New interinstitutional, multimodal presurgical evaluation protocol associated with improved seizure freedom for poorly defined cases of focal epilepsy in children

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  • 1 Montreal Neurological Institute and Hospital, McGill University Health Center, Department of Neurology and Neurosurgery, McGill University;
  • | 2 McConnell Brain Imaging Centre, Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University;
  • | 3 Department of Pediatric Surgery, Division of Neurosurgery, Montreal Children’s Hospital, Montreal, Quebec, Canada;
  • | 4 Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan;
  • | 5 Montreal Neurological Institute, McGill University;
  • | 6 Division of Neurology and Department of Clinical Neurophysiology, Montreal Children’s Hospital;
  • | 7 Pediatric Radiology, Montreal Children’s Hospital, McGill University;
  • | 8 Division of Nuclear Medicine, Medical Imaging, CHU Ste-Justine and Montreal Children’s Hospital; and
  • | 9 Neuroimaging of Epilepsy Laboratory, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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OBJECTIVE

In an attempt to improve postsurgical seizure outcomes for poorly defined cases (PDCs) of pediatric focal epilepsy (i.e., those that are not visible or well defined on 3T MRI), the authors modified their presurgical evaluation strategy. Instead of relying on concordance between video-electroencephalography and 3T MRI and using functional imaging and intracranial recording in select cases, the authors systematically used a multimodal, 3-tiered investigation protocol that also involved new collaborations between their hospital, the Montreal Children’s Hospital, and the Montreal Neurological Institute. In this study, the authors examined how their new strategy has impacted postsurgical outcomes. They hypothesized that it would improve postsurgical seizure outcomes, with the added benefit of identifying a subset of tests contributing the most.

METHODS

Chart review was performed for children with PDCs who underwent resection following the new strategy (i.e., new protocol [NP]), and for the same number who underwent treatment previously (i.e., preprotocol [PP]); ≥ 1-year follow-up was required for inclusion. Well-defined, multifocal, and diffuse hemispheric cases were excluded. Preoperative demographics and clinical characteristics, resection volumes, and pathology, as well as seizure outcomes (Engel class Ia vs > Ia) at 1 year postsurgery and last follow-up were reviewed.

RESULTS

Twenty-two consecutive NP patients were compared with 22 PP patients. There was no difference between the two groups for resection volumes, pathology, or preoperative characteristics, except that the NP group underwent more presurgical evaluation tests (p < 0.001). At 1 year postsurgery, 20 of 22 NP patients and 10 of 22 PP patients were seizure free (OR 11.81, 95% CI 2.00–69.68; p = 0.006). Magnetoencephalography and PET/MRI were associated with improved postsurgical seizure outcomes, but both were highly correlated with the protocol group (i.e., independent test effects could not be demonstrated).

CONCLUSIONS

A new presurgical evaluation strategy for children with PDCs of focal epilepsy led to improved postsurgical seizure freedom. No individual presurgical evaluation test was independently associated with improved outcome, suggesting that it may be the combined systematic protocol and new interinstitutional collaborations that makes the difference rather than any individual test.

ABBREVIATIONS

EEG = electroencephalography; EZ = epileptogenic zone; FCD = focal cortical dysplasia; fMRI = functional MRI; icEEG = intracranial EEG; IED = interictal epileptiform discharge; MCH = Montreal Children’s Hospital; MEG = magnetoencephalography; MNI = Montreal Neurological Institute; NP = new protocol; OR = odds ratio; PDC = poorly defined case; PP = preprotocol; SEEG = stereo-EEG; SISCOM = subtraction ictal SPECT coregistered to MRI; VBPP = voxel-based postprocessing; VEEG = video-EEG.

Supplementary Materials

    • Supplementary Information (PDF 485 KB)

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