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Jeno M, Zimmerman MB, Shandley S, Wong-Kisiel L, Singh RK, McNamara N, Fedak Romanowski E, Grinspan ZM, Eschbach K, Alexander A, McGoldrick P, Wolf S, Nangia S, Bolton J, Olaya J, Shrey DW, Karia S, Karakas C, Tatachar P, Ostendorf AP, Gedela S, Javarayee P, Reddy S, Manuel CM, Gonzalez-Giraldo E, Sullivan J, Coryell J, Depositario-Cabacar DFT, Hauptman JS, Samanta D, Armstrong D, Perry MS, Marashly A, Ciliberto M. Pediatric Palliative Epilepsy Surgery: A Report From the Pediatric Epilepsy Research Consortium (PERC) Surgery Database. Pediatr Neurol 2024; 157:70-78. [PMID: 38897096 DOI: 10.1016/j.pediatrneurol.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/12/2024] [Accepted: 04/28/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Epilepsy surgery is an underutilized resource for children with drug-resistant epilepsy. Palliative and definitive surgical options can reduce seizure burden and improve quality of life. Palliative epilepsy surgery is often seen as a "last resort" compared to definitive surgical options. We compare patient characteristics between palliative and definitive epilepsy surgical patients and present palliative surgical outcomes from the Pediatric Epilepsy Research Consortium surgical database. METHODS The Pediatric Epilepsy Research Consortium Epilepsy Surgery database is a prospective registry of patients aged 0-18 years undergoing evaluation for epilepsy surgery at 20 pediatric epilepsy centers. We included all children with completed surgical therapy characterized as definitive or palliative. Demographics, epilepsy type, age of onset, age at referral, etiology of epilepsy, treatment history, time-to-referral/evaluation, number of failed anti-seizure medications (ASMs), imaging results, type of surgery, and postoperative outcome were acquired. RESULTS Six hundred forty patients undergoing epilepsy surgery were identified. Patients undergoing palliative procedures were younger at seizure onset (median: 2.1 vs 4 years, P= 0.0008), failed more ASM trials before referral for presurgical evaluation (P=<0.0001), and had longer duration of epilepsy before referral for surgery (P=<0.0001). During presurgical evaluation, patients undergoing palliative surgery had shorter median duration of video-EEG data collected (P=0.007) but number of cases where ictal data were acquired was similar between groups. The most commonly performed palliative procedure was corpus callosotmy (31%), followed by lobectomy (21%) and neuromodulation (82% responsive neurostimulation vs 18% deep brain stimulation). Palliative patients were further categorized into traditionally palliative procedures vs traditionally definitive procedures. The majority of palliative patients had 50% reduction or better in seizure burden. Seizure free outcomes were significantly higher among those with traditional definitive surgeries, 41% (95% confidence interval: 26% to 57%) compared with traditional palliative surgeries and 9% (95% confidence interval: 2% to 17%). Rate of seizure freedom was 46% at 24 months or greater of follow-up in the traditional definitive group. CONCLUSIONS Patients receiving palliative epilepsy surgery trialed more ASMs, were referred later after becoming drug resistant, and had longer gaps between drug resistance and epilepsy surgery compared with patients undergoing definitive epilepsy surgery. The extent of surgical evaluation is impacted if surgery is thought to be palliative. A majority of palliative surgery patients achieved >50% seizure reduction at follow-up, both in groups that received traditionally palliative and traditionally definitive surgical procedures. Palliative surgical patients can achieve greater seizure control and should be referred to an epilepsy surgery center promptly after failing two appropriate anti-seizure medications.
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Affiliation(s)
- Mary Jeno
- Division of Pediatric Neurology, Department of Neurology, University of San Francisco Benioff Children's Hospital Oakland, Oakland, California.
