Epilepsy Surgery Program Research Articles

International conference and workshop "Hallmarks of Epileptic Brain Activity" in Tbilisi, Georgia, October 24-27, 2017.

More than 50 million people worldwide suffer from epilepsy; 80% of them live in low- and middle-income countries where three-fourths of them have no access to appropriate treatment.1 Epilepsy surgery is currently not only the most effective,2 but also a cost-efficient treatment for a drug-resistant form of epilepsy,3 in particular for low- and middle-income countries.4, 5 Georgia is one of the low- to middle-income countries6 that still lacks some of the advanced presurgery diagnostic methods as well as an appropriate epilepsy surgery program. To improve this situation and foster the presurgical diagnosis and implementation of epilepsy neurosurgery, a German-Georgian cooperative project (EpilepCure) was initiated with the financial support of the German Federal Ministry of Education and Research. The launching event of this project took place in Tbilisi on October 24-27, 2017 and was structured as a 2-day scientific conference with 2-day case studies in a subsequent workshop (Figure 1). This event brought together 25 invited European and Georgian physicians and researchers to explore and discuss the current situation in Georgia, the potential to optimize diagnostic tools with a special focus on the presurgical evaluation, and the options for surgical interventions. Details of this public meeting can be found on the project homepage https://epilepcure.wordpress.com/. The broad spectrum of presurgical evaluation and treatment options were introduced in the conference series lectures (Drs. M. Holtkamp, T. Lehmann, and M. Cunningham). In the case studies, German colleagues (Drs. M. Holtkamp and T. Lehmann) emphasized that in patients with discordant indications based on seizure semiology, electroencephalography (EEG) and magnetic resonance imaging (MRI), more sophisticated diagnostic methods, such as intracranial EEG recordings, are required to substantiate the diagnosis and evaluate the potential of surgical intervention. Those methods are still missing in Georgia, but are routinely used in Germany. Therefore, as one aim of the project, the German colleagues offered to assist in their establishment in Georgia. Notable, epilepsy surgery is already feasible in Georgia, with the potential availability of good medical expertise to perform such interventions. In line with this state of the art, the case studies of Georgian colleagues (Drs. S. Kasradze, N. Tatishvili, G. Lomidze, and V. Tsikarishvili) revealed a high potential for surgical intervention with a relatively large proportion of patients with temporal lobe epilepsy and hippocampal sclerosis. Importantly, in contrast to high-income countries,7 these clear-cut cases are still common in Georgia due to the lack of surgical interventions so far.8 These patients with concordant indications have a very good outcome prognosis and do not require the implementation of additional diagnostic efforts, thus representing a favorable starting point to launch a coordinated epilepsy surgery program. The essential diagnostic workup for clear-cut cases, including neurological examination, standard video-EEG, and MRI, is readily available. Therefore, drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis will be a primary focus when starting the implementation of the neurosurgical epilepsy program. One of the most hotly debated themes of the meeting was the topic of high-frequency oscillations (HFOs) as a potential biomarker to localize the epileptogenic focus and to predict surgical outcome (Drs. T. Gloveli, T. Dugladze, P. Bäuerle, and I. Vida). An important conclusion on this discussion was the aim of linking clinical and experimental research to investigate this neural activity signature in human EEG recordings as well as in local field potential recordings in animal models of epilepsy. Having access to a large number of human patients with hippocampal sclerosis, Georgia provides a unique opportunity within the framework of this project to compare data from chronic human and animal model recordings and evaluate the potential of HFOs as a biomarker. Hence, HFOs will be examined by a close collaboration of clinicians and basic researchers. All participants admitted that given the generally favorable situation in the development of epilepsy treatment, the Georgian capital Tbilisi is well suited to establish a central epilepsy full-service cooperative health care unit, with the potential for a deep impact not only for the country, but also for the whole of the South Caucasus, where appropriate epilepsy surgery options are largely still lacking. Therefore, the first meeting in Tbilisi will be followed by the exchange of experts, conferences, and workshops in both countries, with the aim of optimizing presurgical epilepsy diagnostics by training Georgian physicians in advanced diagnostic and neurosurgical strategies and promoting surgical interventions in Georgia in the near future. The meeting in Georgia was financially supported by the German Federal Ministry of Education and Research. None of the authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

