Estimating the Prevalence of Treated Epilepsy Using Administrative Health Data and Its Validity: ESSENCE Study

BACKGROUND AND PURPOSE: Few of the epidemiologic studies of epilepsy have utilized well-validated nationwide databases. We estimated the nationwide prevalence of treated epilepsy based on a comprehensive medical payment database along with diagnostic validation. METHODS: We collected data on patients prescribed of antiepileptic drugs (AEDs) from the Health Insurance Review and Assessment service, which covers the entire population of Korea. To assess the diagnostic validity, a medical records survey was conducted involving 6,774 patients prescribed AEDs from 43 institutions based on regional clusters and referral levels across the country. The prevalence of treated epilepsy was estimated by projecting the diagnostic validity on the number of patients prescribed AEDs. RESULTS: The mean positive predictive value (PPV) for epilepsy was 0.810 for those prescribed AEDs with diagnostic codes that indicate epilepsy or seizure (Diagnosis-E), while it was 0.066 for those without Diagnosis-E. The PPV tended to decrease with age in both groups, with lower values seen in females. The prevalence was 3.84 per 1,000, and it was higher among males, children, and the elderly. CONCLUSIONS: The prevalence of epilepsy in Korea was comparable to that in other East Asian countries. The diagnostic validity of administrative health data varies depending on the method of case ascertainment, age, and sex. The prescriptions of AEDs even without relevant diagnostic codes should be considered as a tracer for epilepsy.

Prevalence of Treated Epilepsy in Korea Based on National Health Insurance Data

The Korean national health security system covers the entire population and all medical facilities. We aimed to estimate epilepsy prevalence, anticonvulsant utilization pattern and the cost. We identified prevalent epilepsy patients by the prescription of anticonvulsants under the diagnostic codes suggesting seizure or epilepsy from 2007 Korean National Health Insurance databases. The information of demography, residential area, the kind of medical security service reflecting economic status, anticonvulsants, and the costs was extracted. The overall prevalence of treated epilepsy patients was 2.41/1,000, and higher for men than women. The age-specific prevalence was the lowest in those in their thirties and forties. Epilepsy was more prevalent among lower-income individuals receiving medical aid. The regional prevalence was the highest in Jeju Island and lowest in Ulsan city. New anticonvulsants were more frequently used than old anticonvulsants in the younger age group. The total annual cost of epilepsy or seizure reached 0.46% of total medical expenditure and 0.27% of total expenditure on health. This is the first nationwide epidemiological report issued on epilepsy in Korea. Epilepsy prevalence in Korea is comparable to those in developed countries. Economic status and geography affect the prevalence of epilepsy.

Efficacy and Safety of Levetiracetam as Adjunctive Treatment in a Multicenter Open-Label Single-Arm Trial in Korean Patients with Refractory Partial Epilepsy: Over 1-Year Follow-Up / 대한간질학회지

PURPOSE: This prospective, open-label study evaluated the efficacy and safety of adjunctive levetiracetam (LEV) in Korean adults with uncontrolled partial epilepsy. METHODS: A total of 100 patients whose partial seizures were inadequately controlled on their current antiepileptic drugs were enrolled and received LEV (1000-3000 mg/day). Seizure count and adverse events (AEs) were recorded by patients. Global evaluation scale (GES) and quality of life (QOLIE-31) were also evaluated. Additionally effectiveness over 1-year follow-up was investigated. RESULTS: Ninety-two patients completed the short-term 16-week trial. The median percent reduction in weekly seizure frequency over the treatment period was 43.2%. The > or =50% and > or =75% responder rates were 45.4% and 36.1%, respectively. Seizure freedom was observed in 17 patients throughout the initial 16-week treatment period. On investigator's GES, 81 patients were considered improved, with 41 patients showing marked improvement. Most QOLIE-31 scales improved significantly. At the end of the trial, 79 chose to continue follow-up treatment with LEV. At the follow-up visit (ranging 60 to 81 weeks), 64 patients were still taking LEV; during the last 16 weeks, 65.6% of patients had > or =50% reduction, 50.0% had > or =75% reduction, and 35.9% had a 100% reduction. Seven patients showed continuous seizure freedom from the initiation of LEV treatment. During the entire treatment period, LEV was withdrawn in 36 patients; due to lack of efficacy in 22, AEs in six, both in three, other reasons in five. CONCLUSION: Adjunctive LEV therapy in patients with refractory partial epilepsy was effective and well-tolerated, as evidenced by the high seizure freedom and retention rates in both the short-term trial and the long-term follow-up.

