Pre-Surgical Evaluation and Seizure Outcome of Surgical Treatments for Pediatric Drug Resistant Epilepsy

Approximately one-third of children with epilepsy have drug-resistant epilepsy (DRE), that is, poorly controlled seizures despite treatment with two or more appropriately selected anti-seizure medications. Although open resective surgery is recommended for DRE, there is variability in the reported seizure outcome. Further, it remains an underutilized treatment because of fear or misconceptions of the risk of surgery. A minimally invasive MRI laser interstitial thermal therapy (MRgLITT) has been suggested as an alternative to open surgery, but effectiveness compared to open surgery is unknown. There has also been reports of changing trends in pre-surgical evaluation and epilepsy surgery in Europe and the USA. It is unclear if such changes are observed in Canada. The dissertation will address these aims: (1) evaluate machine learning (ML) algorithms for predicting seizure outcome after open surgery and compare performance of ML to a classical statistical method; (2) compare seizure outcome, complications and length of hospitalization of MRgLITT to open epilepsy surgery (3) evaluate ML models for prediction of seizure outcome following MRgLITT and identify important predictors of seizure freedom and (4) assess trends of pre-surgical evaluation and epilepsy surgery at the Hospital for Sick Children and compare trends in the later period (2014-2019) to an earlier period (2001-2013). We found that ML algorithms performed well for prediction of seizure outcome following open surgery as well as MRgLITT, and performed better than the classical statistical method. Further, ML could identify important predictors of seizure freedom, which could assist with patient selection for these treatments. In the matched cohort of MRgLITT to open surgery patients, MRgLITT had lower seizure-free outcome than open surgery patients but had the advantage of better safety profile and shorter hospital stay. Such findings are important for pre-surgical counselling of families on the benefits and risks of MRgLITT. We found that despite an increasing number of pre-surgical evaluations, there was a reduction in the number of surgeries, particularly in the later period, due to a larger proportion of patients in whom the seizures could not be localized. Understanding the changing trends will help with decisions on allocating healthcare resources.

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