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Objective  To assess factors associated with favorable seizure outcome after surgery for symptomatic epileptic spasms and improve knowledge on pathophysiology of this seizure type.    Methods  Inclusion criteria were: (1) age between 6 months and 15 years at surgery; (2) active epileptic spasms; (3) follow‐up after surgery >1 year.    Results  We retrospectively studied 80 children (aged 1.3 ± 2 years at seizure onset; 5.8 ± 4 years at surgery, 11.7 ± 5.7 years at last follow up). Magnetic resonance imaging ( MRI ) revealed structural abnormalities in 77/80 patients (96.3%; unilateral in 69: 89.6%). We performed invasive recordings in 24 patients (30%). In 21 patients in whom  MRI  or histopathology detected a lesion, electrodes exploring it constantly captured initial ictal activity at spasm onset. Fifty‐eight patients (72.5%) underwent unilobar and 22 (27.5%) multilobar or hemispheric procedures. At last follow‐up, 49 patients (61.3%) were in Engel class I. Multivariate logistic models showed completeness of resection of the seizure onset zone ( OR  = 0.016, 95% CI : 0.002, 0.122) and of the  MRI  visible lesion ( OR  = 0.179, 95%  CI : 0.032, 0.999) to be significantly associated with Engel class  IA  outcome. Unfavorable outcome was associated with an older age at surgery, when it reflected a longer duration of epilepsy ( OR  = 1.383, 95%  CI : 0.994,1.926).    Interpretation  Data emerging from invasive recordings and the good seizure outcome following removal of discrete epileptogenic lesions support a focal cortical origin of spasms. In patients with discrete epileptogenic lesions, the pragmatic approach to surgery should follow the same principles applied to focal epilepsy favoring, whenever possible, unilobar, one‐stage resections.

Unilobar surgery for symptomatic epileptic spasms