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Epilepsy Surgery

Surgery is considered for children with medically intractable epilepsy, declining neurological function, or syndromes for which medical treatment is known to be ineffective. These determinations require accurate classification of the epilepsy syndrome, knowledge of the natural history, response to anti-epileptic drug trials, and serial assessments of development. Many types of infantile and early childhood epilepsies are hard to classify and of uncertain prognosis.
Although evidence shows that children (even under age 3) who undergo epilepsy surgery soon after epilepsy has started have better outcomes, surgery is not offered as commonly as it should be. [Pindrik: 2018] [Kadish: 2018] [Englot: 2012] Also, there can be significant delays before referral; often there is a mean of up to 60 months and a process where 6 antiepileptic medications have been tried before referral to an epilepsy surgery team. [Prideaux: 2018] The International League Against Epilepsy defines drug-resistance as the failure to respond to 3 well-selected anti-epileptic drugs that are used in isolation or any combination. Because the frequency of seizures in children is often high, the determination of drug-resistance need not take years and, often, can be established within a year of epilepsy onset .

The main types of epilepsy surgery include:
  • Vagal nerve stimulation (VNS) can be used in generalized or focal epilepsy. [Welch: 2018] A VNS reduces seizure frequency by sending regular, low amplitude pulses of electricity to the brain via the vagus nerve. A stimulator device is implanted under the skin in the chest and is about the same size as a cardiac pacemaker. A wire from the device is wound around the vagus nerve in the neck. See Vagus Nerve Stimulator (VNS) for more information.
  • Responsive neuro-stimulation (RNS) is a relatively new therapy. A device is placed in the skull that is connected to electrodes on top of the brain with the placement tailored to the individual. It monitors brain waves, and if seizure activity is detected, it stimulates the brain to try to counter the seizure activity.
  • Lobectomy/lesionectomy (most frequently involving the temporal lobe) is a procedure in which a specific lobe (or lesion within a lobe) of the brain is removed. This is successful in many cases, especially when a lesion is identified on MRI. [Stevelink: 2018] The percentage of cure or significant seizure reduction varies with different criteria/methods used.
  • Corpus callosotomy is a palliative surgery in which the main connection between right and left halves of the brain is cut. It is used most often to reduce injuries related to abrupt drop seizures, but seizure freedom should not be expected.
  • Hemispherectomy/hemispherotomy is a procedure in which half of the brain is removed or disconnected from the surrounding brain. This is a palliative surgery that may result in more significant functional loss (peripheral vision loss, weakness) on the opposite side of the body, but it also has remarkable success in stopping seizures (60-80% depending on circumstances). This has shown to be particularly effective in instances where a prior stroke has caused epilepsy.
If surgery is being considered for a child with seizures, the families can have a reasonable expectation of seizure elimination or substantially fewer disabling seizures, which should improve the quality of life and perhaps help development. There should be minimal risk of significant loss of neurologic function. Children with complete resections of focal structural lesions, identified by MRI, fare best and have seizure-free rates as high as 90%. Many of these lesions are congenital, slow-growing tumors or cerebral dysgenesis. Mesial temporal sclerosis (a common indication in adult epilepsy surgery) is less frequent in children and adolescents, but it has a very favorable surgical outcome. Without a clear lesion on MRI, complete long-term seizure freedom following surgery is less likely (at times only 30-50%); however, it still has a higher likelihood of seizure freedom when compared to continued medication trials (estimated at less than 10%).

Resources

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Helpful Articles

Steinbok P, Gan PY, Connolly MB, Carmant L, Barry Sinclair D, Rutka J, Griebel R, Aronyk K, Hader W, Ventureyra E, Atkinson J.
Epilepsy surgery in the first 3 years of life: A Canadian survey.
Epilepsia. 2009. PubMed abstract

Benifla M, Rutka JT, Otsubo H, Lamberti-Pasculli M, Elliott I, Sell E, RamachandranNair R, Ochi A, Weiss SK, Snead OC 3rd, Donner EJ.
Long-term seizure and social outcomes following temporal lobe surgery for intractable epilepsy during childhood.
Epilepsy Res. 2008;82(2-3):133-8. PubMed abstract

Authors & Reviewers

Initial publication: June 2011; last update/revision: January 2019
Current Authors and Reviewers:
Author: Matthew Sweney, MD
Authoring history
2018: first version: Matthew Sweney, MDA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Englot DJ, Ouyang D, Garcia PA, Barbaro NM, Chang EF.
Epilepsy surgery trends in the United States, 1990-2008.
Neurology. 2012;78(16):1200-6. PubMed abstract / Full Text

Kadish NE, Bast T, Reuner G, Wagner K, Mayer H, Schubert-Bast S, Wiegand G, Strobl K, Brandt A, Korinthenberg R, van Velthoven V, Schulze-Bonhage A, Zentner J, Ramantani G.
Epilepsy Surgery in the First 3 Years of Life: Predictors of Seizure Freedom and Cognitive Development.
Neurosurgery. 2018. PubMed abstract

Pindrik J, Hoang N, Smith L, Halverson M, Wojnaroski M, McNally K, Gedela S, Ostendorf AP.
Preoperative evaluation and surgical management of infants and toddlers with drug-resistant epilepsy.
Neurosurg Focus. 2018;45(3):E3. PubMed abstract

Prideaux L, Barton S, Maixner W, Harvey AS.
Potential delays in referral and assessment for epilepsy surgery in children with drug-resistant, early-onset epilepsy.
Epilepsy Res. 2018;143:20-26. PubMed abstract

Stevelink R, Sanders MW, Tuinman MP, Brilstra EH, Koeleman BP, Jansen FE, Braun KP.
Epilepsy surgery for patients with genetic refractory epilepsy: a systematic review.
Epileptic Disord. 2018;20(2):99-115. PubMed abstract

Welch WP, Sitwat B, Sogawa Y.
Use of Vagus Nerve Stimulator on Children With Primary Generalized Epilepsy.
J Child Neurol. 2018;33(7):449-452. PubMed abstract