Expanding the scope of pediatric epilepsy surgery: Access, indications, and outcomes in a modern cohort

OBJECTIVE: Expanded indications, diagnostic tools, and treatment options have transformed the landscape of modern pediatric epilepsy surgery. Published real-world experiences from large surgical cohorts are still needed. To close this gap, we evaluated access, indications, treatment, and outcomes in a contemporary pediatric epilepsy surgery program. METHODS: We evaluated data from 100 consecutive diagnostic and therapeutic procedures in 62 pediatric and young adult patients. Data collected included demographics, diagnostics, procedures, 12-month seizure and medication outcomes, and adverse events. Primary outcome for patients who underwent treatment with the goal of cure or resection, along with the intent of palliation, was 12-month postoperative Engel/ILAE scores. For those who underwent RNS-implant (alone or in combination with a second procedure) with the goal of seizure reduction, the primary outcome was proportion seizure reduction in the prior 28 days at 12 months postoperatively. RESULTS: Patients largely matched state and regional demographics. Epilepsy types included unifocal (n = 33, 53.2%), multifocal (n = 15, 24.2%), generalized (n = 12, 19.4%), and combined (n = 2, 3.2%). Of the 100 procedures, 36.0% were diagnostic SEEG (n = 35) and 64.0% were treatment procedures (n = 58; note: n = 4 pending). Among patients who underwent surgical treatment with the goal of cure (n = 33), a 12-month Engel I/ILAE I or III outcome was achieved in 81.8% (n = 27). Among patients who underwent RNS implantation, 79.0% were responders (>50% reduction) and 38.0% were super-responders (>90% reduction), with a median seizure reduction of 78% at 12 months. Three treatment procedures (4.7%, n = 3 patients) had a surgical complication, none permanent. SIGNIFICANCE: Contemporary pediatric epilepsy surgery, utilizing modern diagnostic and surgical techniques, including off-label use of RNS, provides safe, effective, accessible, and equitable treatment to children across a broad range of indications, many of whom, historically, have not been considered viable surgical candidates. PLAIN LANGUAGE SUMMARY: "In this article by McLaren et al, 100 consecutive procedures were examined from a modern pediatric epilepsy surgery program. By utilizing advanced diagnostic and surgical techniques, they've shown that pediatric epilepsy surgery can be safe, effective, and accessible across diverse conditions and demographics. Notably, 82% of patients who underwent surgery aimed at curing their condition achieved seizure-freedom in 12 months and 79% of patients with Responsive Neurostimulation (RNS) implants experienced significant seizure reduction."