Precision medicine in pediatric temporal epilepsy surgery: optimization of outcomes through functional MRI memory tasks and tailored surgeries

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  • 1 Neurosciences Center, Seattle Children’s Hospital, Seattle;
  • | 2 Department of Neurological Surgery, University of Washington School of Medicine, Seattle;
  • | 3 Division of Neurosurgery, Seattle Children’s Hospital, Seattle;
  • | 4 Department of Radiology, Seattle Children’s Hospital, Seattle;
  • | 5 Department of Radiology, University of Washington School of Medicine, Seattle;
  • | 6 Clinical Analytics, Seattle Children’s Hospital, Seattle;
  • | 7 Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle;
  • | 8 Department of Neurology, University of Washington School of Medicine, Seattle;
  • | 9 Center for Integrated Brain Research, Seattle Children’s Hospital, Seattle, Washington; and
  • | 10 Epilepsy Center, Department of Neurology, The Johns Hopkins University Medical Center, Baltimore, Maryland
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OBJECTIVE

The goal of epilepsy surgery is both seizure cessation and maximal preservation of function. In temporal lobe (TL) cases, the lack of functional MRI (fMRI) tasks that effectively activate mesial temporal structures hampers preoperative memory risk assessment, especially in children. This study evaluated pediatric TL surgery outcome optimization associated with tailored resection informed by an fMRI memory task.

METHODS

The authors identified focal onset TL epilepsy patients with 1) TL resections; 2) viable fMRI memory scans; and 3) pre- and postoperative neuropsychological (NP) evaluations. They retrospectively evaluated preoperative fMRI memory scans, available Wada tests, pre- and postoperative NP scores, postoperative MRI scans, and postoperative Engel class outcomes. To assess fMRI memory task outcome prediction, the authors 1) overlaid preoperative fMRI activation onto postoperative structural images; 2) classified patients as having "overlap" or "no overlap" of activation and resection cavities; and 3) compared these findings with memory improvement, stability, or decline, based on Reliable Change Index calculations.

RESULTS

Twenty patients met the inclusion criteria. At a median of 2.1 postoperative years, 16 patients had Engel class IA outcomes and 1 each had Engel class IB, ID, IIA, and IID outcomes. Functional MRI activation was linked to NP memory outcome in 19 of 20 cases (95%). Otherwise, heterogeneity characterized the cohort.

CONCLUSIONS

Functional MRI memory task activation effectively predicted individual NP outcomes in the context of tailored TL resections. Patients had excellent seizure and overall good NP outcomes. This small study adds to extant literature indicating that pediatric TL epilepsy does not represent a single clinical syndrome. Findings support individualized surgical intervention using fMRI memory activation to help guide this precision medicine approach.

ABBREVIATIONS

AAN = American Academy of Neurology; BOLD = blood oxygenation level–dependent; fMRI = functional MRI; LiTT = laser interstitial thermal therapy; NP = neuropsychological; RCI = Reliable Change Index; ROI = region of interest; SCH = Seattle Children’s Hospital; TL = temporal lobe; WRAML2 = Wide Range Assessment of Memory and Learning, Second Edition; WT = Wada test.

Supplementary Materials

    • Tables S1-S5 (PDF 277 KB)

Illustration from Cinalli et al. (pp 330–341). Printed with permission from © CC Medical Arts.

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