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Background: Neuropsychological Rehabilitation (NR) helps manage cognitive deficits in epilepsy. As internationally developed programs have limited applicability to resource-limited countries, we developed a program to bridge this gap. This 6-week caregiver-assisted, culturally suitable program has components of (1) psychoeducation, (2) compensatory training, and, (3) cognitive retraining and is called EMPOWER (Indigenized Home Based Attention and Memory Rehabilitation Program for Adult Patients with Drug Refractory Epilepsy). Its efficacy needs to be determined., Methods: We carried out an open-label parallel randomized controlled trial. Adults aged 18-45 years with Drug Refractory Epilepsy (DRE), fluency in Hindi and or English, with impaired attention or memory (n = 28) were randomized to Intervention Group (IG) and Control Group (CG). The primary outcomes were objective memory (Auditory Verbal Learning Test), patient and caregiver reported everyday memory difficulties (Everyday Memory Questionnaire-Revised), number of memory aids in use, depression (Hamilton Depression Rating Scale), anxiety (Hamilton Anxiety Rating Scale) and quality of life (Quality of Life in Epilepsy-31). Intention to treat was carried out for group analysis. In the absence of norms necessary for computing Reliable Change Indices (RCIs), a cut-off of +1.0 Standard Deviation (SD) was utilized to identify clinically meaningful changes in the individual analysis of objective memory. A cut-off of 11.8 points was used for quality of life. Feedback and program evaluation responses were noted., Results: The majority of the sample comprised DRE patients with temporal lobe epilepsy who had undergone epilepsy surgery. Group analysis indicated improved learning (p = 0.013), immediate recall (p = 0.001), delayed recall (p < 0.001), long-term retention (p = 0.031), patient-reported everyday memory (p < 0.001), caregiver-reported everyday memory (p < 0.001), anxiety (p = 0.039) and total quality of life (p < 0.001). Individual analysis showed improvement in 50 %, 64 %, 71 %, 57 %, and 64 % of patients on learning, immediate recall, delayed recall, long-term retention, and total quality of life respectively. Despite improvements, themes indicative of a lack of awareness and understanding of cognitive deficits were identified. Overall, the program was rated favorably by patients and caregivers alike., Conclusion: NR shows promise for patients with DRE, however larger studies are warranted. The role of cognition in epilepsy needs to be introduced at the time of diagnosis to help lay the foundation for education and acceptance., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Hemispherotomy (HS) is an effective treatment for unilateral hemispheric onset epilepsy. There are few publications for HS in adults, and there is no series comparing adults and pediatric patients of HS., Objective: To compare the hemispherotomies done in adult patients with pediatric ones in terms of efficacy and safety., Methods: Data was prospectively collected for HS patients (up to 18 years and more) from Aug 2014 to Aug 2018. Comparison between the groups was made for seizure onset, duration of epilepsy, frequency of seizures, number of drugs, intraoperative blood loss, postoperative seizure control, postoperative stay, postoperative motor functions, and preoperative and postoperative intelligence quotient. Follow-up was one year., Results: A total of 61 pediatric and 11 adults underwent HS. The seizure onset was earlier in children, and the duration of epilepsy was longer in adults. The frequency of seizures per day was more in children being 14.62 ± 26.34 in children, and 7.71 ± 5.21 per day in adults (P - 0.49). The mean number of drugs was similar in the preoperative and postoperative periods in both. Class I seizure outcome was similar in both the groups being 85.24% in children and 90.9% in adults (P - 0.56). Blood loss, postoperative stay, was similar in both the groups. No patient had a new permanent motor deficit. Power worsened transiently in 1 pediatric patient and in 4 adult patients. The visual word reading and object naming improved in both the groups (no intergroup difference), and IQ remained the same in both groups. One adult patient had meningitis, and another had hydrocephalus requiring shunt placement., Conclusion: Hemispherotomy is a safe and effective procedure in adults as in children in appropriately selected patients., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Background and Purpose: In presurgical evaluation for epilepsy surgery, information is sourced from various imaging modalities to accurately localize the epileptogenic zone. Magnetoencephalography (MEG) is a newer noninvasive technique for localization. However, there is limited literature to evaluate if MEG provides additional advantage over the conventional imaging modalities in clinical decision making. The objective of this study was to assess the diagnostic added value of MEG in decision making before epilepsy surgery., Method: This was a prospective observational study. Patients underwent 3 h of recording in a MEG scanner, and the resulting localizations were compared with other complimentary investigations. Added value of MEG (considered separately from high-density electroencephalography) was defined as the frequency of cases in which (i) the information provided by magnetic source imaging (MSI) avoided implantation of intracranial electrodes and the patient was directly cleared for surgery, and (ii) MSI indicated additional substrates for implantation of intracranial electrodes. Postoperative seizure freedom was used as the diagnostic reference by which to measure the localizing accuracy of MSI., Results: A total of 102 patients underwent epilepsy surgery. MEG provided nonredundant information, which contributed to deciding the course of surgery in 33% of the patients, and prevented intracranial recordings in 19%. A total of 76% of the patients underwent surgical resection in sublobes concordant with MSI localization, and the diagnostic odds ratio for good (Engel I) outcome in these patients was 2.3 (95% confidence interval 0.68, 7.86; p = 0.183) after long-term follow-up of 36 months., Conclusion: Magnetic source imaging yields additional useful information which can significantly alter as well as improve the surgical strategy for persons with epilepsy., (© 2021 European Academy of Neurology.)

