====== Epilepsy surgery case series ====== A retrospective study of 196 children who underwent epilepsy surgery between 1994 and 2015 and had a minimum postoperative follow-up of 5 years. Results: The median age at the time of surgery was 9.5 (0.08-19.8) years; 110 (56.1%) had temporal, 62 (31.6%) had extratemporal resections, and 24 (12.2%) had hemispheric surgery. The duration of postsurgical follow-up was between 5 and 20 years (mean±SD: 7 ± 3.2). Overall, 129 of 196 (65.8%) patients had Engel class I outcome at final visit. Among patients who underwent temporal, extratemporal and hemispheric surgery; 84 of 110 (76.4%), 34 of 62 (54.8%), and 11 of 24 (45.8%) patients had complete seizure freedom, respectively (p: 0.016). Patients with tumors had the best outcome, with 83.1% seizure freedom. The number of preoperative antiseizure medications (OR 3.19, 95% CI 1.07-9.48), the absence of postoperative focal epileptiform discharges (OR 8.98, 95% CI 4.07-19.79) were independent predictors of seizure freedom. Across two decades, the age at surgery was decreased (p: 0.003), overall seizure freedom (61.8% vs 68%) did not differ. In the past decade, a higher proportion of malformations of cortical development was operated (14.7% vs 35.9%, p: 0.007). The findings showed favorable long-term seizure outcome in children who underwent epilepsy surgery. The results are encouraging for developing centers with limited resources to establish pediatric epilepsy programs ((Günbey C, Bilginer B, Oğuz KK, Söylemezoğlu F, Ergün EL, Akalan N, Topçu M, Turanlı G, Yalnızoğlu D. Lesional resective epilepsy surgery in childhood: Comparison of two decades and long-term seizure outcome from a single center. Epilepsy Res. 2022 Feb 8;181:106882. doi: 10.1016/j.eplepsyres.2022.106882. Epub ahead of print. PMID: 35168000.)) ===== 2021 ===== 42 [[child]]ren who were referred to an [[epilepsy center]] for surgical evaluation. Sixteen children (38%) were offered [[epilepsy surgery]] and 10 consented. Seizure outcome was classified based on [[ILAE outcome classification]]. All 10 children were having multiple seizures a month on therapeutic doses of three [[antiepileptic drug]]s (AEDs). At a median follow-up of 5.6 years after epilepsy surgery, three children had class 1 outcome (no seizures), four had class 3 outcome (1-3 seizure days/year), and three had class 4 outcome (≥ 50% reduction in seizure frequency). One child was off AEDs, seven were on a single AED, and two were on three AEDs at their last follow-up. Epilepsy surgery had low morbidity and improved seizure control in childhood cancer survivors with drug-resistant epilepsy. Childhood cancer survivors with drug-resistant epilepsy should be referred to an epilepsy center for a higher level of care ((Siddiqui A, McGregor AL, Wheless JW, Klimo P, Boop FA, Khan RB. Utility of [[Epilepsy Surgery]] in Survivors of Childhood Cancer. Neuropediatrics. 2021 Apr 14. doi: 10.1055/s-0041-1728653. Epub ahead of print. PMID: 33853165.)). ===== 2017 ===== Giulioni et al. conducted a retrospective study enrolling 339 consecutive patients with LEATs who underwent surgery between January 2009 and June 2015 at eight Italian epilepsy surgery centers. They compared demographic, clinical, pathologic, and surgical features of patients with favorable (Engel class I) and unfavorable (Engel class II, III, and IV) seizure outcome. In addition, we compared patients with tumor-associated focal cortical dysplasia (FCD) and patients with solitary tumors to identify factors correlated with FCD diagnosis. Fifty-five (98.2%) of 56 patients with medically controlled epilepsy were seizure-free after surgery, compared to 249 (88.0%) of 283 patients with refractory epilepsy. At multivariate analysis, three variables independently predict unfavorable seizure outcome in the drug-resistant group. Age at surgery is largely the most significant (p = 0.001), with an odds ratio (OR) of 1.04. This means that the probability of seizure recurrence grows by 4% for every waited year. The resection site is also significant (p = 0.039), with a relative risk (RR) of 1.99 for extratemporal tumors. Finally, the completeness of tumor resection