- A presurgical evaluation should be considered once a child has not achieved seizure control with two standard anticonvulsants. While waiting for evaluation the 3rd anti-epileptic should be used.
- History
- Perinatal,
- Medical,
- Seizure
- Neurologic examination;
- Video-EEG capture of stereotypical seizures;
- High-resolution MRI
- Neuropsychological examination.
- If isolated lesion noted and lesion not in eloquent areas then can proceed to surgery
- e.g. AVM, tumor
- On occasion intraoperative electrocorticography at the time of planned resection may be adequate/more appropriate than a staged approach.
- If no isolated lesion additional tests to better delineate the epileptogenic zone and functional eloquent cortex
- Language, memory, motor; e.g. PET, SISCOM, magnetoencephalography, fMRI, and Wada testing
- Invasive monitoring in children
- Like adults
- Aims
- Better define the epileptic zone
- Perform extraoperative mapping of potentially eloquent cortex.
- Indicated
- In selected patients invasive monitoring can delineate a seizure focus in the presence of unremarkable MR images.
- Noninvasive methods cannot lateralize the seizure focus
- The seizure semiology + EEG suggest a focal onset but
- Initial bilateral implantation of electrodes may allow lateralization,
- Additional electrodes can then be placed in that hemisphere for specific localization of the seizure focus for resection.
- Equally this approach may show bilateral independent foci—for which surgical resection is rarely an option (though may be in tuberous sclerosis).
- Done for
- Patients with any discordance among their presurgical studies, or with whom there is any concern about overlap of the resection margin and eloquent cortex, invasive monitoring may give the best chance of long-term seizure control without postoperative deficits.
- A greater number of implanted electrodes tends to correlate with improved seizure control after resection, and allows cortical mapping to be tailored to optimize the yield of information especially given the challenges of
- Cognitive, behavioral, and attention problems that may hinder the ability of children with intractable epilepsy to perform specific tasks required for mapping,
- Mapping-induced seizures, and
- Atypical functional anatomy in children who have had seizures during brain development (e.g. language areas relocate).
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