Academic outcomes for epileptic children post-surgery

A study of epileptic children indicates that those who had brain surgery struggled in their class post-surgery.

A new study by a University of Toronto Mississauga researcher has taken the first-ever look at the academic outcomes of children with epilepsy who have had brain surgery, and found that they have a higher chance of struggling in class following their surgery.

Psychology professor Mary Lou Smith was co-leader of a team of researchers who studied the arithmetic, spelling, reading and reading comprehension abilities of children after having resective epilepsy surgery, a procedure that involves removing a part of the brain in order to halt seizures. The patients completed standardized tests both before their surgery and about 14 months afterwards, and all received lower scores on the second test in the first three academic areas. The results, Smith says, challenge a commonly-held but false assumption that stopping seizures can free up brain power for better academic performance.

"The surgery stops the seizures, but it's not like we put a new brain in there. These children still have a preexisting brain abnormality," says Smith, a UTM psychology professor, and a senior associate scientist in the Neurosciences and Mental Health Program in the Research Institute of the Hospital for Sick Children. The study published in the June 2015 edition of the journal Epilepsy & Behavior.

Brain surgery is performed on patients who don't respond to drugs, and whose source of seizures can be pinpointed in the brain. Smith says that of the approximately 25 per cent of people for whom drugs don't work, about 30 per cent meet the criteria to have epilepsy surgery. Working with three other researchers from SickKids and UTM -- including two UTM graduates -- Smith examined the academic achievement levels of 136 children ages 5 to 18, most of whom live in Ontario, and who had underwent pediatric epilepsy surgery between 1995 and 2013. All had completed academic testing as part of their pre-surgical and post-surgical neurological evaluations.

In the pre-surgery tests, most of the children displayed low or underachievement in at least one of the academic domains. This is because children with epilepsy are at higher risk of having cognitive problems in areas such as language, problem solving, learning and memory. The children's post-surgery test results, meanwhile, revealed drops in marks when it came to reading, spelling and numeral operations. Most students decreased about two to six points, but some declined by 10 points or more. This means that while brain surgery can help improve patients' quality of lives by stopping seizures, it doesn't necessarily stall or reverse the tendency toward lower-than-average academic performance.

"What I think is happening now is as they're getting older, they're not progressing at the same rate their peers are progressing, and so as a result of that, over time, you see these lower scores, because the difference between their performance and what's expected given their increasing age is widening," Smith says.

Smith cannot say whether the findings are due to the surgery, the epilepsy, or the children's development, but she is now conducting more research to figure out why. Meanwhile, she says, this new study may be useful to families weighing the pros and cons of surgery for their child with epilepsy.

"This is a tremendously challenging decision for parents, and they want to know the risks and benefits," Smith says. "I think this information is very important for health care providers if they're counseling patients, and for pursuing evidence-based practice."

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Predicting surgery outcomes for epilepsy

This article explains two studies that try to predict surgery outcomes for kids with epilepsy.

Anti-epileptic drugs control seizures and improve quality of life for most people with epilepsy. But for those who find medical treatment ineffective or intolerable, brain surgery is sometimes the next best option. Two studies to be presented at the 68th AES Annual Meeting in December explore the outcomes of brain surgery for children with severe epilepsy.

One study created a decision analysis model to compare how two treatment strategies -medical treatment alone versus brain surgery -- influenced the life expectancy of pediatric patients with refractory epilepsy. Researchers at Boston Children's Hospital developed a decision analysis model with data from the literature. Their findings suggest that surgery increases the odds of a longer life expectancy, compared with medical treatment alone. For example, in a cohort of 10-year old patients, epilepsy surgery in patients with temporal lobe epilepsy yielded 55.2 years of life expectancy, while medical treatment yielded 49.3 years of life expectancy. In extratemporal epilepsy, surgery yielded 54.9 years of life expectancy while medical treatment only yielded 49.3 years. Authors note that the findings suggest that brain surgery is significantly more advantageous than medical treatment alone for eligible children with refractory epilepsy.

A second study examined the effectiveness of resective epilepsy surgery on seizure frequency in children with refractory epilepsy with features of Lennox-Gastaut Syndrome (LGS). Researchers studied 36 patients with LGS who had epilepsy surgery at the Cleveland Clinic for focal, lobar, multilobar resection or hemispherectomy between June 1, 2002 and June 31, 2012. Patients in this study developed epilepsy due to brain lesions or injuries sustained before they were born (17), immediately before or after they were born (10), or between the ages of 2 months and 3 years (9). At the time of surgery, the patients ranged in age from newborn to 18 years, and were experiencing multiple seizures per day.

At follow-up visits conducted 6 months to 6.6 years after surgery, 19 patients were seizure-free. Of the patients still experiencing seizures, two entered late remission 2 years after surgery and five became almost seizure-free, with an average of nine seizures per month. At the last follow-up visit, 24 patients were either seizure-free or had experienced a major reduction in seizure frequency.

"In the past, children with features of Lennox Gastatut syndrome were not considered to be candidates for epilepsy surgery that involves removal of the seizure focus," said Dr. Ahsan Moosa Naduvil, M.D., Staff, section of pediatric epilepsy, Cleveland Clinic Epilepsy Center. "Our study confirms that selected children with early brain lesions may be rendered seizure free with epilepsy surgery."

The authors performed a survival analysis based on the duration of time between seizures, and determined the chance of seizure freedom as 60.1% at 12 months, 51% at 24 months and 40.8% at 30 months or more. According to the authors, the findings suggest that resective epilepsy surgery is an effective treatment option for selected children with LGS secondary to early focal brain lesion or injury.

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Epilepsy surgery can improve children's behavior and mood

Children who undergo specific types of epilepsy surgery have shown to have their mood and behavior to be substantially improved post-surgery.

