Increasing volume and complexity of pediatric epilepsy surgery with stable seizure outcome between 2008 and 2014: A nationwide multicenter study

doi:10.1016/j.yebeh.2017.08.010

Epilepsy & Behavior

Volume 75, October 2017, Pages 151-157

https://doi.org/10.1016/j.yebeh.2017.08.010 Get rights and content

Highlights

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Data on 527 surgical procedures were collected from nine Italian Centers.
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73.6% of patients were in Engel class I, with no significant changes over time.
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Volumes of surgeries increased over time independently from the center.
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Complex surgeries were more frequently performed in high-volume centers.
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There was a high variability across centers concerning evaluation protocols.

Abstract

Objective

The objective of the study was to assess common practice in pediatric epilepsy surgery in Italy between 2008 and 2014.

Methods

A survey was conducted among nine Italian epilepsy surgery centers to collect information on presurgical and postsurgical evaluation protocols, volumes and types of surgical interventions, and etiologies and seizure outcomes in pediatric epilepsy surgery between 2008 and 2014.

Results

Retrospective data on 527 surgical procedures were collected. The most frequent surgical approaches were temporal lobe resections and disconnections (133, 25.2%) and extratemporal lesionectomies (128, 24.3%); the most frequent etiologies were FCD II (107, 20.3%) and glioneuronal tumors (105, 19.9%). Volumes of surgeries increased over time independently from the age at surgery and the epilepsy surgery center. Engel class I was achieved in 73.6% of patients (range: 54.8 to 91.7%), with no significant changes between 2008 and 2014. Univariate analyses showed a decrease in the proportion of temporal resections and tumors and an increase in the proportion of FCDII, while multivariate analyses revealed an increase in the proportion of extratemporal surgeries over time. A higher proportion of temporal surgeries and tumors and a lower proportion of extratemporal and multilobar surgeries and of FCD were observed in low (< 50 surgeries/year) versus high-volume centers.

There was a high variability across centers concerning pre- and postsurgical evaluation protocols, depending on local expertise and facilities.

Significance

This survey reveals an increase in volume and complexity of pediatric epilepsy surgery in Italy between 2008 and 2014, associated with a stable seizure outcome.

Introduction

Epilepsy surgery is underused in children [1], [2], [3] possibly because of the common practice to try all available antiepileptic drugs, the succession of seizure remissions and relapses, and the uncertainties concerning cognitive outcome. An international survey of pediatric epilepsy surgery centers [4] showed that only a third of children had proceeded to surgery within 2 years from epilepsy onset, despite the fact that 60% of these children were experiencing seizures since 2 years of age.

A US community based cohort study estimated the incidence of childhood-onset drug-resistant focal epilepsy as 11.3 per 100,000 per year and that of epilepsy surgery procedures as 1.3 per 100,000 per year [5]. This ninefold difference has been related to the availability of comprehensive presurgical assessment for only 45% of children with drug-resistant epilepsy [5]. Accordingly, a UK survey reported 1.0 per 100,000 epilepsy surgery procedures in children between April 2010 and March 2011 [6]. In contrast, more recent nationwide surveys have demonstrated an increasing utilization of pediatric epilepsy surgery in the US and Europe [3], [7], [8], [9].

Based on previous nationwide reports [3], [7], [8], [9] and the 2008 ILAE survey [4], the Commission on Epilepsy Surgery of the Italian League Against Epilepsy recognized the need to obtain information on common practice of pediatric epilepsy surgery in Italy between 2008 and 2014. This assessment period was determined because most Italian pediatric epilepsy surgery centers were established from 2008 onwards.

Subsequently, a survey was conducted among nine Italian pediatric epilepsy surgery centers that had been identified through a previous Italian League Against Epilepsy epidemiological survey. We aimed at collecting information on common presurgical and postsurgical evaluation protocols and, on volumes and types of surgical interventions, etiologies and seizure outcomes in children operated on between 2008 and 2014. Moreover, the survey aimed at investigating the geographic origin of patients in relation to the distribution of epilepsy surgery centers through the Italian territory and the specialty profile of the referring physicians.

In this study, we report the results of this nationwide multicenter survey.

Section snippets

Material and methods

Information on data collection and statistical analysis methodology are reported as supplementary material.

Each center sent aggregate data to C.B. with no indications to individual patients. Informed consent for all clinical procedures was obtained from all patients.

