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 Seventy-seven percent of the children were free of seizures at one
year after the surgery, compared with seven percent in a control
group of youngsters who received medical therapy alone while waiting
for surgery. Behavior and quality of life also improved.
But surgery also produced serious adverse effects in one-third of
the children, most frequently a weakness on one side of the body,
known as hemiparesis. The researchers said that was to be expected
and, without surgery, patients probably would have experienced
similar problems as a result of their continuing seizures.
"What the study clearly shows is surgery for children produces
seizure freedom compared to children not operated on for similar
conditions," senior author Dr. Manjari Tripathi, a professor of
neurology and epilepsy at the All India Institute of Medical
Sciences in New Delhi, told Reuters Health in a telephone interview.
Not only "does it reassure us that several surgical procedures are
effective," she said, it demonstrates that surgery "should be done
as early as possible" once it becomes clear that a child is not
responding to two anti-seizure medications.
About 50 million people worldwide suffer with epilepsy and drugs
can't control the seizures in approximately 30 percent of the cases.
"This is the first randomized study to look at surgical outcome in
children," said Dr. Donald Schomer, director of the Comprehensive
Epilepsy Program at Beth Israel Deaconess Medical Center in Boston.
He was not involved in the research.
"The results are impressive," he told Reuters Health by phone.
Adults who undergo surgery often suffer from the collective effect
of years of uncontrolled seizures. "The study in kids shows if you
reduce the time from the onset of seizures from the 15 to 20 years
you see in adults down to four to five years, the outcome is much
better. It's documentation that these techniques really work."
Although 77 percent were judged by the Tripathi team to be
seizure-free at the end of the study, some of those children
actually had seizures immediately after surgery. Yet the cases were
judged to be a success because the seizures decreased in frequency
over time. Ultimately, 37 percent never had a seizure in the year
after surgery.
When all seizures were taken into account, children who did not have
surgery were four times more likely to have a seizure during that
year than youngsters in the surgery group, the researchers
calculated.
Success rates ranged from 87 percent to 100 percent depending on the
type of surgery used to correct the child's particular brain
abnormality.
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Surgery improved quality of life and social well-being, and it
didn't affect IQ, something that can decline with ongoing seizures.
But Dr. Schomer said the children were only followed for one year,
and "that may be too soon to see a noticeable change" in the
intelligence quotient.
Post-surgery weakness was seen in 15 of the 19 patients who had a
serious side effect following surgery.
The weakness "is significant," Dr. Tripathi said. "The child may not
be able to ambulate by his- or herself. But with physical therapy,
all regain the lower and upper limb function within six months. The
only thing that does not improve is the wrist and the fingers. They
are left with this minor deficit. But even before surgery, some of
them have this weakness."
Other side effects depended on the area of the brain that was
removed or disconnected from the rest of the brain.
In contrast, 16.5 percent of the children waiting for surgery had a
serious injury as a result of their continuing seizures.
The surgery "had a transforming effect on how they get along in
life," Dr. Tripathi said. "Many could go back school earlier or go
back to being tutored, and get on with their life."
But a major problem facing these children is getting insurance
companies to pay for such surgeries, said Dr. Schomer of Beth
Israel.
Rather than pay $35,000 to $50,000 on surgery that might cure the
problem and prevent further damage to the child, insurance companies
prefer to demand that more drugs be tried, even if the odds of them
working in drug-resistant cases is small, he said.
"Studies like this lend credence to the idea that the earlier you do
it, the better the outcome," he said. "I hope insurance companies
will look at this and realize that early detection and surgery, if
appropriate, will ultimately save them money in the long term."
SOURCE: http://bit.ly/2gVClQv The New England Journal of Medicine,
online October 25, 2017.
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