Certain types of epilepsy surgery led to significant improvements in children's mood and behavioral problems, a researcher said.

Children undergoing left-side resections were more likely to show neuropsychiatric symptom improvements if the target was in the frontal rather than the temporal lobe, while those having right-side surgeries had improvements irrespective of site, said Elizabeth Andresen, PhD, of theCleveland Clinic's Neurological Institute.

Relatively little improvement was seen in mood or behavioral symptoms in children with left-side temporal lobe seizure foci, but the baseline symptom burden was relatively lower to begin with, she said at a press briefing prior to her platform talk at the annual meeting of the American Epilepsy Society.

Andresen noted that neuropsychiatric complaints are extremely common in children with epilepsy. Previous studies have found a nearly five-fold increase in risk of such disorders in such children compared with the general population, and a 2.5-fold risk increase relative to children with other chronic diseases.

Some other studies have found improvements in such symptoms following epilepsy surgery, she said, but they had not examined whether the benefit varied with the surgical site, either by hemisphere or by lobe.

The study was based on a combination of child self-reports and parental assessments using standard instruments, administered before and after 100 surgeries in pediatric epilepsy patients. Of 54 left hemisphere resections, 38 were in the temporal lobe and 16 in the frontal lobe; of 46 right-sided surgeries, 26 were in the temporal lobe and 20 in the frontal.

At patients' neuropsychological evaluation after surgery, 83% were seizure-free. At last follow-up an average of 5 years after surgery, 57% of the cohort still had not had a recurrence of seizures. Patients were from 5 to 16 years of age (mean 11) at surgery, with mean duration of epilepsy symptoms of 5.3 years (SD 3.6).

In children with left-side resections, normalized T-scores for anhedonia, social anxiety, and withdrawn/depressed symptoms declined significantly for those with frontal lobe targets compared with temporal lobe patients.

• Anhedonia: 59 pre, 50 post in frontal lobe; 50 pre, 50 post in temporal lobe (P=0.009)
• Social anxiety: 59 pre, 42 post in frontal lobe; 49 pre, 48 post in temporal lobe (P=0.001)
• Withdrawn/depressed: 59 pre, 55 post in frontal lobe; 58 pre, 50 post in temporal lobe (P=0.039)

For right-sided surgeries, targets in both lobes were associated with declines in a "social problems" composite. Normalized T-scores for this measure declined from 69 to 64 with frontal lobe procedures and from 59 to 56 with temporal lobe resections (P=0.001 with respect to time and P=0.005 between groups).

Depression was significantly relieved after surgery when Andresen and colleagues analyzed the entire 100-patient cohort. Among the 25 patients rated as depressed prior to surgery, 64% were no longer depressed at follow-up.

Similarly, anxiety resolved in 60% of children with presurgical symptoms, Andresen reported.

She noted that 6% of children who had no symptoms of depression before surgery developed symptoms by the time of follow-up, and 11% of the cohort showed new postsurgical anxiety. But she said rates of emergent depression and anxiety symptoms were similar in a group of epileptic children not undergoing surgery who underwent the same neuropsychological testing.

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Predictors of success of epilepsy surgery

New research uses different factors to determine the potential success of epilepsy surgery.

According to this research, developed by researchers of the UPM, CSIC and the Princesa Hospital, personality style, intelligence quotient and hemisphere of seizure origin are factors that would help to predict successfully these surgeries, what would be helpful for surgeons. Researchers reached these conclusions by using predictive models based on machine learning techniques.

Epilepsy surgery is effective in reducing both number and frequency of seizures, particularly in patients withtemporal lobe epilepsy (TLE). However, a significant proportion of these patients continues suffering seizures after surgery.

In order to have information about the results before surgery, researchers from the Computational Intelligence Group of the Schools of Computing UPM assessed the influence of a battery of medical and psychological factors using predictive models developed from machine learning approaches.

They have identified three "very relevant" elements: the hemisphere of seizure origin, intelligence quotient and personality style (applying the Rorschach test). Researchers have obtained a success rate of 90% in terms of predicting the outcome after surgery by using advanced mathematical models for its combination.

From the researcher's point of view, this study opens the door for integration of complex mathematical models in previous assessment of surgeries. The team of medical assessor will have numerical results about the success of the surgery which are known as decision support tools.

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Compulsive Eating Eased by Brain Surgery

A 10-year old girl who suffered compulsive eating caused by a benign brain tumor has the compulsive eating under control after brain surgery to remove the tumor.

Removal of a rare type of benign brain tumor helped bring a young girl's compulsive eating under control, doctors report.

The 10-year-old had what's known as a hypothalamic hamartoma -- a tumor in or around the brain's hypothalamus. One of the symptoms of this type of tumor is extremely early (precocious) puberty, as well as compulsive eating and excessive weight gain.

As reported online April 9 in the Journal of Neurosurgery: Pediatrics, by age 10 the girl already weighed 227 pounds and was gaining an average of five more pounds each month. Medication and counseling did nothing to curb her overeating.

Despite the fact that there was no record of it having been done before, neurosurgeons at the University of Texas-Houston and Children's Memorial Hermann Hospital in Houston decided to remove the girl's hypothalamic hamartoma in an effort to curb her overeating. The doctors called it a "last-ditch effort."

"The decision to proceed with this surgery was undertaken with great thought and after numerous discussions with the patient's family," Dr. David Sandberg, one of the study authors, said in a journal news release. "We were cautious about proceeding with a major operation in which the probability of success was completely unknown."

However, the surgery went well, the girl's appetite immediately lessened and she began eating smaller portions. Eighteen months after the surgery, her weight was still the same as it was before the operation. But it no longer increased, which was the goal of the surgery.

"The patient, her family, and treating physicians were all delighted with the outcome," Sandberg said.

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