Epilepsiechirurgie bei Kindern und Jugendlichen

Zusammenfassung

Die Epilepsiechirurgie hat sich in den letzten Jahren als eine besonders wirksame Behandlungsoption bei Kindern und Jugendlichen mit pharmakoresistenten strukturellen Epilepsien etabliert. Dank der fortschreitenden Entwicklungen in der Neurochirurgie, Anästhesie und Intensivmedizin sind epilepsiechirurgische Eingriffe auch bei Säuglingen möglich und können hervorragende Ergebnisse liefern, vergleichbar mit den Ergebnissen bei Kindern und Jugendlichen. Spätestens bei nachgewiesener Pharmakoresistenz sollte bei Kindern mit strukturellen Epilepsien die Möglichkeit eines epilepsiechirurgischen Eingriffes erwogen und die entsprechende prächirurgische Diagnostik in einem Epilepsiezentrum mit pädiatrischer Expertise eingeleitet werden. Fokale kortikale Dysplasien und glioneuronale Tumore sind die häufigsten Ätiologien bei pädiatrischen Patienten, die epilepsiechirurgisch versorgt werden; in beiden Fällen hängt die postoperative Anfallsfreiheit von der Vollständigkeit der Resektion ab. Im Kindesalter dominieren die multilobären und hemisphärischen Eingriffe, im Gegensatz zu den Erwachsenenkohorten mit vorwiegend resektiven Eingriffen im Bereich des Temporallappens und nur wenigen extratemporalen und hemisphärischen Eingriffen. Die Ausdehnung der Eingriffe nimmt mit dem Alter der epilepsiechirurgischen Kandidaten ab. Kleinere Kinder benötigen oft größere Resektionen, können jedoch mögliche neurologische Defizite aufgrund der funktionellen Plastizität in der Regel gut kompensieren. Die postoperative Anfallsfreiheit hängt vom Epilepsiesyndrom, der zugrunde liegenden Ätiologie und der Abgrenzbarkeit des epileptogenen Areals ab. Zwei Drittel der Kinder bleiben im Langzeitverlauf nach einem epilepsiechirurgischen Eingriff anfallsfrei. Mit der Anfallskontrolle sind oftmals wesentliche Verbesserungen der Entwicklungsverläufe zu beobachten. Neben der Weiterentwicklung nicht-invasiver Methoden in der prächirurgischen Epilepsiediagnostik ist höchste Priorität, das Intervall zwischen Feststellung der Pharmakoresistenz, prächirurgischer Abklärung und epilepsiechirurgischer Behandlung bei geeigneten Kandidaten zu verkürzen. Multizentrische Studien mit längeren Beobachtungsintervallen sind dringend erforderlich, um die Prädiktoren der Anfallsfreiheit und der positiven psychomotorischen Entwicklung der Kinder zu identifizieren und eine verbesserte Kandidatenauswahl und Beratung der Patienten und deren Familien zu ermöglichen.

Abstract

Epilepsy surgery has become established as an effective treatment option for children and adolescents with pharmacoresistant structural epilepsies. Advances in neurosurgery, anesthesia and intensive care have enabled surgical interventions in infants with excellent results. At the latest, when pharmacological resistance is demonstrated, epilepsy surgery should be considered in children with structural epilepsies. Focal cortical dysplasia and glioneuronal tumors are the most common aetiologies in pediatric patients. Postoperative seizure-freedom depends on completeness of resection. In childhood, multilobular and hemispherical interventions predominate while in adult cohorts interventions are primarily in the temporal lobe area. The extent of interventions decreases with age of the surgical candidates. Smaller children often require larger resections, but can generally compensate for neurological deficits due to functional plasticity. Postoperative seizure-freedom depends on the epilepsy syndrome, underlying aetiology and demarcation of the epileptogenic area. Post-operative, two-thirds of the children remain epilepsy-free in the long-term. Significant improvements in the development process are observed with control of epileptic attacks. In addition to the development of non-invasive methods in presurgical epilepsy diagnostics, the highest priority is to reduce the interval between determination of pharmacological resistance, pre-surgical evaluation and surgical treatment in suitable candidates. Multicentric studies with longer observation intervals are needed to identify predictors of seizure-freedom and positive psychomotor development in children and to enable improved selection of candidates and proper advice to patients and their families.

Schlüsselwörter

Epilepsiechirurgie - Pharmakoresistenz - psychomotorische Entwicklung - fokale kortikale Dysplasien - glioneuronale Hirntumore

Key words

epilepsy surgery - pharmacoresistance - development - focal cortical dysplasia - glioneuronal tumor

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