Epilepsy surgery in children

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By Jason S Hauptman MD, Sarat P Chandra MD, and Gary W Mathern MD

Surgical treatment of children with intractable epilepsy involves a clinical approach that recognizes the neurobiology of the developing brain, and this influences the selection of candidates and timing of surgery. The goal of surgery is to reduce epilepsy-induced cognitive disabilities by stopping seizures as soon as possible. Failure of 2 to 3 antiepilepsy drugs identifies children with therapy-resistant epilepsy who should be evaluated at pediatric epilepsy centers that include surgery. In this clinical article, Drs. Jason Hauptman, Sarat Chandra, and Gary Mathern, all from the University of California in Los Angeles, discuss the most common surgically treated pediatric etiologies, including cortical dysplasia, perinatal cerebral infarcts, and mesial temporal lobe lesions; less frequent etiologies include hemimegalencephaly, Rasmussen syndrome, Sturge-Weber syndrome, tuberous sclerosis complex, Landau-Kleffner syndrome, and hypothalamic hamartomas.

Pediatric epilepsy surgeries are often extratemporal and include focal, lobar, multilobar, and hemispheric resections that are curative and corpus callosotomy and vagus nerve stimulators that are palliative. Postsurgery seizure control is obtained in 60% to 80% of children with curative surgery, and operative morbidity and mortality is less than that associated with long-term uncontrolled seizures. After successful epilepsy surgery, neurodevelopment and quality of life are significantly improved. The authors recommend that children with therapy-resistant epilepsy from focal to hemispheric pathologies be promptly referred to pediatric epilepsy centers so that those with surgical syndromes can be identified and treated to prevent catastrophic epilepsy-induced encephalopathy.

Key Points

  • Epilepsy neurosurgery in children strives to enhance cognitive development through early seizure control.
  • Epilepsy neurosurgery in children is not the treatment of last resort. Children should be referred for evaluation once they fail 2 antiepileptic drugs.
  • The most common substrate in pediatric epilepsy surgery is cortical dysplasia, followed by tumors. Hippocampal sclerosis is less frequent in children than in adult epilepsy surgery patients.
  • Success of epilepsy neurosurgery in children depends on removing the entire histopathological substrate.