ARTICLE IN BRIEF
A new study found that after surgery in children with frontal lobe epilepsy, there was overall improvement, with statistically significant score changes in aspects of depression and anxiety in the left frontal lobe group and in both right-sided surgery groups. Self-reported measures also revealed clinically significant improvements in post-operative mood and anxiety in a substantial portion of patients.
Children who undergo surgical resection for epilepsy generally demonstrate good emotional and behavioral outcomes. But a new study found that while children with frontal lobe epilepsy had greater symptoms of depression and anxiety before surgery than children with temporal lobe epilepsy, these symptoms improved significantly following surgery to levels comparable to or below the temporal lobe group. These relationships were most apparent in children who underwent left-sided surgeries.
Those were the findings of a retrospective review of mood and behavior outcomes in children ages 5 to 16 undergoing surgical resection for epilepsy at the Cleveland Clinic Foundation Neurological Institute. The study and findings were reported at the annual meeting of the American Epilepsy Society earlier this month, and an article detailing these results is currently in press for a special issue of Frontiers in Epilepsy.
Elizabeth Andresen, PhD, a post-doctoral fellow at the Cleveland Clinic and a lead author of the study, told Neurology Today that the findings should be reassuring to parents — and to the clinicians who counsel them about treatment options — who are frequently concerned about the effects of surgery on their children with epilepsy. “Parents are often understandably concerned about the effects of surgery on mood, behavior, and personality in their children, wondering `is my kid going to be the same after surgery?'” she said. “Our results show that, overall, children do well post-operatively — not only as a group, but also on an individual level.”
In the study, pediatric patients with epilepsy completed the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scales as part of comprehensive neuropsychological evaluations conducted pre- and post-operatively approximately 10 months apart. Their primary caregivers completed the Achenbach Child Behavior Checklist at both evaluations. Sixty-four patients underwent temporal lobectomy for treatment of epilepsy (38 left and 26 right), and 37 underwent frontal lobe resections (17 left and 20 right).
Among children who underwent left-sided surgeries, analyses revealed significant two-way interactions between time (before and after surgery) and the site of surgery (temporal or frontal lobe) on scales measuring social anxiety, anhedonia, and social withdrawal. Specifically, patients with frontal lobe epilepsy (or their caregivers) endorsed more symptoms on these measures prior to surgery than the group with temporal lobe epilepsy, and reported substantial improvement in those symptoms following surgery.
Among children who underwent right-sided surgeries, no two-way interactions were seen; both frontal and temporal groups reported post-surgical improvements on scales measuring withdrawal, social problems, thought problems, and attention problems.
Dr. Andresen explained that this means on a group level there was overall improvement, with statistically significant score changes in aspects of depression and anxiety in the left frontal lobe group and in both right-sided surgery groups. She added that examination of individual change scores for each child on the self-report measures also revealed clinically significant improvements in post-operative mood and anxiety in a substantial portion of patients. For example, 21 percent of the sample (including 15 percent of the temporal lobe epilepsy patients and 33 percent of the frontal lobe patients) reported clinically significant improvements in overall depression symptoms after surgery, and 38 percent reported post-operative improvements in overall anxiety symptoms. These results are most striking in the left frontal lobe group, where 63 percent of children reported clinically significant improvements in anhedonia, and 100 percent reported clinically significant improvements in social anxiety.
Dr. Andresen said the finding of elevated mood and anxiety symptoms in children with frontal compared to temporal lobe epilepsy was unexpected and requires replication and further research. “Nevertheless, it is encouraging to see marked improvements in psychological symptoms among children with frontal lobe epilepsy following surgery.”
Dr. Andresen noted that individual change scores revealed a small percentage of patients with greater symptom endorsement after surgery and that future work by her and colleagues at Cleveland Clinic will focus on identifying factors that might predict increased depression or behavioral symptoms in children post-surgically. “It may be that changes in cognitive function after surgery contribute to this,” she said. “For example, if cognitive skills decline following surgery, children may have a harder time in school or doing daily tasks, which may affect mood and behavior.”
Overall, the study breaks new ground in an area that has not been extensively researched, Dr. Andresen said. “There isn't a lot of literature out there on the subject because a high volume of participants is required to be able to divide patient groups by both surgical side and site,” she told Neurology Today. Furthermore, “most previous studies, designed primarily to assess seizure outcome, have not formally assessed mood and behavior. So we wanted to make use of available standardized measures of emotion and behavior to look at this in a more systematic way.”
Orrin Devinsky, MD, director of the New York University and Saint Barnabas Epilepsy Centers who reviewed the report, underscored that the statistically significant findings in the report derive from the fact that children with “left frontal epilepsy had more depression and anxiety problems before surgery and that more of these children improved than those who had temporal lobe or right-sided surgery.” But he added that these symptoms also improved in the other surgical groups, though the improvements were not as great.
“It is unclear if the left frontal epilepsy causes more executive or social-emotional deficits,” Dr. Devinsky told Neurology Today. “But one of those or both is likely driving this.”
Referring to a theory that impairment in the region creates “noise” that affects other brain regions affecting mood, behavior and function, he added: “The findings suggest that in children, left frontal lobe epilepsy may have a greater negative effect on mood and anxiety, and that removal of the ‘nociferous’ cortex may have a greater benefit because it is doing more harm. It is likely that removing the ‘static electricity’ impairing normal functions of other brain areas is helping to improve behavior.”
He agreed that the differential findings for left-sided and right-sided surgery need to be replicated and researched, and echoed the belief that these findings support the benefits of surgery on mood and behavior. “Laterality findings have been hard to replicate in stroke and epilepsy,” Dr. Devinsky said. “But the take home message is that epilepsy surgery in children and adults — especially when it produces seizure freedom or significant reductions in seizures — generally leads to significant improvements in mood, anxiety, and quality of life.”