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Pediatric Epilepsy Surgery: Indications and Evaluation

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Abstract

Epilepsy is a common neurological condition in children. It is usually amenable to drug therapy. However, nearly one-third of patients may be refractory to antiseizure drugs. Poor compliance and nonepileptic events should be ruled out as possible causes of drug-resistant epilepsy (DRE). After failing adequate trials of two appropriate antiseizure drugs, patients with focal DRE or poorly classifiable epilepsy or epileptic encephalopathy with focal electro-clinical features should be worked up for surgical candidacy. A randomized controlled trial provided a class I evidence for epilepsy surgery in pediatric DRE. Pre-surgical screening workup typically includes a high-resolution epilepsy protocol brain magnetic resonance imaging (MRI) and a high-quality in-patient video electroencephalography evaluation. Advanced investigations such as positron emission tomography (PET), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) may be required in selected cases especially when brain MRI is normal, and further evidence for anatomo-electro-clinical concordance is necessary to refine candidacy for surgery and surgical strategy. Some children may also need functional MRI to map eloquent regions of interest such as motor, sensory, and language functions to avoid unacceptable neurological deficits after surgery. Selected children may need invasive long-term electroencephalographic monitoring using stereotactically implanted intracranial depth electrodes or subdural grids. Surgical options include resective surgeries (lesionectomy, lobectomy, multilobar resections) and disconnective surgeries (corpus callosotomy, etc.) with the potential to obtain seizure freedom. Other surgical procedures, typically considered to be palliative are neuromodulation [deep brain stimulation (DBS), vagal nerve stimulation (VNS), and responsive neural stimulation (RNS)]. DBS and RNS are currently not approved in children. Pediatric DRE should be evaluated early considering the risk of epileptic encephalopathy and negative impact on cognition.

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Authors and Affiliations

  1. Pediatric Neurology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Priyanka Madaan

  2. Pediatric Epilepsy, Epilepsy Center, Department of Neurology/Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Ajay Gupta

  3. Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India

    Sheffali Gulati

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  1. Priyanka Madaan
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  3. Sheffali Gulati
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PM and SG: Review of literature and preparation of the manuscript; AG: Critical review of manuscript for intellectual content. All authors approved the final version of manuscript to be published and agreed to be accountable for all aspects of the work. SG would act as guarantor for this paper.

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Correspondence to Sheffali Gulati.

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Madaan, P., Gupta, A. & Gulati, S. Pediatric Epilepsy Surgery: Indications and Evaluation. Indian J Pediatr 88, 1000–1006 (2021). https://doi.org/10.1007/s12098-021-03668-x

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