Browsing by Author "Rathore, Chaturbhuj"
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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 Calcified neurocysticercosis lesions and hippocampal sclerosis: Potential dual pathology?(EPILEPSIA, 2012)In areas where cysticercosis is endemic, calcified neurocysticercosis lesion(s) (CNL) and hippocampal sclerosis (HS) commonly coexist in patients with localization-related epilepsies. To understand the pathogenesis of HS associated with CNL, we compared the characteristics of three groups of patients with antiepileptic drugresistant epilepsies: CNL with HS, CNL without HS (CNL alone), and HS without CNL (HS alone). In comparison to patients with CNL alone, those with CNL with HS had CNL more frequently located in the ipsilateral temporal lobe. Those with CNL with HS had a lower incidence of febrile seizures, older age at initial precipitating injury and at onset of habitual complex partial seizures, and more frequent clustering of seizures and extratemporal/bitemporal interictal epileptiform discharges as compared to patients with HS alone. Our study illustrates that HS associated with CNL might have a different pathophysiologic basis as compared to classical HS.Item Cost-effective utilization of single photon emission computed tomography (SPECT) in decision making for epilepsy surgery(SEIZURE-EUROPEAN JOURNAL OF EPILEPSY, 2011)Purpose: To investigate the utility of single photon emission computed tomography (SPECT) without subtraction and MRI co-registration in decision making for epilepsy surgeryMethods: Patients with refractory epilepsy and nonlocalizing or discordant non-invasive data (clinical, long-term VEEG, and MRI) were subjected to interictal and ictal SPECT studies before planning invasive or surgical strategy. Final localization was based upon the preoperative information and seizure freedom after surgery. SPECT was considered to be useful for decision-making if it obviated the need for intracranial monitoring or influenced its planning.Results: 61 patients (mean age, 25.1 +/- 8.3 years) underwent SPECT studies between January 2004 and December 2008. Twenty-two patients had mesial temporal lobe epilepsy (MTLE), 13 had neocortical temporal lobe epilepsy (NTLE), and 26 had extratemporal lobe epilepsy (ETLE). As compared to ETLE, SPECT provided more localizing information (77.3% vs 46.2%, p = 0.006) and influenced the final decision-making (45.4% vs 11.53%, p = 0.005) in a significantly higher number of patients with MTLE. SPECT was particularly useful in patients with lesional TLE and nonlocalizing ictal data and in those with dual pathologies. SPECT did not provide any additional information in patients having either TLE or ETLE with normal MRI.Conclusions: SPECT is useful in a selected group of patients and unlikely to provide additional information in others. By restricting its use in patients who are likely to be benefited, a cost-effective utilization strategy can be employed in countries with limited resources. Due to the small number, these findings need to be validated in a larger group of patients. (C) 2010 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Item Extent of initial injury determines language lateralization in mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS)(EPILEPSIA, 2009)P>Purpose:To assess the prevalence and attributes of atypical language lateralization (ALL) in patients with left mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS).Methods:We recruited consecutive patients with left MTLE-HS, who had undergone resective surgery and had pathologically proven HS. Based on the Wada test, language lateralization was classified into typical (left hemispheric) or atypical (right hemispheric or codominant). We assessed the attributes of patients with ALL using univariate and multivariate analyses.Results:Of 124 patients with left MTLE-HS, 23 (18.5%) had ALL. ALL occurred more frequently in patients with severe initial precipitating injury (IPI), early onset of epilepsy, and a short latent period between IPI and onset of habitual seizures. ALL was more common in patients with bitemporal and extratemporal interictal epileptiform discharges (IEDs) on electroencephalogram (EEG) and extratemporal changes on magnetic resonance imaging (MRI). On multivariate analyses, the age at onset of habitual seizures < 6 years, atypical IPI, nonunilateral temporal IEDs, and extratemporal MRI abnormalities independently predicted ALL. The likelihood of ALL was very low (similar to 1%) when all of these four risk factors were absent, whereas it was very high (> 95%), if any three or all four of them were present.Conclusions:ALL occurs in one-fifth of patients with left MTLE-HS. ALL is more frequent in those with structural or functional extrahippocampal involvement and early onset of epilepsy interrupting the development of normal language networks. Because ALL is uncommon in those with damage/dysfunction restricted to the hippocampus, the hippocampus itself may have only a limited role in determining language lateralization.Item Feasibility of antiepileptic drug withdrawal following extratemporal resective epilepsy surgery(NEUROLOGY, 2012)Objective: To identify the rate of successful antiepileptic drug (AED) withdrawal after resective surgery and the predictors of postwithdrawal seizure recurrence in patients with extratemporal epilepsy.Methods: We retrospectively analyzed the postoperative AED profile of 106 consecutive patients who had completed 2 or more years after resections involving frontal, parietal, and occipital lobes for AED-resistant epilepsy. To identify the potential predictors of seizure recurrence, we compared the attributes of recurred and nonrecurred groups by univariate and multivariate analyses.Results: We attempted AED withdrawal in 94 (88.7%) patients. Forty-four (41.5%) patients had seizure recurrence while reducing AED, of which 14 (31.8%) did not become seizure-free subsequently. On multivariate analysis, an abnormal postoperative EEG and longer preoperative duration of epilepsy predicted seizure recurrence, while early postoperative seizures and presence of gliosis or dysplasia were additional predictors on univariate analysis. At mean follow-up duration of 4.6 years, 63 (59.4%) patients were seizure-free. The cumulative probability of achieving complete AED-free status was 20% at fourth year, 34% at sixth year, 40% at eighth year, and 52% at 10th year after surgery.Conclusions: Following resective extratemporal epilepsy surgery, AED can be successfully discontinued in only in a minority of patients. One-third of patients who recur fail to regain seizure control upon AED reintroduction. Longer duration of epilepsy prior to surgery, abnormal postoperative EEG, early postoperative seizures, and focal gliosis or dysplasia as substrate predispose to seizure recurrence. This information will be helpful in making rational decisions on AED withdrawal following extratemporal resective epilepsy surgery. Neurology (R) 2012;79:770-776Item How safe is it to withdraw antiepileptic drugs following successful surgery for mesial temporal lobe epilepsy?(EPILEPSIA, 2011)P>Purpose:To investigate the feasibility of antiepileptic drug (AED) withdrawal following anterior temporal lobectomy (ATL) and to identify the predictors of post withdrawal seizure recurrence.Methods:We prospectively studied the seizure outcome of 310 consecutive patients, who were followed for a minimum of 5 years following ATL for medically refractory mesial temporal lobe epilepsy. In seizure-free patients, we started AED tapering at 3 months in patients on duotherapy/polytherapy and at 1 year after ATL for those on monotherapy. We used Kaplan-Meier survival curves to estimate the probability of seizure recurrence and complete AED discontinuation, and compared the attributes of recurred and nonrecurred groups of patients by univariate and multivariate logistic regression analyses.Key Findings:Immediately after ATL, 197 patients were on duotherapy and 101 were on monotherapy. We attempted AED withdrawal in 258 patients (83.2%). Sixty-four patients (24.8%) had seizure recurrence while reducing AEDs. Of 26 patients who had seizure recurrence after complete AED withdrawal, 24 (92.3%) again became seizure-free after restarting the AEDs. Absence of hippocampal sclerosis on pathologic examination and abnormal postoperative electroencephalogram (EEG) predicted seizure recurrence on multivariate analysis. At the end of follow-up duration of 8.0 +/- 2.0 years, 163 patients (52.6%) were AED free. The cumulative probability of achieving AED-free status among patients in whom AED withdrawal was attempted, was 44% at fourth year, 65% at sixth year, 71% at eighth year, and 77% at 10th year after ATL.Significance:AED withdrawal can be safely attempted following successful ATL. Seizure recurrences are few and can be managed easily.Item Impaired facial emotion recognition in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS): Side and age at onset matters(EPILEPSY RESEARCH, 2008)To define the determinants of impaired facial emotion recognition (FER) inpatients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS), we examined 76 patients with unilateral MTLE-HS, 36 prior to antero-mesial temporal lobectomy (AMTL) and 40 after AMTL, and 28 healthy control subjects with a FER test consisting of 60 items (20 each for anger, fear, and happiness). Mean percentages of the accurate responses were calculated for different subgroups: right vs. left MTLE-HS, early (age at onset <6 years) vs. late-onset, and before vs. after AMTL. After controlling for years of education, duration of epilepsy and number of antiepileptic drugs (AEDs) taken, on multivariate analysis, fear recognition was profoundly impaired in early-onset right MTLE-HS patients compared to other MTLE patients and control subjects. Happiness recognition was significantly better in post-AMTL MTLE-HS patients compared to pre-AMTL patients white anger and fear recognition did not differ. We conclude that patients with right MTLE-HS with age at seizure onset <6 years are maximally predisposed to impaired fear recognition. In them, right AMTL does not further worsen FER abilities. Longitudinal studies comparing FER in the same patients before and after AMTL will be required to refine and confirm our cross-sectional observations. (C) 2008 Elsevier B.V. All rights reserved.Item Outcome after corpus callosotomy in children with injurious drop attacks and severe mental