Background: Hemispheric disconnection represents a challenging and major epilepsy surgical procedure. This procedure in experienced hands offers excellent results in terms of seizure outcomes, especially for hemispheric pathologies such as Rasmussen's encephalitis, hemispheric dysplasias, hemimegalencephaly. The technique of hemispherotomy has witnessed various modifications over the years, beginning from anatomical hemispherectomy to the current era of minimally invasive functional hemispheric disconnections., Objective: This study aimed to describe the technique of performing endoscopic vertical hemispherotomy using interhemispheric corridor developed by the senior author., Materials and Methods: A 12-year-old girl with seizure onset at the age of 10 years presented with an aura of fear and nausea followed by tonic deviation of eyes to the right and blinking with speech arrest. There were tonic-clonic movements of the right-sided limbs along with ictal spitting and occasional deviation of the angle of mouth to the right. The patient had loss of awareness for the event along with postictal confusion lasting few minutes., Results: Video electroencephalography (VEEG) revealed left parietocentral and left temporal localization. Serial magnetic resonance imaging (MRI) brain over 3 years revealed progressive left hemispheric changes suggestive of Rasmussen's encephalitis. The patient underwent left-sided endoscopic hemispherotomy. At 2 years follow-up, the patient is seizure-free (ILAE [International League Against Epilepsy] Class 1)., Conclusion: Endoscopic hemispherotomy using the interhemispheric approach is an elegant, minimally invasive, reproducible, safe, and efficacious technique., Competing Interests: None

