Surgical candidates in children with epileptic spasms can be selected without invasive monitoring: A report of 70 cases

• Published in: Epilepsy research 2021-10, Vol.176, p.106731-106731, Article 106731
• Main Authors: Erdemir, Gozde, Pestana-Knight, Elia, Honomichl, Ryan, Thompson, Nicolas R., Lachhwani, Deepak, Kotagal, Prakash, Wyllie, Elaine, Gupta, Ajay, Bingaman, William E., Moosa, Ahsan N.V.
• Format: Article
• Language: English
• Subjects: Child; Child, Preschool; Drug-resistant epileptic spasms; Electroencephalography; Epilepsy - complications; Epilepsy - diagnostic imaging; Epilepsy - surgery; Humans; Infant; Infantile spasms; Magnetic Resonance Imaging; Refractory epilepsy; Retrospective Studies; Spasm; Spasms, Infantile - complications; Spasms, Infantile - diagnostic imaging; Spasms, Infantile - surgery; Treatment Outcome
• ISSN: 0920-1211; 1872-6844
• DOI: 10.1016/j.eplepsyres.2021.106731

•Surgical Candidates in Children with Epileptic Spasms can be selected without Invasive Monitoring•A lesion based surgical selection strategy in children with epileptic spams may enable early surgery without the risks of invasive monitoring.•Longer epilepsy duration, and multilobar lesions predict higher risk of seizure recurrence at 6 month follow up.•Presence of multilobar lesion, and bilateral abnormalities on MRI predict higher risk of seizure recurrence on long term. Prior surgical series in children with drug-resistant epileptic spasms have reported use of intracranial EEG monitoring in up to two-third of patients. We report outcome after epilepsy surgery for drug-resistant epileptic spasms in a cohort of children without the use of intracranial EEG monitoring in any of the patients. Medical records of all consecutive children aged 5 years or under who had epilepsy surgery for epileptic spasms at Cleveland Clinic between 2000 and 2018 were reviewed. Post-operative seizure outcome and predictors of prognosis of seizure outcome were analyzed. Seventy children with active epileptic spasms underwent surgical resections during the study period. Mean age at seizure onset was 6.8 (+9.31) months and median age at surgery was 18.5 months. An epileptogenic lesion was identified on brain MRI in all patients; 17 (24%) had bilateral abnormalities. Etiologies included malformations of cortical development (58%), perinatal infarct/encephalomalacia (39%), and tumor (3%). None of the patients had intracranial EEG. Surgical procedures included hemispherectomy (44%), lobectomy/ lesionectomy (33%), and multilobar resections (23%). Twelve children needed repeat surgery; six (50%) became seizure free after the second surgery. At six months follow-up, 73% (51/70) were seizure-free since surgery. At a mean follow-up of 4.7 years, 60% (42/70) had Engel 1 outcome. In those with seizure recurrence, 17 (60%) reported improvement. Shorter epilepsy duration (p = 0.05) and lobar or sub-lobar epileptogenic lesions (p = 0.02) predicted favorable seizure outcome at 6 months after surgery. For long term outcome, patients with bilateral abnormalities on MRI (p = 0.001), and multilobar extent on MRI (p = 0.02) were at higher risk for recurrence. Children with drug-resistant epileptic spasms secondary to an epileptogenic lesion detected on MRI could be selected for epilepsy surgery without undergoing intracranial EEG monitoring. A surgical selection paradigm without intracranial monitori