Epilepsy surgery in children under 3 years of age: surgical and developmental outcomes

Abstract

OBJECTIVE Pediatric epilepsy surgery is known to be effective, but early surgery in infancy is not well characterized. Extensive cortical dysplasia, such as hemimegalencephaly, can cause refractory epilepsy shortly after birth, and early surgical intervention is indicated. However, the complication rate of early pediatric surgery is significant. In this study, the authors assessed the risk-benefit balance of early pediatric epilepsy surgery as relates to developmental outcomes. METHODS This is a retrospective descriptive study of 75 patients who underwent their first curative epilepsy surgery at an age under 3 years at the authors’ institution between 2006 and 2019 and had a minimum 1-year follow-up of seizure and developmental outcomes. Clinical information including surgical complications, seizure outcomes, and developmental quotient (DQ) was collected from medical records. The effects of clinical factors on DQ at 1 year after surgery were evaluated. RESULTS The median age at surgery was 6 months, peaking at between 3 and 4 months. Operative procedures included 27 cases of hemispherotomy, 19 cases of multilobar surgery, and 29 cases of unilobar surgery. Seizure freedom was achieved in 82.7% of patients at 1 year and in 71.0% of patients at a mean follow-up of 62.8 months. The number of antiseizure medications (ASMs) decreased significantly after surgery, and 19 patients (30.6%) had discontinued their ASMs by the last follow-up. Postoperative complications requiring cerebrospinal fluid (CSF) diversion surgery, such as hydrocephalus and cyst formation, were observed in 13 patients (17.3%). The mean DQ values were 74.2 ± 34.3 preoperatively, 60.3 ± 23.3 at 1 year after surgery, and 53.4 ± 25.1 at the last follow-up. Multiple regression analysis revealed that the 1-year postoperative DQ was significantly influenced by preoperative DQ and postoperative seizure freedom but not by the occurrence of any surgical complication requiring CSF diversion surgery. CONCLUSIONS Early pediatric epilepsy surgery has an acceptable risk-benefit balance. Seizure control after surgery is important for postoperative development.

Epilepsy surgery in the first six months of life: A systematic review and meta-analysis

“…The most prevalent complication was the development of a hydrocephalus in 14.7% of all patients. Iwasaki et al observed a complication rate of 33% (19/57 patients) in patients operated before the age of three years, while Dunkley et al reported a complication rate of 12% in the same age group [62,63]. In older patients, reported complication rates range from six to 10.5% [64][65][66].…”

“…The likelihood of developing a hydrocephalus after hemispherotomy is determined to be as high as 23% in the pediatric age group [67,68]. In particular, anatomic hemispherectomies pose a risk factor [67], but also HME and low body weight [63,69]. Due to the high number of operated infants with HME and low body weight, this could result in an increased risk for infants.…”

Case Report: Hemispherotomy in the First Days of Life to Treat Drug-Resistant Lesional Epilepsy

“…Putative and largely unknown complications of an early intervention should be weighed against the risk of life-long developmental drawbacks of ongoing detrimental epilepsy and/or anticonvulsant therapy. However, early epilepsy surgery in infancy is receiving increased attention (10,11). First results are promising with seizure freedom ranging from 66 to 82.7%.…”

Surgical Treatments for Epilepsies in Children Aged 1–36 Months

“…Surgical Mortality A single death 31 was reported across 8 studies. 8 prestudies/poststudies, 19,22,23,28,29,35,36 combined 180 infants Low Surgical mortality after functional hemispherectomy/hemispherotomy is rare.…”

“…Rates of hydrocephalus ranged from 0% to 33%. (9 prestudies/poststudies, 18,19,20,25,26,31,33,35,36 combined over 96 a )…”