Pediatric Epilepsy Surgery: First-Line Defense
Brain
Posted on: Aug 16
Brain
Posted on: Aug 16
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Tags: pediatrics, epilepsy, surgery, seizures, article

Pediatric Epilepsy Surgery: First-Line Defense

Surgery gives certain children the best chance to live seizure-free and should be considered earlier in the treatment process...

Epilepsy affects about 300,000 U.S. children under age 15. Most seizures can be controlled with medication, and some children outgrow their epilepsy. However, about 30 percent of children have medically refractory seizures, which means they do not respond to treatment. For these children, frequent seizures can take a significant toll on cognitive and intellectual development, and many suffer social, emotional and behavioral challenges as a result.

Although surgery is routinely considered for treatment of refractory seizures, it is often viewed as a last resort because of perceived risks. Consequently, some children suffer through years of failed treatment before they are referred to an epilepsy specialist. But that approach shortchanges patients, says Jodi Smith, Ph.D., M.D., a pediatric neurosurgeon who practices at Riley Hospital for Children at Indiana University Health. Surgery gives certain children the best chance to live seizure-free and should be considered earlier in the treatment process, according to Dr. Smith.

“It’s crucial that we reach children sooner, before they become debilitated by chronic seizures, so we can help them become high-functioning and productive members of society with a better quality of life,” she says.

Chronic seizures can have a negative impact on a child’s education as a consequence of learning difficulties and the associated psychosocial effects, such as poor peer relations, behavioral difficulties, poor school performance, depression, anxiety and poor self-esteem. What’s more, the long-term use of multiple seizure medications can be harmful to the developing brain. Early referral to an epilepsy surgery center can help specialists determine if surgery is a viable treatment option before significant cognitive loss occurs and the psychosocial consequences of prolonged disability prevent useful rehabilitation.

“Let’s not wait until they become so debilitated by their seizures that it will be difficult for them to become fully functional after successful seizure surgery,” Dr. Smith says.

Determining who is a candidate

Not all children with refractory seizures are candidates for surgery. Surgery is most successful in—and can often cure—children who have seizures that always originate in the same part of the brain. The earlier epilepsy specialists can localize a child’s seizures, the sooner they can make a recommendation for surgery.

As Indiana’s only Level IV Specialized Epilepsy Center, IU Health Neuroscience provides the most comprehensive diagnostic evaluation available. To isolate the exact area of the brain where seizures occur, epilepsy specialists at IU Health carefully review each child’s case and complete an extensive work-up using intracranial EEG, functional MRI (brain mapping) and PET scan.

If it is determined that the child’s seizures are coming from a specific, non-eloquent area of their brain, neurosurgeons will recommend surgery to remove that area. The most common surgery is a temporal lobectomy, which involves removal of part of the temporal lobe, including a portion of the amygdala and hippocampus. After surgery, about 85 percent to 90 percent of children will be seizure-free, according to Dr. Smith. Some may still require medication, but they will not experience seizures.

“A lot of physicians aren’t sure when to refer their patients for surgery,” Dr. Smith says. “I encourage pediatricians to consult an epilepsy specialist early so they understand the full range of treatment options.”

More complete treatment

Early referral to a specialized epilepsy surgeon is also important for children with a brain lesion and seizures, Dr. Smith says. Often, a seizure may be the first indication of a brain lesion. Neurosurgeons may remove the lesion, expecting that to end seizure activity, only to have the patient suffer continued seizures.

“Sometimes, the tissue surrounding the lesion is actually the seizure focus and removing the lesion alone doesn’t cure the seizures,” Dr. Smith explains. “Without a comprehensive seizure evaluation and detailed brain mapping, surgeons won’t know the exact source of the seizure and surgery can be incomplete.”

Dr. Smith encourages pediatricians and neurologists alike to seek consultation from an epilepsy surgeon as soon as an EEG shows a seizure focus.

For children who are not candidates for resection, additional treatment options include vagal nerve stimulation therapy.

Additional treatment options

For children who are not candidates for resection surgery, a Level IV Specialized Epilepsy Center like that at IU Health Neuroscience provides additional treatment options, including vagal nerve stimulation therapy.

In vagal nerve stimulation, an FDA-approved device known as a pulse generator is implanted under the skin near a child’s left breast bone. Thin connecting leads run up the left side of the neck to an electrode array placed along the vagus nerve and the pulse generator sends occasional electrical impulses along the vagus nerve to the brain.

“It is thought that the impulses cause a desynchronization of the abnormal neurons that are firing, thereby disrupting the seizure activity,” Dr. Smith explains. “Kids tend to have about a 50 percent to 75 percent reduction in seizure frequency, and become more alert and interactive.”

Dr. Smith has been performing vagal nerve stimulator implantations at Riley Hospital for Children at IU Health since 2000 and says the procedure is considered very safe. “We’d love to cure all children completely with resection surgery, but for those children who aren’t candidates for surgery, this is a very good option,” she says. “Some of these kids were on five or six medications and having daily or every-other-day seizures. The improvement in their quality of life is tremendous.”