The Influence of Education on Knowledge of Their Disorder and Quality of Life in Patients with Epilepsy / 대한간질학회지

PURPOSE: The education of the patients is an effective component of comprehensive care, especially in patients with epilepsy. We developed an epilepsy educational program designed to improve the knowledge and understanding of the natural clinical course, the treatment, and prognosis of epilepsy. We evaluated the efficacy of this educational program to epilepsy patient's knowledge of their disorder and quality of life. METHODS: We studied 224 patients with epilepsy from Dongsan Epilepsy Center. All patients completed the Knowledge and Quality of Life in Epilepsy-31 (QOLIE-31) questionnaire before a one-day educational program was completed. Six months after the educational program was given, patients completed the same questionnaire. The results of the two surveys were compared. RESULTS: In the initial questionnaire, about 60% of the patients thought that epilepsy is not related with head trauma. About 40% of the patients thought that epilepsy is a genetic disorder. Over 80% of the patients thought that behavior changes are not related to epilepsy. Over 90% of the patients had correct responses about taking antiepileptic drugs. However, only 60% of the patients had their ideas regarding proper social activity correct. After completing the educational course, the results of the follow-up questionnaires were markedly improved concerning the patients' knowledge of epilepsy. In contrast, the quality of life measures changed a little. CONCLUSION: An epilepsy educational program for patients improves their knowledge of epilepsy. This study was performed with only one education workshop, which is not sufficient to improve the quality of life measures. A well-regulated, systematic educational program is needed to efficiently improve the lives of epileptic patients.

Two Cases of Transient Focal Lesion in the Splenium of the Corpus Callosum after Aggravated Seizures

Transient focal lesions in the splenium of the corpus callosum have been rarely reported in epileptic patients receiving antiepileptic drugs. We examined two patients with epilepsy whose epileptic seizure frequency has drastically increased. The brain MRI findings of these patients showed a transient focal lesion in the splenium of the corpus callosum. Follow up MRI taken 15 days and 6 days later after controlling their seizures demonstrated complete resolution of the lesion, without specific treatment for the lesion.

A Case of ReVersible MRI and SPECT Abnormalities in the Neocortex of the Temporal and Parietal Lobes after a Generalized Seizure

We report a case with reVersible temporal and parietal neocortical abnormalities detected by MRI and SPECT following a brief seizure. Post ictal MRI abnormalities may indicate an underlying structural abnormality, but may also occur in non-lesional epilepsy and represent a transient physiologic change induced by ictal activity.

The Reliability and Validity of Korean QOLIE-31 in Patients with Epilepsy / 대한간질학회지

BACKGROUND: To develop a Korean version of the QOLIE-31 and to confirm its psychometric properties. METHODS: The QOLIE-31 was adapted to Korean language through a translation-back translation procedure. Data were collected from 397 adult epilepsy patients. Patients were administered the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), Korean Wechsler Intelligence Scale (KWIS), the Functional Assessment of Cancer Therapy-General (FACT-G), state scale of the State-Trait Anxiety Inventory (STAI), and the Center for Epidemiological Studies-Depression Scale (CES-D). We assessed internal consistency and test-retest reliabilities and construct validity. RESULTS: Cronbach's alpha ranged from 0.69 to 0.86, and test-retest reliability was between 0.50 and 0.71, demonstrating that the items of OOLIE-31 are internally consistent and temporally stable. Pearson's correlations among the QOLIE-31 and emotional well-being, state anxiety, and depressive symptoms were high. Most QOLIE-31 sub-scales discriminated well between patients according to seizure frequency, number of antiepileptic drugs, employment, economic status and depressive symptoms. CONCLUSION: The Korean version of the QOLIE-31 was reliable, and showed construct validity comparable with the original U.S version. Results confirmed that the QOLIE-31 can be applied as one of the specific measures of quality of life in Korean epilepsy patients.

