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Eriksson MH, Prentice F, Piper RJ, Wagstyl K, Adler S, Chari A, Booth J, Moeller F, Das K, Eltze C, Cooray G, Perez Caballero A, Menzies L, McTague A, Shavel-Jessop S, Tisdall MM, Cross JH, Martin Sanfilippo P, Baldeweg T. Long-term neuropsychological trajectories in children with epilepsy: does surgery halt decline? Brain 2024:awae121. [PMID: 38643018 DOI: 10.1093/brain/awae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/29/2024] [Accepted: 03/16/2024] [Indexed: 04/22/2024] Open
Abstract
Neuropsychological impairments are common in children with drug-resistant epilepsy. It has been proposed that epilepsy surgery may alleviate these impairments by providing seizure freedom; however, findings from prior studies have been inconsistent. We mapped long-term neuropsychological trajectories in children before and after undergoing epilepsy surgery, to measure the impact of disease course and surgery on functioning. We performed a retrospective cohort study of 882 children who had undergone epilepsy surgery at Great Ormond Street Hospital (1990-2018). We extracted patient information and neuropsychological functioning - obtained from IQ tests (domains: Full-Scale IQ, Verbal IQ, Performance IQ, Working Memory, and Processing Speed) and tests of academic attainment (Reading, Spelling and Numeracy) - and investigated changes in functioning using regression analyses. We identified 500 children (248 females) who had undergone epilepsy surgery (median age at surgery = 11.9 years, interquartile range = [7.8,15.0]) and neuropsychology assessment. These children showed declines in all domains of neuropsychological functioning in the time leading up to surgery (all p-values ≤ 0.001; e.g., βFSIQ = -1.9, SEFSIQ = 0.3, pFSIQ < 0.001). Children lost on average one to four points per year, depending on the domain considered; 27-43% declined by 10 or more points from their first to their last preoperative assessment. At the time of presurgical evaluation, most children (46-60%) scored one or more standard deviations below the mean (<85) on the different neuropsychological domains; 37% of these met the threshold for intellectual disability (Full-Scale IQ < 70). On a group level, there was no change in performance from pre- to postoperative assessment on any of the domains (all p-values > 0.128). However, children who became seizure-free through surgery showed higher postoperative neuropsychological performance (e.g., rrb-FSIQ = 0.37, p < 0.001). These children continued to demonstrate improvements in neuropsychological functioning over the course of their long-term follow-up (e.g., βFSIQ = 0.9, SEFSIQ = 0.3, pFSIQ = 0.004). Children who had discontinued antiseizure medication (ASM) treatment at one-year follow-up showed an eight-to-13-point advantage in postoperative Working Memory, Processing Speed, and Numeracy, and greater improvements in Verbal IQ, Working Memory, Reading, and Spelling (all p-values < 0.034) over the postoperative period compared to children who were seizure-free and still receiving ASMs. In conclusion, by providing seizure freedom and the opportunity for ASM cessation, epilepsy surgery may not only halt but reverse the downward trajectory that children with drug-resistant epilepsy display in neuropsychological functioning. To halt this decline as soon as possible, or potentially prevent it from occurring in the first place, children with focal epilepsy should be considered for epilepsy surgery as early as possible after diagnosis.
