Abstracts

Seizure freedom in infantile spasms, hitherto considered a generalized epilepsy syndrome, was reported after surgical resection of focal abnormalities seen on brain PET or MRI. 45-67% patients became seizure free in early case series (9-23 patients) that were limited due to non-availability of high resolution brain MRI in all patients. We report the largest series, so far, of 38 children who had epileptic spasms, a high resolution brain MRI according to a standardized protocol, and underwent surgery for treatment of epilepsy. 41 of 220 patients evaluated for epileptic spasms at the Cleveland Clinic Epilepsy Center (1996-2004) were operated.38 of 41 met inclusion criteria: age of spasm onset [lt] 2years, pre-operative evaluation including video EEG monitoring and high resolution brain MRI (per standard protocol) at the Cleveland Clinic, surgical resection at the Cleveland clinic, and post-operative follow up of at least 6 months. 3 were excluded due to insufficient follow-up. 38 patients (24 males), mean age 4 months (0-21 months) at the onset of spasms, had surgical resection at a mean age of 26 months (2.5 months - 10 years). Mean pre-operative seizure frequency was 50 per day and children had failed a mean of 5.4 drugs prior to surgery. The interictal and ictal EEG were helpful in localization/lateralization in 30 (79%) and 29 (76%) patients respectively. 24 (63%) patients had some of their seizures with focal motor (tonic or clonic) features. 29 (76%) had focal or hemispheric cortical dysplasia, 5 (13%) had remote ischemic stroke, and 4 (11%) had tuberous sclerosis on brain MRI. Mean weight at surgery was 13 kg (5-44 kg). Surgical procedures included hemispherectomy in 27 patients, and lobar or multi-lobar resections in 11 (5 frontal, 5 temporo-occipito-parietal and 1 fronto-parietal) . 4 patients had repeat surgery (anatomic after previous functional hemispherectomy). At a mean post-operative follow up of 17 months (6 months-5 years), 28 (74%) were seizure free, 7 (18%) had [gt]75% reduction in seizures or freedom from most debilitating seizures, and 3 (8%) had no worthwhile improvement. Peri-operative complications included aseptic meningitis(9), intracranial bleeding or ischemic stroke(3), central line or wound infection (1 each) and hydrocephalus (1). There was no peri-operative death. 4 had worsening of pre-existing hemiparesis, 2 each had anticipated visual field deficit or hemiparesis that improved with therapy. Mean anti-epileptic drugs at the last follow up reduced to 1.3. Resective surgery is safe and effective treatment in carefully selected patients with epileptic spasms even at a very young age.Increased experience with high resolution brain MRI, surgical planning, anesthesia and intensive care support may further improve the chances of seizure freedom and lower the rate of complications in young sick infants.