Factors Associated With Favorable Surgical Outcomes in Children With Drug-Resistant Epilepsy Secondary to Neonatal / Perinatal Arterial Stroke: Insights From Pediatric Epilepsy Research Consortium

Document Type

Conference Proceeding

Publication Date

12-8-2024

Abstract

Rationale:
Neonatal and perinatal arterial strokes (PAIS) are significant causes of seizures in children, often leading to drug-resistant epilepsy (DRE), which may benefit from surgical intervention. We aimed to identify factors influencing seizure freedom or >90% seizure reduction in this cohort.
Methods:
We analyzed data from the Pediatric Epilepsy Research Consortium Surgery Database, a prospective, observational multicenter study enrolling children 0-18 years across 27 US pediatric epilepsy centers. We included data from January 2018 to April 2024 for patients with reported PAIS as an etiology of their DRE. Statistical comparisons of clinical features, diagnostic imaging findings, and surgical procedures were made between patients achieving seizure freedom versus others and those with >90% seizure reduction (“favorable outcome”) versus those with < 90%.
Results:
79/108 (73%) completed surgeries, with outcomes available for 71(90%) patients. Fifty-four (68%) patients had favorable outcomes, and 43 (54%) were seizure-free with a median follow-up of 17.5 months [IQR 9.5-27]. Age at seizure onset was significant; patients with onset after seven years had higher seizure freedom rates (76.5%) than those under seven years (48.4%, p=0.039). 73.2% of patients with PAIS as their only etiology achieved favorable outcomes compared to those with PAIS in addition to another etiology (congenital structural 50%, infectious/metabolic/genetic 0%) (p=0.04). EEG localization also mattered; 85% with single-focus EEG findings had favorable outcomes compared to lower rates in multifocal (50%), generalized (66.7%), or mixed generalized/focal findings (25%) (p=0.013). No significant differences were found in demographic variables, number of failed ASMs, seizure types, and specific diagnostic imaging (PET, MEG, SPECT) findings between the groups. Surgical procedures showed variable success. Hemispherectomy (n=36), callosotomy (n=3), lesionectomies (n=18), thermal ablation (n=7) had higher seizure freedom rates (69%, 66%, 61% and 61%, respectively) than neuromodulation (n=15) (6.7%) (p=0.001). Favorable outcomes ( >90% seizure reduction) were noted in 83% of hemispherectomy (n=36), 77% of lesionectomy/lobectomy (n=18), and 100% of thermal ablation cases (n=7) (p< 0.001). Patients undergoing neuromodulation were less likely to have single ictal electrographic focus (18.2% vs 65.6%, p=0.002), congruent MEG (66.7% vs. 100%, p=0.032), isolated encephalomalacia (28.6% vs.68.3%, p=0.004) and more likely to have PAIS plus etiologies (33.3% vs. 4.7%, p=0.001) when compared with other procedures.
Conclusions:
Following epilepsy surgery, over 50% of children with DRE secondary to PAIS achieved seizure freedom, and over 65% experienced significant seizure reduction. Earlier seizure onset, etiologies in addition to PAIS, and multifocal EEG findings are associated with unfavorable outcomes. Hemispherectomy and thermal ablation showed better outcomes than neuromodulation, reflecting patients with less favorable localizing findings.

Comments

American Epilepsy Society Annual Meeting, December 6-10, 2024, Los Angeles, CA

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