retardation(BRAIN & DEVELOPMENT, 2007)Wide variability in patient selection, extent of callosal section and definition of successful outcome between studies make impact of corpus callosotomy on patients with medically refractory epilepsies difficult to interpret. Severe mental retardation is considered to be predictive of unfavorable seizure outcome after callosotomy. Very little attention has been paid on the influence of callosotomy on the psychosocial burden on the patients' families. We evaluated the seizure outcome, and parental perception about change in cognition and behavior of 17 children (median age 9.5 years, range 3.5-18 years) with severe mental retardation (IQ < 30 in all, except one) and injurious drop attacks, who have completed >= 1-year postoperative follow-up after callosotomy. Nearly two-thirds of our patients had >= 90% reduction in drop attacks and generalized tonic-clonic seizures. In the one-stage total callosotomy group, 9 of 11 (82%) patients had favorable outcome, compared to 2 of the 6 (33%) in the partial callosotomy group. Absence of generalized epileptiform discharges on the 1-year postoperative EEG was significantly associated with a favorable seizure outcome. The mean duration of epilepsy prior to callosotomy tended to be shorter among patients with favorable seizure outcome. Postoperative complications were trivial and transient. Nearly three-fourths of the parents appreciated improvements in behavior and attentiveness of their children and were satisfied with the outcome. We conclude that, in children with severe mental retardation and injurious drop attacks, total callosotomy can be undertaken as a one-stage procedure with insignificant morbidity and results in highly favorable seizure outcome. (c) 2007 Elsevier B.V. All rights reserved.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 Prognostic importance of serial postoperative EEGs after anterior temporal lobectomy(NEUROLOGY, 2011)Objective: To assess the value of postoperative EEG in predicting seizure outcome and seizure recurrence following antiepileptic drug (AED) withdrawal in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).Methods: We studied 262 consecutive patients with MTLE-HS with serial EEGs at 3 months, and at 1, 2, and 3 years after anterior temporal lobectomy (ATL), and considered the presence of interictal epileptiform discharges (IED) as abnormal. We attempted AED withdrawal in all seizure-free patients. We defined favorable outcome as freedom from seizures/auras during the entire follow-up period (outcome 1) and during terminal 1-year follow-up (outcome 2).Results: During mean follow-up period of 7.6 (range 5-12) years, 129 (49.2%) patients had favorable outcome 1 and 218 (83.2%) had favorable outcome 2. Of 225 (85.9%) patients in whom AED withdrawal was attempted, 61 (27.1%) had seizure recurrence. Compared to patients with normal EEG, those with IED on 1-year post-ATL EEG had a 3-fold increased risk for unfavorable outcome 1 and 7-fold increased risk for unfavorable outcome 2. The patients in whom all the 4 EEGs were abnormal had 9-fold odds for unfavorable outcome 1 and 26-fold odds for unfavorable outcome 2. An abnormal EEG at 1 year increased the risk of seizure recurrence following AED withdrawal by 2.6-fold.Conclusions: Post-ATL EEG predicts seizure outcome and seizure recurrence following AED withdrawal. Serial EEGs predict outcome better than single EEG. This information will be helpful in counseling of patients after ATL, and in making rational decisions on AED withdrawal. Neurology (R) 2011; 76: 1925-1931Item Prognostic Significance of Interictal Epileptiform Discharges After Epilepsy Surgery(JOURNAL OF CLINICAL NEUROPHYSIOLOGY, 2010)The prognostic significance of interictal epileptiform discharges (IED) after epilepsy surgery is uncertain. We reviewed 20 studies (including 2 unpublished data sets) to assess the usefulness of postoperative EEG findings in predicting seizure outcome after resective epilepsy surgery. Patient selection and methodology varied widely among the studies. The published studies included 1,345 patients (temporal resection, n = 751; extratemporal resection, n = 373; unspecified site, n = 221). We defined a favorable outcome as a postoperative seizure status of Engel class I or equivalent. The frequency of postoperative IED ranged from 13% to 68% (mean, 31.5%). Postoperative IED were strongly associated with an unfavorable seizure outcome for the whole cohort (odds ratio, 3.3; 95% confidence interval, 2.5-4.5), for the subgroup of patients who underwent temporal resection (odds ratio, 2.5; 95% confidence interval, 1.6-4.0), and for the extratemporal resection subgroup (odds ratio, 5.6; 95% confidence interval, 3.9-9.3). Postoperative IED had a modest positive predictive value (52%) but an excellent negative predictive value (71%) for unfavorable seizure outcome. Most IED (>90%) were localized to the site of resection and were also influenced by preoperative spike frequency and completeness of resection. Insufficient data preclude any firm conclusions about the value of postoperative IED in predicting seizure outcomes after hemispherotomy or corpus callosotomy.Item Item Teaching NeuroImages: Diaschisis Is it always reversible?(NEUROLOGY, 2009)