Browsing by Author "Radhakrishnan, Ashalatha"
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Item A case of PANDAS with Kleine-Levin type periodic hypersomnia(SLEEP MEDICINE, 2012)We report on an 11-year-old girl, presenting with clinical features suggesting both pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and Kleine-Levin syndrome (KLS), who was successfully treated with penicillin prophylaxis. KLS is a sleep disorder characterized by recurrent episodes of hypersomnia and at least one of the following symptoms: (1) cognitive or mood disturbances, (2) megaphagia with compulsive eating: (3) hypersexuality with inappropriate behaviors: and (4) abnormal behavior. The etiopathogenesis is still unclear and there is no effective treatment other than symptomatic therapies. This intriguing case report suggests novel insight into the pathogenesis of this rare and enigmatic syndrome. (C) 2011 Elsevier B.V. All rights reserved.Item A critical appraisal on the utility of long-term video-EEG monitoring in older adults(EPILEPSY RESEARCH, 2011)Background: World-over, the majority of patients undergoing video-EEG monitoring (VEM) are in their second or third decades. Although elderly represent the fastest growing segment of population with epilepsy, only few of them undergo VEM. We critically evaluated the utility of VEM in the diagnosis and long-term management of older adults with paroxysmal behavioral events.Methods: 148 consecutive patients aged 45 and above, who underwent long-term (>= 8h) inpatient VEM from 1996 to 2009 formed the study cohort. Utilizing a structured proforma, we gathered their demographic, clinical, electrophysiological and long-term outcome data. VEM was considered as "useful" when it changed the diagnosis and/or management; it was "corroborative" when it helped the treating physician to confirm the diagnosis and "not useful" when it neither helped to improve the diagnosis nor the management.Results: The mean age was 51.3 (SD 6.4) years; mean duration of VEM was 69.3h. Out of 117 patients with a diagnosis of epileptic seizures referred for presurgical evaluation or classification, VEM was "useful" or "corroborative" in 111 patients (94.8%; p = 0.0001). It was also "useful" or "corroborative" in 29 out of 31 patients (93.5%) referred with a suspicion of associated or pure psychogenic non-epileptic seizures (p = 0.0001). None developed any complications during monitoring. At a mean follow-up of 37.7 months there was significant reduction in AED usage in patients with epilepsy (p = 0.0001) and epilepsy with associated PNES (p = 0.001). At a mean follow-up of 34.2 months, all patients with pure PNES were event-free and medication-free at last follow-up (p = 0.002). Twenty-three patients (19.6%) underwent surgery, all except one remaining seizure-free at a mean follow-up of 39.2 months.Conclusions: VEM is a safe and cost-effective investigation strategy in older-adults. It aided in improving the diagnosis, offered better treatment including surgery and helped in excluding non-epileptic paroxysmal events in majority. (C) 2011 Elsevier B.V. All rights reserved.Item A Prospective Study on the Cost-Effective Utilization of Long-Term Inpatient Video-EEG Monitoring in a Developing Country(JOURNAL OF CLINICAL NEUROPHYSIOLOGY, 2009)To investigate diagnostic value, therapeutic benefit and cost-effective utilization of video-EEG monitoring (VEM) in a comprehensive epilepsy program in a developing country, The authors prospectively recruited all patients who underwent long-term (>= 3 hours) inpatient VEM during a 10-month period. The cohort was followed to gather information about the proportion of patients in whom long-term management was altered by VEM and resultant impact on direct health care costs. Out of 143 study subjects (median age 22 years), 102 (71.3%) were referred for presurgical evaluation. The median duration of VEM was 61 hours, and median number of events recorded per patient was 3. Video-EEG monitoring helped to clarify the epilepsy syndromic diagnosis in 123 of 132 (93.2%) patients referred with the diagnosis of epileptic seizures. Video-EEG monitoring confirmed coexistent complex partial seizures in 4 of 11 (36.4%) patients with a referral diagnosis of psychogenic nonepileptic events. During mean follow-up period of 2.2 years, 