Epilepsy Surgery: Bridging the Gap with Minimally Invasive Techniques

Pediatric epilepsy surgery has emerged as a pivotal, evidence-based management strategy for children with focal structural epilepsy.[1] These surgical approaches minimize the risks of epilepsy-related morbidity and mortality while bearing low complication risks. By offering sustained seizure freedom for most eligible patients,[2] epilepsy surgery often allows the discontinuation of antiseizure medications. Additionally, successful surgical interventions have shown significant improvements in cognitive development, behavior, and overall quality of life for affected children. Recent technological advancements have revolutionized the field, expanding the pool of potential candidates and increasing surgical volume. The key to maximizing long-term seizure freedom lies in early,[3] comprehensive diagnostics and appropriate surgical treatment conducted in specialized epilepsy centers with pediatric expertise.[4] [5] [6]

Despite its proven safety and efficacy, a considerable surgical treatment gap persists, with many eligible patients either not receiving epilepsy surgery or experiencing long delays, which may negatively impact seizure[7] and cognitive outcomes.[8] [9] [10] Barriers to surgery include limited access to care, lack of knowledge, and misconceptions. These issues have not been resolved by the rapid expansion of epilepsy infrastructure in recent decades, as patients and their parents continue to turn down surgical options after completing presurgical evaluations. Misconceptions about epilepsy surgery also exist among physicians, many of whom favor nonsurgical options and view surgery as a last resort. Minimally invasive procedures have recently evolved and can address some of these barriers, particularly those related to fear and anxiety, as they may be perceived as less risky.[11]

Historically driven by open techniques, the surgical landscape has been augmented by modern, minimally invasive, and neuromodulatory techniques such as laser interstitial thermal therapy, radiofrequency thermocoagulation, deep brain stimulation (DBS), and responsive neurostimulation (RNS) over the last decade, with increased use of these tools over time.[12] Minimally invasive surgical techniques for epilepsy surgery have lower morbidity, lower mortality, shorter hospitalizations, and pose less risk to the eloquent cortex. However, it is important to note that DBS is currently only approved for adults, while RNS is unavailable in Europe.

In this issue of Neuropediatrics, Nordli and colleagues highlight the significant advancements in minimally invasive epilepsy surgery over the past decades, driven by crucial technological innovations. These advances have improved safety by minimizing adverse effects, reducing infection risk, and preserving eloquent cortex. The authors provide an in-depth examination of technologies for presurgical evaluation to increase the likelihood of achieving complete seizure freedom, as well as the opportunities and risks associated with various minimally invasive procedures. While emerging technologies offer new avenues for data collection, which can ultimately improve the efficacy of epilepsy surgery, careful patient selection is essential to maximize the benefits of minimal invasive surgical approaches in terms of safety and seizure freedom. These evolving techniques may help reframe epilepsy surgery, reducing physicians' reluctance to refer patients for presurgical evaluation, and easing patients' and families' concerns about consenting to surgery.

In conclusion, minimally invasive techniques may help close the epilepsy surgery treatment gap in the long run by increasing patient and parent willingness to proceed with surgical intervention. However, more evidence is needed to establish their efficacy in curing epilepsy in randomized controlled trials compared with the gold standard of resective surgery.

Publication History

Article published online:
09 September 2024

• References

• 1 Cross JH, Reilly C, Gutierrez Delicado E, Smith ML, Malmgren K. Epilepsy surgery for children and adolescents: evidence-based but underused. Lancet Child Adolesc Health 2022; 6 (07) 484-494
• 2 Dwivedi R, Ramanujam B, Chandra PS. et al. Surgery for drug-resistant epilepsy in children. N Engl J Med 2017; 377 (17) 1639-1647
• 3 Ramantani G. Epilepsy surgery in early life: the earlier, the better. World Neurosurg 2019; 131: 285-286
• 4 Jehi L, Jette N, Kwon C-S. et al. Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy. Epilepsia 2022; 63 (10) 2491-2506
• 5 Cross JH, Jayakar P, Nordli D. et al; International League against Epilepsy, Subcommission for Paediatric Epilepsy Surgery, Commissions of Neurosurgery and Paediatrics. Proposed criteria for referral and evaluation of children for epilepsy surgery: recommendations of the Subcommission for Pediatric Epilepsy Surgery. Epilepsia 2006; 47 (06) 952-959
• 6 Gaillard WD, Jette N, Arnold ST. et al; Task Force for Pediatric Epilepsy Surgery, Commission for Pediatrics, and the Surgical Commission of the International League Against Epilepsy. Establishing criteria for pediatric epilepsy surgery center levels of care: report from the ILAE Pediatric Epilepsy Surgery Task Force. Epilepsia 2020; 61 (12) 2629-2642
• 7 Lamberink HJ, Otte WM, Blümcke I, Braun KPJ. European Epilepsy Brain Bank writing group, study group, European Reference Network EpiCARE. Seizure outcome and use of antiepileptic drugs after epilepsy surgery according to histopathological diagnosis: a retrospective multicentre cohort study. Lancet Neurol 2020; 19 (09) 748-757
• 8 Ramantani G, Kadish NE, Anastasopoulos C. et al. Epilepsy surgery for glioneuronal tumors in childhood: avoid loss of time. Neurosurgery 2014; 74 (06) 648-657 , discussion 657
• 9 Ramantani G, Kadish NE, Mayer H. et al. Frontal lobe epilepsy surgery in childhood and adolescence: predictors of long-term seizure freedom, overall cognitive and adaptive functioning. Neurosurgery 2018; 83 (01) 93-103
• 10 Kadish NE, Bast T, Reuner G. et al. Epilepsy surgery in the first 3 years of life: predictors of seizure freedom and cognitive development. Neurosurgery 2019; 84 (06) E368-E377
• 11 Schiltz NK, Fernandez-Baca Vaca G. Epidemiologist's view: addressing the epilepsy surgery treatment gap with minimally-invasive techniques. Epilepsy Res 2018; 142: 179-181
• 12 Barba C, Specchio N, Guerrini R. et al. Increasing volume and complexity of pediatric epilepsy surgery with stable seizure outcome between 2008 and 2014: a nationwide multicenter study. Epilepsy Behav 2017; 75: 151-157