Evaluation of the non-pharmacological treatment as a new modality in the management of children with drug resistant epilepsy

Objective: To evaluate the efficacy and outcomes of non-pharmacological treatment modalities including epilepsy surgery, ketogenic diet (KD), and vagal nerve stimulation (VNS) in pediatric patients with drug-resistant epilepsy (DRE).Methods: We conducted an interventional study of 50 pediatric patients (age range from 1-15 years) with drug-resistant epilepsy who underwent non-pharmacological interventions. Patients were divided into three treatment groups: surgical intervention (n=30), ketogenic diet (n=18), and vagal nerve stimulation (n=2). Treatment outcomes were assessed using Engel classification for surgical patients and percentage seizure reduction for KD and VNS patients.Results: Among the 30 surgical patients (53.3% male, 46.7% female), 76.7% had normal development prior to seizure onset. Surgical procedures included lesionectomy (43.3%), corpus callosotomy (36.7%), functional hemispherotomy (10.0%), and combination callosotomy and lesionectomy (10.0%). Post-surgically, 76.6% achieved Engel Class I outcomes (completely seizure-free or free of disabling seizures), 13.3% had worthwhile improvement (Class III), no Engel class II, and 6.7% showed no worthwhile improvement (Class IV). One patient (3.3%) died from post-surgical complications. Patients with well-defined focal lesions showed the best surgical outcomes.The ketogenic diet group (n=18, 67% male) had a median age of 3 years and included various epilepsy syndromes (Lennox-Gastaut, Dravet syndrome, GLUT1 deficiency). All achieved partial seizure reduction (range: 25-50%, median: 40%). Two patients underwent VNS therapy, achieving 20% and 35% seizure reduction after 1 and 1.5 years of treatment, respectively. One VNS patient subsequently underwent functional hemispherotomy with excellent outcome (Engel Class IA).Conclusion: Non-pharmacological interventions play a crucial role in managing pediatric drug-resistant epilepsy. Epilepsy surgery provides the best seizure control outcomes, particularly in patients with well-defined focal lesions and concordant EEG-MRI findings, with high percentage achieving Engel Class I outcomes. Ketogenic diet offers moderate benefit across various epilepsy syndromes when surgery is not indicated. VNS may provide modest improvement but appears less effective than other interventions in our study. Our findings support a multimodal treatment approach and highlight the importance of comprehensive pre-surgical evaluation to identify optimal candidates for each non-pharmacological intervention.