Pediatric Neurology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Pediatric Epilepsy, Epilepsy Center, Department of Neurology/Neurological Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
Indian J Pediatr. 2021 Oct;88(10):1000-1006. doi: 10.1007/s12098-021-03668-x. Epub 2021 Mar 19.
Epilepsy is a common neurological condition in children. It is usually amenable to drug therapy. However, nearly one-third of patients may be refractory to antiseizure drugs. Poor compliance and nonepileptic events should be ruled out as possible causes of drug-resistant epilepsy (DRE). After failing adequate trials of two appropriate antiseizure drugs, patients with focal DRE or poorly classifiable epilepsy or epileptic encephalopathy with focal electro-clinical features should be worked up for surgical candidacy. A randomized controlled trial provided a class I evidence for epilepsy surgery in pediatric DRE. Pre-surgical screening workup typically includes a high-resolution epilepsy protocol brain magnetic resonance imaging (MRI) and a high-quality in-patient video electroencephalography evaluation. Advanced investigations such as positron emission tomography (PET), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) may be required in selected cases especially when brain MRI is normal, and further evidence for anatomo-electro-clinical concordance is necessary to refine candidacy for surgery and surgical strategy. Some children may also need functional MRI to map eloquent regions of interest such as motor, sensory, and language functions to avoid unacceptable neurological deficits after surgery. Selected children may need invasive long-term electroencephalographic monitoring using stereotactically implanted intracranial depth electrodes or subdural grids. Surgical options include resective surgeries (lesionectomy, lobectomy, multilobar resections) and disconnective surgeries (corpus callosotomy, etc.) with the potential to obtain seizure freedom. Other surgical procedures, typically considered to be palliative are neuromodulation [deep brain stimulation (DBS), vagal nerve stimulation (VNS), and responsive neural stimulation (RNS)]. DBS and RNS are currently not approved in children. Pediatric DRE should be evaluated early considering the risk of epileptic encephalopathy and negative impact on cognition.
癫痫是儿童常见的神经系统疾病。它通常对药物治疗有效。然而，近三分之一的患者可能对抗癫痫药物有抗药性。应排除药物难治性癫痫（DRE）的可能原因，如药物依从性差和非癫痫性事件。在适当的两种抗癫痫药物试验失败后，应考虑对有局灶性 DRE 或分类不良的癫痫或有局灶性电临床特征的癫痫性脑病的患者进行手术评估。一项随机对照试验为儿科 DRE 的手术治疗提供了 I 级证据。术前筛查工作通常包括高分辨率癫痫方案脑磁共振成像（MRI）和高质量住院视频脑电图评估。在某些情况下，可能需要进行高级检查，如正电子发射断层扫描（PET）、单光子发射计算机断层扫描（SPECT）和脑磁图（MEG），尤其是当脑 MRI 正常时，需要进一步的解剖-电-临床一致性证据，以细化手术候选资格和手术策略。一些儿童可能还需要功能磁共振成像来绘制感兴趣的功能区，如运动、感觉和语言功能，以避免手术后出现不可接受的神经功能缺损。一些儿童可能需要使用立体定向植入的颅内深部电极或硬膜下网格进行有创的长期脑电图监测。手术选择包括切除性手术（病灶切除术、叶切除术、多叶切除术）和离断性手术（胼胝体切开术等），有获得无癫痫发作的潜力。其他手术程序通常被认为是姑息性的，包括神经调节[深部脑刺激（DBS）、迷走神经刺激（VNS）和反应性神经刺激（RNS）]。DBS 和 RNS 目前尚未在儿童中获得批准。应考虑到癫痫性脑病的风险和对认知的负面影响，尽早对儿科 DRE 进行评估。