Lateralizing and Prognostic Value of Some Ictal Manifestations in Surgical Treatment of Mesial Temporal Lobe Epilepsy

BACKGROUND: Various ictal manifestations of temporal lobe epilepsy have possibly the value of both lateralizing and localizing the epileptogenic zone. Some ictal manifestations such as hand automatism, dystonic limb posture, head turning, and speech phenomenon might distinguish patients with good surgical outcomes from patients with poor out-comes. METHODS: To determine ictal behavioral differences in patients from these groups, we analyzed 207 seizures from 75 patients (group A) who were seizure free after surgery and 172 seizures from 60 patients (group B) who experienced seizures after surgery. All patients had received an anterior temporal lobectomy with amigdalohippocampectomy, and were followed up for at least 1 year. RESULTS: The lateralizing value of ictal semiology was evaluated in group A. Head turning (HT) was shown in 42% of seizures and had a lateralizing significance. Forced HT indicated a contralateral epileptogenic region. Non-forced HT suggested an ipsilateral epileptogenic region. Unilateral dystonic limb posture with or without automatism of the other side occurred in 53% of seizures and had a lateralizing significance, localizing the seizure onset to the contralateral hemisphere. Abnormal speech and vocalization did not have any lateralizing significance. Contralateral dystonic limb posture without ipsilateral automatism was significantly more frequent in group B (p=0.003) as abnormal speech was more frequent in group A (p=0.001). Non-versive head turning had a higher tendency to occur in group A (p=0.0051). There were no statistically significant differences between the two groups in incidences of versive head turning, unilateral hand automatism without dystonic limb posture, vocalization, and normal speech. CONCLUSIONS: Some ictal manifestations might be helpful in predicting the surgical outcome of temporal lobe epilepsy(TLE) patients. The presence of unidentifiable ictal speech could reflect good surgical outcome in TLE patients. When presurgical video analysis reveal an ictal semiology of contralateral dystonic arm posture without ipsilateral hand automatism, careful presurgical evaluation of the epileptogenic region should be contemplated.

A case of neurosarcoidosis without systemic involvement

Sarcoidosis is a multisystem disorder of unknown cause. The involvement of the nervous system occurs 5% to 27% of patients with sarcoidosis, and neurosarcoidosis without systemic involvement is rare and difficult to diagnose. We present a case of 58-year-old woman with clinical features of multiple cranial and peripheral polyneuropathy with noncaseating granulomatous inflammation. Extensive testing for occult systemic sarcoidosis was negative. Sural nerve biopsy showed several perineural noncaseous granulomatous inflammation with prominent epithelioid cells. Oral steroid therapy led to some improvement. We report a patient with multiple cranial and peripheral polyneuropathy without systemic involvement, suspected sarcoidosis.

Coexistence of Neoplasia and Cortical Dysplasia Associated with Intractable Epilepsy: A Clinical Study of Seven Surgical Patients and Surgical Strategies

A tumor and cortical dysplasia may be the concomitant cause of the causes of intractable epilepsy, but a few studies have examined so far. From among 249 patients who underwent surgery for intractable epilepsy at Dongsan Epilepsy Center, those in whom neoplasia and cortical dysplasia coexisted were selected for this study, and were reviewed the clinical, electrophysiological, neuroimaging and pathological findings. In 17 of 25 lesionrelated epilepsy patients, tumors including dysembryoplastic neuroepithelial tumor(DNT)(n=6), ganglioglioma(n=5), gangliocytoma(n=1), low grade astrocytoma(n=2), oligodendroglioma(n=2), hypothalamic hamartoma(n=1) were verified. Of these 17 cases involving tumors, concomitant cortical dysplasia was observed in 7(DNT; 6, ganglioglioma; 1). All these patients underwent sophisticated presurgical evaluation and intraoperative acute recording(EcoG) for the identification of adjacent or remote epileptogenic areas as well as functional brain mapping by electrical stimulation or SSEP to verify the eloquent areas. In intractable epilepsy, the coexistence of cortical dysplasia and neoplasia is not common, though careful intraoperative evaluation of the tumor and surrounding tissue using electrocorticogram (EcoG) may lead to its pathological identification and excellent surgical results for these rare lesions.

