Pediatric Epilepsy Surgery

Additional Info

• Audio File:uab/ua171.mp3
• Doctors:Rozzelle, Curt;Blount, Jeffrey
• Featured Speaker:Curt Rozzelle, MD | Jeffrey Blount, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4194
• Guest Bio:Curt Rozzelle, MD is a Professor and Director of the UAB Neurosurgery Residency Program. 
  
  Learn more about Curt Rozzelle, MD
  
  Dr. Blount participates in the full spectrum of pediatric neurosurgery but has particular academic interest in the surgical treatment of epilepsy in children, spina bifida, transitional care in spina bifida and public health issues in pediatric neurosurgery. Dr. Blount joined the faculty at UAB in 2000 and is the chief of pediatric neurosurgery. 
  
  Learn more about Jeffrey Blount, MD 
  
  
  Release Date: September 24, 2020
  Expiration Date: September 24, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenters:
  Jeffrey P. Blount, MD
  Chief, Pediatric Neurosurgery, President of the Medical Staff, Children’s Hospital of Alabama
  
  Curtis J. Rozzelle, MD
  Professor, Pediatric Neurosurgery
  
  Dr. Rozzelle has the following financial relationships with commercial interests:
  
  Consulting Fee - Phillips Law Group, P.C., Phoenix, AZ; Campbell, Yost, Claire & Norell, P.C., Phoenix, AZ
  
  Dr. Rozelle does not intend to discuss the off-label use of a product. Dr. Jeffrey Blount and no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:Introduction: UAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please visit UAB medicine.org/medcast, and complete the episodes Post-test. Welcome to UAB MedCast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
  
  Melanie Cole: Welcome to the UAB MedCast. I'm Melanie Cole, and today we're providing an update on the latest surgical interventions and techniques for treating epilepsy in the pediatric population. Joining me in this panel is Dr. Curt Rozzelle. He's a Professor and the Director of the UAB Neurosurgery Residency Program and Dr. Jeffrey Blount. He's the Director in the Division of Pediatric Neurosurgery at UAB Medicine. Gentlemen, it's a pleasure to have you join us today. And Dr. Blount, I'd like to start with you, please tell us a little bit about the prevalence of epilepsy in the pediatric population to kind of set the stage for us. What are you seeing in the trends?
  
  Dr. Blount: So, epilepsy is a very common neurologic illness. About one child in 20 will have a seizure before their 20th birthday. Now one seizure does not epilepsy make, but as a general rule, a seizure becomes epilepsy after about the third seizure. So if you take a population as big as Alabama, that has just under 5 million people, and about a third of them are children. That's about 1.5 million people. If you take a rough estimate that about one in 25 or one in 50 will have epilepsy, you can see how we have thousands of children within the state that have this disease. The bigger issue for us as surgeons is the recognition that came along, oh, about 20 or 25 years ago, that only about two thirds of children respond to medical treatment for their epilepsy. And that one third, that didn't re that don't respond previously had no treatment options, but over the past generation, we've been able to recognize that surgery may play an important role in their care.
  
  Host: Well, thank you for that. And Dr. Rozzele, how have surgical indications evolved over time to encompass a wider variety of epilepsy types, applying epilepsy surgery to more patients? Why are there now more options for pediatric patients with refractory epilepsy, not previously deemed surgical candidates?
  
  Dr. Rozzelle: So theoretically, any child whose seizures can't be controlled medically, which again is about a third of all who have recurrent seizures, is potentially a candidate for epilepsy surgery. And as Dr. Blount mentioned, this is something that's come along really in the last 20, 25 years, prior to that epilepsy surgery was generally thought of in the medical community as almost an experimental sort of procedure. But as surgical treatment options for epilepsy have proven to be effective for the majority of patients who can't be controlled medically that has established epilepsy surgery as an effective and accepted treatment option for those selected patients. And while that initial experience and shift was predominantly in the adult population, as epilepsy surgery has proven to be safe and effective for more and more patients it's been offered and, and found to be just as safe and effective in pediatric patients, if not more so, because the potential advantage of curing someone's epilepsy earlier in life means they reap more benefits for the rest of their life than if they achieve a cure only after adulthood.
  
  Host: Dr. Blount tell us some of the current indications for surgical intervention, speak about patient selection. And while you're doing that, you can tell us about some of the various surgical options that exist based on the seizure type lesion type, give us some of the characteristics that you're looking for?
  
  Dr. Blount: Okay. So the key considerations for candidacy for epilepsy surgery are that the disease is medically resistant. And the Quantum Brody Paper from the New England Journal was, was a landmark paper in this because it showed that if you don't control on two medications, your likelihood of attaining seizure control is less than 5%. So delays in referral are not to the patient's best interest that patients need to be tried on two medications at appropriate dosages and intervals, and given an adequate time for the anti epilepsy meds to work. But if they fail to meds, they should be considered for S for epilepsy surgery. The concepts then center on localization. We attain localization through a stepwise process with our epileptologist. It starts with video EEG, not just a short one, but on prolonged video EEG to attain regional localization. MRI then looks for structural abnormalities and we do functional imaging.
  
  Functional imaging means either PET, IPTIL SPECT, or MEG. Each of those has their own pluses and minuses that can be developed separately, but conceptually globally to implicate a region of brain. The fundamental concept is concordance of information. And we meet in an epilepsy surgery planning conference to discuss the findings of all of those findings. We discuss it. And then we confer with the families. We make recommendations for implantation of a electrode strategies, which then guides resection. Those are the fundamental principles. So any kid who has medical resistance is potentially a good candidate.
  
