Outcome of epilepsy surgery in lesional epilepsy: Experiences from a developing country.

BACKGROUND: Our aim was to report the postoperative seizure outcome and associated factors in patients with lesional epilepsy, in a low-income setting. METHODS: This longitudinal prospective study included patients who underwent epilepsy surgery at Kashani Comprehensive Epilepsy Center between 2014 and 2019. Post-surgical outcomes were reported according to the Engel score, and patients were classified into two groups of seizure free (SF) and not-seizure free (NSF). RESULTS: A total of 148 adult patients, with a mean age of 30.45 ±â€¯9.23 years were included. The SF outcome was reported in 86.5% of patients and antiepileptic drugs (AEDs) were reduced or discontinued in 45.9%. The mean follow-up duration was 26.7 ±â€¯14.9 months. Temporal lobe lesions (76.3%) and mesial temporal sclerosis (MTS) (56.7%) were the most frequent etiologies. Temporal lesion (Incidence relative risk (IRR): 1.76, 95% CI [1.08-2.87], p = 0.023), prior history of CNS infection (IRR:1.18, 95% CI [1.03-1.35], p = 0.019), use of intra-operative ECoG (IRR:1.73, 95% CI [1.06-2.81], p = 0.028), and absence of IEDs in postoperative EEG (IRR: 1.41, 95% CI [1.18-1.70], p < 0.001) were positive predictors for a favorable outcome. CONCLUSION: Many patients with drug-resistant lesional epilepsy showed a favorable response to surgery. We believe that resective epilepsy surgery in low-income settings is a major treatment option. The high frequency of patients with drug-resistant epilepsy in developing countries is associated with high rates of morbidity and mortality. Hence, strategies to increase access to epilepsy surgery in these settings are urgently needed.

The Relationship between Aura and Postoperative Outcomes of Epilepsy Surgery in Patients with Mesial Temporal Sclerosis.

BACKGROUND: We conducted a study to evaluate the relationship between aura types and postoperative outcomes in patients with mesial temporal sclerosis (MTS) to predict the prognosis of patients, accordingly. MATERIALS AND METHODS: In this cross-sectional study, 99 patients with MTS-temporal lobe epilepsy were enrolled based on inclusion and exclusion criteria. The types of aura were evaluated, and the outcomes were categorized according to the Engel scale. Preoperative and postoperative results of patients were compared and analyzed with the Kruskal-Wallis test. RESULTS: About 73.7% of patients had seizure-free after their surgeries. The most of patients (n = 81) were in Class I of Evaluating Engel criteria. About 36.3% had not experienced any aura before their seizures, and among those with aura, the most prevalent aura was abdominal aura in 29 patients (29.3%) followed by other types of aura and affective aura. Most of the patients in Class I, II, III, and IV of Engel scale had an abdominal aura, without aura, effective aura, and abdominal aura, respectively, but this difference was not statistically significant (P = 0.691). CONCLUSION: According to this study, the type of aura cannot predict postoperative outcomes in MTS patients. More studies are needed to evaluate this relation in better-planned studies with greater sample size.

Outcome of lesional epilepsy surgery: Report of the first comprehensive epilepsy program in Iran.

BACKGROUND: We investigated the utility of epilepsy surgery and postoperative outcome in patients with lesional epilepsy in Iran, a relatively resource-poor setting. METHODS: This prospective longitudinal study was conducted during 2007-2017 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with a diagnosis of intractable focal epilepsy, with MRI lesions, who underwent epilepsy surgery and were followed up ≥ 24 months, were included and evaluated for postoperative outcome. RESULTS: A total of 214 patients, with a mean age of 26.90 ± 9.82 years (59.8% men) were studied. Complex partial seizure was the most common type of seizure (85.9%), and 54.2% of the cases had auras. Temporal lobe lesions (75.2%) and mesial temporal sclerosis (48.1%) were the most frequent etiologies. With a mean follow-up of 62.17 ± 19.33 months, 81.8% of patients became seizure-free postoperatively. Anticonvulsants were reduced in 86% of the cases and discontinued in 40.7%. In keeping with previous studies, we found that seizure freedom rates were lower among patients with longer follow-up periods. CONCLUSIONS: We found high rates of seizure freedom after surgery in lesional epilepsy patients despite limited facilities and infrastructure; antiepileptic medications were successfully tapered in almost half of the patients. Considering the favorable outcome of epilepsy surgery in our series, we believe that it is a major treatment option, even in less resource-intensive settings, and should be encouraged. Strategies to allow larger scale utility of epilepsy surgery in such settings in the developing world and dissemination of such knowledge may be considered an urgent clinical need, given the established mortality and morbidity in refractory epilepsy.

