Establishment of low cost epilepsy surgery centers in resource poor setting

Is intraoperative electrocorticography (ECoG) for long-term epilepsy-associated tumors (LEATs) more useful in children?-A Randomized Controlled Trial

OBJECTIVES

The utility of intraoperative electrocorticography (ECoG)-guided resective surgery for pediatric long-term epilepsy-associated tumors (LEATs) with antiseizure medication (ASM) resistant epilepsy is not supported by robust evidence. As epilepsy networks and their ramifications are different in children from those in adults, the impact of intraoperative ECoG-based tailored resections in predicting prognosis and influencing outcomes may also differ. We evaluated this hypothesis by comparing the outcomes of resections with and without the use of ECoG in children and adults by a randomized study.

METHODS

From June 2020 to January 2022, 42 patients (17 children and 25 adults) with LEATs and antiseizure medication (ASM)-resistant epilepsy were randomly assigned to one of the 2 groups (ECoG or no ECoG), prior to surgical resection. The 'no ECoG' arm underwent gross total lesion resection (GTR) without ECoG guidance and the ECoG arm underwent GTR with ECoG guidance and further additional tailored resections, as necessary. Factors evaluated were tumor location, size, lateralization, seizure duration, preoperative antiepileptic drug therapy, pre- and postresection ECoG patterns and tumor histology. Postoperative Engel score and adverse event rates were compared in the pediatric and adult groups of both arms. Eloquent cortex lesions and re-explorations were excluded to avoid confounders.

RESULTS

Forty-two patients were included in the study of which 17 patients were in the pediatric cohort (age < 18 years) and 25 in the adult cohort. The mean age in the pediatric group was 11.11 years (SD 4.72) and in the adult group was 29.56 years (SD 9.29). The mean duration of epilepsy was 9.7 years (SD 4.8) in the pediatric group and 10.96 (SD 8.8) in the adult group. The ECoG arm of LEAT resections had 23 patients (9 children and 14 adults) and the non-ECoG arm had 19 patients (8 children and 11 adults). Three children and 3 adults from the ECoG group further underwent ECoG-guided tailored resections (average 1.33 additional tailored resections/per patient.).The histology of the tailored resection specimen was unremarkable in 3/6 (50%).Overall, the commonest histology in both groups was ganglioglioma and the temporal lobe, the commonest site of the lesion. 88.23% of pediatric cases (n = 15/17) had an excellent outcome (Engel Ia) following resection, compared to 84% of adult cases (n = 21/25) at a mean duration of follow-up of 25.76 months in children and 26.72 months in adults (p = 0.405).There was no significant difference in seizure outcomes between the ECoG and no ECoG groups both in children and adults, respectively (p > 0.05). Additional tailored resection did not offer any seizure outcome benefit when compared to the non-tailored resections.

CONCLUSIONS

The use of intraoperative electrocorticography in LEATs did not contribute to postoperative seizure outcome benefit in children and adults. No additional advantage or utility was offered by ECoG in children when compared to its use in adults. ECoG-guided additional tailored resections did not offer any additional seizure outcome benefit both in children and adults.

Neurosurgery and the World Health Organization Intersectoral Global Action Plan for Epilepsy and Other Neurological Disorders 2022-2031

The World Health Organization's Intersectoral Global Action Plan (IGAP) on Epilepsy and Other Neurological Diseases 2022-2031 is a holistic, interdisciplinary, and intersectoral plan with a strong focus on equity and human rights. The IGAP was unanimously approved by all World Health Organization Member States at the 75th World Health Assembly in May 2022 and provides a framework for researchers and clinicians to study and address national and global inadequacies in the evaluation and management of people suffering from neurological disorders and their prevention. While IGAP has applied epilepsy as an entry point for other neurological disorders, advocacy by neurologists and neurosurgeons has broadened it to include diseases with a large and growing global health footprint such as stroke, hydrocephalus, traumatic brain injury, and brain and spine cancers. The IGAP is important to neurosurgeons globally because it provides the first ever roadmap for comprehensively addressing unmet neurological and neurosurgical care in low- and middle-income countries. Furthermore, it creates an opportunity for neurologists and neurosurgeons to scale up services for neurological diseases in tandem. As such, it provides a structure for the neurosurgery community to become involved in global health initiatives at all levels.

Development and results of the epilepsy surgery in Armenia: hope for a better future

Purpose

We present our experience with the national epilepsy surgery program in Armenia by tracing the development of epilepsy surgery in the largest pediatric neurology department at "Arabkir" Medical Center. This development was possible on the basis of a strong collaboration with the Epilepsy Surgery center at the University Hospital "Sofia St. Ivan Rilski," Sofia, Bulgaria.

Materials and methods

Our material included 28 consecutive patients with lesional drug-resistant epilepsy evaluated. All patients underwent 3 T MRI and Video-EEG monitoring. Brain 18FDG-PET was done in 13 patients in St. Petersburg. Fifteen patients (53%) had preoperative neuropsychological examination before surgery. All operations were done by the same neurosurgical team on site in Arabkir Hospital.