Results

Nine centers provided full information on surgical procedures performed between 2008 and 2014 (see Table 1 for the list of the participating centers). Eight of them also completed the questionnaire on presurgical evaluation and postsurgical follow-up protocols.

Discussion

The results of this survey, which involved nine Italian pediatric epilepsy surgery centers over a period of 7 years, confirm and expand those of previous nationwide reports in the US and Europe [3], [7], [8], and of an international ILAE survey [4]. We observed an increase in volume of surgeries with stability of class I outcome. Moreover, univariate analyses showed a decrease in the proportion of temporal lobectomies and tumors and an increase in the proportion of FCDII, while multivariate

Acknowledgments

This survey has been conducted in the framework of the Commission for Epilepsy Surgery of the Italian League Against Epilepsy.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of interest

There are no conflicts of interest, nor anything to disclose with any of the authors.

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Cited by (26)

Number of epilepsy surgeries has decreased despite an increase in pre-surgical evaluations at a tertiary pediatric epilepsy center in Ontario
2023, Seizure
A recent U.S. study reported that the number of epilepsy surgeries has remained stable or declined in recent years despite an increase in pre-surgical evaluation. This study aimed to evaluate trends in pre-surgical evaluation and epilepsy surgery from 2001 to 2019 and to determine whether these trends have changed in the later period (2014–2019) compared to earlier period (2001–2013).
This study evaluated trends in pre-surgical evaluation and epilepsy surgery at a tertiary pediatric epilepsy center. Children with drug resistant epilepsy who were evaluated for surgery were included. Clinical data, reasons for not undergoing surgery, and surgical characteristics of surgery patients were collected. Overall trends and trends in later period compared to earlier period for pre-surgical evaluation and epilepsy surgery were assessed.
There were 1151 children who were evaluated for epilepsy surgery and 546 underwent surgery. There was an upward trend in pre-surgical evaluation in the earlier period (rate ratio [RR]=1.04 (95%CI:1.02–1.07), p<0.001) and the trajectory of presurgical evaluation in the later period was not significantly different to the earlier period (RR=1.00 [95%CI:0.95–1.06], p = 0.88). Among the reasons for not undergoing surgery, failure to localize the seizures occurred more frequently in later period than earlier period (22.6% vs. 17.1% respectively, p = 0.024). For number of surgeries, there was an upward trend between 2001 and 2013 (RR=1.08 [95%CI:1.05–1.11], p<0.001), and a decreasing trend in the later period compared to earlier period (RR=0.91 [95%CI:0.84–0.99], p = 0.029).
Despite an increasing trend in pre-surgical evaluation, there was a decreasing trend in the number of epilepsy surgery in the later period as there was a larger proportion of patients in whom the seizures could not be localized. Trends in presurgical evaluation and epilepsy surgery will continue to evolve with introduction of technologies such as stereo-EEG and minimally invasive laser therapy.
Resective epilepsy surgery for West syndrome: The Hypsarrhythmic Asymmetric Scoring Scheme is a determining predictor of seizure outcome
2022, Seizure
Citation Excerpt :
When drugs fail to control seizures, a surgical option is recommended for good surgical candidates who manifest focal findings on long-term video EEG and neuroimaging. Surgical treatment initiated early in the disease course may significantly improve both seizure and developmental outcomes [9,10]; a series of studies have shown that a seizure-free outcome is obtained in approximately 60–83% of children with intractable epileptic spasms [10–15]. Successful early surgery in children with a structural etiology is expected to halt decline in cognitive abilities and facilitate postsurgical functional recovery and reorganization owing to the neural plasticity of the immature brain [16], offering substantially enhanced quality of life for both patients and families.
It has been suggested that asymmetric hypsarrhythmia is associated with structural etiology. We devised the Hypsarrhythmic Asymmetric Scoring Scheme (HASS) to quantify the degree of hypsarrhythmic asymmetry in a retrospective series of patients who underwent surgical treatment at our center. The present study aimed to investigate the role of HASS in predicting the postsurgical seizure outcomes.
We retrospectively analyzed the records of 46 children with hypsarrhythmia who underwent resective epilepsy surgery between 2018 and 2020 and were followed up for at least 1 year after surgery. Hypsarrhythmia severity in each hemisphere was quantified and scored. The HASS score was calculated as the difference between the two hemispheres. Univariate results were submitted to logistic regression models to identify independent predictors for favorable surgical outcomes.
Of the 46 patients who underwent resective surgery, Engel's class I–Ⅱ outcomes were achieved in 34 (73.9%). The Engel I–Ⅱ group had a significantly higher HASS score than the Engel Ⅲ–Ⅳ group (p<0.001). Multivariate analysis showed that the HASS score was the only significant predictor of good outcomes (p = 0.011). Further receiver operating characteristic analysis showed that a threshold of 7 yielded a better seizure outcome with a sensitivity of 97.06% and specificity of 83.33%.
As the first hypsarrhythmia scoring system specially designed for presurgical evaluation, the HASS score may contribute to predicting the postsurgical seizure outcome from the electroencephalography perspective.
Epilepsy surgery for children and adolescents: evidence-based but underused
2022, The Lancet Child and Adolescent Health
Citation Excerpt :
Indications for surgery have broadened in the past two decades and now include patients with more complex forms of epilepsy, such as extratemporal epilepsies (ie, frontal cortex epilepsies, insular cortex epilepsies, or posterior cortex epilepsies); epilepsies caused by multiple lesions, bilateral lesions, and widespread lesions; and non-lesional or MRI-negative epilepsies.5 The increasing complexity of patients receiving epilepsy surgery is seen in publications showing increases in the number of paediatric operations,6 the number of preoperative investigations,7,8 and younger age at surgery.9 There is also discussion about the role of surgery for well circumscribed lesions in non-eloquent areas, even for patients who do not have drug resistance, as such surgery could provide a cure and allow patients to possibly wean from medication with a low likelihood of morbidity.10
