Epilepsy Surgery

Surgery is considered for children with medically intractable epilepsy declining neurological function, or syndromes for which medical treatment is known to be ineffective. These determinations require accurate classification of the epilepsy syndrome, knowledge of the natural history, response to anti-epileptic drug trials, and serial assessments of development. Many types of infantile and early childhood epilepsies are hard to classify and of uncertain prognosis.

Although evidence shows that children (even under age 3) who undergo epilepsy surgery soon after epilepsy has started have better outcomes, surgery is not offered as commonly as it should be. [Pindrik: 2018] [Kadish: 2018] [Englot: 2012] Also, there can be significant delays before referral; often, up to 60 months and a process where 6 anti-epileptic medications have been tried before referral to an epilepsy surgery team. [Prideaux: 2018] Drug-Resistant Epilepsy (ILAE) defines drug resistance as failing to respond to 2 well-selected anti-epileptic drugs used in isolation or any combination. Also see [Kwan: 2010].

Because the frequency of seizures in children is often high, the determination of drug resistance need not take years and, often, can be established within a year of epilepsy onset.

Main Types of Epilepsy Surgery

Vagal nerve stimulation (VNS) can be used in generalized or focal epilepsy. [Welch: 2018] A VNS reduces seizure frequency by sending regular, low-amplitude pulses of electricity to the brain via the vagus nerve. A stimulator device is implanted under the skin in the chest and is about the same size as a cardiac pacemaker. A wire from the device is wound around the vagus nerve in the neck. It is a palliative, not curative, procedure that has been performed in adults and in some children with intractable complex partial seizures or generalized tonic seizures who were not candidates for definitive surgical cure. Why this works is not well understood.

Although the VNS has been placed in children younger than 3 years old [Zamponi: 2008], it is usually placed in older children. The VNS is generally well-tolerated and safe for children and adults. The median reduction of seizure frequency is about a third at 1 year and 40% by 18 months. Several months may go by before there is any change, followed by a slow but steady improvement in seizure frequency. In 1 study, 60-90% of children showed a reduction in seizure frequency. [Zamponi: 2008] [Fan: 2018] Complications that occur with VNS use include failure of the device to work (3%), infections (3%), and stimulus-associated hoarseness and swallowing problems. [Smyth: 2003] Sleep-related breathing problems have also been described. [Hsieh: 2008] Evaluation for and treatment with VNS for children is performed in epilepsy clinics. The VNS is reserved for children with intractable seizures. Frequent follow-up with pediatric neurology will be necessary after insertion of the VNS.

Deep brain stimulation (DBS) involves implanting a device to stimulate the anterior nucleus of the thalamus involved in the spread of an initially localized seizure. [Yan: 2018]

Responsive neuro-stimulation (RNS) is a relatively new therapy. A device is placed in the skull that is connected to electrodes on top of the brain or inside the brain with the placement tailored to the individual. It monitors brain waves, and if seizure activity is detected, it stimulates the brain to try to counter the seizure activity.

Lobectomy/lesionectomy (most frequently involving the temporal lobe) is a procedure in which a specific lobe (or lesion within a lobe) of the brain is removed. This is successful in many cases, especially when a lesion is identified on MRI. [Stevelink: 2018] The percentage of cure or significant seizure reduction varies with different criteria/methods.

Corpus callosotomy is a palliative surgery in which the main connection between the right and left halves of the brain is cut. It is used most often to reduce injuries related to abrupt drop seizures, but seizure freedom should not be expected.

Hemispherectomy/hemispherotomy is a procedure in which half of the brain is removed or disconnected from the surrounding brain. This is a palliative surgery that may result in a more significant functional loss (peripheral vision loss, weakness) on the opposite side of the body, but it also has remarkable success in stopping seizures (60-80% depending on circumstances). This has shown to be particularly effective when a prior stroke has caused epilepsy or in epilepsy caused by hemimegalencephaly or Rasmussen’s encephalitis.

If surgery is being considered for a child with seizures, the families can have a reasonable expectation of seizure elimination or substantially fewer disabling seizures, which should improve the quality of life and perhaps help development. There should be minimal risk of significant loss of neurologic function. Children with complete resections of focal structural lesions identified by MRI fare best and have seizure-free rates as high as 80%. [Mehvari: 2019]

Many of these lesions are congenital, slow-growing tumors or cerebral dysgenesis. Mesial temporal sclerosis (a common indication in adult epilepsy surgery) is less frequent in children and adolescents, but it has a very favorable surgical outcome. Without a clear lesion on MRI, complete long-term seizure freedom following surgery is less likely (at times only 30-50%); however, it still has a higher likelihood of seizure freedom when compared to continued medication trials (estimated at less than 10%).

