Can the long-term prognosis of patients with seizures and structural brain lesions be improved by surgical treatment?

Sillanpää et al.1 demonstrated in their prospective study lasting more than 20 years and involving 220 Finnish children with epilepsy that the majority of these patients were seizure-free by the time they became adults. Interestingly, 123 of the originally recruited 245 children had remote symptomatic seizures. Since the study began before neuroimaging techniques such as computed tomography (CT) and magnetic resonance imaging were readily available, it makes sense that the authors reclassified the cause of seizures in numerous patients, thereby reducing the proportion of patients with cryptogenic epilepsy. Gastaut and Gastaut2 examined 42 children with Lennox–Gastaut syndrome (LGS) by CT with abnormal findings in 25 patients including four cases of porencephalic cysts. It is notable that, in Sillanpää’s study, 33 of 39 epileptics who died had remote symptomatic seizures and that, as expected, patients with remote symptomatic seizures were significantly less likely to have a remission. Their proportion in remission was 10% at 15 years after the onset of epilepsy and 25% at 31 years (n = 123). In contrast, 50% of patients with idiopathic seizures (n = 68)were in remission at 15 years after the onset of epilepsy, and 85% at 31 years. We agree with the author’s suggestion that in selected situations, children and adolescents with persistent seizures may be candidates for surgery. However, timely identification of potential candidates for surgery has suffered from the imprecise definition of medically refractory epilepsy3. Children with intractable generalized seizures such as West syndrome (WS) and LGS were usually not considered candidates for cortical resection, because the seizure onset could not be localized to one cortical area. However, we have recently shown that early (not necessarily after 2 years of appropriate but unsuccessful medical therapy) surgical intervention may benefit children with porencephalic cysts and seizures such as WS and LGS4. Of 37 children, 23 (62%) were seizure-free postoperatively and 32 children (86%) had at least a worthwhile reduction according to Engel’s classification. We did not examine the long-term prognosis including social, educational, and employment outcomes in our retrospective report. It certainly would be interesting to prospectively study patients with structural brain lesions and epilepsy5, comparing the long-term impact of surgical and medical treatment.