Emerging surgical therapies in the treatment of pediatric epilepsy

Abstract

In the approximately 1% of children affected by epilepsy, pharmacoresistance and early age of seizure onset are strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. These children often require multiple surgical procedures, including invasive diagnostic procedures with intracranial electrodes to identify the seizure-onset zone. The recent development of minimally invasive surgical techniques, including stereotactic electroencephalography (SEEG) and MRI-guided laser interstitial thermal therapy (MRgLITT), and new applications of neurostimulation, such as responsive neurostimulation (RNS), are quickly changing the landscape of the surgical management of pediatric epilepsy. In this review, the authors discuss these various technologies, their current applications, and limitations in the treatment of pediatric drug-resistant epilepsy, as well as areas for future research. The development of minimally invasive diagnostic and ablative surgical techniques together with new paradigms in neurostimulation hold vast potential to improve the efficacy and reduce the morbidity of the surgical management of children with drug-resistant epilepsy.

Keywords: Epilepsy; MRI-guided laser interstitial thermal therapy (MRgLITT); NeuroPace; laser ablation; responsive neurostimulation (RNS); stereotactic electroencephalography (SEEG).

Figure 1

NeuroPace System. The NeuroPace device is shown with a depth electrode (top lead) and cortical surface electrode (bottom lead) attached to the device, which is implanted in the skull. Reproduced with permission from NeuroPace, Inc. (Mountain View, CA).

Figure 2

Case example of stereotactic electroencephalogram (SEEG) planning and electrode placement. This is a case of a 12-year-old boy presenting with medically refractory epilepsy described as complex, partial seizures with automatisms and confusion. Despite workup by video EEG and imaging, no definitive locus for the epileptic zone could be identified. The patient underwent placement of bilateral SEEG electrodes and, during video monitoring, a deep-seated epileptogenic zone on the right side was identified suggestive of a deep cortical dysplasia. Because of the location of the lesion and epileptogenic zone, traditional diagnostic methods could not delineate the area.