Suicide risk, temperament traits, and sleep quality in patients with refractory epilepsy

ObjectivesThe objective of the study was to access the suicide risk (SR) in patients with refractory epilepsy and its association with temperament and sleep quality. MethodsA total of 50 consecutive patients referred for epilepsy surgery evaluation in the Porto Alegre Epilepsy Surgery Program were included. All patients had a detailed neurologic and psychiatric evaluation, including video-electroencephalogram (VEEG), high-resolution magnetic ressonance imaging (MRI), and neuropsychologic assessment. In addition, structured questionnaires were applied: module C of the MINI-plus (International Neuropsychiatric Interview-Brazilian version 5.0.0), Affective and Emotional Composite Temperament Scale (AFECTS), and Pittsburgh Sleep Quality Index (PSQI). ResultsTen patients (20.0%) showed an increased SR. The most frequent location of the epileptic focus was in the temporal lobe (50%; n=25). Final diagnosis on VEEG comprised epilepsy in 74.0% (n=37), psychogenic nonepileptic seizures (PNES) in 8.0% (n=4), and both in 12%. Thirty patients (60.0%) received surgery indication. Mood disorders were the main psychiatric diagnosis, found in 19 subjects (70.4%), with major depressive disorder (MDD) encountered in 15 patients (55.6%). In the group, SR was more frequent in patients with sleep disorders (p=0.001) and elevated scores of high emotional sensitivity (p=0.003). ConclusionIn this cohort of patients with highly refractory epilepsy, there was a significant association between SR, sleep disorders, and high emotional sensitivity. Careful evaluation of these factors should be performed in these patients to fully access SR.

Long-Term Electroclinical and Employment Follow up in Temporal Lobe Epilepsy Surgery. A Cuban Comprehensive Epilepsy Surgery Program

The purpose of this paper is to present a long- term electroclinical and employment follow up in temporal lobe epilepsy (TLE) patients in a comprehensive epilepsy surgery program. Forty adult patients with pharmacoresistant TLE underwent detailed presurgical evaluation. Electroencephalogram (EEG) and clinical follow up assessment for each patient were carried out. The occurrence of interictal epileptiform activity (IEA) and absolute spike frequency (ASF) were tabulated before and after 1, 6, 12, 24 and 72 months surgical treatment. Employment status pre- to post-surgery at the last evaluated period was also examined. Engel scores follow-up was described as follows: at 12 months 70% (28) class I, 10% (4) class II and 19% (8) class III-IV; at 24 months after surgery 55.2% (21) of the patients were class I, 28.9% (11) class II and 15.1% (6) class III-IV. After one- year follow up 23 (57.7%) patients were seizure and aura-free (Engel class IA). These figures changed to 47.3%, and 48.6% respectively two and five years following surgery whereas 50% maintained this condition in the last follow up period. A decline in the ASF was observed from the first year until the sixth year after surgery in relation to the preoperative EEG. The ASF one year after surgery allowed to distinguish “satisfactory” from “unsatisfactory” seizure relief outcome at the last follow up. An adequate social functioning in terms of education and employment in more than 50% of the patients was also found. Results revealed the feasibility of conducting a successful epilepsy surgery program with favorable long term electroclinical and psychosocial functioning outcomes in a developing country as well.

Hypothalamic hamartomas and Gelastic seizures. Chilean experience in a pediatric epilepsy surgery program during 13 years - Review of the literature

Hypothalamic hamartomas and Gelastic seizures. Chilean experience in a pediatric epilepsy surgery program during 13 years - Review of the literature