Resources

Information & Support

Related Portal Content
Assessment and management information for the primary care clinician caring for the child with seizures:

Answers to questions frequently asked by families with a child diagnosed with seizures:

Families may also benefit from:

For Professionals

Drug-Resistant Epilepsy (ILAE)
Provides information about drug-resistant epilepsy; International League Against Epilepsy.

Helpful Articles

Sharma P, Hussain A, Greenwood R.
Precision in pediatric epilepsy.
F1000Res. 2019;8. PubMed abstract / Full Text

Bello-Espinosa LE, Olavarria G.
Epilepsy Surgery in Children.
Pediatr Clin North Am. 2021;68(4):845-856. PubMed abstract

Authors & Reviewers

Initial publication: June 2011; last update/revision: December 2022

Current Authors and Reviewers:

Author:	Lynne M. Kerr, MD, PhD
Reviewer:	Cristina Corina Trandafir, MD, PhD

Authoring history

2019: update: Matthew Sweney, MD^A

2018: first version: Matthew Sweney, MD^A

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

Page Bibliography

Englot DJ, Ouyang D, Garcia PA, Barbaro NM, Chang EF.
Epilepsy surgery trends in the United States, 1990-2008.
Neurology. 2012;78(16):1200-6. PubMed abstract / Full Text

Fan HC, Hsu TR, Chang KP, Chen SJ, Tsai JD.
Vagus nerve stimulation for 6- to 12-year-old children with refractory epilepsy: Impact on seizure frequency and parenting stress index.
Epilepsy Behav. 2018;83:119-123. PubMed abstract

Hsieh T, Chen M, McAfee A, Kifle Y.
Sleep-related breathing disorder in children with vagal nerve stimulators.
Pediatr Neurol. 2008;38(2):99-103. PubMed abstract

Kadish NE, Bast T, Reuner G, Wagner K, Mayer H, Schubert-Bast S, Wiegand G, Strobl K, Brandt A, Korinthenberg R, van Velthoven V, Schulze-Bonhage A, Zentner J, Ramantani G.
Epilepsy Surgery in the First 3 Years of Life: Predictors of Seizure Freedom and Cognitive Development.
Neurosurgery. 2018. PubMed abstract

Kwan P, Arzimanoglou A, Berg AT, Brodie MJ, Allen Hauser W, Mathern G, Moshé SL, Perucca E, Wiebe S, French J.
Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies.
Epilepsia. 2010;51(6):1069-77. PubMed abstract

Mehvari Habibabadi J, Moein H, Basiratnia R, Badihian S, Zaki B, Manouchehri N, Zare M, Barekatain M, Rahimian E, Mehvari Habibabadi A, Moein P, Aghakhani Y, Amina S, Lhatoo S.
Outcome of lesional epilepsy surgery: Report of the first comprehensive epilepsy program in Iran.
Neurol Clin Pract. 2019;9(4):286-295. PubMed abstract / Full Text

Pindrik J, Hoang N, Smith L, Halverson M, Wojnaroski M, McNally K, Gedela S, Ostendorf AP.
Preoperative evaluation and surgical management of infants and toddlers with drug-resistant epilepsy.
Neurosurg Focus. 2018;45(3):E3. PubMed abstract

Prideaux L, Barton S, Maixner W, Harvey AS.
Potential delays in referral and assessment for epilepsy surgery in children with drug-resistant, early-onset epilepsy.
Epilepsy Res. 2018;143:20-26. PubMed abstract

Smyth MD, Tubbs RS, Bebin EM, Grabb PA, Blount JP.
Complications of chronic vagus nerve stimulation for epilepsy in children.
J Neurosurg. 2003;99(3):500-3. PubMed abstract

Stevelink R, Sanders MW, Tuinman MP, Brilstra EH, Koeleman BP, Jansen FE, Braun KP.
Epilepsy surgery for patients with genetic refractory epilepsy: a systematic review.
Epileptic Disord. 2018;20(2):99-115. PubMed abstract

Welch WP, Sitwat B, Sogawa Y.
Use of Vagus Nerve Stimulator on Children With Primary Generalized Epilepsy.
J Child Neurol. 2018;33(7):449-452. PubMed abstract

Yan H, Toyota E, Anderson M, Abel TJ, Donner E, Kalia SK, Drake J, Rutka JT, Ibrahim GM.
A systematic review of deep brain stimulation for the treatment of drug-resistant epilepsy in childhood.
J Neurosurg Pediatr. 2018;23(3):274-284. PubMed abstract

Zamponi N, Rychlicki F, Corpaci L, Cesaroni E, Trignani R.
Vagus nerve stimulation (VNS) is effective in treating catastrophic 1 epilepsy in very young children.
Neurosurg Rev. 2008;31(3):291-7. PubMed abstract