Purpose: The aim of this study was to compare the diagnostic value and accuracy of ictal SPECT and inter-ictal magnetoencephalography (MEG) in localizing the site for surgery in persons with drug resistant epilepsy., Method: This was a prospective observational study. Patients expected to undergo epilepsy surgery were enrolled consecutively and the localization results from different imaging modalities were discussed in an epilepsy surgery meet. Odds ratio of good outcome (Engel I) were calculated in patients who underwent surgery in concordance with MEG and SPECT findings. Post-surgical seizure freedom lasting at least 36 months or more was considered the gold standard for determining the diagnostic output of SPECT and MEG., Results: MEG and SPECT were performed in 101 and 57 patients respectively. In 45 patients SPECT could not be done due to delay in injection or technical factors. The accuracy of MEG and SPECT in localizing the epileptogenic zone was found to be 74.26 % and 78.57 % respectively. The diagnostic odds ratio for Engel I surgical outcome was reported as 2.43 and 5.0 for MEG and SPECT respectively. The diagnostic odds ratio for MEG in whom SPECT was non-informative was found to be 6.57 [95 % CI 1.1, 39.24], although it was not significantly associated with good surgical outcome. MEG was useful in indicating sites for SEEG implantation., Conclusion: SPECT was found to be non-informative for most patients, but reported better diagnostic output than MEG. MEG may be a useful alternative for patients in whom SPECT cannot be done or was non-localizing., (Copyright © 2021 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objective: We evaluate the potential utility of F-18 FDG-PET in addition to MRI in the diagnostic work-up of patients with autoimmune epilepsy (AE) and propose the inclusion of functional imaging in the antibody prevalence in epilepsy (APE) scoring system., Methods: This was a retrospective analysis in 60 patients, diagnosed and treated for AE, of whom 40 were antibody negative (presumed AE) and 20 were antibody positive (definitive AE). All patients had undergone a dedicated brain and whole body FDG-PET in the department of Nuclear Medicine., Results: In the antibody negative group, MRI supported a diagnosis of AE in 23 patients. Both MRI and PET were indicative in 12 cases, and standalone PET was positive in 8. While MRI alone was diagnostic in 57% (23/40), the combined yield of both modalities was 77% (31/40). When PET scores were added to assign the APE score in MRI negative cases, average APE score was 5.4. In the antibody positive group, MRI supported the diagnosis of AE in 7 patients. Both MRI and PET were positive in 4 patients and standalone PET was positive in 5 patients. While MRI alone was diagnostic in 35% (7/20), the combined yield of both modalities was 60% (12/20). When PET scores were added to assign the APE score in MRI negative cases, average APE score was 6.1., Conclusion: The inclusion of metabolic information from PET distinctly improved (the sensitivity of) APE scores to predict autoimmune origin even in antibody negative cases. A larger prospective study of similar type could justify adoption of FDG-PET into the standard diagnostic procedure., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but additional data are needed from randomized trials., Methods: In this single-center trial, we randomly assigned 116 patients who were 18 years of age or younger with drug-resistant epilepsy to undergo brain surgery appropriate to the underlying cause of epilepsy along with appropriate medical therapy (surgery group, 57 patients) or to receive medical therapy alone (medical-therapy group, 59 patients). The patients in the medical-therapy group were assigned to a waiting list for surgery. The primary outcome was freedom from seizures at 12 months. Secondary outcomes were the score on the Hague Seizure Severity scale, the Binet-Kamat intelligence quotient, the social quotient on the Vineland Social Maturity Scale, and scores on the Child Behavior Checklist and the Pediatric Quality of Life Inventory., Results: At 12 months, freedom from seizures occurred in 44 patients (77%) in the surgery group and in 4 (7%) in the medical-therapy group (P<0.001). Between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the score on the Hague Seizure Severity scale (difference, 19.4; 95% confidence interval [CI], 15.8 to 23.1; P<0.001), on the Child Behavior Checklist (difference, 13.1; 95% CI, 10.7 to 15.6; P<0.001), on the Pediatric Quality of Life Inventory (difference, 21.9; 95% CI, 16.4 to 27.6; P<0.001), and on the Vineland Social Maturity Scale (difference, 4.7; 95% CI, 0.4 to 9.1; P=0.03), but not on the Binet-Kamat intelligence quotient (difference, 2.5; 95% CI, -0.1 to 5.1; P=0.06). Serious adverse events occurred in 19 patients (33%) in the surgery group, including hemiparesis in 15 (26%)., Conclusions: In this single-center trial, children and adolescents with drug-resistant epilepsy who had undergone epilepsy surgery had a significantly higher rate of freedom from seizures and better scores with respect to behavior and quality of life than did those who continued medical therapy alone at 12 months. Surgery resulted in anticipated neurologic deficits related to the region of brain resection. (Funded by the Indian Council of Medical Research and others; Clinical Trial Registry-India number, CTRI/2010/091/000525 .).

Purpose: To determine the impact of intraoperative magnetic resonance imaging (iMRI) in epilepsy surgeries on the extent of surgical resection and seizure outcome along with its feasibility and limitations., Methods: Patients with pharmacoresistant epilepsy (PRE), who underwent surgeries in operating theater equipped with high-field 1.5-Tesla MRI, were evaluated for extent of resection, operative time, scanning time, pathologies, resultant extra resection, and seizure outcomes., Results: Thirty-nine patients with mean age of 18 (range: 3-65) years with PRE underwent surgical intervention. Mean duration of epilepsy was 10.2 years. Surgical interventions included tumor resection (31%), resection of focal cortical dysplasia (28%), mesial temporal lobe surgeries (18%), and disconnection surgeries (23%). iMRI alone, apart from navigation and electrophysiology, improved resection rates in 13% (5 out of 39) of these patients. In lesional group, iMRI modified operative strategy resulting in increased resections in 21% (5/23) patients. Complete resection was observed in 87% of patients. iMRI scanning time constituted 25% (mean: 72 ± 21 min) of time spent under anesthesia by the patient. Major and minor complications were observed in 2.5% and 7.5% of patients, respectively. The mean follow-up was 14 months. Favorable postoperative seizure control (Engel Classes I and II) was achieved in 85% and complete seizure freedom was achieved in 77% of patients (Engel Class IA) at 1-year follow-up., Conclusions: iMRI increases the extent of resection mainly in lesional epilepsy surgeries translating into good seizure outcomes but not found to be much beneficial in prototype mesial temporal sclerosis surgeries and disconnection surgeries.

