography.In children with medically refractory focal epilepsy, surgery has the potential to render these patients seizure-free. Meta-analysis of pediatric epilepsy surgery outcome has shown that for combined temporal and extratemporal lobe epilepsy surgery, seizure-free outcome was 59% and for temporal lobe epilepsy surgery, seizure-free outcome was 62%. 1 We have previously shown that pediatric epilepsy surgery is a cost-effective treatment in the management of children with intractable epilepsy relative to medical therapy.2 As part of the presurgical diagnostic evaluation, the

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“…Hemb et al . and Lamberink et al . have evaluated a much longer period of epilepsy surgery in their institutions (22 years) compared to ours.…”

Section: Discussionmentioning

confidence: 62%

Change in presurgical diagnostic imaging evaluation affects subsequent pediatric epilepsy surgery outcome

et al. 2015

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“…Multicenter cohorts from other pediatric epilepsy centers even report increasing surgical numbers. Lamberink et al found a threefold increase in surgical interventions per year in a retrospective Dutch cohort of 234 children between 1990 and 2011. Barba et al reported an increase from 56 resective surgeries in 2008 to 182 in 2013‐2014 in a survey from nine Italian epilepsy surgery centers.…”

Section: Discussionmentioning

confidence: 99%

“…This may not be the only difference between pediatric and adult series. Children and adolescents seem to have superior and even improving seizure‐free outcome rates . A meta‐analysis of 36 publications (1993‐2012) comprising 1318 children with temporal and 1259 children with extratemporal resections showed seizure freedom rates (Engel class I) of 76% for temporal lobe resections and 56% for extratemporal resections (minimum follow‐up = 12 months) .…”

Section: Introductionmentioning

confidence: 99%

Differences in pediatric and adult epilepsy surgery: A comparison at one center from 1990 to 2014

Cloppenborg

May

Blümcke³

et al. 2018

Epilepsia

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Summary Objective Surgical volumes at large epilepsy centers are decreasing. Pediatric cohorts, however, show a trend toward more resections and superior outcome. Differences in pediatric and adult epilepsy surgery were investigated in our cohort. Methods The Bethel database between 1990 and 2014 was retrospectively analyzed. Results A total of 1916 adults and 1300 children underwent presurgical workup. The most common etiologies were medial temporal sclerosis (35.4%) in adults, and focal cortical dysplasias (21.1%) and diffuse hemispheric pathologies (14.7%) in children. Only 1.4% of the total cohort had normal histopathology. A total of 1357 adults (70.8%) and 751 children (57.8%) underwent resections. Surgery types for children were more diverse and showed a higher proportion of extratemporal resections (32.8%) and functional hemispherectomies (20.8%). Presurgical evaluations increased in both groups; surgical numbers remained stable for children, but decreased in the adult group from 2007 on. The patients’ decision against surgery in the adult nonoperated cohort increased over time (total = 44.9%, 27.4% in 1995‐1998 up to 53.2% in 2011‐2014; for comparison, in children, total = 22.1%, stable over time). Postsurgical follow‐up data were available for 1305 adults (96.2%) and 690 children (91.9%) 24 months after surgery. The seizure freedom rate was significantly higher in children than in adults (57.8% vs 47.5%, P < 0.001) and significantly improved over time (P = 0.016). Significance Pediatric epilepsy surgery has stable surgical volumes and renders more patients seizure‐free than epilepsy surgery in adults. A relative decrease in hippocampal sclerosis, the traditional substrate of epilepsy surgery, changes the focus of epilepsy surgery toward other pathologies.

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“…But beyond the importance of a confident localization hypothesis, our data support the recent call for an integrated localization and etiology-centric approach to epilepsy surgery. 24 Thus far the impact of etiology on seizure outcome has been shown in the setting of better seizure outcomes in patients with tumors 25,26 and malformations of cortical development, 27,28 specifically FCD IIb, 29 without strong data to support tailoring of surgical strategy in relation to suspected etiology. In this cohort, we showed that surgical strategy (completeness of lesion resection) affected outcome differentially in suspected FCD lesions as opposed to other malformations of cortical development (PNH, polymicrogyria), hippocampal sclerosis, and encephalomalacia.…”

Section: Discussionmentioning

confidence: 99%

Localization yield and seizure outcome in patients undergoing bilateral SEEG exploration

et al. 2018

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Summary Objective: We aimed to determine the rates and predictors of resection and seizure freedom after bilateral stereo-electroencephalography (SEEG) implantation. Methods: We reviewed 184 patients who underwent bilateral SEEG implantation (2009-2015). Noninvasive and invasive evaluation findings were collected. Outcomes of interest included subsequent resection and seizure freedom. Statistical analyses employed multivariable logistic regression and proportional hazard modeling. Preoperative and postoperative seizure frequency, severity, and quality of life scales were also compared. Results: Following bilateral SEEG implantation, 106 of 184 patients (58%) underwent resection. Single seizure type (P = 0.007), a family history of epilepsy (P = 0.003), 10 or more seizures per month (P = 0.004), lower number of electrodes (P = 0.02), or sentinel electrode placement (P = 0.04) was predictive of undergoing a resection, as were lack of nonlocalized (P < 0.0001) or bilateral (P < 0.0001) ictal-onset zones on SEEG. Twenty-six of 81 patients (32% with follow-up greater than 1 year) remained seizure-free. Predictors of seizure freedom were single seizure type (P = 0.01), short epilepsy duration (P = 0.008), use of 2 or fewer antiepileptic drugs (AEDs) at the time of surgery (P = 0.0006), primary localization hypothesis involving the frontal lobe (P = 0.002), sentinel electrode placement only (P = 0.02), and lack of overlap between ictal-onset zone and eloquent cortex (P = 0.04), along with epilepsy substrate histopathology (P = 0.007). Complete resection of a suspected focal cortical dysplasia showed a trend to increased likelihood of seizure freedom (P = 0.09). The 44 of 55 patients (80%) who underwent resection and experienced seizure recurrence had >50% seizure reduction, as opposed to 26 of 45 patients (58%) who continued medical therapy alone (P = 0.003). Seventy-two percent of patients had a clinically meaningful quality of life improvement (>10% decrease in the Quality of Life in Epilepsy [QOLIE-10] score) at 1 year. Significance: A strong preimplantation hypothesis of a suspected unifocal epilepsy increases the odds of resection and seizure freedom. We discuss a tailored approach, taking into account localization hypothesis and suspected epilepsy etiology in guiding implantation and subsequent surgical strategy.

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Changing profiles of pediatric epilepsy surgery candidates over time: A nationwide single‐center experience from 1990 to 2011

Cited by 63 publications

References 38 publications

Change in presurgical diagnostic imaging evaluation affects subsequent pediatric epilepsy surgery outcome

Change in presurgical diagnostic imaging evaluation affects subsequent pediatric epilepsy surgery outcome

Differences in pediatric and adult epilepsy surgery: A comparison at one center from 1990 to 2014

Localization yield and seizure outcome in patients undergoing bilateral SEEG exploration

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