Characteristics Leading to Delayed Surgical Referral for Children with Drug Resistant Epilepsy
Abstract number :
1.33
Submission category :
9. Surgery / 9B. Pediatrics
Year :
2023
Submission ID :
409
Source :
www.aesnet.org
Presentation date :
12/2/2023 12:00:00 AM
Published date :
Authors :
Presenting Author: M. Scott Perry, MD – Cook Children's Medical Center
Grace Newell, MD – Texas Christian University, Anne Burnett Marion School of Medicine; Dallas Armstrong, MD – University of Texas Southwestern Medical Center; Kinza Meghani, NA – University of Texas Southwestern Medical Center; michael Ciliberto, MD – University of Iowa Hospitals and Clinics; Jason Coryell, MD – Oregon Health and Sciences University/Doernbecher Children's Hospital; krista Eschbach, MD – University of Colorado/Children's Hospital Colorado; Allyson Alexander, MD – University of Colorado/Children's Hospital Colorado; pradeep Javarayee, MD – Medical College of Wisconsin/Children's Hospital of Wisconsin; kheder Ammar, MD – Children's Healthcare of Atlanta; Satya Gedela, MD – Emory University College of Medicine/Children's Healthcare of Atlanta; cemal Karakas, MD – University of Louisville School of Medicine/Norton Children's Hospital; Samir Karia, MD – University of Louisville School of Medicine/Norton Children's Hospital; Jeffrey bolton, MD – Boston Children's Hospital; Dewi Depositario-Cabacar, MD – George Washington University/Children's National Hospital; Ernesto Gonzalez-Giraldo, MD – University of California-San Francisco; Zachary Grinspan, MD, MS – Weill-Cornell Medicine; Srishti Nangia, MD – Weill-Cornell Medicine; Jason Hauptman, MD – Seattle Children's Hospital; Ahmad Marashly, MD – The Johns Hopkins Hospital; michael McCormack, MD – vanderbilt University/Monroe Carell Jr Children's Hospital; Shilpa Reddy, MD – Vanderbilt University/Monroe Carell Jr Children's Hospital; patricia McGoldrick, MD – Boston Children's Health Physicians of NY and Connecticut; Steven Wolf, MD – Boston Children's Health Physicians of NY and Connecticut; Nancy Mcnamara, MD – Michigan Medicine; Erin Romanowski, MD – Michigan Medicine; joffre Olaya, MD – Children's Hospital of Orange County; Daniel Shrey, MD – Children's Hospital of Orange County; debopam Samanta, MD – University of Arkansas for Medical Sciences; Rani Singh, MD – Atrium Health/Levine Children's Hospital; Primyavada Tatachar, MD – Ann and Robert H Lurie Children's Hospital; Lily Wong-Kisiel, MD – Mayo Clinic College of Medicine; Adam Ostendorf, MD – Ohio State University/Nationwide Children's
Rationale: Approximately thirty percent of children with epilepsy do not achieve seizure freedom with anti-seizure medications (ASMs) and are diagnosed with drug resistant epilepsy (DRE). Epilepsy surgery is frequently the best next treatment, however, many children experience delays to surgical referral. Identifying patient characteristics leading to delayed evaluation is critical to shorten the duration to surgery and improve outcomes.
Methods: We identified children ≤18 years of age at the time of surgical evaluation enrolled in the Pediatric Epilepsy Research Consortium Surgery Database. Only children undergoing their first surgical evaluation were included and children without data on number of failed ASMs prior to evaluation were excluded. We defined delay to surgical evaluation via two methods: 1) failure of three or more ASMs prior to surgical evaluation or 2) surgical Phase 1 evaluation >1 year from failure of their second ASM. We then compared sociodemographic and epilepsy variables for patients failing ≤2 vs three or more ASMs and patients evaluated ≤1 year vs >1 year from failure of second ASM. Chi-square tests for categorical data and independent t-tests for numerical data were performed using SPSS. Using binary logistic regression, variables of significance were analyzed and identified followed by multilinear regression to determine the most impactful variable(s) leading to surgical evaluation delay. For significant characteristics, we investigated if they influenced surgical outcome defined using the Engel scoring system.
Results: A total of 1,767 patients were included: 802 (45%) failing ≤2 ASMs vs 965 failing three or more. Age at failure of second ASM was known for 1044 (59%) patients, 578 referred for evaluation ≤1 year and 466 referred >1 year from DRE diagnosis. Children with delayed surgical evaluation often have generalized seizures, abnormal neurological exams, early age at epilepsy onset, failure of VNS or Ketogenic diet, and undergo palliative procedures (Tables 1 and 2). When defined by three or more ASM failure, delayed surgical referral is most influenced by palliative surgical intent and abnormal neurological exams, followed by age at referral and seizure onset (p< 0.03). When delay was measured by duration from DRE diagnosis, younger age at referral followed by younger age at failure of second ASM had the greatest impact (p< 0.001). While the majority of patients in both delayed groups had palliative surgeries, 63% of those surgeries resulted in favorable outcomes (Engel 1, 21%; 2, 17%; 3, 25%) at the longest duration of follow up (mean duration of follow up was 14.6 months).
Surgery