Medically refractory seizures have a significant impact on a child’s functioning and quality of life. By presenting the full range of treatment options, including surgery, and referring patients to epilepsy specialists, physicians can help families make the best decision for their child’s future

Tags: pediatrics, epilepsy, surgery, seizures, article
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Pediatric Epilepsy Surgery: First-Line Defense

Surgery gives certain children the best chance to live seizure-free and should be considered earlier in the treatment process...

Epilepsy affects about 300,000 U.S. children under age 15. Most seizures can be controlled with medication, and some children outgrow their epilepsy. However, about 30 percent of children have medically refractory seizures, which means they do not respond to treatment. For these children, frequent seizures can take a significant toll on cognitive and intellectual development, and many suffer social, emotional and behavioral challenges as a result.

Although surgery is routinely considered for treatment of refractory seizures, it is often viewed as a last resort because of perceived risks. Consequently, some children suffer through years of failed treatment before they are referred to an epilepsy specialist. But that approach shortchanges patients, says Jodi Smith, Ph.D., M.D., a pediatric neurosurgeon who practices at Riley Hospital for Children at Indiana University Health. Surgery gives certain children the best chance to live seizure-free and should be considered earlier in the treatment process, according to Dr. Smith.

“It’s crucial that we reach children sooner, before they become debilitated by chronic seizures, so we can help them become high-functioning and productive members of society with a better quality of life,” she says.

Chronic seizures can have a negative impact on a child’s education as a consequence of learning difficulties and the associated psychosocial effects, such as poor peer relations, behavioral difficulties, poor school performance, depression, anxiety and poor self-esteem. What’s more, the long-term use of multiple seizure medications can be harmful to the developing brain. Early referral to an epilepsy surgery center can help specialists determine if surgery is a viable treatment option before significant cognitive loss occurs and the psychosocial consequences of prolonged disability prevent useful rehabilitation.

“Let’s not wait until they become so debilitated by their seizures that it will be difficult for them to become fully functional after successful seizure surgery,” Dr. Smith says.

Determining who is a candidate

Not all children with refractory seizures are candidates for surgery. Surgery is most successful in—and can often cure—children who have seizures that always originate in the same part of the brain. The earlier epilepsy specialists can localize a child’s seizures, the sooner they can make a recommendation for surgery.

As Indiana’s only Level IV Specialized Epilepsy Center, IU Health Neuroscience provides the most comprehensive diagnostic evaluation available. To isolate the exact area of the brain where seizures occur, epilepsy specialists at IU Health carefully review each child’s case and complete an extensive work-up using intracranial EEG, functional MRI (brain mapping) and PET scan.

If it is determined that the child’s seizures are coming from a specific, non-eloquent area of their brain, neurosurgeons will recommend surgery to remove that area. The most common surgery is a temporal lobectomy, which involves removal of part of the temporal lobe, including a portion of the amygdala and hippocampus. After surgery, about 85 percent to 90 percent of children will be seizure-free, according to Dr. Smith. Some may still require medication, but they will not experience seizures.

“A lot of physicians aren’t sure when to refer their patients for surgery,” Dr. Smith says. “I encourage pediatricians to consult an epilepsy specialist early so they understand the full range of treatment options.”

More complete treatment

Early referral to a specialized epilepsy surgeon is also important for children with a brain lesion and seizures, Dr. Smith says. Often, a seizure may be the first indication of a brain lesion. Neurosurgeons may remove the lesion, expecting that to end seizure activity, only to have the patient suffer continued seizures.

“Sometimes, the tissue surrounding the lesion is actually the seizure focus and removing the lesion alone doesn’t cure the seizures,” Dr. Smith explains. “Without a comprehensive seizure evaluation and detailed brain mapping, surgeons won’t know the exact source of the seizure and surgery can be incomplete.”

Dr. Smith encourages pediatricians and neurologists alike to seek consultation from an epilepsy surgeon as soon as an EEG shows a seizure focus.

For children who are not candidates for resection, additional treatment options include vagal nerve stimulation therapy.

Additional treatment options

For children who are not candidates for resection surgery, a Level IV Specialized Epilepsy Center like that at IU Health Neuroscience provides additional treatment options, including vagal nerve stimulation therapy.

In vagal nerve stimulation, an FDA-approved device known as a pulse generator is implanted under the skin near a child’s left breast bone. Thin connecting leads run up the left side of the neck to an electrode array placed along the vagus nerve and the pulse generator sends occasional electrical impulses along the vagus nerve to the brain.

“It is thought that the impulses cause a desynchronization of the abnormal neurons that are firing, thereby disrupting the seizure activity,” Dr. Smith explains. “Kids tend to have about a 50 percent to 75 percent reduction in seizure frequency, and become more alert and interactive.”

Dr. Smith has been performing vagal nerve stimulator implantations at Riley Hospital for Children at IU Health since 2000 and says the procedure is considered very safe. “We’d love to cure all children completely with resection surgery, but for those children who aren’t candidates for surgery, this is a very good option,” she says. “Some of these kids were on five or six medications and having daily or every-other-day seizures. The improvement in their quality of life is tremendous.”

Medically refractory seizures have a significant impact on a child’s functioning and quality of life. By presenting the full range of treatment options, including surgery, and referring patients to epilepsy specialists, physicians can help families make the best decision for their child’s future

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