Paediatric epilepsy surgery is an increasingly used evidence-based management option with low risks for complications. Developments in neuroimaging techniques and other advanced diagnostics have widened the spectrum of children who could benefit from the procedure, and surgery is now considered a standard management approach for epilepsy. Available data indicate that early surgery improves outcomes. Despite these considerable advances, epilepsy surgery in children is still underused. In this Review, we summarise the indications, patient selection, principles of presurgical investigations, optimal timing, and types of epilepsy surgery. We also examine comprehensive outcomes after surgery, including seizure outcomes, complications, cognition, neurodevelopment, vocational outcome, and health-related quality of life of children and their parents. Successful epilepsy surgery could lead to improvement in all these areas. Children should, therefore, be referred early for evaluation in an appropriately competent centre.
Safety and effectiveness of surgery for epilepsy in children. Experience of a tertiary hospital in Ecuador
2021, Neurologia
Existe suficiente evidencia sobre la utilidad de la cirugía como alternativa terapéutica para pacientes con epilepsia farmacorresistente, sin embargo este tratamiento es subutilizado especialmente en países en desarrollo. El objetivo de este trabajo fue determinar la efectividad y seguridad de la cirugía de epilepsia en un hospital terciario de Ecuador.
Se describe el resultado de la cirugía de epilepsia en 27 niños y adolescentes en el Hospital Baca Ortiz, de Quito, Ecuador, teniendo en cuenta las siguientes variables antes y después de la cirugía: reducción de la frecuencia de crisis, Engel posquirúrgico, mejoría en la calidad de vida y presencia de complicaciones graves por la cirugía.
Se realizaron 21 callosotomías y seis cirugías resectivas. La frecuencia de crisis media se redujo de 465 mensual antes de la cirugía a 37,2 mensual después de la misma (p<0,001), mientras que la puntuación en la escala de calidad de vida aumentó de 12,6 a 37,2 puntos (p<0,001), el 72,7% de los pacientes mejoró la calidad de vida. Entre las cirugía resectivas, en dos epilepsias del lóbulo temporal y una del cuadrante posterior se logró Engel Ia, una hemisferotomía por encefalitis de Rasmusen quedó en Engel IIa y dos hamartomas hipotalámicos, uno logró Engel III y otro Engel Ia pero falleció a mediano plazo por complicación posquirúrgica. La otra complicación grave fue un hidrocéfalo que llevó a la muerte a un lactante con espasmos infantiles refractarios sometido a callosotomía.
El resultado favorable se observó en el 92,5% de los pacientes.
There is sufficient evidence on the usefulness of surgery as a therapeutic alternative for patients with drug-resistant epilepsy; however this treatment is underutilized, especially in developing countries.
We describe the outcomes of epilepsy surgery in 27 paediatric patients at Hospital Baca Ortiz in Quito, Ecuador. Our analysis considered the following variables: reduction in seizure frequency, surgery outcome according to the Engel classification, improvement in quality of life, and serious complications due to surgery.
21 corpus callosotomies and 6 resective surgeries were performed. The mean seizure frequency decreased from 465 per month before surgery to 37.2 per month thereafter (p<.001); quality of life scale scores increased from 12.6 to 37.2 (p<.001), and quality of life improved in 72.7% of patients. Regarding resective surgery, 2 patients with temporal lobe epilepsy and one with posterior quadrant epilepsy achieved Engel class IA, and one patient undergoing hemispherotomy due to Rasmussen encephalitis achieved Engel class IIA. Two patients underwent surgery for hypothalamic hamartoma: one achieved Engel III and the other, Engel IA; however, the latter patient died in the medium term due to a postoperative complication. The other major complication was a case of hydrocephalus, which led to the death of a patient with refractory infantile spasms who underwent corpus callosotomy.
Favourable outcomes were observed in 92.5% of patients.
Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers
2021, Epilepsy and Behavior
Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients’ access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients’ access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers’ success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.
Underutilization of epilepsy surgery: Part I: A scoping review of barriers
2021, Epilepsy and Behavior
Citation Excerpt :
Notably, the increasing complexity of the patients in the surgical pool has been established in several studies. Barba et al. retrospectively evaluated volume and type of epilepsy surgery among nine epilepsy surgery centers in Italy over a period of 7 years (2008–2014) and noted increasing complexity of pediatric epilepsy surgery [104]. In another retrospective study comprising of data from 10 European countries also showed that the total number of pediatric epilepsy surgeries increased from 383 in 2008–2009 to 551 in 2014–2015 with particular increase in extratemporal lobe surgeries (specifically significant for ≥7 years old) [105].
One-third of persons with epilepsy have seizures despite appropriate medical therapy. Drug resistant epilepsy (DRE) is associated with neurocognitive and psychological decline, poor quality of life, increased risk of premature death, and greater economic burden. Epilepsy surgery is an effective and safe treatment for a subset of people with DRE but remains one of the most underutilized evidence-based treatments in modern medicine. The reasons for this quality gap are insufficiently understood. In this comprehensive review, we compile known significant barriers to epilepsy surgery, originating from both patient/family-related factors and physician/health system components. Important patient-related factors include individual and epilepsy characteristics which bias towards continued preferential use of poorly effective medications, as well as patient perspectives and misconceptions of surgical risks and benefits. Health system and physician-related barriers include demonstrable knowledge gaps among physicians, inadequate access to comprehensive epilepsy centers, complex presurgical evaluations, insufficient research, and socioeconomic bias when choosing appropriate surgical candidates