Efficacy of the Danish epilepsy surgery programme

Despite optimal medical treatment, approximately one-third of patients with epilepsy continue to have seizures. Epilepsy surgery is widely accepted as a therapeutic option in the selected subset of patients with drug-resistant focal epilepsy. Here, we report the results of the Danish epilepsy surgery programme from 2009 to 2014. A total of 169 consecutive patients, operated at Rigshospitalet, were included. Information was gathered from digital patient records. Before 1-year follow-up, two patients were lost to follow-up and three were referred to new surgery. The median years of drug resistance before operation were 11years. At 1-year follow-up (n=164), seizure outcomes were as follows: 65% Engel I (free from disabling seizures), 51% Engel IA (completely seizure free) and 9% Engel IV (no worthwhile improvement), and for patients operated in the medial temporal lobe (n=114): 70% Engel I, 56% Engel IA, 5% Engel IV. The outcomes of the 53 patients needing intracranial EEG recording (ICR) were not significantly different from the patients only evaluated with surface EEG. None of the eight MRI-negative patients operated outside the medial temporal lobe after ICR were free of disabling seizures. 12% of MTLE patients developed de novo depression after epilepsy surgery despite good surgical outcome. Three patients required rehabilitation due to post-operative hemiplegia. The outcomes of the Danish epilepsy surgery programme align with international results found in recent meta-analyses. Serious complications to epilepsy surgery are seldom. In accordance with international recommendations, Danish drug-resistant patients should be referred to epilepsy surgery evaluation at an earlier stage of the disease.

Verbal and Nonverbal Memory in Hemispherectomy: Lateralization Effects

AbstractHemispherectomy is a routine surgery performed for children with intractable seizures and often in the midst of a life-threatening emergency such as status epilepticus. As the following article will demonstrate, studies of neurocognitive outcome in general, and memory in specific, following hemispherectomy are mixed, although findings tend to indicate stronger lateralization of verbal memory. This is often demonstrated by loss of verbal memory following left hemispherectomy, although there are few studies focusing solely on hemispherectomy and neurocognitive outcome. We examined data from 25 patients who participated in the University of California, Los Angeles (UCLA) Pediatric Epilepsy Surgery Program (right hemisphere = 7; left hemisphere = 18). The California Verbal Learning Test-Children's Version was used as a verbal memory correlate, and the doors visual recall was used as a correlate of nonverbal memory. Based on a review of the literature, we hypothesized that (1) verbal memory would be significantly different between hemispheres with higher scores in the remaining left hemisphere; (2) nonverbal memory would be significantly different between hemispheres with higher scores in the remaining right hemisphere. Exploratory analyses were also undertaken. Implications for lateralization, medical factors, and plasticity are discussed.

Decrease in mortality of adult epilepsy patients since 1980: lessons learned from a hospital-based cohort.

Data on mortality in patients with epilepsy have been available since the 1800s. They consistently show a 2-3-fold increase compared to the general population. Despite major advances in diagnostic tools and treatment options, there is no evidence for a decrease in premature deaths. The temporal trend of mortality in a hospital-based epilepsy cohort over three decades was assessed. A hospital-based incidence cohort was recruited from a specialized epilepsy outpatient clinic at Innsbruck Medical University between 1980 and 2007, divided by decade into three cohorts and followed for 5 years after initial epilepsy diagnosis. Deaths and their primary causes were determined using probabilistic record linkage with the Austrian death registry. Age-, sex- and period-adjusted standardized mortality rates (SMRs) were computed in relation to the general population of the same area and grouped according to time of diagnosis. In all, 122 deaths in 4549.9 person-years (1954.5 women, 2595.2 men) were identified. The overall SMR was 2.2 [95% confidence interval (CI) 1.8-2.6] and decreased from 3.0 (95% CI 2.1-4.3) in 1980-1989, to 2.7 (95% CI 2.0-3.5) in 1990-1999 and to 1.4 (95% CI 1.0-2.0) in 2000-2007. This study indicates a decrease in mortality in newly diagnosed epilepsy patients over the last three decades. This may be due to advances in diagnosis and treatment over the past three decades, including early identification of drug resistance, introduction of new anti-epileptic drugs and establishment of a comprehensive epilepsy surgery programme in this region.