48 patients (33.6%) underwent epilepsy Surgery. A significant decrease in antiepileptic drug polytherapy, and minimization in recurring direct medical and nonmedical costs occurred. In addition to immediate diagnostic usefulness, VEM contributes significantly to long-term therapeutic and economic benefits for patients with difficult to diagnose and treat paroxysmal events.Item Acute subdural effusion in vasculitis(NEUROLOGY INDIA, 2008)We report a 29-year-old man with a unique presentation of vasculitis as acute unilateral subdural effusion and meningoencephalitis. Magnetic resonance imaging showed a brainstem lesion that spread to the thalamus over time. There were no systemic features of vasculitis other than a positive pathergy test. Histopathological examination I from the pathergy site showed neutrophilic infiltrate and leucocytoclastic vasculitis. The condition was steroid responsive and he remained in remission at two years' follow-up. The anatomy of the brainstem lesion, absence of other inflammatory and infective conditions on evaluation suggests a vasculitic pathology either as primary central nervous system angiitis or as neurological presentation of systemic vasculitis like Behcet's disease although the international diagnostic criteria for Behcet's were not fulfilled.Item An audit of the presurgical evaluation and patient selection for extratemporal resective epilepsy surgery in a resource-poor country(SEIZURE-EUROPEAN JOURNAL OF EPILEPSY, 2012)Purpose: The selection of ideal candidates for extratemporal resective epilepsy surgery is a challenge in resource-poor countries because of the limited presurgical diagnostic facilities and their affordability. To audit the presurgical evaluation strategy and selection for extratemporal resective epilepsy surgery in a resource-poor region.Methods: From the prospective database maintained at an epilepsy surgery center in southern India, we reviewed the data of consecutive patients who underwent presurgical evaluation from January 2005 through December 2008 for antiepileptic drug-resistant focal epilepsies emanating from the frontal, parietal and occipital lobes. Out of 285 patients, only 71 (24.9%) underwent resective surgery; the remaining 214 (75.1%) patients could not be selected for surgery. We inquired the reasons for their exclusion from surgery.Results: The difference in the rates of seizure-free outcome between surgical and non-surgical groups was highly significant (73.2% vs. 7.7%, P < 0.0005). The major reasons for exclusion from surgery were normal MRI in 107 (50%), inability to afford invasive EEG monitoring in 40 (18.7%) and lesion location adjacent to eloquent cortical areas in 27 (12.6%) patients. While clustering of seizures and presence of preoperative neurological deficits favored surgical selection, the presence of secondary generalized seizures and discordant interictal epileptiform abnormalities were associated with exclusion from surgery.Conclusions: We conclude that, in a resource-poor country, ideal candidates for extratemporal resective epilepsy surgery are those with well-circumscribed lesions not adjoining eloquent cortical areas. In such patients, concordant EEG findings and absence of preoperative secondary generalized seizures reinforce selection for surgery. (C) 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Item Atonic variant of benign childhood epilepsy with centrotemporal spikes (atonic-BECTS): A distinct electro-clinical syndrome(BRAIN & DEVELOPMENT, 2012)Purpose: To describe the clinical and electroencephalographic features, treatment strategies and outcome in a series of children with the atonic variant of benign childhood epilepsy with centrotemporal spikes (atonic-BECTS).Material and methods: Out of the 148 patients with BECTS reviewed from January 2005 to June 2010 in our Institute, there were seven (5%) with atonic-BECTS. All underwent video EEG, high-resolution magnetic resonance imaging (MRI), neuropsychological evaluation and language assessment. Their progress was followed. In addition to sodium valproate, three were treated with steroids, followed by intravenous immunoglobulin (IVIG) when the seizures relapsed while tapering or after stopping the steroids.Results: All of the children had earlier onset (mean = 2.4 years), increased frequency and