The advantages of operating on a child at an earlier age include not only the benefit of improved recovery from morbidity, but also the decreased impact of drug toxicity and ictal events on the child’s functional development.
The choice of surgical procedure depends on the nature of the seizure syndrome. The ideal indications for epilepsy surgery both in the adult and the pediatric populations are disabling seizures that are refractory to high therapeutic levels of AEDs and secondary to a well-defined region of seizure onset that lies within functionally silent cortex. A focal cortical resection, either temporal or extratemporal, is appropriate if the seizure focus can be localized to a specific cortical area. When there is no clearly localized focus, a focus within eloquent cortex, more than one focus, or generalized seizure activity, especially with atonic or tonic events leading to drop attacks, a disconnection procedure such as a corpus callosotomy or multiple subpial transections may be appropriate.
Those patients with a focal area of abnormality and undergo a focal resection have the greatest chance of achieving a seizure-free state. For those to undergo a corpus callosotomy, this is more a palliative procedure that while it may greatly benefit the patient in regard to specific seizure type and quality of like, is not likely to achieve complete seizure control. Temporal lobe resections account for approximately two-thirds of all procedures currently performed at epilepsy surgery centers, reflecting the predominance of adult patients with intractable temporal lobe epilepsy.
In pediatric epilepsy surgery centers, greater proportions of patients undergo extratemporal, multilobar, and hemispheric resections, though temporal resections still predominate. The surgical options and techniques for epilepsy surgery in children are described briefly here. It would be otherwise beyond the scope of this medium to other than highlight the important facets.
Lastly, it is important for the patient and the family to understand the expectations as to outcome and risk/benefit in advance of surgery. When dealing with the pediatric patient, family expectations as to "perfect" outcomes must be addressed. Often these children have multiple underlying abnormalities that while a successful surgery might make the child seizure free, the long-term outcome as to function, cognition, and behavior may not be optimal. Discussing these concerns preoperatively is necessary so as not to build in unreasonable hope of a completely normal child.