Patterns of anti-seizure medication (ASM) use in pediatric patients with surgically managed epilepsy: A retrospective review of data from Boston Children's Hospital.

Up to 30 % of patients with epilepsy are medically intractable, defined as persistent seizures despite 2 or more appropriate anti-seizure medications (ASMs) at therapeutic doses. Such patients require non-pharmacologic management that often includes epilepsy surgery. This paper aims to assess the pre-operative ASM use patterns of patients who were surgically managed. Retrospective review of children who underwent surgery for epilepsy at Boston Children's Hospital between January 2010 and December 2014 were performed. Patient demographics, covariates, etiology, surgery type and ASM use patterns were assessed. Patient characteristics were displayed using descriptive statistics, correlation between ASM use and patient covariates were calculated with the Spearman coefficient, and univariate analysis was performed with Cox regression analysis. 141 consecutive records of children were reviewed. All underwent one of four surgical procedures: focal resection, hemispherectomy, corpus callosotomy, or magnetic resonance-guided laser interstitial thermal therapy (MRgLITT). In this cohort, at the time of surgical evaluation the average number of pre-operative ASMs trialed was 5.2 and the average number of current ASMs was 2.6. The mean age of seizure onset was 4.4 years, the mean age at the time of surgery was 11.1 years, and the average time from seizure onset to surgery was 6.7 years. The number of total pre-operative ASMs was significantly related to longer time to surgery. Focal resection was associated with decreased ASM use and corpus callosotomy was associated with increased ASM use. Patients with radiographic findings that confer better surgical candidacy did not use fewer pre-operative ASMs or undergo earlier surgical referral. Despite guidelines that encourage early surgical referral and evaluation for drug-resistant epilepsy, a delay in surgical referral was seen in clinical practice, as evidenced by an average trial of 5.2 ASMs prior to referral, and an average lag of 6.7 years between time of seizure onset and surgery. Increased medication trials was directly correlated with increased time to definitive surgery. Improved education amongst neurologists for earlier surgical referral is required, especially for pathologies associated with good surgical outcome.

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Declaration of Competing Interest The authors have no conflicts of interest to disclose.