increased duration of focal seizures compared to typical BECTS. Head drop and truncal sway due to axial or axiorhizomelic atonia occurring several times per day or week was the key manifestation. The atonic seizures worsened with carbamazepine in three, clonazepam in two and clobazam in one. When the atypical seizures commenced, some children developed one or more of the following problems: hyperactivity, attention deficit, clumsy gait, and mild cognitive or language dysfunction. Three children became seizure free, one on steroids and the other two on IVIG.Conclusions: BECTS in children with an early age of onset and frequent and prolonged seizures is more likely to evolve into atonic-BECTS. Carbamazepine and some benzodiazepines may worsen these seizures. Three children became seizure free with immunomodulatory therapy, one on steroids and the other two on IVIG, and had complete resolution of the transient motor and cognitive impairment. Atonic-BECTS needs to be differentiated from Lennox-Gastaut syndrome since it is potentially treatable and children recover with no sequel. Although all the children in this series continued to be on treatment with sodium valproate it is currently undetermined whether they would have required to do so if followed up for an extended period of time. (c) 2011 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.Item Clinical and functional outcome and factors predicting prognosis in osmotic demyelination syndrome (central pontine and/or extrapontine myelinolysis) in 25 patients(JOURNAL OF NEUROLOGY NEUROSURGERY AND PSYCHIATRY, 2011)Aims To assess the functional and clinical outcome in a sizeable cohort of patients with osmotic demyelination syndrome (ODS) and to characterise the factors which could predict the final outcome.Methods Twenty five consecutive patients with ODS formed the study cohort. The diagnosis of ODS was based on clinical features with corroborating imaging findings. Two functional scales-Functional Independent Measure (FIM) and Disability Rating Scale (DRS)-were applied to assess the functional status at the time of admission, discharge and last follow-up. Patients who became independent for activities of daily living (ADL) at last follow-up were classified as favourable outcome, and those who died or became dependent for ADL were classified as a poor outcome group respectively. The Fisher exact test and Manne-Whitney U test were used to assess categorical and continuous variables respectively.Results The mean age at diagnosis was 53 +/- 14 years. Five (20%) had central pontine myelinolysis, seven (28%) had extrapontine myelinolysis, and 13 (52%) had both. Hyponatraemia and hypokalaemia were noted in 20 (80%) and 10 (40%) patients respectively. Six (24%) received intravenous methylprednisolone. Eleven (46%) had a favourable outcome at a mean follow- up of 2.262.5 years. Hyponatraemia <= 115 mEq (p=0.04), associated hypokalaemia (p 0.04) and low Glasgow Coma Scale (GCS) (p=0.008) at presentation were predictive of poor outcome. The mean FIM score at admission (p=0.05) and at discharge (p=0.01), and mean DRS at admission (p=0.05) were predictive of poor outcome.Conclusions Higher GCS scores, better scores in functional scales in hospital, less severe hyponatraemia and absence of superadded hypokalaemia predicted favourable outcome.Item Coexistence of idiopathic generalized epilepsy among surgically treated patients with drug-resistant temporal lobe epilepsy(EPILEPSY RESEARCH, 2011)Introduction: Failure to identify the association antiepileptic drug (AED)-resistant temporal lobe epilepsy (TLE) with idiopathic generalized epilepsy (IGE) can interfere with decision for anterior temporal lobectomy (ATL) and prediction of post-ATL seizure outcome.Methods: Out of the 664 consecutive patients who underwent ATL between March 1995 and December 2007, 12 (1.8%) had coexisting IGE. The decision for ATL was made after a thorough discussion in the multidisciplinary patient management conference based upon the concordance between the clinical, electroencephalographic and magnetic resonance imaging data. All of them underwent epilepsy surgery for AED-resistant TLE.Results: In seven of the 12 patients, IGE was not identified until post-ATL. During a median follow-up period of 8.5 years, 8 of our 12 patients were seizure-free; the