Epilepsy Surgery For Congenital Or Early Brain Lesions

Identification of candidates for epilepsy surgery was originally derived from experience in adult and adolescent patients, often with epileptogenic lesions acquired later in life. In this patient population, the hallmark features predicting postoperative seizure freedom included focal lesion seen on neuroimaging, together with congruent focal features on seizure semiology, ictal, and interictal electroencephalography (EEG). In the 1990s, with successful surgical treatment of group of children with infantile spasms due to focal cortical dysplasia, it became accepted that in very young surgical candidates, the seizure semiology and the EEG may lack the focal features that are characteristic of epileptogenic lesions acquired later in life. Congenital or early-acquired brain lesions that occur during the phase of rapid brain growth and development in the environment of immature nervous system have special implications for the clinical and electrophysiological phenotype of epilepsy, with generalized and sometimes contralesional EEG discharges in up to one-fourth of children. In these children with a congenital or early-acquired lesion, the evaluation and decision for epilepsy surgery is no longer based on traditional unilateral or focal findings on EEG and seizure semiology. Instead it is based on the comprehensive picture of a child with severe epilepsy, a potentially epileptogenic unilateral lesion seen on MRI, and focal or generalized EEG and seizure types. Early surgery may be warranted in selected children with severe epilepsy to reduce the seizure and medication burden and capitalize on the period of plasticity to maximize developmental potential.