Results

The majority of the patients in our cohort benefited from the epilepsy surgery as 25 (89%) are free of disabling seizures (Engel class I) and three patients (11%) did not improve substantially (Engel class IV). Eleven patients (39%) are already ASM-free after surgery, 4 (14%) are on monotherapy, 11(39%) get two drugs, and 2(7%) are on polytherapy, one of them still continues having seizures. In 12 patients (43%), we were able either to withdraw therapy or to decrease one of the ASM.

Conclusion

We believe that, although small, yet encompassing patients along the usual age spectrum and with the most frequent pathologies of drug-resistant epilepsies, our experience can serve as a model to develop epilepsy surgery in countries with limited resources.

Resective epilepsy surgery in a limited-resource settings: A cohort from a multi-disciplinary epilepsy team in a developing country

BACKGROUND

Multidisciplinary pre-surgical evaluation is vital for epilepsy surgery decision and outcomes. Resective epilepsy surgery with assisted monitoring is currently a standard treatment for focal drug resistant epilepsy (DRE). In resource-limited countries, lack of epilepsy surgery center is a huge challenge. We presented and illustrated how to create a multidisciplinary protocol with resource-limited settings in a developing country and epilepsy surgery outcome using brain mapping and monitoring techniques for ensuring satisfactory resection.

METHODS

We created multicentric incomplete but complementary units covering all epilepsy-related sub-specialties and covering a wide geographical area in our country. Then, we conducted a prospective and multicentric study with low resource settings on patients with focal DRE, who underwent resective epilepsy surgery and were followed up for at least 12 months and were evaluated for postoperative seizure outcome and complications if present. Preoperative comprehensive clinical, neurophysiological, neuropsychological, and radiological evaluations were performed by multidisciplinary epilepsy team. Intraoperative brain mapping including awake craniotomy and direct stimulation techniques, neurophysiological monitoring, and electrocorticography was carried out during surgical resection.

RESULTS

The study included 47 patients (18 females and 29 males) with mean age 20.4 ± 10.02 years. Twenty-two (46.8%) patients were temporal epilepsy while 25 (53.2%) were extra-temporal epilepsy. The epilepsy surgery outcome at the last follow up was Engel Class I (seizure free) in 35 (74.5%), Class II (almost seizure free) in 8 (17%), Class III (worthwhile improvement) in 3 (6.4%), and Class IV (no worthwhile improvement) in 1 patient (2.1%).

CONCLUSION

With low resource settings and lack of single fully equipped epilepsy center, favorable outcomes after resective surgery in patients with focal DRE could be achieved using careful presurgical multidisciplinary selection, especially with using intraoperative brain mapping and electrocorticography techniques.

Surgical treatment of epilepsy - Initial experience from a comprehensive epilepsy program in coastal South India

Objectives

The objectives of this study were to share our initial experience with epilepsy surgery and provide an overview on the surgical treatments of epilepsies.

Materials and Methods

This was a retrospective analysis of the demographics and clinical and investigative features of patients who underwent epilepsy surgery between January 2016 and August 2021. Postoperative seizure outcome was categorized according to modified Engel's classification, and the minimum period of follow-up was 1 year.

Results

The study group included 30 patients with an age ranging from 6 years to 45 years (mean: 22.28 years, median: 20 years) and a male: female ratio of 20:10. The epilepsy duration before surgery ranged from 3 years to 32 years (median: 7 years). Majority of our patients underwent resective surgeries (28/30 = 93.3%), and disconnection procedures were done in two patients. This included one functional hemispherotomy and one posterior quadrantic disconnection. Temporal lobe resective surgery was the most common procedure (16/30 = 53.3%), followed by eight frontal lobe and two parietal lobe surgeries. Among resective surgeries, majority were lesional surgeries and the pathologies included mesial temporal sclerosis (4), dysembryoplastic neuroepithelial tumor (8), ganglioglioma (6), cavernoma (4), focal cortical dysplasia (2), gliosis (1), and one case of hypothalamic hamartoma. Intraoperative electrocorticography was used in all cases for optimizing surgical resection/disconnection. Nearly two-thirds of our patients (66.6%) had an Engel's Class I outcome, five patients had Engel's Class II outcome, three patients had Class III outcome, and one patient did not have any worthwhile improvement. Temporal lobe surgery patients had a better seizure outcome compared to extratemporal surgeries (84% vs. 74%). Overall, complications were minimal and short lasting, and comprised meningitis in three patients (5.6%) and transient worsening of hemiparesis following hemispherotomy in two patients. There was no mortality or long-lasting major morbidity in our patients.

Conclusion

In carefully selected patients with drug-resistant epilepsy, surgery offers an excellent chance of becoming seizure-free with significant improvement in overall quality of life. Majority of the common epilepsy surgery procedures can be performed through a multidisciplinary approach even in centers with limited resources.

How to successfully establish an epilepsy care center in resource-limited countries: A scoping systematic review

PURPOSE

The aim of the current study was to systematically review the literature on establishing epilepsy care centers in resource-limited nations in the world and to provide a comprehensive roadmap on this significantly needed endeavor. This work may provide guidance on how to develop an epilepsy care center in other resource-limited places in the world.

