Factors Influencing Surgical Approach and Seizure Outcomes in Pediatric MRI-Positive Temporal Lobe Epilepsy: One-Stage Versus Two-Stage Surgical Interventions

Document Type

Conference Proceeding

Publication Date

12-7-2024

Abstract

Rationale: This study aimed to determine the factors influencing the decision to perform one-stage versus two-stage surgical interventions and to compare seizure outcomes in pediatric patients with MRI-positive temporal lobe epilepsy (TLE).
Methods: We analyzed data from the Pediatric Epilepsy Research Consortium Surgery Database, collecting prospective and observational data between January 2018 and April 2024 from children (< 18 years of age) assessed for epilepsy surgery across 22 pediatric epilepsy centers in the USA. This study included patients with MRI-positive TLE who underwent epilepsy surgery, categorized into one-stage (without intracranial monitoring) and two-stage (with intracranial monitoring) groups. A multivariate logistic regression analysis was used to identify factors associated with the choice of one vs. two-stage surgeries. Clinical characteristics and seizure outcomes were compared between the groups.
Results: The study included 352 patients (248 one-stage vs 104 two-stage surgeries). Patients undergoing one-stage procedure more often had MRI-evident lesions congruent with EEG localization (p=0.04), whereas those undergoing two-stage surgeries more often had abnormal findings on neurological exam (p=0.001), higher median number of antiseizure medications (ASMs) (p < 0.001), neuropsychological testing (p=0.001) and more often underwent neuromodulation (p=0.01) and procedures including regions in addition to the temporal lobe (p=0.02). There were no significant differences when comparing individual races though White patients were 2.59 times more likely to receive 2 stage surgery than Black patients. Follow-up outcomes demonstrated no significant difference in the proportion of patients achieving seizure freedom between the groups (p=0.09). Regression analysis revealed that an abnormal neurological exam (OR=1.86, p=0.03), the number of current ASMs (OR=1.52, p=0.01), divergent MRI and EEG findings (OR=4.14, p=0.002), completion of neuropsychological testing (OR=8.5, p < 0.001) and inclusion of extra-temporal region (OR=0.42, p=0.02) for surgery were significantly associated with the choice of a two-stage surgeries. Subgroup analysis in patients with mesial temporal sclerosis (n=48) or focal cortical dysplasia (n=68) revealed no differences between the two surgery groups with regards to seizure free rates, (p=0.76 and p=0.88, respectively).
Conclusions: This study demonstrates that in pediatric MRI-positive TLE, two-stage surgical interventions allow similar seizure-free outcomes compared to one-stage procedures in patients with more complex epilepsy presentations, such as those with divergent MRI and EEG findings, abnormal neurological exams, and involvement of extra-temporal regions. This finding underscores the necessity of a judicious selection process for determining the surgical approach, emphasizing that invasive monitoring may not universally translate to better seizure control but can be crucial for achieving similar outcomes in complex cases.

Comments

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

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