Surgical outcomes for medically intractable epilepsy in low- and middle-income countries: a systematic review and meta-analysis.

OBJECTIVEThe aim of this study was to describe the current state of epilepsy surgery and establish estimates of seizure outcomes following surgery for medically intractable epilepsy (MIE) in low- and middle-income countries (LMICs).METHODSThe MEDLINE and Embase databases were searched without publication date restriction. This search was supplemented by a manual screen of key epilepsy and neurosurgical journals (January 2005 to December 2016). Studies that reported outcomes for at least 10 patients of any age undergoing surgery for MIE in LMICs over a defined follow-up period were included. A meta-analysis with a random-effects model was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. Pooled estimates of seizure freedom and favorable seizure outcomes following anterior temporal lobectomy with or without amygdalohippocampectomy (ATL ± AH) were reported.RESULTSTwenty studies were selected, of which 16 were from Asian centers. The average age at surgery in all studies was less than 30 years, and the average preoperative duration of epilepsy ranged from 3 to 16.1 years. Mesial temporal sclerosis accounted for 437 of 951 described pathologies, and 1294 of the 1773 procedures were ATL ± AH. Based on 7 studies (646 patients) the pooled seizure freedom estimate following ATL ± AH was 68% (95% CI 55%-82%). Based on 8 studies (1096 patients), the pooled estimate for favorable seizure outcomes was 79% (95% CI 74%-85%).CONCLUSIONSSurgery for MIE in LMICs shows a high percentage of seizure freedom and favorable outcomes. These findings call for a concerted global effort to improve timely access to surgery for MIE patients in these regions, including investments aimed at refining existing and establishing additional centers.

Loss of Consciousness at Onset of Aneurysmal Subarachnoid Hemorrhage is Associated with Functional Outcomes in Good-Grade Patients.

BACKGROUND: Transient loss of consciousness (LOC) is one of the most common presentations of aneurysmal subarachnoid hemorrhage (SAH) and may be an indicator of early brain injury. In this study, we examined the association of LOC and functional outcomes in patients with good-grade SAH. METHODS: We searched the Subarachnoid Hemorrhage International Trialists Repository for patients who presented with LOC at ictus of SAH. A propensity score analysis was performed on good-grade patients (defined as World Federation of Neurosurgical Societies grade 1-3) to balance selected covariates between those with and without LOC. The primary outcome was Glasgow Outcome Score (GOS) at 3 months (with poor outcome defined as a GOS of 1-3). Secondary outcomes were delayed cerebral ischemia (DCI), rebleed, length of hospital stay, and time to death. RESULTS: A propensity score-matching algorithm identified 336 patients (168 with and 168 without LOC at ictus). The proportion of patients with poor functional outcome at 3 months was significantly higher in the cohort with LOC at ictus compared with the matched cohort without LOC at ictus (30% vs. 19%; P = 0.02). There was a nonsignificant trend toward greater mortality in the patients with LOC at ictus (19% vs. 13%; P = 0.14). There were no significant differences in the secondary outcomes between the 2 cohorts. CONCLUSIONS: LOC at ictus of SAH is associated with a higher rate of unfavorable functional outcomes but not of mortality, DCI, or rebleed in patients with good-grade SAH. Future studies should further investigate the putative mechanisms through which LOC mediates early brain injury in SAH.

The use of ultrasound-stimulated contrast agents as an adjuvant for collagenase therapy in chronic total occlusions.

AIMS: To investigate the effectiveness of combining collagenase and ultrasound-stimulated microbubble (USMB) treatments in reducing the mechanical force required for crossing a guidewire through CTOs. METHODS AND RESULTS: Experiments were conducted on ex vivo specimens of a rabbit femoral artery CTO model (n=45 total samples). Four primary groups were employed: control (n=6), collagenase only (n=15), USMB only (1 MHz frequency) (n=5), and collagenase+USMB (n=19). In one set of experiments the force required to puncture through CTO samples was measured and it was found that the puncture force was 2.31-fold lower for the combined treatment group relative to the comparable collagenase-only group (p<0.05). In a second set of experiments, the total protein and hydroxyproline content of the supernatant solution adjacent to the CTO was analysed. Significantly higher hydroxyproline levels were measured in collagenase+USMB treated CTOs (0.065 g/mL) compared to collagenase (0.030 g/mL), USMB (0.003 g/mL) and control (0.004 g/mL) (p<0.05), indicating that the combined treatment augmented collagenase degradation. CONCLUSIONS: Ultrasound-stimulated microbubbles improved the effectiveness of collagenase in reducing the force required to cross experimental CTOs. This new approach may have the potential to reduce treatment times and improve the success rates of emerging collagenase-based treatments of CTO.