Surgical evaluation in children <3 years of age with drug-resistant epilepsy: Patient characteristics, diagnostic utilization, and potential for treatment delays

Michael Scott Perry; Sabrina Shandley; Max Perelman; Rani K Singh; Lily Wong-Kisiel; Joseph Sullivan; Ernesto Gonzalez-Giraldo; Erin Fedak Romanowski; Nancy A McNamara; Ahmad Marashly; Adam P Ostendorf; Allyson Alexander; Krista Eschbach; Jeffrey Bolton; Steven Wolf; Patricia McGoldrick; Dewi F Depositario-Cabacar; Michael A Ciliberto; Satyanarayana Gedela; Kumar Sannagowdara; Samir Karia; Daniel W Shrey; Priya Tatachar; Srishti Nangia; Zachary Grinspan; Shilpa B Reddy; Patel Shital; Jason Coryell

doi:10.1111/epi.17124

Surgical evaluation in children <3 years of age with drug-resistant epilepsy: Patient characteristics, diagnostic utilization, and potential for treatment delays

Epilepsia. 2022 Jan;63(1):96-107. doi: 10.1111/epi.17124. Epub 2021 Nov 15.

Authors

Michael Scott Perry¹, Sabrina Shandley¹, Max Perelman², Rani K Singh³, Lily Wong-Kisiel⁴, Joseph Sullivan⁵, Ernesto Gonzalez-Giraldo⁵, Erin Fedak Romanowski⁶, Nancy A McNamara⁶, Ahmad Marashly⁷, Adam P Ostendorf⁸, Allyson Alexander^{9

10}, Krista Eschbach¹¹, Jeffrey Bolton¹², Steven Wolf¹³, Patricia McGoldrick¹³, Dewi F Depositario-Cabacar¹⁴, Michael A Ciliberto¹⁵, Satyanarayana Gedela¹⁶, Kumar Sannagowdara¹⁷, Samir Karia¹⁸, Daniel W Shrey¹⁹, Priya Tatachar²⁰, Srishti Nangia²¹, Zachary Grinspan²¹, Shilpa B Reddy²², Patel Shital²², Jason Coryell²

Affiliations

¹ Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA.
² Doernbecher Children's Hospital, Oregon Health Science Center, Oregon Health and Sciences University, Portland, Oregon, USA.
³ Division of Neurology, Department of Pediatrics, Atrium Health/Levine Children's Hospital, Charlotte, North Carolina, USA.
⁴ Divisions of Child Neurology and Epilepsy, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
⁵ Benioff Children's Hospital, University of California, San Francisco Weill Institute for Neurosciences, San Francisco, California, USA.
⁶ Division of Pediatric Neurology, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.
⁷ Division of Pediatric Neurology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA.
⁸ Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA.
⁹ Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
¹⁰ Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado, USA.
¹¹ Department of Neurology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
¹² Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA.
¹³ Boston Children's Health Physicians of New York and Connecticut, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, USA.
¹⁴ Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA.
¹⁵ Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹⁶ Department of Pediatrics, Emory University College of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
¹⁷ Department of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
¹⁸ Department of Neurology, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky, USA.
¹⁹ Children's Hospital of Orange County, Orange, California, USA.
²⁰ Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA.
²¹ Weill-Cornell Medicine, New York, New York, USA.
²² Department of Pediatric Neurology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee, USA.

PMID: 34778945
DOI: 10.1111/epi.17124

Abstract

Objective: Drug-resistant epilepsy (DRE) occurs at higher rates in children <3 years old. Epilepsy surgery is effective, but rarely utilized in young children despite developmental benefits of early seizure freedom. The present study aims to identify unique patient characteristics and evaluation strategies in children <3 years old who undergo epilepsy surgery evaluation as a means to assess contributors and potential solutions to health care disparities in this group.

Methods: The Pediatric Epilepsy Research Consortium Epilepsy Surgery Database, a multicentered, cross-sectional collaboration of 21 US pediatric epilepsy centers, collects prospective data on children <18 years of age referred for epilepsy surgery evaluation. We compared patient characteristics, diagnostic utilization, and surgical treatment between children <3 years old and those older undergoing initial presurgical evaluation. We evaluated patient characteristics leading to delayed referral (>1 year) after DRE diagnosis in the very young.

Results: The cohort included 437 children, of whom 71 (16%) were <3 years of age at referral. Children evaluated before the age of 3 years more commonly had abnormal neurological examinations (p = .002) and daily seizures (p = .001). At least one ancillary test was used in 44% of evaluations. Fifty-nine percent were seizure-free following surgery (n = 34), with 35% undergoing limited focal resections. Children with delayed referrals more often had focal aware (p < .001) seizures and recommendation for palliative surgeries (p < .001).

Significance: There are relatively few studies of epilepsy surgery in the very young. Surgery is effective, but may be disproportionally offered to those with severe presentations. Relatively low utilization of ancillary testing may contribute to reduced surgical therapy for those without evident lesions on magnetic resonance imaging. Despite this, a sizeable portion of patients have favorable outcome after focal epilepsy surgery resections.

Keywords: childhood epilepsy; epilepsy surgery; pharmacoresistant.

MeSH terms

Child
Child, Preschool
Cross-Sectional Studies
Drug Resistant Epilepsy* / diagnosis
Drug Resistant Epilepsy* / surgery
Electroencephalography / methods
Epilepsy* / diagnosis
Epilepsy* / surgery
Humans
Prospective Studies
Retrospective Studies
Seizures / surgery
Time-to-Treatment
Treatment Outcome