Positron emission tomography (PET) scan in epilepsy.

Positron Emission Tomography (PET) has an advantage in localizing epileptogenic zones for successful surgery in several epileptic syndromes. Among the most radiopharmaceutical used in PET studies in epilepsy are [18F] fluorodeoxyglucose (FDG) and [11C]flumazenil (FMZ). Unilateral temporal hypometabolism (UTH) seen in FDGPET was shown to correlate well with ictal EEG origins in 60-90 % of temporal lobe epilepsy (TLE) patients. PET aids in surgical decision-making in TLE patients with discordant data from initial presurgical evaluation, in bitemporal disease and in nonlesional TLE. However, PET adds little in lesional TLE with congruent data. The extent of glucose hypometabolic area was shown to correlate with post-operative outcomes. PET may reduce the need for invasive EEG in bitemporal epilepsy. Abnormal FMZ binding has been proposed to guide the location of subdural electrode placement in extratemporal epilepsy (ETE). FMZ-PET and FDG-PET were shown to be sensitive in visualizing areas of cortical dysgenesis. Focal FDG-PET abnormality was demonstrated in 20 % of children with West’s syndrome and has provided a revolutionary approach for surgical treatment. Resection of the focal hypometabolism has rendered good control of infantile spasms and restoration of developmental delay. PET use of alpha-[11C] methyl-L-tryptophan (AMT), a serotonin precursor, has been shown to selectively localize epileptogenic tuber in the tuberous sclerosis complex as well as in identifying epileptic residual tissue following surgical failure. PET has potential in determining eloquent brain areas and in studying mechanisms of epilepsy. In epilepsy surgery, PET can be used with worthwhile cost-benefit even in a country with limited resources.

Successful resection of Hypothalamic Hamartoma with intractable gelastic seizures--by transcallosal subchoroidal approach.

A 19-year old female with intractable gelastic seizures was found to have 0.7 x 1.8 x 1.8 cm elliptical mass on the floor of the third ventricle. The signal intensity on the Magnetic Resonance Imaging (MRI) was consistent with the Hypothalamic Hamartoma (HH). Ictal EEG demonstrated rhythmic 7 Hz waves over Fp2, F4, and C4 with spreading to the right temporal region and then bilaterally. Ictal Single Photon Emission Computerized Tomography (SPECT) showed hyperperfusion at hypothalamic and medial frontopolar regions. The patient underwent surgical resection using Trans Callosal Subchoroidal Approach (TCSA) to the third ventricle. Pathological finding confirmed the diagnosis of hypothalamic hamartoma. Following the operation, she has been seizure free up to 12 months. Thereafter, provoked seizures seldom occurred and there has been improvement in her memory, emotional control and independence. This appears to be the first report of this surgical approach for HH, which is less likely to disturb memory function compared to previously described interfoniceal approach.

The first invasive EEG monitoring for surgical treatment of epilepsy in Thailand.

The authors report the first invasive electroencephalography (EEG) monitoring in Thailand in a patient who had intractable left temporal lobe epilepsy. The seizure origin and functioning cortices were identified The corresponding epileptogenic zone was resected without functional deficit. The patient has become seizure free 1 year since surgery. Subdural EEG monitoring with cortical stimulation have been developed at this tertiary epilepsy center The technique provides essential evidence for the surgical decision so that the best post operative outcome can be achieved.

Quality of life after successful epilepsy surgery: evaluation by occupational achievement and income acquisition.

OBJECTIVES: A comprehensive epilepsy surgery program has been developed at Chulalongkorn University Hospital, Thailand to reach an international standard level, rendering patients good surgical outcomes comparable to developed countries. After successful operation, seizure free patients have become independent, self earning or employed. However, quality of life (QOL) in terms of occupational achievement and income acquisition after epilepsy surgery has never been studied. These indicators reflect the ultimate QOL in the aspects of actual independency, intact brain functions, mental health and psycho-social interactions. The authors therefore conduct the study on improvement of QOL after successful epilepsy surgery using these parameters. MATERIAL AND METHOD: One hundred and eleven intractable epilepsy who have become seizure free to worthwhile improved (Engel class I to III) after standard presurgical evaluation and epilepsy surgery from January 2002 to December 2004 were evaluated. The patients were followed up for 3 years. The occupational status and incomes were categorized according to the ranking of the patients' functioning levels. The pre and post surgery work abilities, employment and incomes were interviewed and compared. Mc Nemar test and paired t-test were used for statistical analyses. RESULTS: The average age of the 111 adults (54 males and 57 females) was 33.7 +/- 9.2 years. Eighty two percent of the patients had temporal lobe epilepsy (TLE) with mesial temporal sclerosis (MTS) and underwent standard anterior temporal lobectomy. The rest had tumors, cortical dysplasia or scar and received lesionectomy or cortical resection assisted by intra-operative or intra-cranial EEG. The overall seizure free rate is 83.8%. The occupational status of the subjects was shown to improve significantly after surgery from unemployed to higher categories of professional achievement (p < 0.001). The number of unemployed and no income individuals decreased from 66 to 25 cases (62.1% reduction rate) after surgery (p < 0. 001). Reciprocally, the number of persons who achieved professional jobs with regular incomes or salaries increase from 30 to 53 cases (43.4% increasing rate) (p < 0.001). The patients who have not acquired any income increment showed improvement in working ability after epilepsy surgery. The average annual incomes per capita shows the increasing rate of 45.08%, from 55,657.85 Baht (approximately U.S. dollars 1390) to 80,748.15 Baht (approximately U.S. dollars 2018), with strong statistical significance (p < 0.001). The improvement is best seen in seizure free than in non-seizure free subjects. CONCLUSION: The present study, to the authors 'knowledge, is the first to use work abilities, professional achievement and income acquisition to assess the ultimate QOL after epilepsy surgery. Most subjects have been shown to significantly improve their postoperative lives in terms of occupational accomplishment and income increment, especially in seizure free individuals. The need for expansion of epilepsy surgery is emphasized.

