The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review

Beatty, Christopher W.; Lockrow, Jason; Gedela, Satyanarayana; Gehred, Alison; Ostendorf, Adam P.

doi:10.1016/j.spen.2021.100917

Cited by 17 publications

(14 citation statements)

References 102 publications

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“…25 This "surgical treatment gap" has been steadily improving in the United States pediatric population but epilepsy surgery still remains underutilized. 13,26,27 The underutilization of pediatric epilepsy surgery is multifactorial and includes racial, ethnic, socioeconomic, and medical disparities. Although safe, effective, and recommended for all patients with DRE, there is a misconception amongst patients and health care providers that surgery remains a "last resort" and perceived as being experimental, ineffective, and high risk.…”

Section: Review Article 29mentioning

confidence: 99%

“…These patients tend to have poorer cognitive function, [1][2][3] decreased quality of life, 4,5 and decreased life expectancy [6][7][8] . Despite being refractory to medications, 10 to 50% of these patients have safe available surgical treatment options [9][10][11][12][13] that can be curative, decrease Keywords ► pediatric epilepsy ► minimally invasive surgery ► laser interstitial thermal therapy ► laser ablation ► radiofrequency thermocoagulation ► radiotherapy ► endoscopy…”

Section: Introductionmentioning

confidence: 99%

“…These patients tend to have poorer cognitive function, 1 2 3 decreased quality of life, 4 5 and decreased life expectancy 6 7 8 . Despite being refractory to medications, 10 to 50% of these patients have safe available surgical treatment options 9 10 11 12 13 that can be curative, decrease seizure frequency, decrease dependence on antiepileptic medications, improve cognitive development, decrease mortality, and lead to an improved quality of life. 14 15 16 17 18 19 20 21 Potential benefits with surgical treatment diminish with delay 22 and prompt evaluation for surgical treatment is recommended for patients with DRE.…”

Section: Introductionmentioning

confidence: 99%

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Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

Treiber

Bayley

Curry

2023

Journal of Pediatric Epilepsy

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Conventional epilepsy surgery performed by microsurgical dissection typically requires large cranial working windows created with high-speed drills and lengthy incisions. In the past few decades, minimally invasive techniques have been developed with smaller incisions, comparable efficacy, shorter hospitalizations, and better safety profiles. These minimally invasive alternatives utilize stereotactic, ultrasonic, radiotherapeutic, and endoscopic techniques. Although not able to completely replace conventional surgery for all etiologies of epilepsy, these minimally invasive techniques have revolutionized modern epilepsy surgery and have been an invaluable asset to the neurosurgeon's repertoire. The endoscope has allowed for surgeons to have adequate visualization during resective and disconnective epilepsy surgeries using keyhole or miniature craniotomies. Modern stereotactic techniques such as laser interstitial thermal therapy and radiofrequency ablation can be used as viable alternatives for mesial temporal lobe epilepsy and can destroy lesional tissue deep areas without the approach-related morbidity of microsurgery such as with hypothalamic hamartomas. These stereotactic techniques do not preclude future surgery in the settings of treatment failure and have been used successfully after failed conventional surgery. Multiple ablation corridors can be performed in a single procedure that can be used for lesioning of large targets or to simplify treating multifocal epilepsies. These stereotactic techniques have even been used successfully to perform disconnective procedures such as hemispherotomies and corpus callosotomies. In patients unable to tolerate surgery, stereotactic radiosurgery is a minimally invasive option that can result in improved seizure control with minimal procedural risks. Advances in minimally invasive neurosurgery provide viable treatment options for drug-resistant epilepsy with quicker recovery, less injury to functional brain, and for patients that may otherwise not choose conventional surgery.

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Section: Review Article 29mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

Treiber

Bayley

Curry

2023

Journal of Pediatric Epilepsy

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“…In low-income countries the issue is more pronounced since there are limited centers capable of performing epilepsy surgeries. Children face substantial barriers to attaining epilepsy surgery even when it is indicated, often the result of poor understanding of surgery on the part of • Medical comorbidities their families and healthcare providers, as well as due to system disparities in care (76). In all settings, there is a combination of patient-related factors, physician-related factors, and health system factors, which factor into underutilization of epilepsy surgery (77).…”

Section: Gaps In Epilepsy Surgery Utilizationmentioning

confidence: 99%

Treatment gaps in epilepsy

Pellinen

2022

Front. Epidemiol.

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Over 50 million people around the world have epilepsy, and yet, epilepsy recognition and access to care are ongoing issues. Nearly 80% of people with epilepsy live in low-and middle-income countries and face the greatest barriers to quality care. However, there are substantial disparities in care within different communities in high-income countries as well. Across the world, under-recognition of seizures continues to be an issue, leading to diagnostic and treatment delays. This stems from issues surrounding stigma, public education, basic access to care, as well as healthcare worker education. In different regions, people may face language barriers, economic barriers, and technological barriers to timely diagnosis and treatment. Even once diagnosed, people with epilepsy often face gaps in optimal seizure control with the use of antiseizure medications. Additionally, nearly one-third of people with epilepsy may be candidates for epilepsy surgery, and many either do not have access to surgical centers or are not referred for surgical evaluation. Even those who do often experience delays in care. The purpose of this review is to highlight barriers to care for people with epilepsy, including issues surrounding seizure recognition, diagnosis of epilepsy, and the initiation and optimization of treatment.

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“…Compared with other treatments, surgical treatments are distinctive in aiming to address underlying structural causes of epilepsies but are likely underused. 5 , 6 Resection or disconnection of epileptogenic brain tissue can lead to seizure freedom (curative surgery) or seizure reduction (palliative surgery). Several factors may affect the outcomes including underlying pathology, surgery type, location, extent of resection, and concordance of presurgical evaluations.…”

mentioning

confidence: 99%

Surgical Treatments for Epilepsies in Children Aged 1–36 Months

Tsou

Kessler

et al. 2023

Neurology

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Objectives:Early-life epilepsies (epilepsies in children 1 to 36 months old) are common and may be refractory to anti-seizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1 to 36 months without infantile spasms.Methods:EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤ 36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥ 10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology were reported together.Results:Eighteen studies (in 19 articles) met inclusion criteria. Sixteen pre/post studies reported on efficacy and twelve studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For non-hemispheric surgeries seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, ILAE I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations.Surgical mortality was rare for functional hemispherectomy/hemispherotomy, and non-hemispheric resections. Low strength of evidence suggests post-operative hydrocephalus is uncommon for infants undergoing non-hemispheric procedures for epilepsy.Conclusion:Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL).Registration:This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.

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The Missed Value of Underutilizing Pediatric Epilepsy Surgery: A Systematic Review

Cited by 17 publications

References 102 publications

Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

Treatment gaps in epilepsy

Surgical Treatments for Epilepsies in Children Aged 1–36 Months

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