Objective: F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and ictally subtracted single photon emission tomography (iSPECT) are important for localizing the epileptogenic focus. The following study analyzes the role of inter-concordance between FDG-PET and iSPECT in predicting long-term outcomes after epilepsy surgery., Methods: We prospectively evaluated (January 2003-January 2008) patients undergoing surgery for temporal or extratemporal drug refractory epilepsy (DRE) who had at least a 5 years follow up. Patients with MRI and video EEG (vEEG) concordance for the seizure focus underwent iSPECT and FDG-PET. Concordance of the iSPECT and FDG-PET with each other and with the substrate (defined by MRI and vEEG) for temporal and extra-temporal epilepsies was evaluated and correlated with outcomes., Results: One hundred twenty-three patients (74 males) were included in the study (mean age at time of surgery: 18.9±10.41 years). The mean age of onset of seizures was 9.87±8.37 years. The most common semiology was complex partial (45%). When both FDG-PET and iSPECT were concordant with each other, this translated into a (class I Engel at 5 years) outcome of 62% for extra-temporal epilepsies (provided they were also concordant with the lesion, as defined by MRI and vEEG). This percentage was significant (p<0.01) compared with all other situations (both FDG-PET/iSPECT not concordant to MRI/vEEG, only PET or iSPECT concordant with MRI/vEEG). This correlation was not found for the temporal epilepsies, where the MRI and vEEG were the most important prognostic parameters. In both temporal and extratemporal epilepsies the concordance of the iSPECT/FDG-PET with the MRI/vEEG correlated with a better 5-year outcome (temporal: 70% vs 25%; extra-temporal: 62% vs 33%; p<0.05)., Significance: Concordance between non-invasive investigations iSPECT and FDG-PET is an important predictive factor for surgical outcomes in extra-temporal epilepsy., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: To objectively mark out abnormal areas of magnetic resonance imaging (MRI), positron emission tomography (PET), and electrocorticography (ECoG) using neuronavigation so as to 1) enhance the accuracy of margins of the epileptogenic zone and 2) understand the relationships of all the three modalities with each other., Methods: A prospective study was conducted of 37 patients with intractable epilepsy due to lesional, neocortical pathologies from noneloquent areas. Prior to surgery, fusion and transfer of MRI and PET images onto a neuronavigation system was performed. At surgery, this was correlated to intraoperative ECoG using the electrode as referential points. An objective score was created for every electrode point that was correlated with MRI and PET abnormality at the point. The extent of surgical resection was mapped out using these data., Results: From a total of the data recorded from 1280 electrode points, 23.5% were located over the lesion. In addition, over the lesions, 93% of PET and 66% of ECoG points were abnormal. Over the perilesional areas, 43% of PET and 45% of ECoG points were abnormal. Using these data for surgery, both lesional and perileisonal areas were resected; 33/37 patients had good outcome (25 Engel I, 8 Engel II) (mean follow-up: 23.6 ± 3.2 months; range 18-31 months)., Conclusion: Multimodal imaging and ECoG using this method seems to provide a better objective localization of the epileptogenic foci., (Copyright © 2014 Elsevier Inc. All rights reserved.)

