From the Guidelines
Focal seizures in pediatric patients should be treated with anti-seizure medication (ASM) as the initial treatment of choice, with epilepsy surgery considered for drug-resistant cases.
Treatment Approach
- The treatment approach for focal seizures in pediatric patients involves a comprehensive evaluation, including scalp video/electroencephalography (EEG) telemetry, structural and functional magnetic resonance imaging (MRI), and molecular neuroimaging using positron emission tomography (PET) or single-photon emission computed tomography (SPECT) 1.
- Pharmacotherapy with ASM is the initial treatment of choice, with approximately 70% of patients responding to the first or second ASM 1.
- For patients with drug-resistant focal epilepsy, epilepsy surgery is a promising treatment option, with approximately 65% of patients becoming seizure-free 1.
Diagnostic Evaluation
- MRI is the first imaging investigation for patients with focal epilepsy, enabling the clinician to decide if there is a structural aetiology for the patient’s epilepsy 1.
- [18F]FDG PET may provide important information for treatment planning and prediction of postsurgical seizure outcome, especially in patients with negative or doubtful findings on MRI 1.
- Ictal perfusion SPECT or ictal subtraction perfusion SPECT can be useful in localizing the seizure onset zone for a tailored resection 1.
Special Considerations
- In pediatric patients with focal epilepsy, the aetiology is often multifactorial, including tumours, birth-related lesions, or malformations of cortical development (MCD) 1.
- Early epilepsy surgery may show some benefit in patients with tuberous sclerosis complex (TSC) or other underlying conditions 1.
- [18F]FDG PET can play a valuable role in non-invasively lateralizing and localizing the main epileptogenic tuber as an area of glucose hypometabolism 1.
From the Research
Treatment Recommendations for Focal Seizures in Pediatric Patients
- The treatment of focal seizures in children is based on the use of first-generation and recently introduced antiepileptic drugs, as well as nonpharmacological treatments such as the ketogenic diet, vagus nerve stimulation, and surgical therapy 2.
- First-line therapy consists of prophylactic antiepileptic drugs, with carbamazepine and valproic acid considered as first-line antiepileptic therapies for children with partial seizures 2.
- New antiseizure medications have improved the drug profile compared to preexisting ones, and clinicians should consider patient and medication-specific characteristics during the drug choice process 3.
- For focal seizures, levetiracetam is effective, and other medications such as valproate, lamotrigine, topiramate, and clobazam may be considered 4.
- Refractory cases should be referred for an epilepsy surgery workup, and dietary treatments and neurostimulation may be considered in refractory cases who are not good candidates for surgery 5.
- The latest antiseizure medications have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors 3.
Factors to Consider in Treatment Choice
- Patient-specific characteristics, such as age, seizure type, and comorbidities, should be considered during the drug choice process 3.
- Medication-specific characteristics, such as efficacy, tolerability, and potential interactions, should also be considered 3.
- The goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or a significant seizure reduction, while minimizing antiseizure medication-related adverse events 3.
Nonpharmacological Treatments
- The ketogenic diet may be considered as an adjunctive treatment for refractory partial seizures 2.
- Vagus nerve stimulation may be considered in refractory cases who are not good candidates for surgery 5.
- Epilepsy surgery should be considered in patients who are refractory to medical treatment, and tertiary care facilities with experience in epilepsy surgery should undertake the screening for epilepsy surgical candidates 4.