Special Issue on Minimally Invasive Pediatric Epilepsy Surgery

 

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The advent of minimally invasive epilepsy surgery has markedly increased the number of epilepsy surgery candidates. A paradigm shift in the selection of candidates for pediatric epilepsy surgery has made this a very exciting time for pediatric epilepsy surgery. Historically, treatment options for medically refractory epilepsy, defined as the failure of two or three appropriate antiseizure medications or disabling seizures (including medication side effects),[1] include a trial of another antiseizure medication, the ketogenic diet or one of its variants, or epilepsy surgery. Traditionally, the surgical options, either a cortical resection or disconnection, especially a resection in the carefully selected patient, had a greater potential for seizure freedom but both required craniotomy.

A treatment gap for epilepsy surgery has also existed. This gap refers to the actual number of epilepsy surgery procedures performed versus the number of potential procedures. Minimally invasive epilepsy surgery techniques have overcome some of these considerations responsible for this gap, such as parent or patient willingness to undergo epilepsy surgery. In the past, epilepsy surgery candidates were selected with a bias toward seizure freedom, relegating the remaining patients to medical therapies that have a lower chance for seizure freedom. This selection bias for candidates more likely to achieve seizure freedom limited surgical options, especially for those with multifocal epilepsy. Along with these technical advancements, surgical outcome expectations have also changed, from a “curative” mindset to one that targets the more disabling seizures and treats them, realizing that residual seizures may still occur.

We review the specific reasons behind the explosion of minimally invasive epilepsy surgery in this special issue of the Journal of Pediatric Epilepsy. This results from technological advances in multiple fields in addition to the philosophical change regarding outcomes. The shift from subdural explorations to the use of stereoelectroencephalography has allowed bilateral explorations and reduced the morbidity associated with subdural grids and strips. Improvements in computational and functional neuroimaging have led to a better definition of the epileptogenic lesion and in determining the function of the surrounding cortex. The development of minimally invasive techniques for removing the epileptic focus, or network node, such as magnetic resonance-guided laser interstitial thermal therapy and high intensity focused ultrasound, has removed many of the perceived barriers to epilepsy surgery held by families and referring physicians. The introduction of neuromodulation, which alters membrane excitability, starting with vagus nerve stimulation, then deep brain stimulation, and now, responsive neurostimulation, allows us to inhibit an epileptic focus, or network node, rather than destroy it. And finally, the exciting new field of molecular neurosurgery, including gene therapy, RNA modulation, or intraventricular drug delivery, may potentially further expand the treatment for medically refractory epilepsy patients not appropriate for epilepsy surgery or have failed prior epilepsy surgery.

In summary, the identification of the appropriate candidate for pediatric epilepsy surgery has changed from choosing patients with focal epilepsy more likely to become seizure free to determining the appropriate epilepsy surgery procedure for each specific patient, including those with genetic, multifocal, or generalized epilepsy. It is exciting that there may now be some type of surgical option for virtually every child with refractory epilepsy. Hopefully this issue will excite the reader on these remarkable advancements in epilepsy treatment.

Publication History

Article published online:
05 January 2023

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• References

• 1 Cross JH, Jayakar P, Nordli D. et al; International League against Epilepsy, Subcommission for Paediatric Epilepsy Surgery, Commissions of Neurosurgery and Paediatrics. Proposed criteria for referral and evaluation of children for epilepsy surgery: recommendations of the Subcommission for Pediatric Epilepsy Surgery. Epilepsia 2006; 47 (06) 952-959
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