OBJECTIVE. To effectively combine functional MRI (fMRI), diffusion tensor tractography (both guided by neuronavigation) along with cortical stimulation (CS) for surgery of eloquent cortex (EC) lesions. MATERIALS AND METHOds. Fifteen patients with lesions adjacent to the eloquent motor and sensory cortex were included. Preoperative fMRI and diffusion tensor imaging were performed and then integrated into the neuronavigation system. Intraoperative CS of sensory/motor cortex was performed to localize the EC under awake condition and this was correlated with areas active on fMRI utilizing neuronavigation. For excision of the deeper structures, CS, and tractography guided by neuronavigation were utilized. RESULTS. A total of 127 cortical sites were evaluated with CS in 15 patients. The overall sensitivity, specificity, and accuracy of fMRI were 79%, 85%, and 82%, respectively, keeping the areas positive on CS as a referential parameter. Tractography helped in resecting the deeper areas of the tumor, but was not very accurate due to brain shift. However, it was useful in roughly assessing the deeper areas close to the long tracts. The risk of developing persistent neurological deficits was 6%. Pathologies included gliomas in ten patients, cavernous malformation in two patients, meningioma in one patient, and focal cortical dysplasia and Dysembryonic neuroepithelial tumor in one patient each. Near total excision was achieved in 7/10 (> 95% excision) gliomas and a total excision in all others lesions. CONCLUSIONS. Lesions directly over the EC present a special surgical challenge. The challenge lies in excising these lesions without producing any deficits. These goals may be achieved better by combined use of multimodal neuronavigation (fMRI and tractography) and intraoperative mapping with CS under awake conditions.

Purpose: The purpose of this study was to assess axis-I DSM-IV psychiatric disorders in patients at baseline and 3 months after surgery for medically refractory temporal lobe epilepsy., Method: The Mini International Neuropsychiatric Interview (MINI) and Quality of Life in Epilepsy Inventory-10 (QOLIE-10) were evaluated before and 3 months after surgery in 50 consecutive patients (21 females, 29 males) with medically refractory temporal lobe epilepsy (persistent seizures>2/month, despite treatment with ≥2 appropriate drugs in adequate doses for ≥2 years) who underwent surgery [anterior temporal lobectomy with amygdalo-hippocampectomy (for mesial temporal sclerosis in 40), electrocorticography-guided lesionectomy (for other lesions in 10)]., Results: Twenty-six patients (52%) had an axis-I psychiatric disorder [26% depressive disorder, 28% anxiety disorder] at baseline, while 30 (60%) patients had an axis-I psychiatric disorder [28% depressive disorder, 28% anxiety disorder] at 3 months after surgery. Twenty percent developed a new psychiatric disorder, while 12% showed improvement postsurgery. Mean QOLIE-10 scores improved from 23.78 to 17.80 [24 (48%) patients showed ≥5-point improvement]. Thirty-four (68%) patients had no seizure, 6 (12%) had non-disabling seizures, while 2 (4%) had disabling seizures after surgery. High frequency of seizures prior to surgery (p<0.038) and seizure occurrence after surgery (p<0.055) predicted the presence of psychiatric disorders after surgery. No clinical characteristic could predict development of new psychiatric disorder after surgery., Conclusion: Psychiatric dysfunction in the early postsurgery period is seen in nearly half of patients undergoing surgery for temporal lobe epilepsy, is mild in nature, and does not adversely affect quality of life but may cause significant clinical problems when it arises de novo postsurgery., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of surgery on subjective and objective measures of sleep quality among patients with medically refractory focal epilepsy., Methods: In a prospective cohort study, patients with medically refractory epilepsy undergoing epilepsy surgery were recruited. All patients were assessed seven days pre- and three months post-surgery in terms of history pertaining to epilepsy and sleep, Epworth sleepiness score (ESS), one week sleep log and over night polysomnography (PSG)., Results: Among 17 patients (mean age 18, 11 males), seizure frequency had reduced (p=0.04) and self reported sleep parameters had significantly improved (reduced total duration of night time sleep, regularity on one week sleep log and ESS (p<0.05)) three months following epilepsy surgery. Patients with good surgical outcome (n=12) showed reduced seizure frequency (p=0.01) and reduced ESS with corresponding reduction in arousal index (AI) (p=0.02) and increase in total sleep time (p=0.03), postoperatively. Three patients in the good surgical outcome group showed reduction in apnea-hypopnea index (AHI) from more than five to less than five. There was no significant change either in seizure frequency, self reported clinical parameters or PSG parameters among patients with poor surgical outcome., Conclusion: Epilepsy surgery improves subjective sleep parameters in patients with medically refractory epilepsy during the early post operative period. Successful epilepsy surgery may improve objective (PSG documented) sleep quality, sleep architecture and obstructive sleep apnea with resultant reduction in excessive daytime sleepiness., (Copyright © 2012. Published by Elsevier B.V.)