has a trend toward significance (p = 0.092), with an RR of 1.82 for incomplete resection. Among pediatric patients, a longer duration of epilepsy was significantly associated with preoperative neuropsychological deficits (p < 0.001). A statistically significant association was observed between FCD diagnosis and the following variables: tailored surgery (p < 0.001), temporal resection (p = 0.001), and surgical center (p = 0.012). The nationwide LEATs study gives important insights on factors predicting seizure outcome in refractory epilepsy and determining variability in FCD detection. Timely surgery, regardless of pharmacoresistance and oriented to optimize epileptologic, neuropsychological, and oncologic outcomes should be warranted ((Giulioni M, Marucci G, Pelliccia V, Gozzo F, Barba C, Didato G, Villani F, Di Gennaro G, Quarato PP, Esposito V, Consales A, Martinoni M, Vornetti G, Zenesini C, Efisio Marras C, Specchio N, De Palma L, Rocchi R, Giordano F, Tringali G, Nozza P, Colicchio G, Rubboli G, Lo Russo G, Guerrini R, Tinuper P, Cardinale F, Cossu M; Commission for Epilepsy Surgery of the Italian League Against Epilepsy. Epilepsy surgery of "low grade epilepsy associated neuroepithelial tumors": A retrospective nationwide Italian study. Epilepsia. 2017 Aug 14. doi: 10.1111/epi.13866. [Epub ahead of print] PubMed PMID: 28804898. )). ---- Three hundred fifty-two patients underwent surgical resection and there was one death. Forty-two percent had invasive monitoring. Thirty patients (9%) had microscopic infarct. Univariable analyses showed that microscopic infarct was higher among patients with invasive monitoring relative to no invasive monitoring (20% vs. 0.5%, respectively, p < 0.001). Eighteen patients (5%) had macroscopic infarct on CT or MRI. Univariable analysis showed no significant difference in macroscopic infarct between invasive monitoring and no invasive monitoring (8% vs. 3%, respectively, p = 0.085). One patient with microscopic infarct had transient right hemiparesis, and two with both macroscopic and microscopic infarct had unexpected persistent neurologic deficits. Thirty-two major complications (9.1%) were reported, with no difference in major complications between invasive monitoring and no invasive monitoring (10% vs. 7%, p = 0.446). In the multivariable analysis, invasive monitoring increased the odds of microscopic infarct (odds ratio [OR] 15.87, p = 0.009), but not macroscopic infarct (OR 2.6, p = 0.173) or major complications (OR 1.4, p = 0.500), after adjusting for age at surgery, sex, age at seizure onset, operative type, and operative location. Microscopic infarct was associated with invasive monitoring, and none of the patients had permanent neurologic deficits. Macroscopic infarct was not associated with invasive monitoring, and two patients with macroscopic infarct had persistent neurologic deficits ((Rubinger L, Hazrati LN, Ahmed R, Rutka J, Snead C, Widjaja E. Microscopic and macroscopic infarct complicating pediatric epilepsy surgery. Epilepsia. 2017 Jan 23. doi: 10.1111/epi.13667. [Epub ahead of print] PubMed PMID: 28111751. )). ===== 2016 ===== A total of 3060 patients were presurgically studied, and resective surgery was performed in 66.8% (n=2044) of them: medial temporal sclerosis (MTS): n=675, 33.0%; benign tumour (BT): n=408, 20.0%; and focal cortical dysplasia (FCD): n=284, 13.9%. Of these, 1929 patients (94.4%) had a follow-up of 2 years, and 50.8% were completely seizure free (Engel IA). Seizure freedom rate slightly improved over time. Presurgical evaluations continuously increased, whereas surgical interventions did not. Numbers for MTS, BT and temporal lobe resections decreased since 2009. The number of non-lesional patients and the need for intracranial recordings increased. More evaluated patients did not undergo surgery (more than 50% in 2010-2013) because patients were not suitable (mainly due to missing hypothesis: 4.5% in 1990-1993 up to 21.1% in 2010-2013, total 13.4%) or declined from surgery (maximum 21.0% in 2010-2013, total 10.9%). One potential reason may be that increasingly detailed information on chances and risks were given over time. The increasing volume of the presurgical programme largely compensates for decreasing numbers of surgically remediable syndromes and a growing rate of informed choice against epilepsy surgery. Although comprehensive diagnostic evaluation is offered to a larger group of epilepsy patients, surgical numbers remain stable ((Cloppenborg T, May TW, Blümcke I, Grewe P, Hopf LJ, Kalbhenn T, Pfäfflin M, Polster T, Schulz R, Woermann FG, Bien CG. Trends in epilepsy surgery: stable surgical numbers despite increasing presurgical volumes. J Neurol Neurosurg Psychiatry. 