remaining 4 patients only had infrequent myoclonus. In two them, AEDs were discontinued; others were on montherapy for IGE.Conclusions: Our study highlights the rare association of IGE with TLE, the most common AED-resistant focal epilepsy syndrome. As the seizure outcome following ATL is similar in AED-resistant TLE patients with and without IGE, their co-existence is not a contraindication for ATL. Future studies should explore the molecular genetic basis of the rare association between these two epilepsy syndromes. (C) 2011 Elsevier B.V. All rights reserved.Item Corpora amylacea in mesial temporal lobe epilepsy: Clinico-pathological correlations(EPILEPSY RESEARCH, 2007)Purpose: To investigate the etectro-clinical significance of premature accumulation of corpora amylacea (CoA) in the resected hippocampus of patients with medically refractory mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).Methods: We compared the clinical and EEG characteristics, and post-operative seizure outcome of 373 (mean age 29.4 years, range 7-55 years) surgically treated MTLE-HS patients with (MTLE-HS-CoA(+), n = 129 [34.5%]) and without. (MTLE-HS-CoA(-), n = 244 [65.5%]) CoA.Results: Age at surgery was significantly higher and duration of epilepsy before surgery was significantly longer for MTLE-HS-CoA(+) patients compared to MTLE-HS-CoA(-) patients. Although the distribution of interictal epileptiform EEG abnormalities did not differ, type 1 ictal EEG pattern was more frequent in MTLE-HS-CoA(+) patients. Among the 21 patients with major interictal psychosis detected prior to epilepsy surgery, 19 (90.5%) belonged to MTLE-HS-CoA(+) group. Schizophrenia-like psychosis was most. prevalent. The post-operative seizure-free outcome was comparable, but significantly more MTLE-HS-CoA(-) patients were free of antiepileptic drugs.Conclusions: Overall, our observations support the hypothesis that the pathological process in MTLE-HS is progressive. MTLE-HS-CoA(+) patients are predisposed to increased psychiatric morbidity. In vivo detection of hippocampal CoA accumulation in the future will help us to understand the neurobiological significance of this phenomenon. (C) 2007 Elsevier B.V. All rights reserved.Item Do sphenoidal electrodes aid in surgical decision making in drug resistant temporal lobe epilepsy?(CLINICAL NEUROPHYSIOLOGY, 2012)Objective: The utility of sphenoidal electrodes (SPh) in analyzing interictal epileptiform discharges (IEDs) and ictal electrography remains controversial, despite its widespread use.Methods: One hundred and twenty-two consecutive patients with presumed temporal lobe epilepsy (TLE) who underwent presurgical evaluation were prospectively studied. SPh and Silverman's electrodes were placed, in addition to routine electrodes in 10-20 international system. IEDs and ictal electroencephalography (EEG) were analyzed separately in bipolar and referential montages. The proportion of patients selected for surgery after adjusting for SPh placement based on the earlier ictal onset and IEDs were analyzed.Results: Of the 8701 IEDs in SPh, only 65% were seen over the scalp bipolar montage; 1392 (16%) IEDs were confined to SPh electrodes, and were not seen at scalp bipolar montage (p < 0.001). Spike amplitudes were highest at SPh (p < 0.001). Of the 592 seizures analyzed, 62 (61%) had simultaneous SPh and scalp onset, while in 26 (25%) SPh onset preceded the scalp.Conclusions: Out of the 35 patients with unilateral mesial temporal sclerosis (MTS) with additional neocortical changes and/or non-lateralized bitemporal IEDs and/or diffuse ictal onset (group 1), 27 were selected for surgery (77%). About 7% was selected for surgery in this group by SPh placement. Also, in patients with bilateral MTS (group 2), 25% (5/20) were chosen for anterior temporal lobectomy, SPh provided an additional benefit in 11% (p < 0.001). Patients with normal magnetic resonance imaging (group 3) and temporal plus epilepsy (group 4) had a lower surgical yield, only 12% and 9.5% could undergo surgery. They were denied surgical candidacy with SPh (p < 0.001). Significance: One-third of patients after SPh placement were selected for resective surgery obviating the need for invasive monitoring. The maximum yield was noted in unilateral MTS (associated with additional neocortical features