Surgical outcome of cortical dysplasias presenting with chronic intractable epilepsy: A 10-year experience.

Background: There has been sparse description of cortical dysplasias (CDs) causing intractable epilepsy from India. Aim: Clinical retrospective study of CDs causing intractable epilepsy that underwent surgery. Materials and Methods: Fifty-seven cases of CDs reviewed (1995 till July 2006) are presented. All patients had intractable epilepsy, and underwent a complete epilepsy surgery workup (inter ictal electroencephalography (EEG), video EEG, MRI as per epilepsy protocol, SPECT {interictal, ictal with subtraction and co-registration when required}, and PET when necessary). Surgical treatment included a wide exposure of the pathology with a detailed electrocorticography under optimal anesthetic conditions. Mapping of the sensori-motor area was performed where indicated. Procedures included resection either alone or combined with multiple subpial transactions when extending into the eloquent areas. Results: Our study had 28 (49.12%) cases of isolated focal CDs, and 29 (50.67%) with dual pathology. Average age at the time of onset of seizures in our series was 7.04 years (three months to 24 years), and average age at the time of surgery was 10.97 years (eight months to 45 years). Among coexistent pathologies, one had associated MTS, 16 had coexistent gangliogliomas and 12 (dysembryonic neuroepithelial tumor) DNTs. At an average follow-up of 3.035 years (range 5-10 years), three patients were lost to follow-up. Fifty-one per cent (29/57) patients had a good outcome (Engel Grade I) and 26%(15/57) had a Grade II outcome. Conclusion: Cortical dysplasias have a good outcome if evaluated and managed with concordant electrical and imaging modalities.

Neuropathological spectrum of lesions associated with intractable epilepsies: a 10-year experience with a series of 153 resections.

BACKGROUND: Surgical management of intractable epilepsies is currently an established mode of therapy in various clinical settings. AIMS: To retrospectively evaluate the neuropathological findings in both temporal and extratemporal lobe resections in such patients. MATERIALS AND METHODS: The study included resected specimens from patients with intractable epilepsy managed at a tertiary care hospital of India, during a 10-year period (1995-2004). RESULTS: A total of 153 patients, with mean age of 19.4 years and male predominance (73.2%) were included in the study. Overall, there was a predilection for the temporal lobe (73.2%), while 41cases were extratemporal in location. On histopathology, mesial temporal sclerosis (MTS) (24.8%) was the commonest lesion, followed by tumors (19.6%) and isolated focal cortical dysplasia (FCD - 15.11%). Other less common findings included Rasmussen encephalitis, non-specific gliosis and vascular malformations. In addition, 20.9% (32 cases) had dual lesions, majority of which included FCD with ganglioglioma (15 cases) or with dysembryoplastic neuroepithelial tumor (12 cases). In the temporal lobe, neoplasms and dual lesions formed the majority (apart from MTS), unlike dual lesions followed by neoplasms and FCD, in the extratemporal location. CONCLUSION: This series demonstrates that most patients with chronic intractable epilepsy have significant histopathological findings and highlights the neuropathological spectrum of such lesions, in the Indian context. This was similar to that reported from the West, but different from the single Indian series available in the literature. Further, the overall profile of temporal lobe lesions was not different from the extratemporal ones.

Sellar Tuberculoma: An unusual infection.

Tuberculomas are common intracranial lesions in our country. However, tubercular infection of pituitary gland is very unusual. We present a case of intrasellar tuberculoma mimicking pituitary adenoma, and suggest the radiological features and management. A 22-year-old woman had presented with generalized dull aching mild to moderate headache for 8 months and decreased vision in both eyes for 6 months. Visual acuity was 6/9 in both eyes but visual fields and fundus examination were normal. There were no other significant findings. CT scan and MRI (brain) showed a sellar- suprasellar lesion. The pituitary stalk was thickened, as was the mucosa of sphenoid sinus, which raised the suspicion of an infectious pathology other than pituitary macroadenoma. Surgery was performed through sublabial transsphenoid route. A firm, rubbery, yellowish, non-suckable and relatively avascular lesion was found in the sella. Only subtotal decompression was done. Frozen section biopsy was suggestive of inflammatory pathology. Histopathology revealed features compatible with tuberculosis. We suggest that tuberculosis should be considered in the differential diagnosis of sellar lesions, especially if associated with contrast enhancement and thickening of sphenoid sinus mucosa or pituitary stalk, particularly in patients from tuberculosis endemic areas. Most of these patients are negative for workup for systemic tuberculosis. Intraoperatively, a frozen section should be sent and if it shows inflammatory pathology, only a decompression for biopsy should be done. We do not advise radical decompression of these lesions as anti-tubercular treatment is sufficient for cure.