The difference among stress and rest normal reference databases using non-corrected, scatter corrected, and scatter with attenuation corrected Bull's eye myocardial perfusion scintigraphy in both genders.

OBJECTIVES: To compare 3 types of Bull's eye normal reference maps; non-corrected, scatter corrected, and scatter with attenuation corrected Bull's eye in both genders. MATERIAL AND METHOD: Sixty-seven normal healthy males and females volunteered for the present study. After screening tests to identify low post-test (exercise EKG) likelihood of coronary artery disease, 41 subjects (20 males and 21 females) had stress and rest myocardial perfusion scintigraphy (99mTc-sestamibi). The data were reconstructed by filtered back projection reconstruction in three ways as follows; (1) non-correction (NoC), (2) scatter elimination only (SC), (3) scatter elimination and attenuation correction (SC+AC). Three sets of reconstructed data of both stress and resting studies were added into 6 sets of Bull's eye. The data of each Bull's eve were normalized to 100% of the maximum count. Percentage of uptake in each area was compared by t-test statistics. RESULTS: Stress and rest count distribution of NoC and SC sets were lowest at the inferior wall, followed by the septal wall, anterior wall, and lateral wall in both genders. In the SC+AC sets; septum and lateral walls showed more uptake than anterior and inferior walls. A significant difference of percentage uptake between stress and rest images at septum in NoC and SC images in male and in SC image in female was observed. No difference was seen in the SC+AC groups. CONCLUSION: There was similarity of count distribution between NoC and SC images. SC+AC caused more uniform image. However; some non-uniformity was observed. The use of sex-independent SC+AC bull's eye is possible. Stress study can be omitted for bull's eye collection of normal files.

The effect of phenobarbital on the accuracy of technetium-99m diisopropyl iminodiacetic acid hepatobiliary scintigraphy in differentiating biliary atresia from neonatal hepatitis syndrome.

Biliary atresia (BA) and neonatal hepatitis syndrome (NHS) are major causes of cholestatic jaundice in infancy. Technetium-99m diisopropyl iminodiacetic acid hepatobiliary scintigraphy (99mTc-DISIDA scan) is widely used in the differentiation of these two entities. The objective of this study was to evaluate the effect of phenobarbital premedication on the accuracy of 99mTc-DISIDA scan. Ninety-five cholestatic infants (38 females and 57 males) with an age range of 2 weeks to 4 months (mean 2.1 mo) who underwent 99mTc-DISIDA scan testing were retrospectively reviewed. The patients were divided into 3 groups according to the history of phenobarbital administration prior to 99mTc-DISIDA scan examination. Group 1 (n = 48), group 2 (n = 29), and group 3 (n = 18) received phenobarbital at the dosage of 5 mg/kg/day for at least 5 days, less than 5 mg/kg/day or less than 5 days, and no premedication, respectively. The accuracy of 99mTc-DISIDA scan in differentiating BA from NHS in group 1, 2, and 3 was 72.92 per cent, 89.66 per cent, and 100 per cent, respectively. No significant difference was seen between the patients who received and did not receive phenobarbital in terms of age at presentation, age at onset of jaundice, and liver function tests. In conclusion, phenobarbital therapy may not be necessary prior to 99mTc-DISIDA scan examination in the evaluation of cholestatic infants and thus a delay in diagnosis and surgical therapy of BA can be avoided.

Relationship between vesicoureteral reflux and renal cortical scar development in Thai children: the significance of renal cortical scintigraphy and direct radionuclide cystography.

Relationship of vesicoureteral reflux (VUR), urinary tract infection (UTI) and subsequent renal scarring nowadays is still in question. This study aimed to determine 1) the incidence of cortical scarring in Thai children presenting with upper urinary tract infection, 2) the association between VUR with acute pyelonephritis and subsequent renal scarring, 3) the use of DMSA and direct radionuclide cystography (DRNC) scintigraphy in children with UTI. Sixty newly diagnosed UTI children underwent DRNC and Tc-99m DMSA renal cortical scintigraphy at the time of first UTI diagnosis and 6 months later. There were no significant differences of age, sex, type of antiobiotics and pathogens (E. coli vs non-E. coli) between those who did and did not develop scars (p>0.05). 58/98 of 1st DMSA abnormal kidneys (59.18%) developed scars. 60.20 per cent of 98 positive 1st DMSA had VUR while 80.33 per cent of 61 with VUR had positive 1st DMSA. 59.02 per cent of these 61 kidneys developed scars. Scar occurrence were 18.7 times in high grade VUR compared to low grades. In conclusion, there was a high incidence of acute pyelonephritis in the presence of VUR but acute pyelonephritis does not necessarily need VUR for its development. High grade reflux with upper UTI, is a strong indicator for renal scarring. Children presenting with UTI, irrespective of age, sex, or pathogen, should have both DMSA and DRNC scintigraphy performed to identify upper UTI and high risk patients who will develop subsequent renal scarring.