When is surgery appropriate for childhood epilepsy?

Epilepsy surgery is often considered when seizures do not respond to medication. In general, children with epilepsy who have not responded well to two to three trials of appropriately selected anti-seizure medication should be considered for possible epilepsy surgery. Of the roughly 500,000 children in the U.S. with epilepsy, nearly 30% will continue to have seizures despite medications.

Epilepsy surgery encompasses a wide variety of treatments performed by neurosurgeons to eliminate the source of seizures, prevent the spread of seizures, stimulate the brain to stop seizures, or otherwise change seizure circuits. The goal of surgery is to eliminate seizures or reduce the number and severity of seizures.

Surgery is an important treatment option to consider for all types of seizures, including focal, generalized, multifocal, drop attacks (atonic seizures), and gelastic seizures. Children will undergo a formal and detailed epilepsy surgery evaluation to determine whether all of the seizures are coming from a resectable location.

If it’s determined that a child is a surgical candidate, the Neuroscience Center at Children’s Hospital of Philadelphia (CHOP) offers the most advanced techniques and highly innovative procedures. The center’s team has expertise in many new epilepsy techniques, including laser ablation, robotically implanted stereo EEG, and implantation of various neurostimulation devices.

The decision to proceed with epilepsy surgery can be a difficult one for families, but for some patients, epilepsy surgery is the best option to eliminate or reduce seizures. Depending on the type of epilepsy a child has, many children can be cured of their epilepsy with surgery, and some no longer require anti-seizure medication. Others have significant reduction in seizure frequency and severity.

The center’s team partners with families to discuss the surgical options available, the risks and benefits of surgery, and how to talk to their child and other family members about epilepsy surgery. There is also the opportunity to meet families that have taken the epilepsy surgery journey and hear about their experiences first-hand.

Pre-surgery evaluation

CHOP’s Neuroscience Center utilizes a team approach to identify the best management options for patients with drug-resistant epilepsy. The evaluation of any child for epilepsy surgery includes input from specialists in epilepsy, electroencephalogram (EEG), neuroradiology, psychology, neuropsychology, neurogenetics, neurosurgery and anesthesiology — and, of course, ongoing input from patients and families.

The initial evaluation for epilepsy surgery typically includes:

• A detailed history of the nature of the seizures
• A neurological exam to look for clues about where seizures may begin
• A brain magnetic resonance imaging (MRI) scan
• A brain magnetoencephalogram (MEG) scan
• Video recording of some seizures in the epilepsy monitoring unit
• Psychological and social assessments,
• Neuropsychological testing

Positron emission tomography (PET), functional MRI (fMRI) and transcranial magnetic stimulation (TMS) may also be performed.

Once these tests are completed, you and your child meet with a neurologist and neurosurgeon to further discuss the options for epilepsy surgery. Your neurologist and neurosurgeon will work closely together, and with your family, to determine a treatment plan that will deliver the best chance of improving your child's symptoms and reducing seizures.

If your child is not already under the care of a CHOP neurologist, and you would like to explore the possibility of epilepsy surgery, please contact the Pediatric Epilepsy Program for a second opinion consultation.

Deep experience with epilepsy surgery

The Pediatric Epilepsy Program team within the Neuroscience Center is experienced in performing epilepsy surgery in children of all ages and with all types of epilepsy. It is one of the highest volume epilepsy surgery centers in the country, offering the most advanced surgical techniques available in the treatment of children with epilepsy.

This highly skilled pediatric neurosurgical team has expertise in the full array of procedures used to treat seizures. The team uses all of the information gathered during a child’s evaluation to plan the most appropriate interventions, such as resection, disconnection, laser ablation, or placement of responsive neurostimulator electrodes.

Surgical procedures for pediatric epilepsy

Procedures include:

• Minimally invasive, Rosa robot-assisted stereoelectroencephalography (sEEG) to pinpoint the precise source of the seizure activity in the brain and map parts of the brain that must be preserved
• Laser ablation brain surgery for a minimally invasive approach to corpus callosotomy, hypothalamic hamartoma, as well as other small seizure foci
• Functional hemispherotomy to disconnect parts of the brain through a small craniotomy
• Robotic-assisted responsive neurostimulation (RNS) for children with seizures coming from areas of the brain that control language, motor or sensory function
• Deep brain stimulation (DBS) for children with focal or multifocal epilepsy
• Vagus nerve stimulation (VNS) to send small electrical pulses from the vagus nerve in the neck to the brain
• Resection with a dedicated pediatric neuroanesthesia team
• Awake craniotomy with a dedicated intraoperative neuropsychology team

The team uses the least invasive procedures available, which offer many benefits to patients, such as less post-operative pain, decreased length of stay, lower risk of infection and improved outcomes. By making epilepsy surgery safer and easier to tolerate, these treatment options become available to more children.

CHOP's dedicated pediatric anesthesiologists have specialized training in managing pain in children and are prepared to keep children comfortable and safe before, during and after surgery. Children have different needs than adults when it comes to anesthesia, and this team has both the technical skills needed to care for the smallest patients, as well special knowledge of the effects and dosages of medications for children of all ages.

Why choose CHOP for pediatric epilepsy surgery?

The Pediatric Epilepsy Program at CHOP’s Neuroscience Center is one of the largest programs of its kind in the world. As an accredited level 4 epilepsy center, CHOP is recognized by the National Association of Epilepsy Centers as having the expertise and facilities to provide the highest-level medical and surgical evaluation and treatment for children with epilepsy. An interdisciplinary team of pediatric epilepsy specialists partners with physicians around the world to provide exceptional care for children with epilepsy. From initial diagnosis and testing to the most complex and technologically advanced epilepsy surgery, a multidisciplinary approach and state-of-the-art technology enable the team to provide individually tailored epilepsy treatment options for children suffering from seizures.