| | | | - Sabrina Shandley
- Neurosciences Research Center, Cook Children's Medical Center, Fort Worth, Texas
| | - Lily Wong-Kisiel
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Rani Kaur Singh
- Department of Pediatrics, Atrium Health-Levine Childrens Hospital, Wake Forest University School of Medicine, Charlotte, North Carolina
| | - Nancy McNamara
- Michigan Medicine Pediatric Neurology, CS Mott Children's Hospital, Ann Arbor, Michigan
| | - Erin Fedak Romanowski
- Michigan Medicine Pediatric Neurology, CS Mott Children's Hospital, Ann Arbor, Michigan; Division of Pediatric Neurology, Department of Pediatrics, University of Michigan Health, Ann Arbor, Michigan
| | - Zachary M Grinspan
- Department of Pediatrics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Allyson Alexander
- Department of Neurosurgery, Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Patricia McGoldrick
- BCHP Neurology at Hawthorne, Boston Children's Health Physicians of New York and Connecticut, Valhalla, New York
| | - Steven Wolf
- Neurology at Hawthorne, Boston Children's Health Physicians of New York and Connecticut, Valhalla, New York
| | | | - Jeffrey Bolton
- Department of Neurology, Boston Children's, Boston, Massachusetts
| | - Joffre Olaya
- Department of Pediatrics, UC Irvine Children's Hospital of Orange County, Orange, California
| | - Daniel W Shrey
- Department of Pediatrics, UC Irvine Children's Hospital of Orange County, Orange, California
| | - Samir Karia
- Department of Neurology, Norton Neuroscience Institute and Children's Medical Center, University of Louisville, Louisville, Kentucky
| | - Cemal Karakas
- Division of Child Neurology, Department of Neurology, Norton Neuroscience Institute and Children's Medical Center, University of Louisville, Louisville, Kentucky
| | - Priyamvada Tatachar
- Division of Neurology - Epilepsy Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam P Ostendorf
- Associate Division Chief of Research, Inpatient Epilepsy and Epilepsy Surgery Program, Neurology Division, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Satyanarayana Gedela
- Department of Neurology, Nemours Children's Health, Nemours Children's Hospital, Orlando, Florida
| | - Pradeep Javarayee
- Division of Child Neurology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shilpa Reddy
- Division of Pediatric Neurology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad McNair Manuel
- Department Pediatric Neurology, Our Lady of the Lake Health, Baton Rouge, Louisiana
| | - Ernesto Gonzalez-Giraldo
- Department of Neurology, Division of Epilepsy, University of California-San Francisco, San Francisco, California
| | - Joseph Sullivan
- Department of Neurology, Division of Epilepsy, University of California-San Francisco, San Francisco, California; Benioff Children's Hospital Pediatric Epilepsy Center of Excellence, University of California San Francisco, San Francisco, California
| | - Jason Coryell
- Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, Oregon
| | | | - Jason Scott Hauptman
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Dallas Armstrong
- Department of Pediatrics and Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Scott Perry
- Neurosciences Research Center, Cook Children's Medical Center, Fort Worth, Texas; Jane and John Justin Institute for Mind Health at Cook Children's Medical Center, Fort Worth, Texas
| | - Ahmad Marashly
- Neurology Department, Epilepsy Division, The Johns Hopkins University, Baltimore, Maryland
| | - Michael Ciliberto
- Department of Biostatistics, University of Iowa, Iowa City, Iowa; Child Neurology, Department of Pediatrics, University of Iowa, Iowa City, Iowa
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Jehi L, Braun K. Does etiology really matter for epilepsy surgery outcome? Brain Pathol 2021; 31:e12965. [PMID: 34196987 PMCID: PMC8412085 DOI: 10.1111/bpa.12965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Multiple factors influence the outcomes of epilepsy surgery. Prognostic indicators varying from clinical characteristics, imaging findings, ictal, and interictal electrophysiological activity have been linked to surgical outcomes. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: 1)‐ does etiology matter? and 2)‐ how could it matter? The goal is to review the existing literature on the relationship between etiology and surgical outcomes to provide the best possible judgment as to whether a causal relationship exists between histopathology and the ultimate surgical outcome as an initial step. Then, we delve into the possible mechanisms via which such relationships can be explained. We conclude with a call to action to the epilepsy surgery and histopathology research community to push the mechanistic understanding of the pathology‐outcome interaction and identify actionable knowledge and biomarkers that could inform patient care in a timely fashion. In this review, we focus on the relatively under‐studied role of the underlying epilepsy histopathology in driving post‐surgical outcomes, specifically focusing on the broad categories of seizure outcomes and cognitive outcomes. For each of these two outcomes of interest, we answer two questions: (1) does etiology matter? and (2) how could it matter? We then delve into the mechanisms of these answers.
