Evaluation and Pre-treatment Planning of Pediatric Epilepsy: A Team Based Approach
ASNR 2019 Proceedings
Purpose Pediatric epilepsy is often managed conservatively, however some patients with drug-resistant epilepsy (DRE) may necessitate the need for surgical treatment. Thorough presurgical evaluation is essential, as a multitude of physiologic, anatomic, and psychosocial factors are involved in planning for epilepsy surgery. Detection of a surgically treatable lesion and its volume, can define the feasibility and type of treatment. This necessitates a combination of optimized imaging in concert with multiple other disciplines. Our purpose is to present a multidisciplinary approach used at our institution for presurgical evaluation in pediatric epilepsy surgery.Materials and Methods We will first review the components of our multidisciplinary epilepsy team (Pediatric Epileptologists/Neurosurgeon, Neuroradiologist, Neuropsychologist, among others). Subsequently we will review cases of DRE and highlight, step-by-step, our preoperative planning process and review each of the key components. •Medical history/physical exam (semiology of seizure) •Clinical testing: Scalp electroencephalography [EEG], Neuropsychological testing, Magnetoenecephalography [MEG], relevant laboratory studies •Imaging: MRI with epilepsy and presurgical protocol including specifics that we use to optimize detection of subtle lesions, functional MRI (fMRI), interictal FDG-PET, Ictal/ Interictal SPECT After completing the presurgical evaluation, the preimplantation "anatomo-electro-clinical" hypotheses formulation, a critical element in the process of planning the placement of Stereoelectroencephalography (SEEG) electrodes, will be generated to identify the epileptogenic region. Results Our multidisciplinary approach helps navigate the intricacies associated with preoperative evaluation of pediatric epilepsy. Identification of lesions by imaging is critical in seizure control. Gathered data affects the type of treatment, ranging from robotic guided laser ablation, to focal resection to functional hemispherectomy. Preoperative imaging of DRE is unique, given the subtle nature of cortical dysplasias, the necessity to correlate with other imaging (SPECT/PET, MEG), as well as correlation with the semiology of seizures. Conclusions Our institution has developed a multidisciplinary approach, utilizing advanced MR imaging and invasive preoperative planning (stereo EEG) to improve our ability to evaluate and treat complex cases of DRE. Following review of our workflow, the neuroradiologist, especially in centers that wish to pursue pediatric epilepsy management, should have an understanding of the steps involved and imaging protocols, in evaluating these patients.
Bhatt, M; Krishnan, A; Laoprasert, P; and Arndt, D, "Evaluation and Pre-treatment Planning of Pediatric Epilepsy: A Team Based Approach" (2019). Conference Presentation Abstracts. 12.