Unexpected marked seizure improvement in paediatric epilepsy surgery candidates

PurposeEpilepsy surgery is performed based on the assumption that medical refractory epilepsy will continue. Rarely seizure freedom occurs before surgery is performed, while the patient is being evaluated as an epilepsy surgery candidate. The aim of this study was to describe the number of children withdrawn from an epilepsy surgery programme due to unexpected seizure improvement. MethodsWe retrospectively studied 173 children under 18 years with medical refractory epilepsy referred for epilepsy surgery between 1996 and 2010. Medical records were reviewed in 2012 and 2015. ResultsAt the first evaluation point in 2012, 13 patients were withdrawn from the epilepsy surgery programme due to unexpected marked improvement. In 2015, 6 of them were still seizure free. They had unexpected seizure freedom due to change in AED treatment (n=3) or after a febrile episode (n=3). The mean number of years they had had seizures was 3.4 years (range 0.6–6.2 years) and the number of seizures at inclusion was 209 per month (range 6–750 per month). The duration of follow-up was 6.6 years after inclusion into the epilepsy surgery programme (range 4.0–13.0 years). The aetiology of the epilepsy for these patients was heterotopia (n=1), focal cortical dysplasia (n=3), infarction (n=1) and unknown, with normal MRI (n=1). They all had an IQ in the normal range. Two of the remaining 7 children were operated later. ConclusionUnexpected seizure control may occur during epilepsy surgery evaluation.

Elevated basal glutamate and unchanged glutamine and GABA in refractory epilepsy: Microdialysis study of 79 patients at the yale epilepsy surgery program.

Aberrant glutamate and γ-aminobutyric acid (GABA) neurotransmission contribute to seizure generation and the epileptic state. However, whether levels of these neurochemicals are abnormal in epileptic patients is unknown. Here, we report on interictal levels of glutamate, glutamine, and GABA in epilepsy patients at seizure onset and nonepileptic sites, cortical lesions, and from patients with poorly localized neocortical epilepsies. Subjects (n = 79) were medically refractory epilepsy patients undergoing intracranial electroencephalogram evaluation. Microdialysis probes (n = 125) coupled to depth electrodes were implanted within suspected seizure onset sites and microdialysis samples were obtained during interictal periods. Glutamate, glutamine, and GABA were measured using high-performance liquid chromatography. Probe locations were subsequently classified by consensus of expert epileptologists. Glutamate levels were elevated in epileptogenic (p = 0.03; n = 7), nonlocalized (p < 0.001), and lesional cortical sites (p < 0.001) when compared to nonepileptogenic cortex. Glutamate was also elevated in epileptogenic (p < 0.001) compared to nonepileptogenic hippocampus. There were no statistical differences in GABA or glutamine, although GABA levels showed high variability across patients and groups. Our findings indicate that chronically elevated extracellular glutamate is a common pathological feature among epilepsies with different etiology. Contrary to our predictions, GABA and glutamine levels were not decreased in any of the measured areas. Whereas variability in GABA levels may in part be attributed to the use of GABAergic antiepileptic drugs, the stability in glutamine across patient groups indicate that extracellular glutamine levels are under tighter metabolic regulation than previously thought. Ann Neurol 2016;80:35-45.

Surgical outcomes in patients with intraoperative Electrocorticography (EcoG) guided epilepsy surgery-experiences of a tertiary care centre in India

IntroductionThe Comprehensive Epilepsy Surgery Program was started in 2001 at K.E.M. Hospital, Mumbai with the aim of performing epilepsy surgeries at highly concessional rates. We have started using intraoperative Electrocorticography (EcoG) since 2009 in patients with tumors, Mesial Temporal Sclerosis (MTS) plus and focal cortical dysplasia (FCD). This study highlights our experience with EcoG and it's utility in epilepsy surgery.introduction Methods51 patients with drug resistant epilepsy due to temporal and extra-temporal tumors, MTS plus and FCD underwent pre-surgical evaluation and ECoG guided epilepsy surgery through our program. The surgical procedures employed included intraoperative EcoG guided lesionectomy or a lesionectomy with Anterior Temporal Lobectomy (ATL). Postoperative MRI and EEG were done. Seizure freedom was categorized as per Engel's classification. ResultsAt a mean follow up of 33 months (range: 14–69 months), 43 out of 51(84.31%) patients were completely seizure free post-surgery (Engel's Class I). Among the patients who were not seizure free, 3 patients were in Engel's Class II and 5 patients were in Engel's Class III. Presence of a residual lesion on postoperative MRI (p < 0.001), abnormal postoperative EEG (p < 0.001) and persistent spikes on post-resection EcoG (p < 0.05) had a significant statistical association with poor seizure freedom post-surgery. ConclusionThe success of epilepsy surgery depends upon accurate localization and complete resection of the epileptogenic tissue, both of which are aided by intraoperative EcoG.Thus, intraoperative EcoG is a useful adjunct in epilepsy surgery to achieve optimal seizure freedom in cases of MTS plus, focal cortical dysplasia and tumors. Even the patients who are not seizure free can achieve worthwhile improvement post surgery.