or non-lateralized bilateral temporal interictal IEDs or diffuse ictal onset in scalp EEG) and in bilateral MTS. Those with normal MRI/temporal plus epilepsy could be excluded from direct resective surgery. (C) 2011 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.Item Evolution and long term outcome in patients presenting with large demyelinating lesions as their first clinical event(JOURNAL OF THE NEUROLOGICAL SCIENCES, 2010)Objectives: To describe the long term evolution and outcome of a homogeneous cohort of patients (n = 14) with large demyelinating lesions (LDLs) as the first clinical event from a group of idiopathic inflammatory demyelinating diseases of central nervous system.Methods: Detailed review of LDLs from December 2002-January 2007 was made. Patients had at least two magnetic resonance imaging (MRI) and minimum follow-up of 2 years. The disability was assessed using Estimated Expanded Disability Status Scale (EDSS) and Rappaport Disability Rating Scale (DRS) at onset and last follow-up.Results: Fourteen consecutive LDL patients (male = 7), with mean age 32.7 years and mean follow-up of 45.5 months were included. Motor deficits (79%) and cognitive symptoms (43%) marked the onset, none had optic neuritis. All except two responded to steroids. Follow-up MRI showed complete resolution in 43%, 57% showing marked reduction in size. On follow-up, 2 relapsed. Mean EDSS and DRS at presentation were 5.93 and 9.07 and at last follow-up were 1.75 and 2.25 (p<0.001).Conclusions: Our data suggests that, patients presenting with LDLs as their first clinical event behaves distinctly in their presentation, imaging characteristics, prognosis and long term outcome as compared to MS and ADEM. Albeit significant disability at the onset, these patients show an excellent response to treatment with good functional recovery in long term and rare relapses. (C) 2010 Elsevier B.V. All rights reserved.Item Hyperreflexic Guillain-Barre syndrome.(Annals of Indian Academy of Neurology, 2010)Guillain-Barre syndrome (GBS) is an acquired acute autoimmune polyradiculoneuropathy. The 2 features considered essential for the diagnosis of GBS are progressive motor weakness and areflexia. There have been several descriptions of reflex preservation and hyperreflexia in axonal variant of GBS in Chinese, Japanese, and European populations but it is not common in the Indian subcontinent. We report 2 such cases discussing the pathophysiology and management aspects. This case report is to impress upon treating physicians and neurologists in training that a hyperreflexic variant of GBS albeit rare, should not be missed in a given clinical setting.Item Long-term outcome and prognosis of patients with emergent periodic lateralized epileptiform discharges (ePLEDs)(SEIZURE-EUROPEAN JOURNAL OF EPILEPSY, 2012)Purpose: Emergent EEG (eEEG) is an EEG performed on a non-elective basis upon request from a clinician for a seemingly emergency indication. Little is known about the long-term prognosis of patients with emergent periodic lateralized epileptiform discharges (ePLEDs).Methods: We analyzed the EEG and clinical records of patients with ePLEDs from January 2002 to December 2008.Results: Out of 1948 eEEGs, 79 (4%) patients had ePLEDs. Sixty-three patients had ePLEDs and 16 had eBiPLEDs (emergent bilateral periodic lateralized epileptiform discharges). The etiology of ePLEDs was CNS infection and inflammation (35.4%), stroke (32.9%), and metabolic encephalopathy (11.4%). Of the surviving 52 (65.8%) patients with ePLEDs, 34(65.4%) had persistent seizures during a mean follow-up of 28 months (range 12-72 months). Seizure as the initial presentation was more commonly seen in children as compared to adults (64% versus 31%, p = 0.005). CNS infection and inflammation were also seen more frequently in the pediatric age group (50% versus 27%, p = 0.04). At follow-up, patients with eBiPLEDs had more seizures than patients with ePLEDs (87.5% versus 61.3%).Conclusion: ePLEDs is associated with significant morbidity and mortality. However, the etiology of ePLEDs and brain dysfunction will influence the long-term outcome. This information is invaluable for prognostication and underscores the importance of rigorous management of patients with ePLEDs. (C) 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Item