Pediatric Epilepsy Program Offers Advanced Treatments
John N. Gaitanis, MD, is a pediatric neurologist at Hasbro Children’s Hospital.
Epilepsy is the most frequent chronic neurologic condition in childhood, affecting one percent of children worldwide. Fifty million people worldwide have epilepsy.
Because of the strong interdisciplinary collaboration in the Pediatric Epilepsy Program we have been developing since 2019 at Hasbro Children’s Hospital, we are able to offer very advanced therapies for children in southern New England who have epilepsy. Surgical treatment for epilepsy is among them.
When a child fails to respond to medications, he or she is said to have pharmacoresistant epilepsy. Pharmacoresistance implies that you have tried at least two medications that should control seizures and have failed to get relief. Unfortunately, one-third of people with epilepsy do not respond to anti-seizure medications.
Patients of the Pediatric Epilepsy Program receive diagnostic evaluation and treatment that is carefully tailored to maximize seizure control and minimize impact on cognition, learning, and other developmental areas of concern.
Advanced Diagnostic Testing
One advanced diagnostic test that we employ at Hasbro Children’s Hospital is stereotactic electroencephalography (SEEG).
The precision of traditional scalp electroencephalograms (EEGs) is limited by the filtering effect of the layers of bone and tissue between the scalp electrodes and the epileptogenic zone (where the seizure activity originates). SEEG, while invasive, provides a far higher quality of signal for the physician to interpret, and yields precise information about the area of the brain where the abnormal electrical activity is taking place.
In intractable cases of epilepsy, when you need to consider removing an area of the brain to stop the seizures, you need to be extremely accurate, and that’s where recording abnormal electrical activity directly within the brain is fundamental.
SEEG begins with a minimally invasive operation in which a neurosurgeon — in our case, Dr. Konstantina Svokos or Dr. Wael Asaad — places extremely fine electrodes into the brain, usually in more than one location. The child then stays in the hospital under close clinical and EEG monitoring until he or she experiences one or more seizures, and the implanted electrodes record precisely where they originate.
There are many techniques that we can use to remove the area where seizures originate. One is the classic craniotomy, where the surgeon opens the skull and surgically removes the epileptogenic area. A less invasive technique is laser ablation, which uses heat to destroy the brain tissue that causes the seizures.
We did the first stereo EEG procedure in the history of Hasbro Children’s in February 2020. We are now capable of utilizing laser – again, never done previously in children at our hospital — and we are also exploring another technique called responsive neurostimulation (RNS), which is approved for use in adults, but can be considered for off-label use in select younger children.
The RNS device is similar to a heart pacemaker, but it monitors brain waves with tiny electrodes implanted in areas where seizures are originating. When activity that indicates a seizure is detected, it emits small bursts of stimulation, with the aim of helping brain waves return to normal.
RNS is an option when invasive EEG shows that seizures are originating from a crucial part of the brain that you cannot surgically resect or destroy with laser because it controls language or movement, for example, or when seizures are originating from multiple areas of the brain. In such cases, before RNS was invented, we had no targeted therapeutic option.
Chances of seizure control after failing two medications are extremely low: less than 2 percent. By comparison, an appropriately chosen candidate for surgery can be free of seizures in as many as 80 percent of cases.
When you evaluate a child for an invasive procedure, you have to keep in mind how much the seizures are impacting their life. One end of the spectrum is a child with an explosive onset of epilepsy who experiences several seizures a day and has failed two drugs in eight months, such as an 8-year-old girl who is a patient of mine, while others may take years to become drug resistant. Watch the story on turnto10.com.
Side effects of medications can affect a child’s academic performance and psychosocial development. Epilepsy is linked to psychiatric comorbidities such as depression, anxiety and ADHD and contributes to high unemployment later in life. People with epilepsy in adulthood are less likely to be able to find a life partner or form a family. There still is significant social stigma surrounding epilepsy, even in high-income countries.
Early Diagnosis of Children with Epilepsy Is Vital
Diagnosing and treating children who have epilepsy early is vital, because you are setting them up for the best possible outcome in their lives. Many will go on to graduate from college, to have families, to live independently.
The pathway to surgery is can be long and complex, and often entails several tests and procedures. It’s an emotional journey for the family, as well as physically draining. However, with surgery, a child is given the possibility of achieving seizure freedom. When they continue to rely on medication, that may not be the case.
At Hasbro Children’s, our Pediatric Epilepsy Program Surgical Conference meets monthly to discuss the options for each patient. Our collaborative team of experts includes epileptologists, neurosurgeons, neuropsychologists, neuroradiologists, specialized nursing and technical teams, and nutrition specialists.
Having a comprehensive pediatric epilepsy program at Hasbro Children’s Hospital has many implications. Advancement in patient care is our most important goal. But there are other benefits, such as the valuable research that is ongoing in an academic medical center like ours.
At Hasbro Children’s Hospital, we now have a full array of options for treatment of pediatric epilepsy. It’s exciting to see how things are developing and we look forward to helping all children in our community achieve a life free of seizures.