Temporal plus epilepsy is a major determinant of temporal lobe surgery failures.

Reasons for failed temporal lobe epilepsy surgery remain unclear. Temporal plus epilepsy, characterized by a primary temporal lobe epileptogenic zone extending to neighboured regions, might account for a yet unknown proportion of these failures. In this study all patients from two epilepsy surgery programmes who fulfilled the following criteria were included: (i) operated from an anterior temporal lobectomy or disconnection between January 1990 and December 2001; (ii) magnetic resonance imaging normal or showing signs of hippocampal sclerosis; and (iii) postoperative follow-up ≥ 24 months for seizure-free patients. Patients were classified as suffering from unilateral temporal lobe epilepsy, bitemporal epilepsy or temporal plus epilepsy based on available presurgical data. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom over time. Predictors of seizure recurrence were investigated using Cox proportional hazards model. Of 168 patients included, 108 (63.7%) underwent stereoelectroencephalography, 131 (78%) had hippocampal sclerosis, 149 suffered from unilateral temporal lobe epilepsy (88.7%), one from bitemporal epilepsy (0.6%) and 18 (10.7%) from temporal plus epilepsy. The probability of Engel class I outcome at 10 years of follow-up was 67.3% (95% CI: 63.4-71.2) for the entire cohort, 74.5% (95% CI: 70.6-78.4) for unilateral temporal lobe epilepsy, and 14.8% (95% CI: 5.9-23.7) for temporal plus epilepsy. Multivariate analyses demonstrated four predictors of seizure relapse: temporal plus epilepsy (P < 0.001), postoperative hippocampal remnant (P = 0.001), past history of traumatic or infectious brain insult (P = 0.022), and secondary generalized tonic-clonic seizures (P = 0.023). Risk of temporal lobe surgery failure was 5.06 (95% CI: 2.36-10.382) greater in patients with temporal plus epilepsy than in those with unilateral temporal lobe epilepsy. Temporal plus epilepsy represents a hitherto unrecognized prominent cause of temporal lobe surgery failures. In patients with temporal plus epilepsy, anterior temporal lobectomy appears very unlikely to control seizures and should not be advised. Whether larger resection of temporal plus epileptogenic zones offers greater chance of seizure freedom remains to be investigated.

Is psychiatric assessment essential for better epilepsy surgery outcomes?

Epilepsy surgery is one of the most accepted and beneficial treatment for resistant epilepsies. However there is some variability in the comprehensive epilepsy care programs offered globally. Many centers do not do a psychiatric assessment unless required. It is now evident from a large body of research that epilepsy is associated with psychiatric morbidity which is also seen in patients considered for epilepsy surgery. There is also evidence to state that the risk for worsening or de novo psychiatric disorders is often seen post surgery. This calls for a comprehensive psychiatric assessment of all patients enrolled for the epilepsy surgery program to be evaluated pre and post surgically to minimize the risk of post surgical psychological disturbances and/or poor quality of life. Efficacious treatment of psychiatric disorders in those having psychiatric morbidity contributes to improved patient wellbeing, seizure freedom and better quality of life. Hence there is a need for most centers globally to include regular psychiatric assessment of epilepsy surgery patients as a protocol.

Commentary: Epilepsia's Wada survey.

