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.

Health-related quality of life using QOLIE-31: Before and after epilepsy surgery a prospective study at a tertiary care center.

Background: Outcome following epilepsy surgery has traditionally been measured in terms of relief of seizures. However, changes in health-related quality of life (HRQOL) after surgery for intractable epilepsy are also important to document. There are no studies on the Indian population which assess the outcome of epilepsy surgery in terms of HRQOL. Materials and Methods: We conducted a prospective study on the patients undergoing epilepsy surgery for intractable seizures, between February 2004 and May 2006 at our center. All patients cleared for epilepsy surgery by the epilepsy surgery team were taken up for study. All patients Results: Thirty-six patients satisfying the inclusion/exclusion criteria were included in the analysis. Twenty-nine of these (Group 1) had good seizure outcome (Engel 1 and 2), while seven patients (Group 2) had poor seizure outcome (Engel 3 and 4) at six months. Overall, 77% of all study patients were completely seizure-free at follow-up. There was no baseline difference in the seven domains of QOLIE-31 between the two groups. There was very significant improvement (P value> 0.005 using paired sample T test) in all the domains of QOLIE-31 in the good outcome group after surgery. Health-related quality of life improvement was seen in all the domains in the poor outcome group also, however, it was statistically significant only for the following parameters: seizure worry, overall QOL, emotional wellbeing, energy fatigue and social functioning domains. Improvement in seizure worry, overall QOL, emotional wellbeing and social functioning was significantly more in Group 1 as compared to Group 2. Conclusion: Complete seizure-free state after surgery is associated with very significant improvement in HRQOL parameters. Several, but not all parameters of HRQOL as assessed by QOLIE-31, improved after surgery even in the poor seizure outcome group. The improvement in domains of seizure worry, overall QOL, emotional wellbeing and social functioning is significantly more in those patients in whom complete seizure-free state is achieved.

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.

Neuropathological spectrum of Rasmussen encephalitis.

BACKGROUND: Rasmussen encephalitis (RE) is a chronic epileptic disorder of unknown etiology, and is clinically characterized by progressive neurological deterioration, focal seizures often progressing to intractable epilepsy, cognitive decline and hemispheric atrophy. AIMS: We report the spectrum of neuropathological changes seen in RE, and discuss the evolutionary mechanisms of this disease. MATERIALS AND METHODS: Surgically obtained specimens from RE patients diagnosed during 2002-2004 at this institute were evaluated for the presence and extent of different histopathological features of RE. The H&E and immunohistochemistry stained slides were also evaluated for the type and distribution pattern of inflammatory infiltrates, along with a semiquantitative evaluation for the severity of inflammation. RESULTS: Four cases of RE were admitted during the study period, all of which presented with partial seizures with successive deterioration to intractable epilepsy. The age at onset varied between 5 and 10 years (mean 7.8 years), with three male and one female patients. Subsequently, all four patients underwent hemispherotomy. Histopathological features of perivascular lymphocytic infiltrate, neuronal loss, microglial nodules, and reactive astrocytosis, with or without evidence of neuronophagia confirmed a diagnosis of RE. These cases also had varying degrees of T-cell-rich (CD3-positive) inflammatory infiltrates and CD68-immunopositive microglial proliferation. It was observed that the severity of inflammation had a trend to inversely correlate with the duration of symptoms. CONCLUSION: It is proposed that an accurate evaluation and histopathological grading of these lesions may possibly have a role in patient prognostication.

Giant intraparenchymal neurocysticercosis: unusual MRI findings.

We report a case of surgically proven giant neurocysticercosis (NCC). MR imaging revealed an unusually large solitary parenchymal cystic lesion showing signal intensity similar to CSF on all pulse sequences, with internal septations and a small nodule in the anterior aspect of this lesion compatible with this diagnosis. Identification of a scolex in a cystic lesion with CSF intensity plays a key role in the diagnosis of NCC. The presence of internal septations is an atypical feature.