Medically refractory epilepsy associated with temporal lobe ganglioglioma: Characteristics and postoperative outcome(CLINICAL NEUROLOGY AND NEUROSURGERY, 2006)Objectives: To define the postoperative seizure outcome and its predictors in patients with ganglioglioma-related temporal lobe epilepsy (TLE).Patients and methods: We reviewed the pre- and post-surgical evaluation data of 23 patients with temporal lobe ganglioglioma, who had completed >= 1 year of postoperative follow-up. They comprised 4.9% of the patients with TLE and 67.6% of the tumoral TLE operated in a developing country epilepsy center during an 8-year period.Results: Median age at surgery was 20 years; median duration of epilepsy prior to surgery was 9 years. Magnetic resonance imaging (MRI) revealed tumor in mesial temporal location in 18 patients (78.3%) and in the lateral localtion in 2; in the remaining 3, involved both mesial and lateral regions. EEG abnormalities were localized to the side of lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 19 (82.6%) patients were completely seizure-free. Epileptiform abnormalities persisting in the 1-year postoperative EEG predicted unfavorable seizure outcome.Conclusion: We emphasize that, in patients with temporal lobe ganglioglioma, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority. (c) 2005 Elsevier B.V. All rights reserved.Item Periodic Lateralized Epileptiform Discharges in Fulminant Form of SSPE(CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES, 2009)Item Post-irradiation "acquired cavernous angiomas" with drug resistant seizures(EPILEPSY RESEARCH, 2011)Cavernomas are well-known congenital vascular lesions with presumably high epileptogenicity. We report two patients who developed cavernomas; both were in remission from childhood acute lymphoblastic leukemia following standard chemo-radiotherapy. They developed drug-resistant focal epilepsy secondary to cavernomas and were subjected to surgical/medical management. This report highlights the ictogenesis of radiation-induced "acquired" cavernous angiomatosis in the brain. Appropriate treatment, including resection of these lesions in selected cases, improves the quality of life in such patients. (C) 2011 Elsevier B.V. All rights reserved.Item Role of three-dimensional fluid-attenuated inversion recovery (3D FLAIR) and proton density magnetic resonance imaging for the detection and evaluation of lesion extent of focal cortical dysplasia in patients with refractory epilepsy(ACTA RADIOLOGICA, 2010)Background: Focal cortical dysplasia (FCD) is often associated with epilepsy. Identification of FCD can be difficult due to subtle magnetic resonance imaging (MRI) changes. Though fluid-attenuated inversion recovery (FLAIR) sequence detects the majority of these lesions, smaller lesions may go unnoticed while larger lesions may be poorly delineated.Purpose: To determine the ability of a specialized epilepsy protocol in visualizing and delineating the extent of FCD.Material and Methods: We compared the imaging findings in nine patients with cortical malformation who underwent routine epilepsy MR imaging as well as a specialized epilepsy protocol. All imaging was done on a 1.5T MR unit. The specialized epilepsy protocol included 3D FLAIR in the sagittal plane as well as proton density (PD) and high-resolution T2-weighted (T2W) images in the transverse plane.Results: In all nine patients, the specialized protocol identified lesion anatomy better. In three patients in whom routine MRI was normal, the specialized epilepsy protocol including 3D FLAIR helped in identifying the lesions. One of these patients underwent surgery, and histo-pathology revealed a cortical dysplasia. In one patient, lesion characterization was improved, while in the remaining patients the extent of the FCD was more clearly demonstrated in the 3D FLAIR and PD images. Statistical analysis of images for cortical thickness, cortical signal intensity, adjacent white matter abnormalities, and gray-white matter junction showed significant statistical difference in the ability of 3D FLAIR to assess these aspects over conventional images. PD images were also found superior to the routine epilepsy protocol in assessment of cortical signal, adjacent white matter, and gray-white matter junction.Conclusion: Specialized