The potential equivalence of non-invasive approaches for establishing language and memory representation to invasive methods (e.g., Wada testing, cortical simulation mapping) in epilepsy surgery candidates is an important topic of discussion, and we thank the editors of EPILEPSIA for the opportunity to present our rationale as to why we consider it premature to make broad pronouncements that invasive approaches should be abandoned. Our comments were intended to be balanced, acknowledging the differences in backgrounds and skills across epilepsy surgery programs, and thus were couched in probabilistic rather than absolute terms to reflect this variability. We recognize that the readership poll on the initial controversy dialogue was never intended to be scientific, and indeed, the sample size is insufficient to allow any broad generalizations. The goals of such polls, however, are to encourage greater participation of EPILEPSIA readers on topics for which there is a lack of consensus, and the equivalence of invasive and non-invasive measures of language and memory during preoperative evaluation is such a topic. No exchanges will convince persons with strongly held beliefs to abandon them, although commentary and dialogue are important to articulate the clinical rationale behind choice of methods. From our perspective, the survey questions addressing the persuasiveness of our clinical rationale could be improved upon, and perhaps future EPILEPSIA controversy authors could supply several questions similar to what is typically necessary in continuing education courses. For example, neither Papanicolaou nor our manuscript directly addressed the necessity of Wada testing as part of the evaluation for temporal lobe epilepsy, but rather, discussed whether existing non-invasive approaches to language and memory provide information that is sufficiently equivalent to Wada results so that Wada testing itself becomes unnecessary, a comparison that was explicitly probed regarding MEG and fMRI vs. intracranial grids. That over half of responders indicated intracranial grids are still necessary for cortical localization despite MEG and fMRI is a valuable data point reflecting diverse clinical practice. It would be interesting to have included a question as to whether MEG and fMRI were sufficiently developed so that Wada testing should be fully abandoned across all epilepsy programs. While we never argued whether Wada testing should or should not be performed on all temporal lobe epilepsy surgical candidates, the survey findings that no European responders felt that the Wada is necessary reflects the greater emphasis of using fMRI to minimize Wada testing by epilepsy clinicians in Europe in the epilepsy literature. We reassert our belief, though, that it is premature to develop position statements asserting that the Wada test (or stimulation mapping) is unnecessary due to the availability of non-invasive measures of language and memory fMRI or MEG since non-invasive approaches have important limitations that are not always fully appreciated or acknowledged by non-expert users, and that such a position does not reflect the opinion of many clinicians who actively manage and follow epilepsy patients to optimize their epilepsy care.

Psychiatric outcome of epilepsy surgery in patients with psychosis and temporal lobe drug-resistant epilepsy: A prospective case series

ObjectivesTemporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses. MethodsSurgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square–Fisher tests were used. ResultsDuring 2000–2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I–II (p<0.05). ConclusionsPatients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.

Extraoperative neurostimulation mapping: results from an international survey of epilepsy surgery programs.

Extraoperative electrical stimulation mapping (ESM) to identify functional cortex is performed prior to neurosurgical resection at epilepsy surgery programs worldwide. However, the procedure remains unstandardized, with no established clinical guidelines. We sought to determine the current range in ESM practice parameters across established epilepsy surgery centers. We developed and distributed a 31-question survey to 220 epilepsy centers worldwide regarding current practice parameters of ESM. Questions addressed preoperative assessment, technical stimulation parameters, language testing protocols, criteria for identification of positive or negative functional sites, management of mapping complications, and postoperative functional outcome. Survey responses were obtained from 56 centers. These revealed marked practice variability in virtually all aspects of the ESM procedure. These aspects included critical procedure components such as electrical stimulation settings, the types of language functions tested, the operational definition of a language error, size of surgical resection margin, cortical locations mapped for language, testing in the presence of afterdischarges, and medical management of mapping complications. Forty-one percent of centers reported at least one persistent adverse language outcome despite preserving all eloquent sites defined by their stimulation mapping procedure. The striking variations in practice across centers are likely to influence mapping results, which directly affect the boundaries of cortical resection and, consequently, might worsen either seizure or functional outcomes. Clearly, adverse functional outcomes occur despite mapping procedures that were perceived to be adequate. Investigation of critical technical and procedural aspects of stimulation mapping is warranted, with the ultimate goal of establishing empirically based practice guidelines to improve the safety and efficacy of ESM and resective epilepsy surgery. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Effects of an inpatient rehabilitation program after temporal lobe epilepsy surgery and other factors on employment 2 years after epilepsy surgery