Purpose: To assess the outcome of a pediatric population operated for drug-resistant epilepsy from a large tertiary care center in India., Methods: Retrospectively: quality of life (QOL); prospectively: preoperative assessment included interictal EEG, MRI (as per epilepsy protocol), video-EEG. Ictal SPECT (with subtraction) and PET were performed when required. QOL scores were assessed using the HASS or SSQ for seizure severity, Quality of Life in Childhood Epilepsy (QOLCE) for QOL, and Child Behavior Check List (CBCL) for behavior., Results: 142 were operated from January 2000 to June 2011 by the senior author. 118 patients with at least 1 year of follow-up were included in the study. Mean age at surgery was 9.8 ± 4.3 years. In addition, 40 patients underwent QOL assessment prospectively both before and after surgery. Mean duration of epilepsy was 5.3 ± 3.3 years. A class I outcome (Engel's) was seen in 79.5% patients, class II in 8.6%, class III in 10.7%, and class IV in 1 patient. As per surgical procedures, class I outcome in patients who underwent temporal resection, hemispherotomy and extratemporal resection was 76, 87 and 72%, respectively. QOL scores correlated with duration of seizures, epileptic encephalopathy and outcome of surgery, but not with side of surgery, age and sex., Conclusions: This study, the largest reported from India, has demonstrated satisfactory results for epilepsy surgery in children., (Copyright © 2011 S. Karger AG, Basel.)

Medically intractable epilepsy (MIE) resulting from postinfectious etiologies requiring surgery have been uncommonly reported. A series of 28 cases are presented (hospital prevalence 5.7%). The mean duration of epilepsy prior to surgery was 8.2 +/- 2.1 years. The mean time of onset of epilepsy after central nervous system infection was 1.4 +/- 0.9 years (range 0-19 years). The pathologies included postpyogenic meningitic/encephalitic sequel (8), neurocysticercosis (6), tuberculomas/posttuberculous etiology (4), postpyogenic abscess of otogenic etiology (4), posttraumatic abscess-related gliosis (2), and gliosis of unknown infectious etiology (4) cases. Surgery included mesial temporal (11), lateral temporal (4), frontal (9), parietal (2) resections and hemispherotomy (1). Hippocampal sclerosis was seen in nine cases (4 neurocysticercosis) and this occurred in younger persons as compared to neocortical epilepsies. Good outcome (Engel class I and II) was seen in 23 of 28 cases (Engel class I in 17).

Dysembryoplastic neuroepithelial tumor (DNT) is a relatively newly described entity and is an important cause of intractable epilepsy. We report 32 cases of DNT who were operated and treated in our hospital over a period of 12 years. Immunostaining for various proliferative markers and tumor suppressor gene proteins was done to assess the proliferative potential of these tumors. The most common presentation was partial complex seizures followed by generalized tonic-clonic seizures, focal motor seizures, and myoclonus. The most common location was temporal lobe followed by frontal and in one patient lesion was multifocal. All patients were seizure free at the last postoperative follow-up which varies from 12 to 96 months with mean of 33.7 months. Microscopic examination showed classical histology comprising of intracortical multinodular microcystic lesions with floating neurons. Proliferative indices were very low (<1%) and tumor suppressor gene protein expression was not seen in the present study. Cortical dysplasia of the surrounding brain was observed in 37.3% of cases.

Byline: Ramesh. Doddamani, Manjari. Tripathi, Raghu. Samala, Mohit. Agrawal, Bhargavi. Ramanujam, Jitin. Bajaj, Shabari. Girishan, Madhavi. Tripathi, C. Bal, Ajay. Garg, P. Chandra Background: The management of hypothalamic hamartomas (HH) [...]

Magnetic resonance imaging (MRI) of the brain with angiography and vessel wall imaging showed multiple subcortical white matter bleeds in bilateral fronto-parietal, temporal, and cerebellar hemispheres (Fig. Dear sir, Guillain Barre Syndrome (GBS) is an acute polyradiculoneuropathy which is characterized by progressive limb weakness, variable sensory disturbance, absence of deep tendon reflexes, and autonomic dysfunction. [Extracted from the article]

A case study of a 50‑year‑old lady presented to the emergency with one day history of multiple simple partial seizures involving right arm and face without any motor deficit or loss of consciousness. Topics include neoplastic etiology was suspected and anti‑edema medicines including steroids, anti-epileptic drugs and other supportive measures; and contrast‑enhanced imaging revealed a well‑defined multi‑lobulated lesion in subcortical white matter of left posterior frontal region.

