- Email: [email protected]
Epilepsy surgery in childhood
Compte-rendu de congrès • Neuroméditerranée VIII
© 2007. Elsevier Masson SAS. Tous droits réservés
for familial epilepsy, which may elucidate the pathophysiology of the epilepsies in general.
● Epilepsy surgery in childhood J. Helen Cross Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, London, UK.
Epilepsy surgery is not new; it has been documented for over one hundred years. With advances in neurosurgical and neuroanaesthetic techniques and relative low morbidity from planned neurosurgical procedures, earlier surgery has been advocated in children. However the majority of adults coming to an epilepsy surgery programme have had a history of seizures since childhood so why have they not been evaluated earlier? There is no doubt that the range of individual presenting for surgery in childhood remains wider than that in adulthood. Whilst temporal lobectomy is the most common procedure in adults, this procedure makes up 20-50p.cent of paediatric surgical series. Developmental tumours remain the commonest pathology, although hippocampal sclerosis makes up a significant number. In addition the clinical spectrum of HS may be wider than previously thought, with a high incidence of behaviour disorder amongst those children coming for surgical evaluation. In particular, as with developmental pathologies, there appears to be a subgroup who are within the autistic spectrum range in whom benefits are clear from surgical resection with or without complete seizure freedom. Hemispherectomy makes up a further one third of procedures performed. This is where the clinical spectrum remains the most wide, ranging from the early onset catastrophic syndromes seen with some developmental lesions to those with near normal cognition but a progressive pathology such as Rasmussens encephalitis. Whatever the underlying cause of the hemisyndrome associated with epilepsy, early evaluation is warranted to determine the best timing of surgery if appropriate. Extratemporal resections make up a further third of procedures, although suitable candidates may be more difficult to determine. Although detailed imaging techniques, both structural and functional, have allowed non invasive evaluation of an increasing number of children, invasive EEG recording may be required either where the exact limits of the epileptogenic area are not defined, or where a structural abnormality may be in close proximity to functional cortex. Functional procedures (corpus callosotomy, multiple subpial transection) are considered in a few highly selected cases with specific goals for outcome. The role of vagal nerve stimulation is still being evaluated. The outcome from surgery is most commonly reported with regard to seizure freedom although of course there are other considerations of particular relevance in childhood. Where a focal resection has been performed, the degree of epileptogenic tissue removed is likely to be a major determinant of seizure freedom although the degree to which
485
this can be achieved is also related to the underlying pathology. There is some evidence that seizure outcome following surgery for developmental lesions may deteriorate with time, that is the likelihood of seizure freedom is less in the longer as opposed to the short term but that outcome with such lesions may be better with earlier surgery. The lesser likelihood of seizure control however does not preclude consideration, providing the aims of surgery are realistic and clearly identified preoperatively. Many children are also likely to achieve a substantial reduction in seizure frequency with a reduction in anticonvulsant requirement. Developmental and behavioural outcome have been reported as improved following surgery in many studies but have been difficult to quantify, particularly in the very young. As a consequence it is important to obtain as much information as possible about the nature of the epilepsy and the procedure planned prior to any surgery, with clear outcome aims clarified with the family.
● Monotherapy versus polytherapy of anti-epileptic drugs: why and when H.S. Hosny Prof of Neurology, Cairo University, Cairo Egypt.
Antiepileptic drug treatment of epilepsy to prevent or minimize recurrent epileptic seizures begins with the use of a single agent as monotherapy. The primary reason why two or more drugs are used together is the failure of monotherapy to control the seizures. Depending on the seizure type or syndrome, control may be complete or very poor. In adult onset seizures control varies between 35p.cent and 60 p.cent for partial seizures and 80p.cent for idiopathic generalized tonic-clonic seizures. When seizures continue despite increasing doses of AEDs to the maximum that can be tolerated, a second AED is usually added to the first in an effort to to achieve complete seizure control. The aim of this study is to assess the efficacy of AEDs in monotherapy in partial and generalized epilepsy and whether it is needed to reach the maximal tolerated dose in uncontrolled patients at a moderate dose or early switch to polytherapy. A total of 600 patients were classified (according to the ILAE) and evaluated, 225 who had an idiopathic generalized epilepsy and the rest with partial epilepsy. The results and recommendations will be discussed in the presentation.
● Management of affective disorders in epilepsy eylert E. Brodtkorb Senior Consultant, Professor, Department of Neurology and Clinical Neurophysiology St. Olav’s Hospital, Trondheim University Hospital, Norway.