Surgical Treatment for Intractable Childhood Epilepsy

PURPOSE: For certain forms of childhood epilepsy that remain uncontrolled despite adequate treatment with standard antiepileptic medication, surgical therapy should be considered as a potential treatment. The prognosis for seizure control after early surgery is favorable and is at least comparable with that of adults. With the exception of the obvious benefit conferred by alleviating seizures at a younger age, early surgery also later improves psychosocial status and adaptive function. This study was performed to evaluate the efficacy of epilepsy surgery. METHODS: We analyzed the results of 28 cases of intractable childhood epilepsy who underwent epilepsy surgery at the epilepsy center of Dongsan Medical Center between February, 1993 and January, 1996. They followed up for at least 15 months after surgery. Seizures began at 14 days to 15 years (mean 6.3 years) after birth and had been refractory to antiepileptic medications. Presurgical evaluations of epilepsy included detailed clinical history, scalp/sphenoidal EEG, Video-EEG monitoring, neuroimaging, neuropsychological test, Wada test and invasive study with subdural electrodes. RESULTS: Temporal lobectomy (with or without corticectomy) was performed in 13 cases, extratemporal lobectomy in 11 cases (frontal lobe n=7, parietal lobe n=2, frontoparietal n=1, parietooccipital n=1), functional hemispherectomy in two cases and corpus callosotomy in two cases. The surgical outcome was better in temporal lobe epilepsy compared with that of extratemporal lobe epilepsy. In temporal lobe epilepsy, seven of 13 cases had class I outcome grade, four cases had class II and the rest had class III and class IV. In extratemporal lobe epilepsy, five of 11 cases had class I outcome and the remainders had class III, IV. CONCLUSION: Our results agree with previous reports that epilepsy surgery can provide relief from intractable seizure in pediatric patients, but more extensive study for the patients' cognitive and behavior status will be necessary.

The clinical study of benign paroxysmal positional vertigo of horizontal semicircular canal origin

BACKGROUND & OBJECTIVES: It was well known that benign paroxysmal positional vertigo(BPPV) was caused by the involvement of the posterior semicircular canal, but there were a few reports about horizontal canal variant of BPPV. We studied the clinical features electronystagmographic (ENG) findings and the possible mechanism of BPPV of the horizontal canal(HBPPV). METHODS: We examined 10 cases of HBPPV with episodic vertigo and intense horizontal geotropic nystagmus provoked by rotation of the head in a supine position. Six patients underwent ENG and we recorded four patients' nystagmus, provoked by rotating head from extreme lateral, mid and nose-up position to extreme contralateral direction in supine position. RESULTS: All observed horizontal nystagmus beated towards the ground on both sides and were more pronounced when head was rotated to pathological side. In rotating to pathological side, nystagmus had mean latency of 2.6+/-1.8 seconds, peak velocity of slow phase of 66,8+/-19.7 degree/second and mean duration of 24.7+/-3.4 seconds. In rotating to healthy side the nystagmus had 3. 7+/- 2.9, 38.0+/-11.5 and 22.5+/-4. Secondary phase nystagmus occurred in 2 patients and fatigue was observed in 4 patients. The slow phase velocity of nystagmus was relative to the distance of head rotation. The duration of attack is 3 to 17 days(6.9+/-5.2days). Liberatory manuever had relatively a good effect. CONCLUSION: HBPPV represents the origin of horizontal semicircular canal and has a good prognosis Above findings support that mechanism of horizontal BPPV is canalolithiasis.

Serum Anti-Acetylcholine Receptor Antibody, Interleukin-2 and Soluble Interleukin-2 Receptor Level in Myasthenia Gvavis

Objective/BACKGROUND: Serum levels of anti-acetylcholine receptor antibody (AChR-Ab), interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R) may represent markers of disease severity in myasthenia gravis (MG). This study was performed to evaluate the correlations between disease severity and immunological parameters such as serum AChR-Ab, IL-2 and sIL-2R level and between each immunological parameters. METHODS: Serum levels of AChR-Ab, IL-2 and sIL-2R were measured in 30 MG patients and in 22 healthy controls. Results : Serum levels of AChR-Ab and sIL-2R were higher in MG than in healthy controls (p<0,01). The occurrence of IL-2 positive serum samples was 46.7% in MG but none in controls. There were no significant correlations between disease severity and immunological parameters and between each immunological parameters. Conclusions : Serum IL-2 and sIL-2R levels may not represent markers of disease severity in MG, In order to further document the correlation between each parameters, follow-up of individual patients with serial serum samplings may be necessary.

