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Which patients are most likely to respond
Broadly, the etiology of epilepsy can be divided
into three groups. About 30 percent of cases are
presumed to be genetic — and among this group,
there is about a 90-percent response rate with drug
treatment. The second group — about 20 percent
of the patients — have a structural brain problem,
something we can identify on imaging studies.
This group fares the worst on drugs; only about a
50-percent response rate. These are also generally
the patients who might be candidates for surgery.
And then for the remaining 50 percent of cases,
we are unable to diagnose the cause.
The important thing from the perspective of
referring physicians is that among children with
structurally caused epilepsy, after they have failed
to respond to two or three drugs, the chance
of continued medical therapy controlling the
epilepsy is less than 5 percent. So there is no reason
to continue trying more drugs before referring to
a specialty center.
Beyond the daily impact, what is the long-term
danger of continued uncontrolled seizures?
Having medically refractory epilepsy has
two major impacts on a child’s life. Frequent
seizures, especially during the formative years
of early brain development — before age 5 and
especially before age 2 — are strongly linked to
significant developmental delay that is generally
not reversible. These children don’t gain their
intellectual capacities at the same rate as other
children, and our data suggest that if you don’t
obtain seizure control within about 18 months of
onset in a child, that child ending up with an IQ
above 80 is difficult if not impossible. Frequent
seizures are also associated with premature death,
generally from accidents and sudden unexpected
death related to epilepsy.
This poor natural history of the disease — cognitive
problems along with increased mortality —
justifies a surgical intervention in medically
refractory patients if a targeted area can be
identified, particularly because of our success
rates. So it is critically important that a child whose
seizures are not adequately controlled by two-to-
three trials of anti-epilepsy drugs be referred to a
specialty center for evaluation and treatment —
both to confirm the cause and to address whether
there are alternate treatments. UCLA’s Pediatric
Epilepsy Surgery Program is one such specialty
center, with more than 25 years of experience in
What does epilepsy surgery in children
involve, and what are the outcomes at UCLA?
Epilepsy surgery in children involves different
types of operations, from focal resections for
different etiologies to cerebral hemispherectomy —
removal of half of the brain. Many of these are very
rare, which is another reason for having a child
and family come to a major referral center where
there is experience in rare conditions. UCLA
has operated on more than 750 children, with
published outcome measures and quality metrics
that are among the best in the world. Our short-
and long-term seizure-free outcomes are 75-to-80
percent, and are sustained over many years post-
surgery. These outcomes have improved over time,
due to the tireless efforts of our team. This is a team
effort — including the pediatric epileptologist and
surgeon, who work together to assess the risks and
benefits of surgery in a particular case; and the
expertise of the anesthesiologists, pathologists,
pediatric intensive care unit and the imaging
group that has worked with us to develop new
technologies to identify subtle legions that would
have been missed five or six years ago.
Dr. Mathern operates on a young patient.
Epilepsy surgery in children involves
different types of operations, from focal
resections for different etiologies to
cerebral hemispherectomy — removal of
half of the brain.
Do those technologies help to identify more
Yes. We are better at identifying structural
abnormalities in the brain than we were even
10 years ago. We are able to move children from
the group whose epilepsy has an unknown origin
to the group with a known structural cause by
using more advanced imaging, as well as through
refinements in our EEG technique. It’s important
to stress that referral to our center doesn’t mean
that every child gets surgery. We start with a
comprehensive evaluation by our team of experts.
Tests may include inpatient video EEG monitoring
to capture and characterize the seizures; and
imaging, such as FDG-PET and MRI. If the child
is truly medically refractory and we have a target,
then we will offer surgery.
“UCLA has operated on
more than 750 children,
with published outcome
measures and quality
metrics that are among
the best in the world.”
7 UCLA Physicians Update