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Clinical Outcomes 11 to 30 Years After Pediatric Epilepsy Surgery
TAKE-HOME MESSAGE
- Long-term outcomes (>10 years) of patients who had undergone pediatric epilepsy surgery were evaluated in this study, and the investigators found that, although seizure control was excellent, adverse effects related to the surgery were under-reported. Although almost half the patients were seizure-free and off antiseizure medications and three-fourths of the patients reported an improvement in seizure control, half also reported new postoperative symptoms, with almost one-third reporting these symptoms as permanent. These included visual field deficits, cognitive and language deficits, and motor deficits or decline. Interestingly, earlier focal surgery did not affect the long-term clinical outcomes.
- This study provides insights into the long-term outcomes of pediatric epilepsy surgery and shows that the intervention has positive seizure-control outcomes with the ability to provide a cure in almost half of the patients; however, adverse effects are significant and may need better quantification and assessment to understand the impact on daily functioning.
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
Pediatric epilepsy surgery promises seizure freedom or even cure of epilepsy. We evaluated the long-term (≥10 years) adult clinical outcome including surgery-related adverse events and complications, which are generally underreported.
METHODS
A monocentric, single-arm, questionnaire study in now adult patients who underwent epilepsy surgery during childhood. A novel ad hoc parental/patient questionnaire, which addressed diverse outcome domains was applied.
RESULTS
From a total of 353 eligible patients, 203 could be contacted (3 patients died of causes unknown) and 101 (50%) returned appropriately filled-in surveys. No evidence for a survey-response bias was found. The rate of surgical complications according to the patient records was 9%. As regards the survey, half of the parents/patients reported surgical adverse events (expected and unexpected issues) and one-third reported permanent aversive sequels. Two-thirds of the patients were seizure-free during the last year before follow-up; 63% were Engel class 1A; favorable seizure outcomes (including auras only) were obtained in 73%; and 54% were seizure-free and off antiseizure medicine (ASM), that is, cured of epilepsy. In non-seizure-free patients, seizure relapse occurred at any time during the follow-up interval but 87% of those with a seizure-free first postoperative year were seizure-free at follow-up. One patient experienced a seizure relapse during the ASM withdrawal trial but became seizure-free again with ASMs. Eleven patients reported an increased number of ASMs as compared to the time before surgery. Earlier focal surgery did not affect the long-term clinical outcome.
SIGNIFICANCE
Pediatric epilepsy surgery was capable of curing epilepsy in about one-half of the children and to significantly control seizures in about three-fourths. Long-term success of focal surgery did not depend on age at surgery or duration of epilepsy. Surgical adverse events including complications may be underreported and must be assessed more thoroughly.
Additional Info
Disclosure statements are available on the authors' profiles:
Clinical adult outcome 11-30 years after pediatric epilepsy surgery: Complications and other surgical adverse events, seizure control, and cure of epilepsy
Epilepsia 2022 Dec 05;[EPub Ahead of Print], C Hoppe, K Beeres, JA Witt, R Sassen, C HelmstaedterFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The International League Against Epilepsy defines drug-resistant epilepsy as the failure of adequate trials of two tolerated, appropriate drugs to produce sustained seizure freedom.1 This definition is based on published outcomes of therapeutic trials. Once two drugs have failed, epilepsy surgery should be considered, and published data from a randomized trial shows that surgery provides significant benefits in the short term when offered within 2 years of the onset of persistent, disabling seizures.2 A strong argument can be made for early operation, as the elimination of seizures is associated with reduced risk of mortality and morbidity associated with seizures, improved quality of life, and the potential for improved educational and occupational attainment.
We and others have observed that the average delay from the onset of epilepsy to surgery is approximately 20 years, subjecting too many individuals to unnecessary decades of suffering from epilepsy. The present study provides evidence that epilepsy surgery provides long-term benefits in children who were later assessed as adults. A minimum of 10 years follow-up was required, with an average age at surgery of 11 years and an average age at follow-up of 30.6 years. A variety of procedures were performed, from unilobar resections to hemispherectomy. After a mean of nearly 20 years, 66% of the patients were seizure- and aura-free at the last assessment, and 73% were free of disabling seizures (seizures with impairment of awareness). Moreover, 84% of the seizure-free patients no longer required antiseizure medication. Another 8% had 10 or fewer disabling seizures when last assessed. These results confirm the durability of the benefits from epilepsy surgery, with the remarkable observation that medication is often no longer necessary. Given the medical and psychosocial adverse effects caused by uncontrolled seizures, this study provides robust support for advising surgery in childhood. Children whose seizures continue to their adult years suffer the greatest psychosocial impairments, and epilepsy surgery offers a life-transforming opportunity.
What is the risk of surgery and is the freedom from seizures worthwhile? Although 9% had surgical complications, none (or perhaps one) were permanent. Approximately half of the patients reported some postsurgical adverse effects, including visual field deficits, memory or language deficits, further decline of preoperative motor deficits, headache, dizziness, etc. Unfortunately, the study does not place these in context and we do not know the extent to which these adverse effects impacted daily life or psychosocial development. Although many patients undoubtedly had neurological deficits prior to the operation, the degree of change remains to be defined; the subset who required hemispherectomy, for example, undoubtedly had major preoperative deficits. What might have happened without surgery also remains uncertain, and it is possible that neurological decline might be observed in these individuals. What is certain, however, is that the costs of uncontrolled seizures, from excess mortality and hospitalizations to unemployment, would be partly or completely avoided in patients who have a successful surgery.3
Epilepsy surgery continues to be underutilized, and this study should lead physicians to refer children for consideration of early surgical intervention. Curing epilepsy in a child allows that child to grow to adulthood without suffering from the disability and morbidity imposed by uncontrolled seizures. This is a major achievement that should foster greater independence and better quality of life. Epilepsy usually first appears in childhood, and early surgical intervention should be considered in children once it is clear that medications have failed.
References