PERC Analysis Highlights Factors Influencing Candidacy for Pediatric Drug-Resistant Epilepsy Surgery

Using data from the Pediatric Epilepsy Research Consortium, a newly presented analysis revealed that about 21% of children evaluated at pediatric epilepsy centers in the United States for surgical treatment of drug-resistant epilepsy (DRE) are not offered the procedure following their initial evaluation. These findings, presented at the 2025 American Epilepsy Society (AES) Annual Meeting, held December 5-9, in Atlanta, Georgia, highlight considerable variability in candidate selection across both institutions and patient characteristics.¹

In the analysis, investigators included 2480 patients from 29 National Association of Epilepsy Centers (NAEC) Level 4 programs out of 3966 patients in the PERC surgery database, a prospective, observational multicenter study enrolling children aged 0 to 18 years at 38 U.S. pediatric epilepsy centers. Researchers assessed the rate at which centers declined to offer surgery after evaluating a patient for surgical candidacy. Overall, the results showed that 532 patients were not offered the treatment following presurgical evaluation, with a median rate of 17% (IQR, 10%–28%).

"Surgery is an effective, yet underutilized, treatment for many children with [DRE]. While factors associated with favorable outcome following surgery are known, the decision to offer surgical treatment rests with each epilepsy center," lead author Avery Caraway, MS, research scientist of neurosciences at Cook Children's Health Care System, and colleagues wrote.¹ "Threshold to offer surgery differs across institutions and may be related to center experience, resources, or other factors."

The analysis examined patient and epilepsy characteristics, as well as details of the presurgical evaluation, and compared them across institutions based on the center’s decision to offer epilepsy surgery following phase 1 evaluation. Researchers performed logistic regression to assess the association between significant variables and the decision not to offer surgery.

In the analysis, the participating institutions provided program-level information, including annual number of epilepsy surgery evaluations, number of participants in epilepsy surgery conferences, years of program experience, and NAEC level. Investigators also evaluated the correlations between program characteristics and rates of not offering surgery.

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All told, several factors were significantly associated with the likelihood of being offered surgery, and all of them showed substantial variability across institutions. In the logistic regression analysis, findings demonstrated that patients with monthly seizures (OR, 2.25; 95% CI, 1.81–2.79; P <.01), nonstructural epilepsy etiology (OR, 2.00; 95% CI, 1.55–2.59; P <.01), and those who did not undergo functional MRI (OR, 2.49; 95% CI, 1.88–3.33; P <.01) had the highest likelihood of being declined surgery. Across centers, these characteristics were present in patients not offered surgery in 0%–51%, 0%–59%, and 0%–61% of cases, respectively.

Authors noted that program-level data for the analysis were provided by 21 pediatric epilepsy centers. Additional findings from the study showed that there was a strong negative correlation between the number of epilepsy surgery conference participants and the rate of not offering surgery (Pearson r = –0.75). Furthermore, researchers reported that other program-level variables demonstrated weak or no correlation (r < .35).

“On average, 1 in 5 pediatric patients is determined not to be a suitable candidate for epilepsy surgery following presurgical evaluation in the US,” Caraway et al noted.¹ “Certain patient characteristics are correlated with the decision to not offer epilepsy surgery; however, the influence of these variables differs considerably between institutions and may be related to program composition. This variability may have impact on patient outcomes and supports further research to help standardize candidate selection.”

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REFERENCES
1. Caraway A, Novotny E, Ostendorf A, et al. Characteristics Affecting Decision to Not Offer Epilepsy Surgery Following Presurgical Evaluation Across US Pediatric Epilepsy Centers. Presented at: AES 2025; December 5-9; Atlanta, Georgia. Abstract 1.415.