METHODS

Web of science, Science Direct, and MEDLINE (accessed from PubMed) from inception to March 2023 were systematically searched for relevant published manuscripts. In all electronic databases, the following search strategy was implemented and these key words were used (title/abstract): epilepsy AND resource. The inclusion criteria were all original studies and articles written in English.

RESULTS

We could identify nine manuscripts on how to successfully establish an epilepsy care center in resource-limited countries. Two models were identified for such an endeavor: developing a team of trained healthcare professionals (e.g., in Iran, India, China, Vietnam) or a twin affiliation between an advanced epilepsy surgery program in a developed country and a starting program in a developing country (e.g., in Georgia, Tunisia).

CONCLUSION

In order to successfully establish an epilepsy care center in resource-limited countries four pillars are needed: presence of skillful healthcare professionals, having access to basic investigative technologies (i.e., MRI and EEG), a careful planning, and raising awareness.

Current practices in epilepsy monitoring units (EMU) in India

AIM

As an initial step to develop guidelines for epilepsy monitoring units (EMUs) appropriate for developing countries, we inquired the existing practices in EMUs in India.

METHODS

After checking for the content and face validity as well for clarity, we sent a 52-item online non-anonymized questionnaire to all the 52 EMUs in India.

RESULTS

The questionnaire was completed by 51 of the 52 EMUs (98% response rate). The majority of the EMUs are located in major cities and 51% are located in non-governmental corporate hospitals. There are total of 122 prolonged video-EEG monitoring (PVEM) beds in India and 70% EMUs have ≤2 beds. Approximately two-thirds of the EMUs have defined protocols for pre-procedure consent and risk assessment, management of seizure clusters and status epilepticus, continuous observation of patients, and peri‑ictal testing. Only one-third of the EMUs have protocols for management of post-ictal psychosis, anti-suffocation pillows, and protected environment within bathrooms. The waiting period for PVEM is more (49.9 ± 101 vs. 4.9 ± 10.9 days; p = 0.04) and mean cost for 3-day PVEM is less (INR 8311 ± 9021 vs. 30,371 ± 17,563; p <0.0001) in public as compared to private hospitals. There was a negative correlation between cost of PVEM and the waiting period (r=-0.386; p = 0.01). Safety practices are similar in public and private hospitals.

CONCLUSIONS

Although practices in EMUs in India vary widely, they are comparable to those in developed countries. India has severe shortage of EMUs and long waiting lists for affordable PVEM.

Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers

Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.

Herbal Medicine in the Treatment of Epilepsy

Epilepsy is one of the most common disorders of the central nervous system. Although epilepsy is common worldwide, approximately 80% of epileptic patients live in the developing countries or those with low-middle income. Up until the second decade of the 20th century, epilepsy was treated mostly by traditional remedies. Today, antiepileptic drugs are used as a general treatment instead to prevent and control epileptic seizures. However, patient access to these drugs is hindered due to the healthcare systems of their countries and a number of other reasons, such as cultural, socio-demographic, and financial poverty. In addition, approximately 30-40%of epileptic patients suffer from refractory epilepsy, additionally, AEDs have adverse side-effects that can lead to treatment failure or reduce the patient's quality of life. Despite recent advances in the treatment of epilepsy, there is still a need for improving medical treatment with a particular focus on efficacy, safety, and accessibility. Since herbal medicines have been used for many centuries around the world for treating epilepsy, it is, therefore, plausible that a rigorous study on herbal medicine and phytochemical components within plants of various species and origin may lead to the discovery of novel AEDs. Nowadays, many medicinal plants used in different cultures and regions of the world have been identified. Most phytochemical components of these plants have been identified and, in some cases, their targets located. Therefore, it is possible that new, effective, and accessible anticonvulsants drugs can be obtained from a medicinal plant.

Initiating a new national epilepsy surgery program: Experiences gathered in Georgia

Surgery is the most effective therapeutic approach for medically refractory epilepsies and a safe and cost-efficient treatment in terms of long-term expenses of direct, indirect, and intangible costs. Georgia is a Caucasian low- to middle-income country with a remarkable effort to deal with epileptic diseases, but without an appropriate epilepsy surgery program. To address the needs for such a service in this country, two joint German-Georgian projects were initiated in 2017 and 2019. In the framework of these projects, a productive exchange program involving German and Georgian experts was undertaken in the past two years. This program included training and mentoring for Georgian clinical colleagues, as well as joint case conferences and workshops with the aim of optimizing presurgical diagnostics and preparing for an epilepsy surgery program in Georgia. Finally, a postsurgical medium- and long-term follow-up scheme was organized as the third component of this comprehensive approach. As a result of our efforts, the first patients underwent anterior temporal lobectomy and all of them remain seizure-free up to the present day. Hence, epilepsy surgery is not only feasible, but also already available in Georgia. In this report, we aim to share our experiences in the initiation and implementation of surgical epilepsy intervention in Georgia and illustrate our recent endeavor and achievements.