Underrepresented Populations in Pediatric Epilepsy Surgery

Resective epilepsy surgery in pediatric patients with normal MRI: outcomes, challenges, and cost-effectiveness in low-resource settings

BACKGROUND

Pediatric patients with drug-resistant epilepsy and normal preoperative MRIs present significant challenges in surgical planning. Advanced diagnostic techniques, including PET, SPECT, and intraoperative ECOG, are used to localize seizure foci, but their high cost and limited availability pose challenges, especially in low-resource settings. This study aims to evaluate the outcomes of resective epilepsy surgery in these cases and assess the role of advanced imaging in a middle-income country.

METHODS

This retrospective cohort study included 12 pediatric patients (mean age 10.21 years) with normal preoperative 3 T MRI who underwent resective epilepsy surgery or functional hemispherectomy between 2007 and 2021 at two centers in Medellín, Colombia. Demographic, clinical, and surgical data were collected, including the use of advanced imaging techniques (PET, SPECT) and intraoperative ECOG. Seizure outcomes were assessed using the Engel Epilepsy Surgery Outcome Scale.

RESULTS

Of the 12 patients, 10 underwent extratemporal resections, and 2 underwent temporal lobe surgery. Seven patients had advanced imaging, and 5 were evaluated with intraoperative ECOG. At 2-year follow-up, 83.3% of patients who underwent resective surgery achieved favorable outcomes (Engel Classes I and II). Temporal lobe resections had a higher rate of seizure freedom (50%) compared to extratemporal resections (30%), although the difference was not statistically significant (p = 0.47). Reoperations due to seizure recurrence were required in 30% of extratemporal resections (p = 0.02). Complications were minimal, with three superficial wound infections. Histopathology revealed cortical dysplasia in 33.3% of cases.

CONCLUSION

Epilepsy surgery in pediatric patients with normal MRIs can yield favorable outcomes, especially with temporal lobe resections. Advanced imaging improves localization but remains costly, highlighting the need for cost-effective surgical strategies in resource-limited settings.

Patient and provider attitudes regarding sudden unexpected death in epilepsy disclosure at a low-resource, minority community health center

BACKGROUND

Sudden Unexpected Death in Epilepsy (SUDEP) is a complication of epilepsy responsible for approximately 1 death per 1000 patients. The literature has demonstrated minimal SUDEP disclosure between providers and patients, although patients have consistently reported desire to know about their risk. However, the majority of these studies has been conducted in Caucasian populations which did not seek to include lower socio-economic class individuals. Thus, the purpose of this study is to determine patient and provider attitudes regarding SUDEP disclosure at a community health center serving minority, predominantly Hispanic, patients.

METHODS

This cross-sectional study utilized surveys distributed to patients with epilepsy (n = 20), patients with diabetes (n = 20), those with no chronic disease (n = 20) and providers (n = 13). Online surveys were distributed to 13 providers whereas phone surveys were conducted for patients with epilepsy. In-person surveys were distributed to patients with diabetes and no chronic disease to serve as comparison groups. Surveys were available in both Spanish and English. Patient surveys consisted of demographic information and questions evaluating their current knowledge and preferences regarding disclosure of a potentially fatal disorder.

RESULTS

Twenty patients with epilepsy, 20 patients with diabetes, 20 patients without chronic diseases, and 9 providers responded to the online or in-person surveys. Of the patients with epilepsy, 90 % (n = 18/20) were Hispanic which was not significantly different from the comparison groups. 45 % (n = 9/20) believed they had a higher rate of death due to epilepsy with only 3 patients having heard of SUDEP prior to the survey, and only 1 learning this from a physician. All patients wanted to know everything there was to know regarding their condition, including a higher risk of unexpected death. Most patients (85%, n = 17/20) believe everyone with epilepsy should be informed of SUDEP and this information should come from their provider (90 %, n = 18/20). Results were similar for both comparison groups, except patients with diabetes unanimously desired to know about a theoretical risk of death at the time of diagnosis. Of the providers, 66.7% (n = 6/9) never discuss SUDEP, with the remaining 33.3% (n = 3/9) discussing SUDEP rarely. The primary reason for not discussing SUDEP was not knowing enough about it (66.7%, n = 5/9).