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Affiliation(s)
- Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kees Braun
- Dept. of Neurology & Neurosurgery, University Medical Center Utrecht, Utrecht University, the Netherlands
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de Knegt VE, Hoei-Hansen CE, Knudsen M, Jakobsen AV, Mûller E, Thomsen KM, Jespersen B, Uldall PV, Børresen ML. Increase in cognitive function is seen in many single-operated pediatric patients after epilepsy surgery. Seizure 2020; 81:254-262. [PMID: 32911236 DOI: 10.1016/j.seizure.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The recurrent seizures of pediatric drug-resistant epilepsy (DRE) are known to impair brain development and can lead to a loss in cognitive functioning. Surgery is increasingly being used to treat children with DRE. This study investigates the pre- and postoperative cognitive function in a pediatric epilepsy surgery cohort as well as predictive determinants of change in intelligence quotient (IQ) following surgery. METHODS A consecutive series of 91 Danish children who underwent focal resective epilepsy surgery between January 1996 and December 2016 were included. All underwent preoperative cognitive evaluation and were reevaluated at 1-year and/or 2-year follow-up. Single-operated and multi-operated patients were examined separately. RESULTS 79 of 91 patients were single-operated. Single-operated patients received less anti-epileptic drugs (AED) and experienced a decrease in seizure frequency postoperatively, p < 0.001. IQ increased postoperatively (IQ change ± standard deviation: 3.3 ± 14.0), p < 0.05. High preoperative seizure frequency was a significant predictor for decreased IQ, p < 0.01. Multi-operated patients did not experience a reduction in AED treatment. Surgery and continued AED treatment did, however, result in significantly better seizure control, p < 0.01. IQ remained unchanged in multi-operated patients. CONCLUSION Epilepsy surgery allowed for IQ gains in single-operated patients. Preoperative seizure frequency was a significant predictor of IQ change following surgery. Interactions between other, not included, possible predictors remain to be examined. Single-operated patients had the best cognitive outcome. The inclusion of a non-surgical control group is needed to assess the extent of the beneficial effects of surgery on cognitive ability.
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Affiliation(s)
| | | | - Marianne Knudsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anne Vagner Jakobsen
- Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Elisabeth Mûller
- Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Katrine Moe Thomsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bo Jespersen
- Department of Neurosurgery, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Vilhelm Uldall
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Neuropediatrics, The Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Malene Landbo Børresen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.
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Lee B, Bae MI, Eum D, Ntungi AM, Jun B, Min KT. Bleeding properties according to surgical sites during pediatric craniotomy: a retrospective study comparing the two stages of epilepsy surgery. Anesth Pain Med (Seoul) 2020; 15:283-290. [PMID: 33329826 PMCID: PMC7713839 DOI: 10.17085/apm.20010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
Background During pediatric epilepsy surgery, due to low circulating blood volume, intraoperative bleeding can result in significant hemodynamic instability, thereby requiring meticulous hemodynamic and transfusion strategies. Knowing the source of bleeding during the procedure would allow medical staff to better prepare the perioperative protocols for these patients. We compared intraoperative bleeding between the first (involving skin to meninges) and second (involving brain parenchyma) stages of epilepsy surgery to investigate the differences between various anatomical sites. Methods We reviewed the electronic medical records of 102 pediatric patients < 14 years old who underwent two-stage epilepsy surgeries during January 2012–December 2016. Invasive subdural grids were placed via craniotomy during Stage 1 and the epileptogenic zone was removed during Stage 2 of the surgery. We compared the volume of intraoperative bleeding between these two surgeries and identified variables associated with bleeding using multivariate regression analysis. Results Both surgeries resulted in similar intraoperative bleeding (24 vs. 26 ml/kg, P = 0.835), but Stage 2 required greater volumes of blood transfusion than Stage 1 (18.4 vs. 14.8 ml/kg, P = 0.011). Massive bleeding was associated with patients < 7 years of age in Stage 1 and weighing < 18 kg in Stage 2. Conclusions The volume of intraoperative bleeding was similar between the two stages of pediatric epilepsy surgery and was large enough to require blood transfusions. Thus, blood loss during pediatric epilepsy surgery occurred at both anatomic sites. This indicates the necessity of early preparation for blood transfusion in both stages of pediatric epilepsy surgery.
