It is found that the association between early epilepsy surgery and seizure reduction in palliative procedures reflects the heterogeneity of the population, including different types of surgical procedures and lesional and nonlesional epilepsies.
Abstract
Objective
Epilepsy duration is a modifiable risk factor in the outcome of definitive epilepsy surgery; however, an analogous effect in palliative procedures has not been shown. We reviewed the Pediatric Epilepsy Surgery Database data for an association between epilepsy duration and seizure reduction in palliative procedures.
Methods
Patients enrolled between January 2018 and April 2025 who underwent their first epilepsy surgery with palliative intent with 6 months of follow-up were included. Procedures included neuromodulation, corpus callosotomy, hemispherotomy, lesionectomy, and lobectomy where surgical intent was not seizure freedom. Outcomes of seizure freedom, 90% seizure reduction, and 50% seizure reduction were considered at 6-12 months and >12 months from surgery. Duration from epilepsy onset to surgery was compared for patients above and below each outcome threshold at each time point. Logistic regression analysis for the association between epilepsy duration and seizure reduction adjusted for potential confounders including procedure type, etiology, and other clinical factors. Logistic regression analysis was performed on the overall cohort and subgroups of patients with each procedure.
Results
A total of 588 patients were included. Initial univariate analysis suggested that epilepsy duration at time of surgery was significantly associated with seizure freedom and 90% seizure reduction at both 6-12 months and >12 months. After adjusting for confounders, only seizure freedom at >12 months was significantly associated with duration of epilepsy. When individual procedures were considered, only lobectomy was sensitive to duration of epilepsy in multivariate analysis, with significant impacts on >50% and >90% seizure reduction at >12 months. Lesional epilepsy predicted seizure freedom at >12 months. Neuromodulation and corpus callosotomy were less likely to achieve seizure reduction than other procedures.
Significance
We did not find an association between early epilepsy surgery and seizure reduction. This reflects the heterogeneity of our population, including different types of surgical procedures and lesional and nonlesional epilepsies.
OBJECTIVE
Epilepsy surgery in tuberous sclerosis complex (TSC) is underutilized but associated with improved seizure control and better neurocognitive outcomes. Here we focus on utilization of repeated surgeries to improve seizure control.
METHODS
We performed a retrospective chart review of 62 pediatric patients with TSC, who underwent a total of 120 epilepsy surgeries at Boston Children's Hospital and Stanford University from 2011 to 2025. We collected patient seizure control over time, following single or multiple surgeries, details of the surgery performed, the location(s) and timing of post-operative seizure recurrence.
RESULTS
Twenty-nine patients (47%) had a single surgery and 33 (53%) underwent repeat epilepsy surgeries. There were no significant differences in surgical approaches (laser vs open) or demographic or clinical factors between patients with single vs repeated surgeries. Patients with one or two surgeries had similar rates of seizure freedom from the targeted epileptic foci: 76% single and 66% two or more surgeries. Overall seizure freedom from all foci was 69% for a single surgery and 55% for two or more surgeries. Seizure freedom rates for the targeted foci decreased following the third through fifth surgeries, but some patients still achieved overall seizure freedom: 33% following the third and 40% the fourth surgery. Seizure recurrences were primarily from prior targeted foci (57%), but 29% were from new foci that became clinically apparent after the first surgery. The presence of interictal epileptiform activity prior to surgery had modest sensitivity 75% (25/33) for prediction of an eventual seizure focus. Timing of surgery had some impact on outcome, with earlier surgery associated with increased seizure freedom.
SIGNIFICANCE
Repeat surgeries whether near a prior surgical site or addressing a novel seizure focus have the potential to render most children with TSC seizure-free. Earlier surgery had some evidence for improving outcomes and timing of surgery should be studied in greater detail.
Alexandria Valdrighi, Kevin Pearsson, Jurriaan M. Peters et al.· Epilepsia· 0 citations
Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark, and DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes.
Debopam Samanta, A. Caraway, Andrew T. Knox et al.· Neurology Clinical Practice· 0 citations
Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
A. Caraway, Nancy A. Mcnamara, Andrew T. Knox et al.· Epilepsia· 0 citations
This time-resolved analysis suggests that early seizure control is primarily influenced by surgical and tumor burden-related factors, whereas long-term seizure outcomes and recurrence appear to be predominantly determined by the clinical presentation at diagnosis rather than treatment-related variables.
Kyung-Il Park, Chul-Kee Park, Soon-Tae Lee et al.· Epilepsia· 0 citations
Complete resection of the epileptogenic zone offers the best chance of seizure control in patients with drug-resistant epilepsy. However, surgical management remains challenging when the epileptogenic zone is located within or adjacent to eloquent brain regions. Awake craniotomy (AC), combined with intraoperative functional mapping, has the potential to maximize resection while preserving neurological function. Despite its increasing use, evidence regarding its safety and efficacy in epilepsy surgery remains limited. This study aimed to systematically evaluate the feasibility, reported safety, and reported seizure outcomes of awake craniotomy in patients undergoing surgery for drug-resistant non-oncological epilepsy.
A systematic literature search was conducted in PubMed, Scopus, and Web of Science databases in accordance with PRISMA guidelines.
Seven retrospective studies comprising 231 patients from six countries were included; 120 patients underwent AC. Four studies (57.1%) included mixed adult and pediatric populations and three (42.9%) included adults only; however, none provided age-stratified seizure or complication outcomes, precluding separate pediatric analysis. Reported seizure duration ranged from 2 to 39 years. The frontal lobe was the most frequently involved region (
n
= 52; 43.3%), followed by the temporal lobe (
n
= 27; 22.5%), and cortical dysplasia was the most common underlying pathology (
n
= 30; 25.0%). Language and sensorimotor functions were the most commonly mapped eloquent areas, each reported in five studies (71.4%). Seizure outcomes were predominantly assessed using the Engel classification. Complete seizure freedom (Engel class I) was reported in 69 of 120 AC patients (57.5%); a random-effects single-arm synthesis estimated an Engel I proportion of 59.3% (95% CI: 46.3–71.2%; I2 = 31.9%). Comparisons with surgery under general anesthesia (GA) were available in only two non-randomized studies and should be interpreted cautiously. No study reported conversion from AC to GA. Postoperative neurological deficits were largely transient, with a low reported incidence of permanent morbidity. Owing to substantial differences in patient selection, surgical indications, and study design, these findings should be considered exploratory and should not be interpreted as demonstrating comparable seizure outcomes or treatment effectiveness.
In carefully selected patients with drug-resistant non-tumor epilepsy involving or adjacent to eloquent cortex, AC with intraoperative functional mapping appears feasible and may help preserve neurological function while enabling tailored resection. The current evidence base remains limited by retrospective designs, heterogeneous populations and techniques, inconsistent outcome reporting, and sparse comparative data; therefore, efficacy and equivalence with surgery under general anesthesia should not be inferred.
M. Mofatteh, M. Mashayekhi, Sho Giersztein et al.· BMC Surgery· 0 citations
Postoperative ASM reduction was associated with domain-specific cognitive improvement following ATL, particularly in WM, which support ASM tapering as a potentially modifiable factor influencing postoperative cognitive outcomes.
Kazushi Ukishiro, S. Osawa, M. Ogawa et al.· Epilepsia· 0 citations
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