  Dr. Rozzelle: So, I think it's also worth looking at this from a little different perspective, and that is our ideal surgical candidate would be a child with refractory epilepsy who were able to localize the region of the brain. That's the source of their seizures with multiple con-coordinate testing modalities and critically that that region of brain that should not be in eloquent cortex. And so that's a patient that we have a very high likelihood of curing their epilepsy either with a surgical resection or with an ablative treatment option.
  
  Dr. Blount: I completely agree with that and appreciate the refinement on my comment. I would also add that even kids that have a more generalized process still potentially can benefit from tools in the surgical toolbox, which is to say kids with medically resistant, generalized epilepsy are potential candidates for implantation of a Vega nerve stimulator, which is a very helpful device for kids that have generalized epilepsy. So medically resistant epilepsy is really the fundamental overarching principle that if kids are suffering, if they are still seizing, that a surgical review is probably worthwhile.
  
  Dr. Rozzelle: Yeah, I agree. I was only describing sort of our ideal scenario, but that's not to say that we don't have effective treatment options that are surgical, that we can offer patients that don't quite meet our ideal set of criteria for sure.
  
  Host: Dr. Rozzelle, do you feel that despite the growing appreciation for the developmental and psychosocial effects of pediatric drug resistant epilepsy, do you feel there are too few surgical referrals and Dr. Blount mentioned early referral, what do you attribute this to? And please reiterate the importance of early referral.
  
  Dr. Rozzelle: So I think there's still a substantial reluctance in the community, both on the professional side with potential referring physicians and, and, and I'm sure from parents as well, because the idea of brain surgery is frightening and it's not, not something that should be taken lightly but the potential and real adverse effect of continued seizures that aren't controlled are over time, much more detrimental to the patient then the risk of surgical intervention. So statistically there's every reason to think that there are a lot more patients out there that we could help with surgery than we're currently seeing.
  
  Host: Dr. Blount, as we wrap up, speak about patient outcomes for this population, why is this continuum of care so important for success?
  
  Dr. Blount: Epilepsy surgery that's carefully planned and executed has a very high safety margin and a very good effectiveness. Depending on how crisply the epilepsy localizes, north of 70% of kids that undergo epilepsy surgery can be rendered either seizure-free or with such a low seizure burden that things are readily controlled with medication. That's a market difference from where many of these kids start. The incidents of complications related to epilepsy surgeries in general, quite low as Dr. Rozzele alluded earlier, it still remains surgery. And we're very upfront with patients about the small level of real risks that do exist, but it's a low risk profile. And it's significantly lower than what we refer to as the natural history of the disease, which is if it's left untreated. So rough rule of thumb is about two thirds likelihood of being able to make a very substantive impact with about a five to 8% collective risk of any sort of problem whatsoever. And about half that for any sort of long lasting unexpected problem.
  
  Dr. Rozzelle: I just wanted to add that a newer, contemporary less invasive options, both for the placement of intracranial electrodes and for bleeding seizure focus that that can help ameliorate some of the patient and family anxiety regarding surgical treatment of epilepsy, because we can accomplish a lot of the things now with minimally invasive techniques that used to require a craniotomy opening and exposing the brain.
  
  Host: And Dr. Rozzele as a last word. The UAB Epilepsy Center has a focus that's engaging multidisciplinary teams to best treat your patients. Please tell us what this looks like for your team. Tell us a little bit about why this is so important and what you would like referring physicians to know about the center?
  
  Dr. Rozzelle: Well, the center is very much a multidisciplinary effort, and as Dr. Blount alluded to earlier, it all starts with the initial evaluation in the epilepsy monitoring unit under the direction of our epilepsy neurology colleagues. But that's only the beginning. The team includes a number of advanced practice nurses. Neuro-Psychology is a very critical component of the entire program because we're not only trying to stop seizures, but we're trying to preserve, and perhaps even create a situation for improvement in the in the patient's psychosocial development, learning, etcetera. We rely very heavily on a number of different imaging modalities. So our radiology colleagues also provide a very important contribution to the overall effort. And it all comes together once a week, which coincidentally that that'll be later this morning, every Wednesday, we have our multidisciplinary epilepsy surgery patient evaluation conference, where patients are presented one at a time, we review all of the evidence of where their are coming from. And then there's a group discussion to consider the advantages and potential downsides of the various treatment options that we have available so that we can then carry to the family a consensus recommendation for what we think is the best approach for their child's individual clinical scenario.
  
  Dr. Blount: I completely agree with that. Can I just add the one point that I would also make is that it's important to remain the context that this morning we've been talking about the pediatric effort and in under the broad UAB umbrella there's also an adult program that is very vigorous and undertakes exactly the same activities in the adult community. And each program is busy enough that we're very collaborative and very cooperative, but we do our daily work separate from one another. But the point to emphasize to referring physicians is that state-of-the-art surgical evaluation and care for epilepsy is available both for adult and pediatric populations under the broad UAP umbrella.
  
  Host: Thank you gentlemen so much for joining us today and telling us about the UAB Epilepsy Center. It was fascinating information and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of the UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
• Hosts:Melanie Cole, MS