Biological and psychosocial factors may interact in a complex way in affective and seizure disorders. This fact is important when considering management of mood dysfunction in patients with epilepsy. Psychological difficulties and
NEUROMÉDITERRANÉE VIII
© 2007. Elsevier Masson SAS. Tous droits réservés
for familial epilepsy, which may elucidate the pathophysiology of the epilepsies in general.
● Epilepsy surgery in childhood J. Helen Cross Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, London, UK.
Epilepsy surgery is not new; it has been documented for over one hundred years. With advances in neurosurgical and neuroanaesthetic techniques and relative low morbidity from planned neurosurgical procedures, earlier surgery has been advocated in children. However the majority of adults coming to an epilepsy surgery programme have had a history of seizures since childhood so why have they not been evaluated earlier? There is no doubt that the range of individual presenting for surgery in childhood remains wider than that in adulthood. Whilst temporal lobectomy is the most common procedure in adults, this procedure makes up 20-50p.cent of paediatric surgical series. Developmental tumours remain the commonest pathology, although hippocampal sclerosis makes up a significant number. In addition the clinical spectrum of HS may be wider than previously thought, with a high incidence of behaviour disorder amongst those children coming for surgical evaluation. In particular, as with developmental pathologies, there appears to be a subgroup who are within the autistic spectrum range in whom benefits are clear from surgical resection with or without complete seizure freedom. Hemispherectomy makes up a further one third of procedures performed. This is where the clinical spectrum remains the most wide, ranging from the early onset catastrophic syndromes seen with some developmental lesions to those with near normal cognition but a progressive pathology such as Rasmussens encephalitis. Whatever the underlying cause of the hemisyndrome associated with epilepsy, early evaluation is warranted to determine the best timing of surgery if appropriate. Extratemporal resections make up a further third of procedures, although suitable candidates may be more difficult to determine. Although detailed imaging techniques, both structural and functional, have allowed non invasive evaluation of an increasing number of children, invasive EEG recording may be required either where the exact limits of the epileptogenic area are not defined, or where a structural abnormality may be in close proximity to functional cortex. Functional procedures (corpus callosotomy, multiple subpial transection) are considered in a few highly selected cases with specific goals for outcome. The role of vagal nerve stimulation is still being evaluated. The outcome from surgery is most commonly reported with regard to seizure freedom although of course there are other considerations of particular relevance in childhood. Where a focal resection has been performed, the degree of epileptogenic tissue removed is likely to be a major determinant of seizure freedom although the degree to which
485
this can be achieved is also related to the underlying pathology. There is some evidence that seizure outcome following surgery for developmental lesions may deteriorate with time, that is the likelihood of seizure freedom is less in the longer as opposed to the short term but that outcome with such lesions may be better with earlier surgery. The lesser likelihood of seizure control however does not preclude consideration, providing the aims of surgery are realistic and clearly identified preoperatively. Many children are also likely to achieve a substantial reduction in seizure frequency with a reduction in anticonvulsant requirement. Developmental and behavioural outcome have been reported as improved following surgery in many studies but have been difficult to quantify, particularly in the very young. As a consequence it is important to obtain as much information as possible about the nature of the epilepsy and the procedure planned prior to any surgery, with clear outcome aims clarified with the family.
● Monotherapy versus polytherapy of anti-epileptic drugs: why and when H.S. Hosny Prof of Neurology, Cairo University, Cairo Egypt.
Antiepileptic drug treatment of epilepsy to prevent or minimize recurrent epileptic seizures begins with the use of a single agent as monotherapy. The primary reason why two or more drugs are used together is the failure of monotherapy to control the seizures. Depending on the seizure type or syndrome, control may be complete or very poor. In adult onset seizures control varies between 35p.cent and 60 p.cent for partial seizures and 80p.cent for idiopathic generalized tonic-clonic seizures. When seizures continue despite increasing doses of AEDs to the maximum that can be tolerated, a second AED is usually added to the first in an effort to to achieve complete seizure control. The aim of this study is to assess the efficacy of AEDs in monotherapy in partial and generalized epilepsy and whether it is needed to reach the maximal tolerated dose in uncontrolled patients at a moderate dose or early switch to polytherapy. A total of 600 patients were classified (according to the ILAE) and evaluated, 225 who had an idiopathic generalized epilepsy and the rest with partial epilepsy. The results and recommendations will be discussed in the presentation.
● Management of affective disorders in epilepsy eylert E. Brodtkorb Senior Consultant, Professor, Department of Neurology and Clinical Neurophysiology St. Olav’s Hospital, Trondheim University Hospital, Norway.
Biological and psychosocial factors may interact in a complex way in affective and seizure disorders. This fact is important when considering management of mood dysfunction in patients with epilepsy. Psychological difficulties and
NEUROMÉDITERRANÉE VIII