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Affiliation(s)
- Maria H Eriksson
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Freya Prentice
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Rory J Piper
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Konrad Wagstyl
- Imaging Neuroscience, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Sophie Adler
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Aswin Chari
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - John Booth
- Digital Research Environment, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Friederike Moeller
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Krishna Das
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Christin Eltze
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Gerald Cooray
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Clinical Neuroscience, Karolinska Institutet, Solna 171 77, Sweden
| | - Ana Perez Caballero
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Amy McTague
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Sara Shavel-Jessop
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Martin M Tisdall
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Young Epilepsy, Lingfield RH7 6PW, UK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
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Eriksson MH, Whitaker KJ, Booth J, Piper RJ, Chari A, Sanfilippo PM, Caballero AP, Menzies L, McTague A, Adler S, Wagstyl K, Tisdall MM, Cross JH, Baldeweg T. Pediatric epilepsy surgery from 2000 to 2018: Changes in referral and surgical volumes, patient characteristics, genetic testing, and postsurgical outcomes. Epilepsia 2023; 64:2260-2273. [PMID: 37264783 PMCID: PMC7615891 DOI: 10.1111/epi.17670] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Neurosurgery is a safe and effective form of treatment for select children with drug-resistant epilepsy. Still, there is concern that it remains underutilized, and that seizure freedom rates have not improved over time. We investigated referral and surgical practices, patient characteristics, and postoperative outcomes over the past two decades. METHODS We performed a retrospective cohort study of children referred for epilepsy surgery at a tertiary center between 2000 and 2018. We extracted information from medical records and analyzed temporal trends using regression analyses. RESULTS A total of 1443 children were evaluated for surgery. Of these, 859 (402 females) underwent surgical resection or disconnection at a median age of 8.5 years (interquartile range [IQR] = 4.6-13.4). Excluding palliative procedures, 67% of patients were seizure-free and 15% were on no antiseizure medication (ASM) at 1-year follow-up. There was an annual increase in the number of referrals (7%, 95% confidence interval [CI] = 5.3-8.6; p < .001) and surgeries (4% [95% CI = 2.9-5.6], p < .001) over time. Duration of epilepsy and total number of different ASMs trialed from epilepsy onset to surgery were, however, unchanged, and continued to exceed guidelines. Seizure freedom rates were also unchanged overall but showed improvement (odds ratio [OR] 1.09, 95% CI = 1.01-1.18; p = .027) after adjustment for an observed increase in complex cases. Children who underwent surgery more recently were more likely to be off ASMs postoperatively (OR 1.04, 95% CI = 1.01-1.08; p = .013). There was a 17% annual increase (95% CI = 8.4-28.4, p < .001) in children identified to have a genetic cause of epilepsy, which was associated with poor outcome. SIGNIFICANCE Children with drug-resistant epilepsy continue to be put forward for surgery late, despite national and international guidelines urging prompt referral. Seizure freedom rates have improved over the past decades, but only after adjustment for a concurrent increase in complex cases. Finally, genetic testing in epilepsy surgery patients has expanded considerably over time and shows promise in identifying patients in whom surgery is less likely to be successful.
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Affiliation(s)
- Maria H Eriksson
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
- The Alan Turing Institute, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
| | | | - John Booth
- Digital Research Environment, Great Ormond Street Hospital NHS Trust, London, UK
| | - Rory J Piper
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - Aswin Chari
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Ana Perez Caballero
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital NHS Trust, London, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital NHS Trust, London, UK
| | - Amy McTague
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Sophie Adler
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Konrad Wagstyl
- Imaging Neuroscience, UCL Queen Square Institute of Neurology, London, UK
| | - Martin M Tisdall
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
- Young Epilepsy, Lingfield, UK
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
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Abstract
Executive skills are those involved in concept formation, problem solving, switching tasks, inhibiting inappropriate responses, initiating rapid and fluent responses, planning and sustained attention. Different patterns of disorder amongst these skills have been found in several developmental abnormalities including autism, attention deficit hyperactivity disorder (ADHD) and Turner's syndrome (TS). This study explored, for the first time, executive skills in children with Klinefelter's syndrome (KS), a sex chromosome abnormality in which there is one or more additional X-chromosomes. Intelligence in KS is normal but there is academic underachievement. A battery of executive tasks was administered, in a series of case studies, to three 10-year-old boys with KS and to controls matched for age, sex and intelligence. The results demonstrate that children with KS have impairments in executive skills. However, the pattern of impairment is task-specific. There is evidence from multiple tasks of impairment in inhibitory skills, for each case of KS. In contrast, concept formation, problem solving, task switching and speeded responding are normal. These results support theories that argue for distinct sub-components of executive skills within development that may develop relatively independently. The results have relevance for modelling both child and adult executive systems. They also confirm that an additional X-chromosome has highly selective effects upon the consequent cognitive phenotype seen in development.
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Affiliation(s)
- Christine M Temple
- Developmental Neuropsychology Unit, Department of Psychology, University of Essex, Wivenhoe Park, Colchester CO4 3SQ, UK.
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