OBJECTIVE
Surgery is an effective, yet underutilized treatment for children with drug-resistant epilepsy. Although predictors of surgical outcomes are well described, the decision to recommend surgery varies by institution. We aim to evaluate the rates of not recommending surgery, identify associated patient characteristics, and quantify variability across centers.
METHODS
We queried the Pediatric Epilepsy Research Consortium Surgery database, a prospective multicenter cohort of children (0-18 years) undergoing initial evaluation for epilepsy surgery. Patients with documented surgical decisions were included. Demographic, clinical, and presurgical evaluation variables were compared by surgical recommendation status. Logistic regression identified factors associated with not recommending surgery. Mixed-effects models quantified between-center variability.
RESULTS
Among 2480 patients across 29 centers, 532 (21%) were not recommended epilepsy surgery (median center rate 17%, interquartile range [IQR] 10%-28%). After accounting for patient characteristics associated with surgical candidacy, substantial variation in decision-making remained across centers, with a median twofold difference in the odds of not recommending surgery between otherwise similar patients evaluated at different institutions (Median Odds Ratio = 2.25; Intraclass Correlation Coefficient = .18). The clinical characteristics most strongly associated with not recommending surgery included monthly or less frequent seizures (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.75-2.69), non-structural etiology (OR 2.02, 95% CI 1.56-2.61), and taking ≤2 anti-seizure medications (ASMs) (OR 1.67, 95% CI 1.34-2.08, all p's < .01). These characteristics showed minimal clustering across centers (ICCs < .05).
SIGNIFICANCE
One in five children evaluated for epilepsy surgery are not recommended to pursue surgical treatment. Although clinical factors influence decision-making, they do not explain the substantial variation in recommendations across pediatric epilepsy centers. Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
A. Caraway, Nancy A Mcnamara, Andrew T. Knox et al.· Epilepsia· 0 citations
BACKGROUND AND OBJECTIVES
Despite its proven effectiveness, epilepsy surgery for drug-resistant epilepsy (DRE) remains underutilized and frequently delayed. Previous studies of epilepsy duration before surgery-using variable delay thresholds (2-20 years)-were small, single-center cohorts focused mainly on temporal/frontal lobe epilepsy, showed better seizure freedom with earlier surgery, but did not distinguish total epilepsy duration from DRE duration. As contemporary epilepsy surgery now includes broader indications and emphasizes faster evaluation, the timing and impact of evaluation across this wider population remain unclear. We examined factors associated with evaluation timing from DRE diagnosis and its effect on surgical outcomes in a large multicenter cohort.
METHODS
Using a prospective database across 29 US centers, we analyzed associations between patient and epilepsy factors and DRE-to-evaluation interval-defined as the interval from DRE diagnosis to phase 1 video-EEG admission, categorized as shorter (<1 year) or longer (≥1 year)-and compared seizure freedom between groups using multivariable logistic regression adjusted for etiology, seizure type, neuroimaging, and surgical factors.
RESULTS
Among 1,310 children, 720 (55%) had shorter and 590 (45%) longer DRE-to-evaluation intervals. Shorter interval was associated with lesional epilepsy (OR 1.65, 95% CI 1.30-2.08), focal seizures (2.80, 2.13-3.70), and normal neurologic exams (1.86, 1.49-2.33). Structural congenital and acquired etiologies were linked to shorter interval, while genetic etiologies (1.73, 1.30-2.32) were linked to longer interval. Among 624 surgical patients (357 shorter, 267 longer), seizure freedom occurred in 53% vs 27% (3.04, 2.17-4.29; p < 0.01). After adjustment, longer interval remained independently associated with lower seizure freedom (0.59, 0.35-1.00; p = 0.0497). DRE-to-evaluation interval, not total epilepsy duration, predicted outcomes.
DISCUSION
In this first large multicenter study across diverse epilepsy types applying a 1-year benchmark, nearly half of pediatric patients experienced delays, particularly those with MRI-negative, generalized, or genetic epilepsies. Delays from DRE diagnosis were independently associated with reduced seizure freedom, supporting presurgical evaluation within 1 year as an evidence-based quality benchmark.
Debopam Samanta, A. Caraway, Andrew T. Knox et al.· Neurology Clinical Practice· 0 citations