To evaluate the effects of a postsurgical rehabilitation program on employment status 2 years after temporal lobe epilepsy surgery in relation to other predictors. Employment outcome 2 years after temporal lobe resection in a group of 232 adult patients with the offer of a 3-week inpatient rehabilitation program immediately after surgery ("Reha group") was compared to a group of 119 patients who had surgery before such a rehabilitation program existed. One hundred thirty-nine (59.9%) of the Reha group patients attended the rehabilitation program. Further predictors for employment outcome were analyzed using multivariate logistic regression analysis. Preoperatively, the groups did not differ significantly in variables relevant for employment, including employment rate. Two years after surgery, the rate of those not being employed had decreased in the Reha group from 38.4% to 27.6% (p < 0.001, McNemar test), and slightly increased in the control group (37.8-42.0%; n.s.), resulting in a difference of 14.4% in favor of the Reha group (p = 0.008). General unemployment rates during the two observation periods were similar. In addition to the offer of rehabilitation support ("Reha group") and preoperative employment, the following other variables were shown as significant predictors of employment post surgery in multivariate regression analysis: seizure outcome, diagnosis of a personality disorder preoperatively, and age at surgery (all, p < 0.01; Nagelkerkes R(2) = 0.59). Independently from other factors, a 3-week inpatient rehabilitation program after temporal lobe epilepsy surgery seems to improve employment status 2 years after surgery.

National epilepsy surgery program: realistic goals and pragmatic solutions.

There are multiple social, economic, and medical challenges in establishing successful epilepsy surgery programs in India and in other low- and middle-income countries (LAMIC). These can be overcome by reproducing pragmatic and proven epilepsy surgery models throughout the country with a larger aim of developing a national epilepsy surgery program so as to provide affordable and quality surgical care to all the deserving patients. An organized national epilepsy surgery support activity can help interested centers in India and in neighboring countries in developing epilepsy surgery programs.

Video electroencephalogram telemetry in temporal lobe epilepsy.

Temporal lobe epilepsy (TLE) is the most commonly encountered medically refractory epilepsy. It is also the substrate of refractory epilepsy that gives the most gratifying results in any epilepsy surgery program, with a minimum use of resources. Correlation of clinical behavior and the ictal patterns during ictal behavior is mandatory for success at epilepsy surgery. Video electroencephalogram (EEG) telemetry achieves this goal and hence plays a pivotal role in pre-surgical assessment. The role of telemetry is continuously evolving with the advent of digital EEG technology, of high-resolution volumetric magnetic resonance imaging and other functional imaging techniques. Most of surgical selection in patients with TLE can be done with a scalp video EEG monitoring. However, the limitations of the scalp EEG technique demand invasive recordings in a selected group of TLE patients. This subset of the patients can be a challenge to the epileptologist.

An overview of pre-surgical evaluation.

The success of an epilepsy surgery program depends upon the early identification of potential surgical candidates and selecting from them, ideal candidates for surgery, who are destined to have a post-operative seizure-free outcome without any unacceptable neurological deficits. Since epilepsy surgery centers in resource-poor countries will lack the full range of state-of-the-art technologies usually available in resource-rich countries to perform pre-surgical evaluation, cost-effectively utilization of the locally available investigative facilities to select the surgical candidates becomes challenging. In the present era of rapid electronic communications and telemedicine, it has become possible for epilepsy surgery centers to pool their technological and human resources and to partner with centers nationally and internationally in implementing pre-surgical evaluation strategies.

National epilepsy surgery support activity.

While there are over one million people with drug-resistant epilepsy in India, today, there are only a handful of centers equipped to undertake presurgical evaluation and epilepsy surgery. The only solution to overcome this large surgical treatment gap is to establish comprehensive epilepsy care centers across the country that are capable of evaluating and selecting the patients for epilepsy surgery with the locally available technology and in a cost-effective manner. The National Epilepsy Surgery Support Activity (NESSA) aims to provide proper guidance and support in establishing epilepsy surgery programs across India and in neighboring resource-poor countries, and in sustaining them.