Evaluation of dual pathology among drug-resistant epileptic patients with hippocampal sclerosis.

PURPOSE: Dual pathology (DP) is defined as simultaneous presence of hippocampal sclerosis (HS) and any other pathology in the brain. Since this is a less probed concept, we aimed to evaluate the frequency and characteristics of DP among drug-resistant epileptic patients with HS. METHODS: This is a cross-sectional study conducted during 2007-2016 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with diagnosis of drug-resistant epilepsy and HS were enrolled in the study, and demographic data, seizure semiology, EEG findings, and MRI findings were collected. We compared these variables between three groups of DP, unilateral HS, and bilateral HS. RESULTS: Of the 200 enrolled cases, 29 patients (14.5%) had DP and 21 patients (10.5%) had bilateral HS; the remaining patients had unilateral HS. The average age of patients with DP was 30.03, and 65.5% of them were male. Patients with DP had more EEG discharges from regional and multi-focal sites compared to unilateral HS (P value < 0.001). Also, complex partial seizure (CPS) was more commonly presented in patients with unilateral HS (96.8%). Comparison of disease characteristics between DP and bilateral HS showed no difference in most categories (P > 0.05). CONCLUSIONS: We found DP among 14.5% of our drug-resistant epileptic patients with HS. DP patients mostly presented with CPS and had high proportion of ictal and interictal EEG discharges from regional and multi-focal areas. Gliosis and focal cortical dysplasia were the most common pathologies among DP patients. Patients with DP showed a similar behavior to bilateral HS in many features.

An Undiagnosed Case of Hypothalamic Hamartoma with a Rare Presentation.

Background. Hypothalamic hamartomas (HHs) are rare tumor-like malformations that may present with complex partial seizures refractory to anticonvulsants in adulthood. The condition may be misdiagnosed because of rarity. Case Presentation. We report a 25-year-old man with complaint of seizures presented by falling, tonic spasm of limbs, oral automatism, vocalization, and hypermotor activities. His seizures started at the age of one month and presented as eye deviation and upper limbs myoclonic jerk, followed by frequent seizures with variable frequency. The patient had delayed developmental milestones and was mentally retarded. He was hospitalized and underwent video-EEG monitoring and neuroimaging, and the diagnosis of HH was made. The patient became candidate for surgery after that. Conclusion. In this case, the underlying etiology of seizures was diagnosed after 25 years. HH is a rare condition and neurologists may encounter very small number of these cases during their practice. Therefore, they should consider it in patients who present with suspected signs and symptoms.

Prognostic value of ictal onset patterns in postsurgical outcome of temporal lobe epilepsy.

Background: To investigate ictal onset patterns (IOP) in scalp electroencephalography (EEG) of patients with temporal lobe epilepsy (TLE) and their prognostic effect on the postoperative outcome. Methods: We conducted a retrospective cohort study between 2011 and 2015 in our referral Epilepsy Surgery Center enrolling adult patients with refractory TLE and a visible epileptogenic lesion in magnetic resonance imaging (MRI), who underwent epilepsy surgery. Demographic, clinical and MRI findings were collected and ictal findings during video-EEG monitoring were reviewed in detail. The correlation between preoperative findings and the postsurgical outcome was analyzed. Results: We reviewed 303 seizures in 93 patients. Rhythmic theta and rhythmic spike/sharp and wave were respectively the most common initial ictal pattern and late significant discharges. Engel class I outcome was observed in 88.2% of patients. Female sex, aura, the absence of secondary generalization, rhythmic theta as initial ictal pattern and concordance of ictal-interictal EEG findings were correlated with favorable 1-year postsurgical outcome. Conclusion: Preoperative clinical and EEG findings can provide valuable information regarding postsurgical prognosis in TLE patients.

