Anesthesia for epilepsy surgery in children

Postoperative outcomes following pediatric intracranial electrode monitoring: A case for stereoelectroencephalography (SEEG)

BACKGROUND

For patients with medically refractory epilepsy, intracranial electrode monitoring can help identify epileptogenic foci. Despite the increasing utilization of stereoelectroencephalography (SEEG), the relative risks or benefits associated with the technique when compared with the traditional subdural electrode monitoring (SDE) remain unclear, especially in the pediatric population. Our aim was to compare the outcomes of pediatric patients who received intracranial monitoring with SEEG or SDE (grids and strips).

METHODS

We retrospectively studied 38 consecutive pediatric intracranial electrode monitoring cases performed at our institution from 2014 to 2017. Medical/surgical history and operative/postoperative records were reviewed. We also compared direct inpatient hospital costs associated with the two procedures.

RESULTS

Stereoelectroencephalography and SDE cohorts both showed high likelihood of identifying epileptogenic zones (SEEG: 90.9%, SDE: 87.5%). Compared with SDE, SEEG patients had a significantly shorter operative time (118.7 versus 233.4 min, P < .001) and length of stay (6.2 versus 12.3 days, P < .001), including days spent in the intensive care unit (ICU; 1.4 versus 5.4 days, P < .001). Stereoelectroencephalography patients tended to report lower pain scores and used significantly less narcotic pain medications (54.2 versus 197.3 mg morphine equivalents, P = .005). No complications were observed. Stereoelectroencephalography and SDE cohorts had comparable inpatient hospital costs (P = .47).

CONCLUSION

In comparison with subdural electrode placement, SEEG results in a similarly favorable clinical outcome, but with reduced operative time, decreased narcotic usage, and superior pain control without requiring significantly higher costs. The potential for an improved postoperative intracranial electrode monitoring experience makes SEEG especially suitable for pediatric patients.

Anesthesia for intracranial surgery in infants and children

PURPOSE OF REVIEW

Age-related differences in the surgical lesions, anatomy and physiological responses to surgery and anesthesia underlie the clinically relevant differences between pediatric patients and their adult counterparts. Anesthesiologists need to be aware of the unique challenges in the anesthetic management of the pediatric neurosurgical patient.

RECENT FINDINGS

Neurosurgeons with subspecialty training in pediatrics have driven advances in intracranial surgery in infants and children. Subspecialization in pediatric neurosurgery and critical care has resulted in more favorable outcomes. Innovations in tumor, epilepsy and endoscopic and cerebrovascular neurosurgery are constantly being adapted to the pediatric patient. The highly specialized nature of these and other pediatric neurosurgical procedures prompt calls for similarly trained anesthesiologists for management of these infants and children.

SUMMARY

The aim of this review is to highlight the impact of these techniques on the intraoperative management of the pediatric neurosurgical patient. These issues are essential in minimizing perioperative morbidity and mortality.

Perioperative anesthetic implications of epilepsy surgery: a retrospective analysis

PURPOSE

Drug-resistant epilepsy (DRE) occurs in about 30 % of individuals with epilepsy. For seizure control, a wide range of surgical procedures are performed, depending on the underlying pathology. To address the anesthetic and perioperative concerns in these patients, we analyzed the data of persons with DRE who underwent epilepsy surgery at our institute.

METHODS

A retrospective analysis of patients who underwent epilepsy surgery from 2005-2010 was performed. For data collection and analysis, patients were divided into three groups: Group I (temporal lobe epilepsy), Group II (extratemporal lobe epilepsy), and Group III (multilobar epilepsy and others).

RESULTS

A total of 241 surgical procedures were performed on 235 persons with DRE. The procedures included temporal (149) and extratemporal (47) lobe resection, hemispherotomy (31), corpus callosotomy (5), vagus nerve stimulation (3), and implantation of invasive cerebral electrodes (6). General anesthesia was the more common anesthetic technique; awake craniotomy was performed in only five cases. Intraoperative neuromonitoring was used most frequently in Group II. Patients in Group III had the longest intraoperative course and the greatest blood loss. The overall incidence of postoperative mechanical ventilation was 17.84 %, with 53.84 % of patients in Group III alone. At one-year follow-up, a good outcome was seen in 78 % of temporal lobe resection, 55 % of extratemporal cortical resection, 82 % of hemispherotomy, and 80 % of corpus callosotomy procedures.

CONCLUSIONS

Careful preoperative selection and meticulous perioperative management are the most significant factors for success of epilepsy surgery. Although temporal and extratemporal lobe surgeries have a fairly stable perioperative course, multilobar epilepsy requiring disconnective surgery poses a greater challenge.

Safety, feasibility and complications during resective pediatric epilepsy surgery: a retrospective analysis

Background

Resective epilepsy surgery is an established and effective method to reduce seizure burden in drug-resistant epilepsy. It was the objective of this study to assess intraoperative blood loss, transfusion requirements and the degree of hypothermia of pediatric epilepsy surgery in our center.

Methods

Patients were identified by our epilepsy surgery database, and data were collected via retrospective chart review over the past 25 years. Patients up to the age of 6 years were included, and patients with insufficient data were excluded.

Results

Forty-five patients with an age of 3.2 ± 1.6 (mean ± SD) years and a body weight of 17 [14; 21.5] kg (median [25%, 75% percentile]) were analysed. Duration of surgery was 3 h 49 min ± 53 min, which was accompanied by an intraoperative blood loss of 150 [90; 300] ml. This corresponded to 11.7 [5.2; 21.4] % of estimated total blood volume, ranging from 0 to 75%. A minimal haemoglobin count of 8.8 ± 1.4 g/dl was measured, which was substituted with erythrocyte concentrate (100 [0; 250] ml) in 23 patients. Body core temperature dropped from 36.0 ± 0.7°C at baseline to a minimum of 35.7 ± 0.7°C, and increased significantly (p < 0.001) thereafter to 37.1 ± 0.7°C until the end of surgery. A significant (p = 0.0003) correlation between duration of surgery and blood loss (Pearson r = 0.52) was observed. However, age, minimal body temperature or number of antiepileptic drugs seemed to have no impact on blood loss.

Conclusion

Resective epilepsy surgery is a safe procedure even in the pediatric population, however it is associated with significant blood loss especially during long surgical procedures.

[Perioperative considerations in vagal nerve stimulator implantation]

Vagal nerve stimulation has become an a important tool in the treatment of refractory epilepsy, which continues to be the main indication for this technique. Other therapeutic indications are emerging, however, and vagal nerve stimulation has now been approved for major depression. Additional possible uses under study include morbid obesity, Alzheimer disease, chronic pain syndromes, and certain neuropsychologic disorders. This review considers perioperative aspects relevant to using this therapeutic procedure with a view to facilitating better and more integrated management of its application.