Abstract
Objective:Diffusion tensor imaging (DTI) is a useful neuroimaging technique for surgical planning in adult patients. However, no systematic review has been conducted to determine its utility for pre-operative analysis and planning of Pediatric Epilepsy surgery. We sought to determine the benefit of pre-operative DTI in predicting and improving neurological functional outcome after epilepsy surgery in children with intractable epilepsy.Methods:A systematic review of articles in English using PubMed, EMBASE and Scopus databases, from inception to January 10, 2020 was conducted. All studies that used DTI as either predictor or direct influencer of functional neurological outcome (motor, sensory, language and/or visual) in pediatric epilepsy surgical candidates were included. Data extraction was performed by two blinded reviewers. Risk of bias of each study was determined using the QUADAS 2 Scoring System.Results:13 studies were included (6 case reports/series, 5 retrospective cohorts, and 2 prospective cohorts) with a total of 229 patients. Seven studies reported motor outcome; three reported motor outcome prediction with a sensitivity and specificity ranging from 80 to 85.7 and 69.6 to 100%, respectively; four studies reported visual outcome. In general, the use of DTI was associated with a high degree of favorable neurological outcomes after epilepsy surgery.Conclusion:Multiple studies show that DTI helps to create a tailored plan that results in improved functional outcome. However, more studies are required in order to fully assess its utility in pediatric patients. This is a desirable field of study because DTI offers a non-invasive technique more suitable for children.Advances in knowledge:This systematic review analyses, exclusively, studies of pediatric patients with drug-resistant epilepsy and provides an update of the evidence regarding the role of DTI, as part of the pre-operative armamentarium, in improving post-surgical neurological sequels and its potential for outcome prediction.
Highlights
Pediatric epilepsyAccording to the current guidelines of the International League Against Epilepsy (ILAE), epilepsy is defined as disease of the brain characterized by the presence of at least two unprovoked seizures happening more than 24 h apart, or one unprovoked seizure with a likelihood of more than 60% of having another one, or an established diagnosis of an epilepsy syndrome.[1]
The studies by Kokkinos and Shinoda were case reports in which Diffusion tensor imaging (DTI) was used to assess the relationship of the corticospinal tracts (CST) with the region of interest resulting in a tailored surgical plan to avoid this tract resulting in preservation of motor function in both patients..[41,45]
The last three studies by Nelles, Jeong and Wang focused on the use of DTI for predicting motor outcome after epilepsy surgery and showed that quantitative values calculated with DTI, such as fractional anisotropy (FA) and the robustness of the CST, can accurately predict post-operative motor function with a specificity that ranges between 69.6 and 100% and a sensitivity of 80–85.7%49–51 (Figure 5)
Summary
Pediatric epilepsyAccording to the current guidelines of the International League Against Epilepsy (ILAE), epilepsy is defined as disease of the brain characterized by the presence of at least two unprovoked seizures happening more than 24 h apart, or one unprovoked seizure with a likelihood of more than 60% of having another one, or an established diagnosis of an epilepsy syndrome.[1]. Surgical resection for pediatric drug-resistant epilepsy has a clear benefit as shown by a randomized controlled trial by Dwivedi and collaborators in 2017 that randomly allocated 116 pediatric patients to either a surgery with medical treatment group or to a medical treatment only group. At 12 months, 77% of the patients from the surgery group were completely seizure-free compared to 7% in the medical treatment group only.[7] there is a fine balance between the risks and benefits of such procedure, especially when the epileptogenic foci is located in areas of the brain that contain important white matter tracts (WMT) that are involved in vital functions such as language, vision, motor function and sensation.[8] knowledge of the location of these tracts is vital to perform a safe surgical resection and guarantee optimal
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