MRI sequences and techniques should be performed whenever there is a high suspicion of cortical dysplasia, especially when they remain occult on conventional MR protocols. These techniques can also be used to define lesion extent more precisely.Item Selection of ideal candidates for extratemporal resective epilepsy surgery in a country with limited resources(EPILEPTIC DISORDERS, 2010)Aim. To investigate how to select ideal candidates for extratemporal resective epilepsy surgery, without compromising efficacy and safety, in countries with limited pre-surgical diagnostic facilities. Method. From the prospective database maintained at an epilepsy surgery centre in southern India, we reviewed the attributes of consecutive patients who had completed at least two years of follow-up after resections involving frontal, parietal and occipital lobes for medically refractory focal seizures. Results. Of 386 patients diagnosed with extratemporal refractory epilepsies during the study period, 61 (15.8%) were selected based on the presence of magnetic resonance imaging (MRI)-identified lesions (in all) and concordant scalp recorded electroencephalographic (EEG) data (in nearly two thirds). Seventeen (27.8%) required invasive investigations either to define the ictal onset zone, eloquent area, or both. During a median follow-up period of five years, 63% of our patients were seizure-free, excluding the presence of auras. Permanent disabling neurological sequelae occurred in three (4.9%) patients. According to univariate analysis, pre-operative secondary generalised seizures and interictal epileptiform discharges (IEDs), during a one-year post-operative EEG monitoring period, portended unfavourable seizure outcome. In multivariate analysis, frontal lobe resections and IEDs in post-operative EEGs were independent predictors of unfavourable outcome. Conclusions. Extratemporal resective epilepsy surgery can be undertaken in countries with limited resources with efficacy and safety, comparable to that in developed countries, when patients are selected based on the presence of MRI-identified lesions and scalp EEG concordance. In such patients, invasive EEG examinations, when necessary, can be undertaken by limited coverage of cortical areas at an affordable cost.Item Susceptibility weighted imaging in the diagnostic evaluation of patients with intractable epilepsy(EPILEPSIA, 2009)Aim: Dedicated magnetic resonance imaging (MRI) protocol can diagnose epileptogenic abnormalities in patients with intractable epilepsy. However, it is not sufficiently sensitive to detect small calcified lesions that may result from infections, tumors, or vascular malformations. This study aims to study the impact of the addition of T2*gradient echo/susceptibility weighted imaging (T2*GRE/SWI) sequence to a dedicated MRI protocol.Method: One hundred thirty-seven patients with intractable epilepsy underwent MRI using conventional epilepsy protocol with addition of T2*GRE/SWI sequence. Comparison of the images with and without these sequences was done for detection of calcified abnormalities/vascular abnormalities. In patients with calcified lesions, MRI findings were correlated either with histopathology or computerized tomography (CT) to confirm the presence of calcification.Results: In 16 patients the sequence gave additional information compared to conventional imaging protocol. The sequence helped in better characterization of lesions in all patients. In three patients it helped in detecting the lesion and in another three it appeared useful as it best characterized the lesions. Additional lesions were detected in two patients with old calcified granulomas. Important additional information was supplied in four patients, whereas in the remaining patients lesion conspicuity was increased.Conclusion: T2*GRE/SWI sequence should form part of routine epilepsy protocol as it increases sensitivity by detecting occult calcified lesions or vascular malformations that may be responsible for the patient's seizures. This is especially important in patients from developing countries who have post-infective calcified lesions responsible for seizures and who undergo only MRI as the imaging modality for intractable seizures.Item Teaching NeuroImages: Idiopathic intracranial hypertension MRI features(NEUROLOGY, 2010)