Ultra-Early Epilepsy Surgery Significantly Improves Seizure Control Safely

Jonathan Roth, MD

Data from a multinational, multicenter, retrospective study evaluating epilepsy surgery for infants with drug-resistant epilepsy (DRE) younger than 3 months of age found that the procedure is associated with excellent seizure control and is not associated with more permanent morbidity than surgery in older infants.

Lead author Jonathan Roth, MD, pediatric neurosurgeon, Tel Aviv Medical Center, and colleagues also concluded that, “surgical treatment should not be postponed to treat DRE in very young infants based on their age.” To build upon limited literature regarding such “ultra-early” epilepsy surgeries, investigators collected data on 64 patients who underwent 69 surgeries before the age of 3 months. Epilepsy characteristics, surgical details, epilepsy outcome, and complications were all recorded. Procedures included 12 focal resections, 7 lobectomies, and 48 hemispheric surgeries (of which 25 were peri-insular, 12 were vertical functional hemispherectomies, 10 were anatomical hemispherectomies, and 1 was unknown).

Excellent seizure outcome, measured as International League Against Epilepsy (ILAE) grade 1, was achieved in 66% of cases over a median follow-up of 41 months (interquartile range [IQR], 19-104). While there was a slightly higher percentage of patients who had excellent seizure outcome using hemispheric surgery compared to focal, investigators deemed that there was no significant correlation between ILAE grade and the type of surgery (P = .44).

Overall, 22 infants (34%) underwent additional epilepsy surgery. The need for additional surgery was the only variable that showed a significant correlation with ILAE grade. Of the patients who did not undergo additional surgery, 85% were ILAE grade 1-2, compared to 39% of those who did not need additional surgery (P = .001).

READ MORE: Neurology Trainees Report Alarming Lack of SUDEP Knowledge

A reduction of preoperative number of medications by at least 1 drug occurred in 45 (79%) of those with available number of medications before and after surgery. Postoperative patients were receiving 0-6 (median, 1; IQR, 0.75-3) antiseizure medications (ASMs), as opposed to 1­-11 (median, 4; IQR, 3-4) before surgery (P <.0001), a median reduction of 2 drugs (IQR, 1-3).

Investigators also noted that these results are only applicable when performed by highly experienced teams. “Excellent surgical technique, anesthesia, and intensive care treatment are all prerequisite for achieving good results, and only centers with experience in complex surgeries in very young infants should handle such cases,” Roth et al wrote.

There was no significant association between the type of surgery and the number of antiseizure medications before surgery, after surgery, or the change in the number of drugs. All 14 patients off all medication were in the ILAE grade 1 group. Additionally, 33% of all ILAE grade 1 patients were off all ASMs.

Sixteen patients (25%) needed additional blood products, 7 (11%) had respiratory complications, 4 (6.25%) had infections (meningitis or abscess) and 7 (11%) had wound complications. Additionally, 13 patients (20%) had postoperative hydrocephalus necessitating a shunt. There were no perioperative deaths in the study.

Several variables such as seizure type, preoperative electroencephalogram (EEG), preoperative magnetic resonance imaging (MRI), presence of preoperative status epilepticus, and need for preoperative sedation, were all not significantly correlated with seizure outcome. Other variables such as intraoperative complications, postoperative need for blood products, or postoperative complications also did not demonstrate significance with seizure outcomes.

Surgery location was on the right in 36, on the left in 30, and in the posterior fossa in 1 infant. The following complications occurred during surgery: 7 experienced hypotension, 4 had hypothermia, and 5 had respiratory-related complications.

The benefits of epilepsy surgery for patients with DRE have become documented frequently in recent years. Lara Jehi, MD, chief research officer and epilepsy specialist, Cleveland Clinic, has been at the forefront of efforts to raise awareness about the positive effects it can have on this specific patient population. Watch an exclusive conversation NeurologyLive had with her below, as she details the mounting evidence for its role as an intervention for patients.

REFERENCE

Roth J, Constantini S, Ekstein M, et al. Epilepsy surgery in infants up to 3 months of age: safety, feasibility, and outcomes: a multicenter, multinational study. Epilepsia. Published online June 14, 2021. doi: 10.1111/epi.16959