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[Pre- and intra-operative evaluation of epileptic children with intractable seizure disorders: the hospital for sick children].

The pediatric epilepsy management team in the Hospital for Sick Children, Toronto, Canada, consists of neurologists, neurophysiologists, neurosurgeons, neuropyschologists, clinical nurse specialist/nurse practitioners, social workers, EEG technologists and psychiatrists. The patients are initially referred to us for the diagnosis of seizure disorders. Epileptic foci and eloquent cortices are identified by neurophysiological studies such as EEG, MEG and SEP. Epileptogenic lesions can be visualized by MRI, the language, motor and sensory cortices by fMRI and the regions of hypoperfusion and hypometabolism in the epileptic foci, by SPECT and PET, respectively. The results of these studies are then discussed by members of the team. For patients with lesional epilepsy, an intraoperative image guided system and intraoperative electrocorticography are used, when lesionectomy, lobectomy and additional multiple subpial transection (MST) are performed. Patients without an identifiable lesion require intracranial invasive video EEG using subdural grids or depth electrodes, which are constructed based on MEG spike sources, seizure semiology and scalp video EEG. After the identification of the epileptogenic and functional zones, maximum cortical excision and MST are performed to control seizures and to minimize functional deficits. Pediatric neurologists should assess the intractability of epilepsy, identify the epileptogenic zone, determine the excisable epileptic region, and minimize postoperative side effects, thereby leading the epilepsy management team.