A case study of a 22‑year‑old woman who developed acute onset altered behavior in the post‑partum state and was initially misdiagnosed to have cortical vein thrombosis. Topics include Electroencephalogram (EEG) revealed periodic sharp wave complexes synchronized with the jerks; and Considering a possibility of Acute Disseminated Encephalomyelitis (ADEM) she was pulsed with steroids and discharged.

Objectives: To review clinical characteristics and response to immunomodulation therapy in autoimmune encephalitis presenting with status epilepticus (SE), epilepsy, and cognitive decline. Design: Observational, prospective case series. Setting: All India Institute of Medical Sciences, New Delhi, India. Materials and Methods: Prospective analysis of 15 patients, who presented with SE, epilepsy, cognitive decline, and other neurological symptoms with positive autoantibodies. Demographic and clinical characteristics were recorded. Brain magnetic resonance imaging (MRI), cerebrospinal-fluid analysis (CSF), and tumor screening were done periodically. Treatment received and responses (categorized as per patients and treating doctor's information) were noted. Results: There were 15 (males = 10) patients of autoimmune encephalitis. The mean age of presentation was 24 years (range: 2-64 years). The most common onset was subacute (64%) and four (29%) patients presented as SE. Predominant clinical presentations were seizures (100%) almost of every semiology. CSF was done in 10 patients; it was normal in 60%. Brain MRI was done in all patients, in six (40%) it was normal, six (40%) showed T2W and FLAIR hyperintensities in bilateral limbic areas. Antibodies found were the N-methyl-D-aspartate receptor antibody in seven (50%), voltage-gated potassium channel antibody in five (36%), two of antiglutamic acid decarboxylase, and one patient with double stranded DNA (dsDNA) antibodies. None showed evidence of malignancy. Patients received immunotherapy, either steroids, intravenous immunoglobulin, or both. Follow-up showed significant improvement in majority of cases, neither further seizures nor relapse in nine (67%) cases. One death occurred, due to delayed presentation. Conclusions: Uncommon but potentially reversible causes of SE, epilepsy, and cognitive decline may be immune-related and high index of suspicion will prevent missing the diagnosis. [ABSTRACT FROM AUTHOR]

We describe the metabolic phenotype on F-18 fluorodeoxyglucose positron emission tomography (PET) in a 13-year-old female with myelin oligodendrocyte glycoprotein (MOG) antibody-positive encephalitis. Unilateral hemispheric hypometabolism on PET may be the metabolic phenotype of autoimmune epilepsy associated with MOG antibody. [ABSTRACT FROM AUTHOR]

Purpose: To assess the outcome of a pediatric population operated for drug-resistant epilepsy from a large tertiary care center in India. Methods: Retrospectively: quality of life (QOL); prospectively: preoperative assessment included interictal EEG, MRI (as per epilepsy protocol), video-EEG. Ictal SPECT (with subtraction) and PET were performed when required. QOL scores were assessed using the HASS or SSQ for seizure severity, Quality of Life in Childhood Epilepsy (QOLCE) for QOL, and Child Behavior Check List (CBCL) for behavior. Results: 142 were operated from January 2000 to June 2011 by the senior author. 118 patients with at least 1 year of follow-up were included in the study. Mean age at surgery was 9.8 ± 4.3 years. In addition, 40 patients underwent QOL assessment prospectively both before and after surgery. Mean duration of epilepsy was 5.3 ± 3.3 years. A class I outcome (Engel's) was seen in 79.5% patients, class II in 8.6%, class III in 10.7%, and class IV in 1 patient. As per surgical procedures, class I outcome in patients who underwent temporal resection, hemispherotomy and extratemporal resection was 76, 87 and 72%, respectively. QOL scores correlated with duration of seizures, epileptic encephalopathy and outcome of surgery, but not with side of surgery, age and sex. Conclusions: This study, the largest reported from India, has demonstrated satisfactory results for epilepsy surgery in children. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article describes the case of an 18-year-old male who developed angiocentric glioma (AG). The patient presented with complex partial seizures since the age of 4 years. AG refers to a rare tumor of the central nervous system (CNS) in children and young adults, and accounts for 2.3% of tumors associated with chronic pediatric epilepsy.