CONCLUSION

Almost all patients with epilepsy had no knowledge of SUDEP, yet desired to know this information within the first two visits. Providers in the primary care setting rarely discuss SUDEP, most often due to lack of knowledge. These results are very similar to those found in mainly white, higher socioeconomic populations and indicate that race should not be a barrier to SUDEP disclosure.

Treatment odyssey to epilepsy surgery in children with focal cortical dysplasia: Risk factors for delayed surgical intervention

OBJECTIVE

To elucidate the patient's journey to epilepsy surgery and identify the risk factors contributing to surgical delay in pediatric patients with drug-resistant epilepsy (DRE) due to focal cortical dysplasia (FCD).

METHODS

A retrospective review was conducted of 93 pediatric patients who underwent curative epilepsy surgery for FCD between January 2012 and March 2023 at a tertiary epilepsy center. The Odyssey plot demonstrated the treatment process before epilepsy surgery, including key milestones of epilepsy onset, first hospital visit, epilepsy diagnosis, MRI diagnosis, DRE diagnosis, and surgery. The primary outcome was surgical delay; the duration from DRE to surgery. Multivariate linear regression models were used to examine the association between surgical delay and clinical, investigative, and treatment characteristics.

RESULTS

The median age at seizure onset was 1.3 years (interquartile range [IQR] 0.14-3.1), and at the time of surgery, it was 6 years (range 1-11). Notably, 46% experienced surgical delays exceeding two years. The Odyssey plot visually highlighted that surgical delay comprised a significant portion of the patient journey. Although most patients underwent MRI before referral, MRI abnormalities were identified before referral only in 39% of the prolonged group, compared to 70% of the non-prolonged group. Multivariate analyses showed that delayed notification of MRI abnormalities, longer duration from epilepsy onset to DRE, older age at onset, number of antiseizure medications tried, and moderate to severe intellectual disability were significantly associated with prolonged surgical delay.

CONCLUSION

Pediatric DRE patients with FCD experienced a long journey until surgery. Early and accurate identification of MRI abnormalities is important to minimize surgical delays.

Neurocognition in Pediatric Temporal Lobe Tumor-Related Epilepsy

Tumor-related epilepsy is a common and understudied neurological comorbidity among pediatric temporal lobe tumor patients that poses risk for neurocognitive impairment (NCI). Forty-one youth with either TLT+ (n = 23) or nonneoplastic temporal lobe epilepsy (n = 18) ages 6-20 years completed routine neuropsychological evaluations. Rates of NCI were similar across groups; however, NCI was more common in nonneoplastic participants on a task of phonemic fluency, p = .047. Younger age of seizure onset and greater number of antiseizure medications were associated with NCI among TLT+ participants only. Preliminary findings suggest separate prognostic models of cognitive outcomes between TLT+ and nonneoplastic epilepsy populations may be needed.

A scalable platform for acquisition of high-fidelity human intracranial EEG with minimal clinical burden