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Affiliation(s)
- Bora Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Il Bae
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Darhae Eum
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Abel Mussa Ntungi
- Department of Anesthesiology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, United Republic of Tanzania
| | - Byongnam Jun
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Tae Min
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Hoppe C, Porębska I, Beeres K, Sassen R, Kuczaty S, Gleissner U, Lendt M, Elger CE, Helmstaedter C. Parents' view of the cognitive outcome one year after pediatric epilepsy surgery. Epilepsy Behav 2019; 101:106552. [PMID: 31698257 DOI: 10.1016/j.yebeh.2019.106552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/06/2019] [Accepted: 09/08/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The cognitive outcome of pediatric epilepsy surgery has mainly been examined on the basis of standardized tests. Here, we analyzed the outcome in six cognitive domains from the parents' view. METHODS Included were consecutive surgical pediatric patients whose parents filled-in a comprehensive questionnaire on cognitive problems in children and adolescents (Kognitive Probleme bei Kindern und Jugendlichen (KOPKIJ); Gleissner et al. 2006) at the preoperative baseline (T1) as well as twelve months thereafter (T2). All children also underwent standard neuropsychological assessments at T1 and T2. RESULTS Parents of 96 patients provided pre- and postoperative KOPKIJ data. Overall, 80% of the children became seizure-free at the follow-up. Group means indicated a strong positive effect of time on KOPKIJ and neuropsychological performance. We found postoperative improvements in five out of six cognitive domains (language, memory, executive functions, attention, school; unchanged: visuospatial abilities). Individually, improvements were twice as likely as declines. However, 33 patients (35%) experienced significant decline in at least one cognitive domain. Later onset of epilepsy resulted in better performance but had no effect on change scores. Seizure-free status, lower antiseizure drug load, and stronger drug reduction after surgery contributed to postoperative cognitive improvements as perceived by the parents; no other effects of clinical factors were obtained (e.g., localization/lateralization). Despite their similar outcome patterns, change scores as derived from parental ratings and neuropsychological assessment were not correlated. CONCLUSIONS Parents acknowledged the overall positive neurocognitive development after pediatric epilepsy surgery as previously shown by standardized tests. Seizure freedom and lower antiseizure drug load contributed to the beneficial cognitive outcome. Even if cognitive improvements outweighed declines, a risk for cognitive decline with impact on everyday functioning does exist.
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Affiliation(s)
- Christian Hoppe
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany.
| | - Izabela Porębska
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany
| | - Kassandra Beeres
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany
| | - Robert Sassen
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany
| | - Stefan Kuczaty
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany
| | - Ulrike Gleissner
- LVR-Klinik Bonn, Kinderneurologisches Zentrum, Waldenburger Ring 46, FRG-53119 Bonn, Germany
| | - Michael Lendt
- St. Mauritius Therapieklinik, Strümper Str. 111, FRG-40670 Meerbusch, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany
| | - Christoph Helmstaedter
- Department of Epileptology, University of Bonn Medical Centre, Venusberg-Campus 1, FRG-53127 Bonn, Germany; St. Mauritius Therapieklinik, Strümper Str. 111, FRG-40670 Meerbusch, Germany
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Abstract
INTRODUCTION Neurovascular lesions are rare and understudied in the pediatric population. Their initial presentation can range from seizures to focal neurologic deficits, as well as headaches. The goal of this study was to examine the clinical presentation and natural history of neurovascular lesions in children with epilepsy. METHODS We reviewed all pediatric epilepsy patients with neurovascular lesions diagnosed between 2006 and 2018 at the University of Alberta and the Stollery Children's Hospital, Edmonton, Canada. Initial clinical presentation and brain imaging, as well as long-term epilepsy and postsurgical outcome, were assessed. RESULTS Of the 14 patients, 10 patients had an initial presentation of focal seizures with impaired awareness, whereas 2 patients presented with headache, 1 presented with visual field defects as well as chronic headaches, and 1 with decreased level of consciousness. Seven patients had cavernous angiomas, 6 had arteriovenous malformation, and 1 patient had an arteriovenous fistula. Notably, all patients with cavernous angiomas and 4 of 6 patients with arteriovenous malformations presented with seizures. Among 9 of the 14 who underwent neurovascular corrective surgery, all 9 patients required long-term antiepileptic treatment of at least 1 antiepileptic drug for seizure control after the operation. CONCLUSION In this novel case series, we describe focal seizures as the initial presentation of pediatric neurovascular lesions. This clinical presentation appears to be independent of the type of neurovascular lesion. Furthermore, unlike our pediatric surgical patients with epilepsy due to other causes, seizure freedom following neurovascular surgery is limited, and patients require long-term antiepileptic treatment.
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Affiliation(s)
- J Kassiri
- 1 Division of Pediatric Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - T Rajapakse
- 1 Division of Pediatric Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - M Wheatley
- 2 Comprehensive Epilepsy Program, University of Alberta, Edmonton, Alberta, Canada
| | - D B Sinclair
- 1 Division of Pediatric Neurology, University of Alberta, Edmonton, Alberta, Canada.,2 Comprehensive Epilepsy Program, University of Alberta, Edmonton, Alberta, Canada
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