The present case highlights the utility of ictal F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in delineating the seizure onset zone in a child with complex partial seizures. Although F-18 FDG PET has been successfully used to delineate interictal hypometabolism, planned ictal FDG PET, in cases with prolonged seizure activity, can provide better spatial resolution than single-photon emission CT by delineating the seizure onset zone and propagation pathway. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 25-year-old woman with intractable epilepsy underwent right temporal lobectomy for right mesial temporal sclerosis. A large vein could be seen near the temporal base along the inner surface of temporal squama after raising the bone flap and opening the dura. Magnetic resonance venography was done in the postoperative period, showing the squamosal type of superficial middle cerebral vein (SMCV) draining into transverse sinus.

Introduction Epilepsy has several comorbidities and associated stigma. Stigma associated with epilepsy is well known and prevalent worldwide. Surgical treatment is an established treatment for drug refractory epilepsy. Following surgery in children, it is possible that the stigma may reduce, but such an effect has not been studied earlier. Materials and methods Analysis of prospectively collected data was performed for pediatric patients at a single tertiary center for treating epilepsy. Child stigma scale, as described by Austin et al., was used to evaluate stigma both pre- and postoperatively. Analysis was done using Paired t test. Results In this study, following surgery, there was significant reduction of stigma (P < 0.001). This was proportional to the reduction in seizures, though there were 9 (30%) patients, who due to persistent neurodisability did not have any reduction of stigma despite having good seizure outcome. Conclusion Surgery in drug-resistant epilepsy helps in reducing stigma. Seizure reduction is probably not the only factor responsible for a change in stigma outcome. [ABSTRACT FROM AUTHOR]

Objectives Access to epilepsy surgery remains a considerable challenge in contemporary healthcare systems. Given the limitations in resources and demand for Epilepsy Monitoring Unit (EMU) assessments, information that can be used to expedite the process is of great value. The purpose of this study was to identify variables prior to EMU admission that may be associated with candidacy for prospective epilepsy surgery. Methods This was a prospective study conducted at the Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. We identified two subgroups of patients from 501 drug refractory epilepsy (DRE) patients admitted in EMU of Neurology Department, AIIMS from 2006 onwards following validation of proposed tool in 40 patients. They on subsequent investigations were either cleared or not cleared for epilepsy surgery. A tool consisting of variables likely to predict surgical candidacy in persons with DRE in Indian settings was developed for identification of patients who might benefit from an early epilepsy surgery evaluation. Results Statistical analysis revealed significant differences between the two groups for several variables. Non-surgical candidates had non-disabling seizures, seizures improved with a combination of drugs, had little/no AEDs side effects and had near normal or normal scalp EEG and MRI brain. Significance Using the best available evidence, we developed a decision making tool which can provide a comprehensive quick guide for determining candidacy for epilepsy surgery evaluations in resource limited settings. Given the demand for EMU assessments, information that can be used to expedite the process is of value. [ABSTRACT FROM AUTHOR]

Background A stereotactically placed laser fiber can deliver thermal energy to an epileptogenic focus in the brain. This procedure is done under intraoperative (thermography) magnetic resonance imaging (MRI) guidance. Thermoablation can lead to edema in the surrounding area and can cause a secondary insult. In this report of 3 cases, we have quantified the edema produced after laser ablation by sequential MRI in the immediate postoperative period. Case Descriptions Three patients with intractable epilepsy underwent a detailed neurologic and neuroradiologic workup to localize the site of epileptogenic foci. Two of the patients had mesial temporal lobe sclerosis, and the other patient had hypothalamic hamartoma. A laser fiber was placed stereotactically in the epileptogenic zone, and MRI-guided thermoablation was done. Postoperatively, T1-weighted and fluid-attenuated inversion recovery (FLAIR)-based volumetric MRI sequences were performed on postoperative days 1, 3, and 5 to quantify the edema. I-Plan software was used for volumetric analysis. Targeted volumes were 0.22, 4.2, and 3.5 mL, and lesions were 0.3, 6.5, and 6 mL, respectively. FLAIR hyperintensity was 2.3, 11.8, and 8.4 mL on the first postoperative day and 1.5, 12.6, and 6.3 mL on postoperative day 8. All patients remained seizure-free during the postoperative period. No complications were observed. Conclusions Laser ablation of epileptic focus is safe. FLAIR hyperintensity in the postoperative period is 3–5 times the targeted volume. However, no significant increase occurs during the first 8 days, and thus steroids can be stopped within 5 days of surgery. [ABSTRACT FROM AUTHOR]