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WHEN TO WEAN ANTI-SEIZURE MEDICATIONS AFTER EPILEPSY SURGERY IN CHILDREN?

Drug Update

Practical Considerations

Epilepsy surgery remains an effective and at times curative option for treatment of drug-resistant epilepsy. Among patients already on multiple anti-seizure medications (ASMs), successful epilepsy surgery may allow them to slowly taper off their anti-seizure medications. However, not all children are able to completely come off of ASMs after epilepsy surgery.

Your child’s doctor will use several factors to help predict whether or not your child may be able to come off anti-seizure medications. Until recently, there has been limited evidence to guide how and when to wean children off ASMs after successful surgery.

There are some useful individualized factors that we can use to help predict seizure freedom and the ability to wean medications. These vary from patient to patient.

It is important to recognize that, even in patients that are successfully weaned off their anti-seizure medications post-surgery, there is always a risk for seizure recurrence. While most studies aiming to understand seizure freedom focus on the first 5 years post-surgery, few have examined how these patients fare in the long term (20+ years). That is why maintaining a long-term relationship with your child’s neurologist is important and why your child should continue to follow-up closely in clinic.

Causes of Seizures Post Surgery

Several factors can contribute to breakthrough post-surgical seizures. The cause of the seizures can be predictive of future seizure-freedom.

  • In general, children who have seizures due to a structural brain abnormality limited to one temporal lobe (which is seen on MRI) have the best chance of seizure freedom.
  • Children with tumors as a cause of their epilepsy do better after resection than children who have brain malformations.
  • Also, children who have a hemispherectomy (removal or disconnection of one hemisphere) are also more likely to develop seizure freedom.
  • Children who have resection of seizures outside of the temporal lobe, called extratemporal epilepsy, have a lower likelihood of being seizure free long term.

Children who have the lowest likelihood of seizure freedom following epilepsy surgery are:

  • Those with an incomplete resection (this may happen if seizures are coming from eloquent cortex – a region of the brain which cannot be removed without causing a significant neurological deficit for the child)
  • Children with additional MRI abnormalities outside of the resection area
  • Those with nonlesional epilepsy (i.e., without a specific structural abnormality on MRI causing seizures)

Planning Ahead

Sometimes a child may have seizures immediately after surgery. This does not mean that the surgery will be a failure. Children can go on to be seizure free or have a decreased seizure frequency, even when experiencing seizures within a couple weeks of surgery.

Following surgery, many patients are motivated to stop ASMs as soon as possible. Known benefits associated with weaning off ASMs include: overall improvements in alertness, learning and behavior, especially for patients on ASMs known to contribute to cognitive slowing and drowsiness (example: topiramate). Weaning ASMs will also do away with other unfavorable side effects. From a practical perspective, weaning ASMs requiring frequent blood draws (example: valproic acid) may also contribute to an improved quality of life.

Importantly, weaning of medication is variable and depends on the patient’s epilepsy, prediction of seizure freedom, and treating physician. Most physicians wait 3-6 months after surgery to consider weaning medications and use an EEG to help guide this decision. Early weaning of medications is associated with a worse outcome and higher likelihood of breakthrough seizures.

Not all patients are able to come off of anti-seizure medications and no epilepsy surgery comes with a 100% guarantee that your child will stop having seizures. We recommend having a conversation with your child’s clinician prior to surgery to know what the plan will be to come off of medications and when.

Higher Rate of Seizure Freedom After Surgery

(% seizure freedom)

Lower Rate of Seizure Freedom After Surgery

(% seizure freedom)

Brain tumor (80%)

Brain malformation (focal cortical dysplasia)

Epilepsy requiring a hemispherectomy (75%)

Nonlesional epilepsy (52%)

Temporal lobe epilepsy (73%)

Multifocal epilepsy

Longer time epilepsy has been refractory (drug resistnat)

Authored by: Melisa Carrasco McCaul MD, PhDNancy McNamara MD on 12/2020

Reviewed by: Elaine Wirrell MD on Thursday, December 10, 2020