Epilepsy surgery before age 3 months is associated with excellent seizure control and does not lead to more permanent morbidity than surgery in older infants, according to study findings published in Epilepsia.
Epilepsy onset during the first few months of life is challenging, especially infants with rare drug-resistant epilepsy (DRE), which requires surgery. “Ultra-early” epilepsy surgery is not common prior to 3 months of age, therefore, the literature and data on the efficacy and safety of DRE surgery and its ability to control seizures is limited. Typically, epilepsy surgery is delayed until the child is older to minimize risks in infants, but living with epilepsy as an infant can also come with its own risks when it comes to seizures and medication. The objective of the current study was to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months.
The multinational, retrospective study included data from 19 epilepsy centers of all children who underwent epilepsy surgery before age 3 months (or 100 days) beyond 40 weeks of gestation from 1999 to 2020.
A total of 64 infants were included (34 male)—55 babies (86%) were full-term, and 9 (14%) were born preterm. Participants’ age at seizure onset ranged from 0 to 49 days (6.6 ± 11.8), and 4 babies (6%) had suspected seizures prior to birth.
The children had 69 surgical procedures before age 3 months, and their age at first surgery was 14 to 113 days (72 ± 22). The procedures included 12 focal resections, 7 lobectomies, and 48 hemispheric surgeries, and no perioperative deaths occurred.
The median follow-up was 41 months (interquartile range [IQR], 19-104), and 22 infants (34%) had additional epilepsy surgery. No significant correlation was observed between type of surgery and need for additional surgery (36% vs 27% for hemispheric and focal resections, respectively, P=.42).
Regarding outcomes, 66% of cases achieved an excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I), 2% achieved ILAE II, 8% achieved ILAE III, 12% achieved ILAE IV, and 12% achieved ILAE V. No significant correlation was found between ILAE grade and surgery type (P =.44).
Among the infants who did not have additional surgery, 85% were ILAE I-II, vs 39% of those who did need additional surgery (P =.0001).
At the most recent follow-up in 58 children for whom data were available, postoperative patients were receiving 0 to 6 (median 1, IQR 0.75-3) antiseizure medications vs 1 to 11 (median 4, IQR 3-4) before surgery (P <.0001), a median decrease of 2 drugs (IQR 1-3). Of this group, 79% had reduced their preoperative number of drugs by at least 1 drug.
In addition to the study’s retrospective design, the researchers noted that they did not obtain participants’ body weight at surgery or data on electrolyte imbalance or fevers. Outcome measures were limited, the study did not include a control group, and data were collected from multiple centers and performed by multiple surgeons.
“Excellent surgical technique, anesthesia, and intensive care treatment are all prerequisite for achieving good results, and only centers with experience in complex surgeries in very young infants should handle such cases,” advised the researchers. “We thus recommend not delaying surgical treatment in the very young based solely on their age.”
Roth J, Constantini S, Ekstein M, et al. Epilepsy surgery in infants up to 3 months of age: safety, feasibility, and outcomes: a multicenter, multinational study. Epilepsia. Published online June 14, 2021. doi: 10.1111/epi.16959