Non-neoplastic Lesions in Temporal Lobe Epilepsy: A Pathologic Review of 64 cases

Temporal lobe epilepsy is characterized by complex partial seizures with either primary intracranial neoplasms or other non-neoplastic lesions. We reviewed 64 cases of surgically resected temporal lobes and amygdalo-hippocampal regions for temporal lobe epilepsy ansed by non-neoplastic lesions to elucidate the incidence and histologic features of each histologic group for a period of 2 years. The patient's age ranged from 12 to 49 years and the ratio of male to female was 42:22. There were 37 cases(57.8%) with single pathology and an additional 20 cases(31.3%) with dual pathology. The emaining 7 cases(10.9%) had no structural alternations. The most common temporal lobe pathology was hippocampal sclerosis in 41 cases(64.1%), diagnosed alone in 21 cases and as dual lesions in 20 cases. The hippocampal neuron loss was most pro,omemt in CA1, followed by CA4, CA3, and CA2. Amygdaloid sclerosis was present in 28 cases(43.8%), lases had 13 dual lesions, 25 cases also had hippocampal sclerosis. The 20 dual lesions showed that 6 cortical dysplasia, 10 microdysgenesis, 1 chronic non-specific inflammatory lesion, and 3 cysticercosis were associated with the various degree of mesial temporal sclerosis. Neuronoglial malformative lesions were identified in 21 cases(32.8%) including 16 dual lesion cases, which composed of 15 microdysgenesis and 6 cortical dysplasia. Neurofilament immunostain for cortical dysplasia revealed abnormally beaded disarray of axons in dysplastic pyramidal cells. The remaining pathologic lesions observed were 1 cysticercosis, 1 chronic non-specific inflammatory lesion, 3 arteriovenous malformation, 2 fibrous nodule, and 1 fibrous adhesions of the arachnoid.

Surgery for seizure-related structural lesions of the brain with intraoperative acute recording(ECoG) and functional mapping

Epilepsy surgery has been demonstrated to be an effective alternative treatment for intractable partial or localization related epilepsy. Primary intracranial neoplasms and other structural lesions of the brain are important etiological factors in patients with partial seizure disorders. A neuroimaging identified lesion in patients with seizures, not necessarily medically refractory, may also be an indication for surgery in selected patients. Twelve patients operated on under local or general anesthesia for resection surgery underwent intraoperative recording(electrocorticogram) and/or functional mapping by electrical stimulation or somatosensory evoked potentials-(SSEPs) for identification of the secondary epileptogenic area and/or functional area; 2 meningiomas, 5 astrocytomas, 1 gangliocytoma, 1 abscess, 1 small AVM, 1 cysticercosis and one gliosis by previous intracerebral hemorrhage with middle cerebral artery(MCA) aneurysm. Among these, additional corticectomy or anterior temporal lobectomy was performed in eleven patients. All the patients did well after surgery with good outcomes as seizure free in nine(75%) out of 12 patients with 11.9 months of follow-up period, without any neurological deficits. Intraoperative recording and functional mapping of adjacent areas of the structural lesions of the brain are useful in surgery and can guide the extent of further resection.

Short Latency Somatosensory Evoked Potentials and Electroencephalography in Stroke

Median nerve somatosensory evoked potentials(SEP) and electroencephalography(E EG) were recorded in 85 patients with stroke(33 with thalamic hemorrhage, 20 with putaminal hemorrhage and 32 with cerebral infarction) to observe the origin of Nl9 and P23 wave responses in median SEP and the origin of slow waves in EEG as well as to evaluate the prognostic correlation between stroke patients and SEP and EEG findings. Nl9 and P23 were absent in 42 4% of patients with thalamic hemorrhage and 70% with putarninal hemorrhage. There was no case in which only P23 was absent in these two groups. In cerebral infarction, the most frequent finding was that both N19 and P23 were absent. P23 was absent with intact Nl9 in 2 cases with localized cortical infarction. Therefore we suggest that N19 develops in thalamus or thalamocatical pathway and P23 in the parietal cortex. There was no significant difference of EEG findings between thalamic hemorrhage and cerebral infarction. It was unlikely that slow waves on EEG is a specific finding in a localized brain lesion. The prognosis was poor in thalamic hemorrhage and cerebral infarction with loss of both Nl9 and P23 in SEP findings and in cerebral infarction with moderate to severe degree of background abnorrnalities in EEG findings. So that, SEP and EEG findings may be useful for prognostic aspect.