Cardiac arrest associated with epileptic seizures: A case report with simultaneous EEG and ECG.

Ictal asystole is a rare, probably underestimated manifestation of epileptic seizures whose pathophysiology is still debated. This report describes two patients who had cardiac asystole at the end of their seizure. The first patient was a 13-year-old boy with complex partial seizures.. His MRI showed symmetrical signal abnormality in the bilateral parietooccipital lobe accompanied by mild gliosis and volume loss. During a 3-day long-term video-EEG monitoring, he had cardiac arrest at the end of one of his seizures that was secondarily generalized. The second one was a 42-year-old veteran with penetrating head trauma in the left frontal lobe due to shell injury. During long-term video-EEG monitoring, he had one generalized tonic-clonic seizure accompanied by bradycardia and cardiac asystole. Asystoles could have a role in the incidence of sudden unexpected death in epilepsy (SUDEP), meaning that the presence of ictal bradycardia is a risk factor for SUDEP. In cases of epileptic cardiac dysrhythmia, prolonged simultaneous EEG/ECG monitoring may be required. Cardiological investigation should be included in epilepsy management.

The effect of Boswellia Serrata on neurorecovery following diffuse axonal injury.

OBJECTIVES: This pilot trial was conducted to establish whether Boswellia Serrata (BS), a traditional herbal medicine, could improve the outcome of patients who have diffuse axonal injury (DAI). METHODS: In total, 38 patients with pure DAI were enrolled in this 12-week, double-blind, randomized, cross-over study. The patients were randomly assigned to receive either placebo (group A, n = 20) or BS capsules (group B, n = 18) for 6 weeks and then switched to the other intervention for another 6 weeks. The disability rating scale (DRS) was used to assess the outcome at 2-, 6- and 12-weeks post-trauma. RESULTS: A non-significant trend for improvement of DRS total scores was observed after the use of BS. Regarding the DRS sub-scores, however, there was significant improvement in 'cognitive ability to self-care' during the second 6 weeks in group A on BS compared to an insignificant spontaneous recovery in group B during the same period on placebo. Moreover, both groups experienced a close-to-significant increase in the cognitive function-related items of the DRS during the periods they were on BS. The reported adverse events were all of mild quality and had similar frequency between the groups. CONCLUSION: These results suggest that BS resin does not significantly affect general outcome, but may enhance the cognitive outcome of patients with DAI.

Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury.

OBJECTIVE: Traumatic brain injury is one of the major causes of death and disability among young people. Methylphenidate, a neural stimulant and protective drug, which has been mainly used for childhood attention deficit/hyperactivity disorder, has shown some benefits in late psychosocial problems in patients with traumatic brain injury. Its effect on arousal and consciousness has been also revealed in the sub-acute phase of traumatic brain injury. We studied its effect on the acute phase of moderate and severe traumatic brain injury (TBI) in relation to the length of ICU and hospital admission. PATIENTS AND METHODS: Severely and moderately TBI patients (according to inclusion and exclusion criteria) were randomized to treatment and control groups. The treatment group received methylphenidate 0.3mg/kg per dose PO BID by the second day of admission until the time of discharge, and the control group received a placebo. Admission information and daily Glasgow Coma Scale (GCS) were recorded. Medical, surgical, and discharge plans for patients were determined by the attending physician, blinded to the study. RESULTS: Forty patients with severe TBI (GCS = 5-8) and 40 moderately TBI patients (GCS = 9-12) were randomly divided into treatment and control groups on the day of admission. In the severely TBI patients, both hospital and ICU length of stay, on average, were shorter in the treatment group compared with the control group. In the moderately TBI patients while ICU stay was shorter in the treatment group, there was no significant reduction of the period of hospitalization. CONCLUSION: There were no significant differences between the treatment and control groups in terms of age, sex, post resuscitation GCS, or brain CT scan findings, in either severely or moderately TBI patients. Methylphenidate was associated with reductions in ICU and hospital length of stay by 23% in severely TBI patients (P = 0.06 for ICU and P = 0.029 for hospital stay time). However, in the moderately TBI patients who received methylphenidate, there was 26% fall (P = 0.05) only in ICU length of stay.