Epilepsy surgery – the role for earlier intervention and when to wean AEDS

Abstract

In well-selected children with focal lesional epilepsy, surgery is the most effective – and only curative – treatment option. If the epileptogenic source is well-localized and outside eloquent brain areas, a focal resection or disconnection is considered. Children with hemispheric pathology and existing neurological deficits may undergo hemispherotomy. The overall chance of seizure-freedom in children is 70-80% at 2 years and 60-70% at 5 years following surgery. A recent randomized trial has confirmed the unequivocal benefits of surgery over continued medical treatment. The number of referrals and surgeries steadily increases in children. Surgical indications have broadened over the past decades, now including generalized epileptic encephalopathies in the context of unilateral structural pathology. An increasing number of MRI-negative children – with presumed focal cortical dysplasia – is evaluated for surgery, using improved functional and structural imaging and invasive monitoring. It has been convincingly demonstrated that postoperative seizure-outcome improves with shorter duration of epilepsy. Epilepsy surgery can improve developmental capacities of children with refractory epilepsy, and shorter epilepsy duration predicts better postoperative cognitive outcome and more cognitive improvement. Finally, AED withdrawal – which can be safely considered early after surgery in many children – is an independent predictor of eventual IQ and of IQ increase after surgery. Given the low risks of epilepsy surgery, the small chance of spontaneous “cure” in focal epilepsy, and the high success-rate of surgery, all children with focal lesional epilepsy should be referred for presurgical evaluation early after diagnosis, even when seizures are well-controlled with one or two AEDs. Epilepsy surgery is an early treatment option rather than a last resort.