TRH stimulation test and DST in patients with stroke

In order to obsetve the effect of stroke on hypothalamic-pituitary axis, TRH stimulabon test and dexamethasone suppression test(DST) were performed in 52 patients with stroke(cerebral infarction, 16 cases; intracerebral hemorrhage, 15 cases: subarachnoid hemorrhage, 21 cases) and 15 age-sex matched patients control without intracrania disease at Keimyung University Dongsan Hospital from April 1987 to August 1988. The results summarized as follows. 1. The frequency of blunted response on TRH stimulation test is significantly higher in total stroke and patients with cerebral infarction than in control(P<0.06, P<0.05). 2. The frequency of DST non-suppression in patients with cerebral infarction is significantly higher than in control, patients with cerebral hemorrhage and patients with subarachnoid hemorrhage(P<0.001, P<0.01, P<0.01). 3. Patients with left hemispheric stroke tend to show more frequent abnormal neuroendocrine test results than patient with right hemispheric stroke. 4. There are no correlation between abnormal neuroendocrine test results and age, sex, size of stroke and Barthel ADL scale. These results suggest stroke can influence on hypothalamic-pituitary axis, more marked in cerebral infarction and left hemispheric lesion.

A Clinical Study on Caudate Hemorrhage

A clinical study was done on 16 cases of caudate hemorrhage which were confirmed with brain CT scan at Keimyung University Dongsan hospital from January 1985 to Februaty 1989 and conclusions obtained are as follow 1. The proportion of caudate hemorrhage was 4,9% of all spontaneous mtracranial parenchymal hemorrhage. 2. The most prevalent age group was 7th decade and sex ratio was slightly higher in female(1.7:1). 3, The most common cause of caudate hemorrhage was hypertension. 4, The major initial symptoms of caudate hemorrhage were nausea and vomiting, followed by headache and altered concsiousness, 5. The major neurologic signs on admission were behavioral abnormalities (disorientation and memory disturbance), neck stiffness, impaired consciousness and hemipareris 6. Hemorrhage involved head(11 cases), body(4 cases) and head and body (1 case) of Caudate, but not tail. 7. The prognosis of caudate hemorrhage is good in our senes, but sequelae such as anxiety, memory disturbance or mild hemiparesis remained in a few cases. 8. From above findings, the caudate nucleus seems to play some roleon memory or behavioral function.

Causative Diseases of 108 Dementia Patients

Underlying caustive diseases were observed on 108 patients with dementia diagnosed on DSM-III, who were admitted to Keimyung university Dongsan hospital during January 1985 to September 1988. The results were summarized as follows. 1. Male to female ratio was approximately 5 to 1. In all diseases causing dementia, male outnumbered female. In particular, alcoholic dementia, multi-infarct dementia, posttraumatic dementia, infection, hydrocephalus and subdural hematoma were almost limited to males. 2. The important causative diseases were alcoholic dementia (21.3%), multi-infarct dementia(18.5%), postanoxic encephalopathy (14.8%), dementia of Alzheimer type (12.1%), head trauma(8.3%), brain tumor (6.5%), pseudodementia(6.5%), infection(4.6%), hydrocephalus (4.6%), and subdural hematoma(2.8%) in the order of frequency. 3. Cerebral trauma was the most common cause of dementia in young adulthod, and alcoholic dementia, multiinfarct dementia and dementia of Alzheimer type were important in middle adulthood. In old age, multiinfarct dementia was noted to be the most common cause. 4. Thorough diagnostic evaluation has uncovered reversible disorders in 19.4% of the total patients and disorders which, though not reversible, nevertheless require active therapeutic intervention in an additional 60.2%.

A case of Nontraumatic Cerebrospinal Fluid Fistula

We reported a case of nontraumatic cerebrospinal fluid fistula who had concomittantly CSF rhinorrhea, pneumocephalus and bacterial meningitis. By metrizamide CT cisternography, we found her CSF fistula was likely to be on the right lateral wall of sphenoidal sinus. She was recovered from her symptoms by medical treatment and has been free of CSF rhinorrhea or meningitis without surgical repair of CSF fistula during recent 1 year follow up.