Epilepsy surgery for children has expanded significantly as a concept in the last 20 years, as it is now widely recognized that it can be tremendously successful in transforming the lives of children suffering from uncontrolled seizures and their families. Advances in the clinical neurosciences, as well as in neurosurgery, pediatric anesthesia, and pediatric neuroradiology, which have increased the efficacy and safety of pediatric epilepsy surgery, coupled with the now well-established concept that uncontrolled seizures are detrimental for the child’s developing brain, have shifted the risk-benefit profile in favor of early surgery in the appropriate patient.
Traditionally, the notion of brain surgery for patients whose seizures could not be controlled with antiepileptic medication was entertained primarily in adults with a well-defined and well-characterized epileptic syndrome, mesial temporal sclerosis. The most frequently performed operation for this group of patients was, therefore, temporal lobectomy, long considered the paradigm of epilepsy surgery. In fact, one of the only prospective, randomized controlled trials in the field of neurosurgery actually showed that temporal lobectomy was better than medical therapy for adult patients with temporal lobe epilepsy, with a seizure-free rate of more than 80% in well-selected patients. Interestingly, the actual incidence of temporal lobectomy epilepsy surgery in the adult population has decreased over the past 20 years. The potential underlying reasons for this observed change have been debated recently, but no clear explanation has been defined. In children, however, a surgical approach was traditionally reserved primarily for children whose epilepsy was thought to be due to an obvious focal structural lesion of the brain such as a brain tumor, a malformation of cortical development, or some type of unilateral hemispheric brain pathology. It has been increasingly recognized, however, during the last 20 years, that many other children may benefit from epilepsy surgery when appropriately identified and evaluated at a comprehensive epilepsy treatment center.
Approximately one-third of the 1% of the overall population in the United States that has epilepsy will be refractory to antiepileptic drugs (AEDs), or ~1 million individuals. If one were to conservatively estimate that approximately 10% of this group will be determined to be appropriate candidates for epilepsy surgery, then that would mean that many more children could potentially benefit from epilepsy surgery than currently do. The optimal candidates for epilepsy surgery are children who have focal epilepsies, arising from a defined “focus” in the brain and characterized by simple or complex partial seizures. This is in contrast to patients with generalized epilepsies, in whom the seizures do not originate in a discreet brain region and for whom only a palliative surgical approach has been offered. This idea has been revised recently, however. In fact, it has increasingly been recognized that some children with generalized or multifocal epilepsy may actually harbor focal pathology that may be amenable to a more curative surgical strategy, similar to that used in patients with focal epilepsies.