Resective Surgery in Young Epilepsy Patients

The majority of infants and young children with intractable epilepsy who undergo resective surgery achieve favorable seizure outcomes, and with few complications, according to a new study. In addition, the majority of the seizure-free children also discontinued antiepileptic medication over the long term.

“This is the first prospective, population-based, longitudinal study to show that resective epilepsy surgery yields persistent seizure freedom or worthwhile reduction of seizure frequency in a majority of cases when performed in infants and young children with severe medically intractable epilepsy,” note the authors, led by Jesper Rheinholdson, of the Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. The findings of this study “emphasize the importance and gains of early referral to epilepsy surgery evaluation in cases of medically intractable epilepsy in infants and young children,” they state.

Based on data from the Swedish National Epilepsy Surgery Register from 1995 to 2010, the researchers studied 47 children under 4 years old who had resective surgery, predominantly temporal lobe resection, frontal lobe resection, and hemispherotomy. They analyzed seizure frequency, antiepileptic drug treatment (AED), neurological deficits, type of operation, histopathological diagnosis, and perioperative complications.

The majority of the patients had seizure onset within the first year of life, and the median age at surgery was 2 years and 1 month. Two-thirds had neurodevelopmental abnormalities.

At the 2-year follow-up, nearly half (45%) of the patients were seizure free, and 8 were off medication. At the long-term follow-up (5 or 10 years), half were seizure free and 11 of them were off medication. About one-third had 75% or more reduction in seizure frequency.

Fourteen children (44%) had sustained seizure freedom from surgery to long-term follow-up. “This finding is important as it implies that the risk of late seizure recurrence is not higher in infants and young children compared to older children and adults,” they state.

The researchers note that more than half of the patients were seizure free 2 years after hemispherotomy.

There was 1 major complication and no deaths, whereas results from early studies suggested a considerable risk of peri- or intraoperative mortality. However, more recent studies have not reported any intra- or perioperative mortality, they note.

Interestingly, the proportion of seizure-free children entirely off medication doubled from 17% to 34% between the 2-year-follow-up and the long-term follow-up. “It remains to determine if attempts of withdrawal from antiepileptic medication should be done earlier in the postoperative period,” they note. “Many children could possibly be spared unnecessary and potentially harmful AED treatment, if earlier withdrawal attempts were introduced into standard clinical practice.”

No significant change in time from epilepsy onset to surgery over the study period was observed. “This further emphasizes the importance of early referral of children with early onset intractable epilepsy of suspected symptomatic aetiology for epilepsy surgery evaluation,” they state.

One hypothesis is that early resective surgery disrupts uncontrolled seizure activity, and thereby improves the postoperative neurodevelopmental trajectory. Multicenter, prospective, longitudinal studies are needed to assess neurodevelopmental, behavioral, and quality of life outcomes after epilepsy surgery in infants and young children, they state.