The results of temporal resection for medically intractable epilepsy in 20 children less than age 5 years with at least 2 years follow-up are reported from Miami Children's Hospital, Florida. The mean age at surgery was 26 months, and the mean age at seizure onset was 12 months. Seizures were typical psychomotor in 4 patients, with staring and oral or gestural automatisms; and psychomotor plus in 7, with aura and frightened appearance, staring, decreased responsiveness followed by movements that were contraversive, lateralized tonic or clonic, and asymmetric tonic posturing. Motor symptoms were prominent in 3, with tonic asymmetric posturing followed by circling and vegetative signs. Clusters of epileptic spasms occurred in 6, mainly clonic. Interictal EEGs showed lateralizing abnormalities in 15 that were concordant, and ictal EEGs were lateralizing and concordant in 18 and nonlateralizing in 2. Brain MRI revealed localizing pathology in 16, and ictal SPECT was concordant in 4/8 cases. Invasive EEG recording was performed in 6 children to delineate the epileptogenic zone and map language cortex. Electrocorticography was performed in the remaining 14 cases. At mean follow-up of 5.5 years following surgery, 65% were seizure-free and 15% had >90% seizure reduction. The etiologic pathology was a tumor in 8 cases, benign developmental in 4 and malignant astrocytoma in 4. Focal cortical dysplasia was found in 6 cases, one with neurofibromatosis. Hippocampal sclerosis was identified in 4. Other pathologies included encephalitis, prior hypoxic-ischemic event, tuberous sclerosis, and white matter gliosis, 1 of each. Patients with the most favorable outcome had psychomotor type seizures, tumor, and complete resection without complications. Stroke occurred in 2 and infection and hydrocephalus in 1. [1]

COMMENT. Cortical resection limited to one temporal lobe for refractory temporal lobe epilepsy is rare in children less than 5 years. This report indicates that surgery in this age group can be associated with favorable outcome, similar to that in older children.

Surgery for epilepsy in children ages 1-15 years. A report from Milan, Italy, found that 60% of 113 patients younger than 16 years (mean age at surgery of 8.8 years) were seizure free following excision of the epileptogenic zone for refractory focal seizures [2]. Variables associated with a significantly lower risk of seizure recurrence were unifocal lesion on MRI, older age at seizure onset, temporal unilobar resection and complete lesionectomy, and glial-neuronal tumor pathology. Results of surgery were strongly dependent on presurgical identification and resection of the epileptogenic zone.

Propeller MRI sequencing for detailed imaging of hippocampal sclerosis. This method is superior to routine MRI sequencies for identifying subtle hippocampal sclerosis (HS), and negates the effects of movement during scans [3]. Signs of HS on MRI are increased hippocampal signal on T2-weighted images and loss of hippocampal volume on T1-weighted images. Periodically Rotated Overlapping Parallel Lines with Enhanced Reconstruction (PROPELLER) sequence compensates for head motion during the MRI scan.