Seizure 2022, Vol 96, Editor’s Choice: Epilepsy surgery in the first six months of life: A systematic review and meta-analysis
While there is an ever-expanding choice of antiseizures medications (ASMs) and evidence that expert optimisation of the medical treatment can provide at least 20% of patients with epilepsies previously considered “refractory” with periods of sustained seizure control (1), about one third of all individuals with epilepsy still fail to become seizure-free with ASMs the long term. In economically developed countries, epilepsy surgery has become an established treatment option for (older) children and (younger) adults with such epilepsies. There is evidence from randomised controlled studies that, in epilepsy surgery candidates, surgical treatment is more likely to control seizures than medical treatment (2), that health related quality of life is likely to improve after surgery (3), that the excess mortality associated with epilepsy is reduced (4), and that epilepsy surgery is cost effective in the long term (5). However, there are ongoing uncertainties about the role of epilepsy surgery in the youngest children (as well as in older adults).
My Editor’s Choice from the current volume of Seizure is a systematic review and meta-analysis of epilepsy surgery in the first year of life by Konstantin L. Makridis et al. (6). In addition to the outcomes listed above, the ability of the child to develop to its full potential is a consideration that is especially important in the treatment of very young children. The potential to recover from brain surgery and to optimise the opportunities for normal intellectual and social development are greatest when epilepsy surgery is carried out early in life. The high level of plasticity of the brain may protect children operated at this time in their lives without the sort of neurological deficits that would be unavoidable if surgery is postponed until they are older. However, for several reasons, epilepsy surgery is also most challenging in the youngest young.
Makridis et al. found a total of 158 reported outcomes of epilepsy surgery in infants up to six months of age in 16 scientific publications. Most children had undergone hemispherotomies rather than focal resections. The rates of achieving seizure freedom were impressive and similar to those reported in adults (although adults would rarely be candidates for hemispherotomies): Whereas 71% became seizure free following hemispherotomy, 58% achieved this status after focal surgery (58%). However, the number of complications was also quite high (27.7%). Hydrocephalus was particularly common, affecting one in six infants postoperatively. Five of every six patients had shown signs of cognitive impairment preoperatively. After surgery, some cognitive improvements were seen, especially among those infants who had become seizure free. One in every five infants who had undergone epilepsy surgery could subsequently stop ASM treatment.
While these findings suggest that epilepsy surgery should definitely be considered in infants with focal seizure disorders amenable to epilepsy surgery, the authors conclude that it should only be carried out at specialised centres with experience of epilepsy surgery in this age group.
(1) Neligan A, Bell GS, Elsayed M, Sander JW, Shorvon SD. Treatment changes in a cohort of people with apparently drug-resistant epilepsy: an extended follow-up. J Neurol Neurosurg Psychiatry. 2012;83(8),810-3.
(2) Wiebe S, Blume WT, Girvin JP, Eliasziw M. Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 2001;345:311-8.
(3) Spencer SS, Berg AT, Vickrey BG, Sperling MR, Bazil CW, Haut S, Langfitt JT, Walczak TS, Devinsky O; Multicenter Study of Epilepsy Surgery. Health-related quality of life over time since resective epilepsy surgery. Ann Neurol 2007;62:327-34.
(4) Sperling MR, Barshow S, Nei M, Asadi-Pooya AA. A reappraisal of mortality after epilepsy surgery. Neurology. 2016 24;86:1938-44.
(5) Sheikh SR, Kattan MW, Steinmetz M, Singer ME, Udeh BL, Jehi L. Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US. Neurology 2020;95:e1404-e1416.
(6) Makridis KL, Atalay DA, Thomale U-W, Tietze A, Elger CE and Kaindl AM. Epilepsy surgery in the first six months of life: A systematic review and meta-analysis. Seizure 2022;96:109-117