1 d'Orio P, et al. J Neurol Neurosurg Psychiatry 2018;0:1–6. doi:10.1136/jnnp-2018-318282 RESEARCH PAPER Surgery in patients with childhood-onset epilepsy: analysis of complications and predictive risk factors for a severely complicated course Piergiorgio d’Orio, 1 Michele Rizzi, 1,2 Valeria Mariani, 1 Veronica Pelliccia, 1 Giorgio Lo Russo, 1 Francesco Cardinale, 1 Michele Nichelatti, 3 Lino Nobili, 1,4 Massimo Cossu 1 Neurosurgery To cite: d’Orio P, Rizzi M, Mariani V, et al. J Neurol Neurosurg Psychiatry Epub ahead of print: [please include Day Month Year]. doi:10.1136/jnnp-2018- 318282 1 "Claudio Munari" Epilepsy Surgery Centre, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy 2 Department of Neuroscience, University of Parma, Parma, Italy 3 Service of Biostatistics, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy 4 Child Neuropsychiatry Unit, DINOGMI, University of Genoa, Genoa, Italy, Istituto Giannina Gaslini, Genova, Italy Child Neuropsychiatry Unit, Istituto Giannina Gaslini, DINOGMI, University of Genoa, Genoa, Italy Correspondence to Dr Massimo Cossu, “Claudio Munari” Center for Epilepsy Surgery, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan 20162, Italy; massimo.cossu@ ospedaleniguarda.it Received 21 February 2018 Revised 12 July 2018 Accepted 15 July 2018 © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Object To compare the occurrence of surgery-related complications in patients with childhood-onset focal epilepsy operated on in the paediatric or in the adult age. To investigate risk factors for surgery-related complications in the whole cohort, with special attention to age at surgery and severe morbidity. Methods A cohort of 1282 patients operated on for childhood-onset focal epilepsy was retrospectively analysed. Occurrence of surgery-related complications, including a severely complicated course (SCC: surgical complication requiring reoperation and/or permanent neurological deficit and/or death), was compared between patients operated on in the paediatric age (<16 year-old; 452 cases) and, respectively, in adulthood (≥16 year-old; 830 cases). The whole cohort of patients was also evaluated for risk factors for a SCC. Results At last contact (median follow-up 98 months), 74.5% of patients were in Engel’s class I (78.0% of children and 73.0% of adults). One hundred patients (7.8%) presented a SCC (6.4% for children and 8.6% for adult patients). Postoperative intracranial haemorrhages occurred more frequently in adult cases. At multivariate analysis, increasing age at operation, multilobar surgery, resections in the rolandic/perirolandic and in insulo- opercular regions were independent risk factors for a SCC. Conclusions Surgery for childhood-onset focal epilepsy provides excellent results on seizures and an acceptable safety profile at any age. Nevertheless, our results suggest that increasing age at surgery is associated with an increase in odds of developing severe surgery-related complications. These findings support the recommendation that children with drug-resistant, symptomatic (or presumed symptomatic) focal epilepsy should be referred for a surgical evaluation as early as possible after seizure onset. INTRODUCTION Surgery is recognised as a useful and effective treat- ment option for drug-resistant focal epilepsy. Its effectiveness and safety have been demonstrated for both adults 1 2 and children. 3 Excellent results on seizures have been reported also in more heteroge- neous series for every age range. 4–6 Childhood-onset epilepsy is often refractory to drug treatment, and the detrimental effects of ongoing seizures, abnormal electrical activity and antiepileptic drugs on brain development, cogni- tive functions and psychosocial outcome have been widely reported. 7 Furthermore, childhood-onset drug-resistant epilepsy has been recognised as a significant risk factor for epilepsy-related mortality. 8 For these reasons, early surgical treatment of chil- dren with symptomatic focal epilepsy has been advocated, in order to contrast the harmful impact of epilepsy on health-related quality of life in the paediatric age. 9 Nevertheless, despite a general increase in volume of surgeries in children, including complex and severe cases, 10 this treatment option appears to be still largely underused. 11 As a consequence, many ideal candidates for paediatric surgery are operated on during adulthood after several years of disease duration. Potential morbidity associated with epilepsy surgery has been claimed as one possible cause of reluctance to refer for surgery of youngest patients with intractable epilepsy. 12 Although data concerning factors associated with a compli- cated postoperative course, including age, are not univocal, several recent studies reported a low rate (5.5%–12%) of complications in the paediatric age. 13–16 In this retrospective single-centre study, we have addressed the issue of risk factors for surgery-re- lated complications in a large series of patients with childhood-onset epilepsy. Our main hypothesis was that surgery performed during the paediatric age is burdened by a lower surgical risk. METHODS Patients We searched our institutional database and clin- ical charts for patients with childhood-onset (<16 years) focal epilepsy treated surgically from 1996 to 2016. All eligible patients were included in the present cohort. Presurgical investigations and surgery were performed only after the patients or their tutors had given their informed consent. The local Ethical Committee approved the present study. Presurgical evaluation A comprehensive presurgical workup included: clinical history, neurological examination, interictal copyright. on 4 September 2018 by guest. Protected by http://jnnp.bmj.com/ J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2018-318282 on 12 August 2018. Downloaded from