Human neuroscience research has been significantly advanced by neuroelectrophysiological studies from people with refractory epilepsy-the only routine clinical intervention that acquires multi-day, multi-electrode human intracranial electroencephalography (iEEG). While a sampling rate below 2 kHz is sufficient for manual iEEG review by epileptologists, computational methods and research studies may benefit from higher resolution, which requires significant technical development. At adult and pediatric Stanford hospitals, research ports of commercial clinical acquisition systems were configured to collect 10 kHz iEEG of up to 256 electrodes simultaneously with the clinical data. The research digital stream was designed to be acquired post-digitization, resulting in no loss in clinical signal quality. This novel framework implements a near-invisible research platform to facilitate the secure, routine collection of high-resolution iEEG that minimizes research hardware footprint and clinical workflow interference. The addition of a pocket-sized router in the patient room enabled an encrypted tunnel to securely transmit research-quality iEEG across hospital networks to a research computer within the hospital server room, where data was coded, de-identified, and uploaded to cloud storage. Every eligible patient undergoing iEEG clinical evaluation at both hospitals since September 2017 has been recruited; participant recruitment is ongoing. Over 350+ terabytes (representing 1000+ days) of neuroelectrophysiology were recorded across 200+ participants of diverse demographics. To our knowledge, this is the first report of such a research integration within a hospital setting. It is a promising approach to promoting equitable participant enrollment and building comprehensive data repositories with consistent, high-fidelity specifications towards new discoveries in human neuroscience.

Delays in the diagnosis and surgical treatment of drug-resistant epilepsy: A cohort study

OBJECTIVE

Delay in referral for epilepsy surgery of patients with drug-resistant epilepsy (DRE) is associated with decreased quality of life, worse surgical outcomes, and increased risk of sudden unexplained death in epilepsy (SUDEP). Understanding the potential causes of delays in referral and treatment is crucial for optimizing the referral and treatment process. We evaluated the treatment intervals, demographics, and clinical characteristics of patients referred for surgical evaluation at our level 4 epilepsy center in the U.S. Intermountain West.

METHODS

We retrospectively reviewed the records of patients who underwent surgery for DRE between 2012 and 2022. Data collected included patient demographics, DRE diagnosis date, clinical characteristics, insurance status, distance from epilepsy center, date of surgical evaluation, surgical procedure, and intervals between different stages of evaluation.

RESULTS

Within our cohort of 185 patients with epilepsy (99 female, 53.5%), the mean ± standard deviation (SD) age at surgery was 38.4 ± 11.9 years. In this cohort, 95.7% of patients had received definitive epilepsy surgery (most frequently neuromodulation procedures) and 4.3% had participated in phase 2 intracranial monitoring but had not yet received definitive surgery. The median (1st-3rd quartile) intervals observed were 10.1 (3.8-21.5) years from epilepsy diagnosis to DRE diagnosis, 16.7 (6.5-28.4) years from epilepsy diagnosis to surgery, and 1.4 (0.6-4.0) years from DRE diagnosis to surgery. We observed significantly shorter median times from epilepsy diagnosis to DRE diagnosis (p < .01) and epilepsy diagnosis to surgery (p < .05) in patients who traveled further for treatment. Patients with public health insurance had a significantly longer time from DRE diagnosis to surgery (p < .001).

SIGNIFICANCE

Both shorter distance traveled to our epilepsy center and public health insurance were predictive of delays in diagnosis and treatment intervals. Timely referral of patients with DRE to specialized epilepsy centers for surgery evaluation is crucial, and identifying key factors that may delay referral is paramount to optimizing surgical outcomes.

Innovations in diagnostic and treatment options for pediatric epilepsy and their anesthetic implications

PURPOSE OF REVIEW

To provide an overview of anesthetic techniques for innovative diagnostic and therapeutic epilepsy procedures performed on pediatric patients.

RECENT FINDINGS

Recent studies have been published on the anesthetic consideration for functional MRI, robotic-assisted stereoelectroencephalography, high-intensity focused ultrasound, and magnetoencephalography. These articles describe the anesthesia management, risks, and outcome for these procedures.

SUMMARY

The number of diagnostic and treatment options being used for the management of pediatric epilepsy has increased significantly. In the past few years, a handful of articles have been published, which describe the anesthetic considerations for these procedures. These studies are helpful to anesthesiologists who are planning an upcoming anesthetic or who are developing a 'best practice' model for their institution. Because unlike other diagnostic studies, failure to understand what effects anesthetics have on the brain, may negate the utility of the study. Although these new findings can be used to provide some anesthesia practice recommendations for epilepsy procedures in which the best management is still unclear, additional high-quality studies are needed.