2016 Oct 5. pii: jnnp-2016-313831. doi: 10.1136/jnnp-2016-313831. [Epub ahead of print] PubMed PMID: 27707870. )). ---- Despite its potential to offer seizure freedom, resective epilepsy surgery (RES) is seldom performed in patients 60 years of age or older. Demonstrating successful outcomes including an improved quality of life may raise awareness about the advantages of referring this underrepresented population for specialized evaluation. Accordingly, Dewar et al investigated outcomes and life fulfillment in patients with an age ≥ 60 years who had undergone RES. All patients who, at the age of 60 years or older, had undergone RES for medically refractory focal onset seizures at the authors' center were evaluated. A modified Liverpool Life Fulfillment (LLF) tool was administered postoperatively (maximum score 32). Seizure outcomes were classified according to the Engel classification system. Twelve patients underwent RES. The majority of patients (9 [75%] of 12) had at least 1 medical comorbidity in addition to seizures. The mean follow-up was 3.1 ± 2.1 years. At the time of the final follow-up, 11 (91.7%) of 12 patients were documented as having a good postsurgical outcome (Engel Class I-II). Half (6 of 12 patients) were completely seizure free (Engel Class IA). Liverpool Life Fulfillment (LLF) data were available for 11 patients. Following surgery, the mean LLF score was 26.7 ± 6. Eight patients (72.7%) noted excellent satisfaction with their RES, with 5 (45.5%) noting postoperative improvements in overall health. CONCLUSIONS Resective epilepsy surgery is safe and effective in patients with an age ≥ 60 years. Over 90% had a good surgical outcome, with 50% becoming completely seizure free despite 1 or more medical comorbidities in the majority. The study data indicated that an advancing age should not negatively influence consideration for RES ((Dewar S, Eliashiv D, Walshaw PD, Engel J Jr, Fried I, Moseley BD. Safety, efficacy, and life satisfaction following epilepsy surgery in patients aged 60 years and older. J Neurosurg. 2016 Apr;124(4):945-51. doi: 10.3171/2015.3.JNS142317. Epub 2015 Sep 18. PubMed PMID: 26381254. )). ===2007=== Loddenkemper et al identified 50 infants among 251 consecutive pediatric patients (<18 years old) undergoing epilepsy surgery. Charts were reviewed for clinical data and neurodevelopmental testing with the Bayley Scales of Infant Development. A developmental quotient was calculated to compare scores of children at different ages. Complete data were available on 24 of 50 infants. Surgeries included 14 hemispherectomies and 10 focal resections. Seventeen patients became seizure free; 5 patients had >90% seizure reduction, 1 had >50% seizure reduction, and 1 had no change. The developmental quotient indicated modest postoperative improvement of mental age. The preoperative and postoperative development quotients correlated well. Younger infants had a higher increase in developmental quotient after surgery. Patients with epileptic spasms were younger and had a lower developmental quotient at presentation, but increase in developmental quotient was higher in this subgroup. After surgery, seizure frequency and developmental quotient improved. Developmental status before surgery predicted developmental function after surgery. Patients who were operated on at younger age and with epileptic spasms showed the largest increase in developmental quotient after surgery ((Loddenkemper T, Holland KD, Stanford LD, Kotagal P, Bingaman W, Wyllie E. Developmental outcome after epilepsy surgery in infancy. Pediatrics. 2007 May;119(5):930-5. PubMed PMID: 17473093.)).