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Increasing volume and complexity of pediatric epilepsy surgery with stable seizure outcome between 2008 and 2014: A nationwide multicenter study

Highlights

Abstract

Objective

Methods

Results

Significance

Introduction

Section snippets

Material and methods

Results

Discussion

Acknowledgments

Funding

Declaration of interest

Lancet Neurol

Eur J Paediatr Neurol

Eur J Paediatr Neurol

Epilepsy Res

Lancet Neurol

Epilepsy Res

Proposed criteria for referral and evaluation of children for epilepsy surgery: recommendations of the subcommission for pediatric epilepsy surgery

Epilepsia

Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009

Epilepsia

Defining the spectrum of international practice in pediatric epilepsy surgery patients

Epilepsia

Frequency, prognosis and surgical treatment of structural abnormalities seen with magnetic resonance imaging in childhood epilepsy

Brain

A survey of adult and pediatric epilepsy surgery in the United Kingdom

Epilepsia

Changing profiles of pediatric epilepsy surgery candidates over time: a nationwide single-center experience from 1990 to 2011

Epilepsia

Improved outcomes in pediatric epilepsy surgery: the UCLA experience, 1986–2008

Neurology

Temporal trends in pre-surgical evaluations and epilepsy surgery in the U.S. from 1998 to 2009

Epilepsy Res

Definition of drug resistant epilepsy: consensus proposal by the ad hoc task force of the ILAE commission on therapeutic strategies

Epilepsia