Browsing by Author "Sarma, P. Sankara"
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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 Community health insurance in Gudalur, India, increases access to hospital care(HEALTH POLICY AND PLANNING, 2010)Background To reduce the burden of out-of-pocket payments on households in India, the government has introduced community health insurance (CHI) as part of its National Rural Health Mission. Indian CHI schemes have been shown to provide financial protection and have the potential to improve quality of care, but do not seem to improve access. This study examines this dimension of CHI performance and explores conditions under which a CHI scheme can improve access to hospital care for the poor.Methods We conducted a panel survey at the ACCORD-AMS-ASHWINI (AAA) CHI scheme in India. The AAA CHI scheme protects the poorest sections of society against hospitalization expenses. 297 insured and 248 matched uninsured households were observed by village volunteers on a weekly basis for 12 months. Any patient presenting with a 'major ailment' in these households was interviewed using a structured questionnaire. Outcomes measured were utilization of hospital services, cost of treatment and quality of treatment received.Results The two cohorts were similar regarding demographic, social and economic parameters. More insured than uninsured households expressed trust in the CHI scheme organizers. Both groups had similar levels of minor ailments, but the insured had higher incidence of chronic and major ailments. Insured patients had a hospital admission rate 2.2 times higher than uninsured patients, independent of confounding factors. This higher rate among the insured was also found in children and those with pre-existing conditions. Vulnerable sections of the insured population-children, pregnant women, the poorest-had the highest admission rates. Most admissions, in both cohorts, took place in the ASHWINI hospital. Credible and trustworthy organizers, effective providers, low co-payments, and low indirect costs contributed to this result.Conclusions A well-designed CHI scheme has the potential to improve access to hospital care, even for vulnerable sections of the community-the poorest, individuals with pre-existing conditions like diabetes and hypertension, and pregnant women.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 Employment concerns of people with epilepsy in Kerala, south India(EPILEPSY & BEHAVIOR, 2007)We examined current employment status, reasons for unemployment.. and related psychosocial concerns of 202 persons with epilepsy from the south Indian state of Kerala. Compared with 19% of the general population, 58% of persons with epilepsy were unemployed. Seizure remission for >= 2 years, monotherapy, better education, ability to travel alone, and ability to drive were significantly associated with being employed. More than three-fourths of the persons with epilepsy had disclosed their epilepsy to their employers and co-workers, which did not adversely affect employment for the majority. The unemployed perceived fear of having seizures and seizure-related falls in the workplace, inadequate education, and antiepileptic drug-induced fatigue as reasons for unemployment. We conclude that unemployment is a major concern of people with epilepsy in this developing region. In addition to optimum seizure control, persons with epilepsy need support in job seeking, in reducing fear of seizures and falls in the workplace, and in identifying their individual abilities and limitations. (c) 2006 Elsevier Inc. All rights reserved.Item Employment outcome and satisfaction after anterior temporal lobectomy for refractory epilepsy: A developing country's perspective(EPILEPSY & BEHAVIOR, 2009)We examined employment Outcome and its determinants in 172 south Indian patients who had undergone anterior temporal lobectomy (ATL) for medically refractory epilepsy. Despite seizure-free outcome in the majority, a significant change in post-ATL employment status occurred only in those involved in skilled jobs. Although factors such as younger age at surgery, shorter duration of epilepsy, longer post-ATL follow-up duration, and lower income were associated with favorable employment outcome in univariate analysis, only shorter duration of epilepsy was independently predictive in the multivariate model. A majority of homemakers appreciated marked improvement in their own day-to-day activities. Our patients did not express their desire to work as a principal aim of epilepsy surgery. To enhance occupational attainment, patients require, before epilepsy surgery, occupational assessment to identify their individual abilities and limitations and counseling in formulating realistic goals. After surgery, they require continued support in vocational training and job seeking. (C) 2009 Elsevier Inc. 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 High school students' knowledge, attitude, and practice with respect to epilepsy in Kerala, southern India(EPILEPSY & BEHAVIOR, 2006)Very little information is available on knowledge, attitude, and practice (KAP) with respect to epilepsy among schoolchildren from developing countries. We quantified KAP with respect to epilepsy among 1213 tenth-grade students of Kerala, southern India. Ninety-eight percent of them had heard or read about epilepsy. However, nearly 60% of students thought that epilepsy was a form of insanity. Allopathic treatment was preferred by more than half of the respondents; however, many had faith in exorcism and visiting religious places as ways to cure epilepsy. Half of the students considered epilepsy a hindrance to education, employment, and marriage. Thirteen percent would be unwilling to sit adjacent to or play with a child with epilepsy. We conclude that although familiarity with epilepsy was high among high school students in Kerala, misconceptions and negative attitudes were alarmingly high. Persistent and effective information campaigns, therefore, are necessary to change their attitudes toward fellow students with epilepsy. (c) 2006 Elsevier Inc. All rights reserved.Item 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 Incidence, Types, Risk Factors, and Outcome of Stroke in a Developing Country The Trivandrum Stroke Registry(STROKE, 2009)Background and Purpose-Despite increasing burden of stroke in developing countries, population-based data are rare. Through the Trivandrum Stroke Registry, we intend to assess incidence, types, risk factors, and outcome of stroke among urban and rural dwellers of a South Indian community.Methods-We ascertained all first-ever strokes occurring among 741000 urban and 185 000 rural inhabitants of Trivandrum, Kerala. In addition to Steps I and 2 of World Health Organization STEPS Stroke Manual, we used multiple supplementary methods to maximize ascertainment of nonfatal and nonhospitalized fatal stroke events in the community.Results-During a 6-month period, 541 strokes were registered, 431 in the urban and 110 in the rural communities. Stroke occurred at a median age of 67 years; only 3.8% of patients were aged <= 40 years. Adjusted annual incidence rates per 100 000 were 135 (95% confidence interval 123 to 146) for total, 135 (122-148) for urban, and 138 (112-164) for rural populations, and 74.8 (66.3 to 83.2), 10.1 (7.0 to 13.2), and 4.2 (2.2 to 6.1) for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, respectively. There was more stroke of undetermined type in the rural community. One or more modifiable risk factors were identified in 90% patients. More rural male patients smoked tobacco. The 28th day case fatality rate was 24.5% for urban and 37.1% for rural populations (P=0.011).Conclusions-There are more similarities than differences between developing and developed countries in the epidemiology of stroke. Compared to urban stroke patients, rural ones are less likely to be optimally investigated and treated. (Stroke. 2009;40:1212-1218.)Item Long-term seizure outcome and its predictors in patients with recurrent seizures during the first year after temporal lobe resective epilepsy surgery(EPILEPSIA, 2011)Purpose: The existing data on the implications of the characteristics of seizures that recur during the first year following epilepsy surgery on subsequent seizure outcome are conflicting. We investigated the impact of recurrent seizures in the first postoperative year and their attributes on long-term seizure outcome.Methods: We studied the postoperative courses of 492 patients who had completed two or more years of follow-up after temporal lobe resective epilepsy surgery. We used Kaplan-Meier survival curves to define long-term seizure outcome and assessed the predictive value of recurrent seizure characteristics on the outcome by univariate and multivariate proportional hazards regression models.Key Findings: In our patients, seizure recurrences during the first postoperative year, irrespective of the attributes of recurrent seizures (such as provoked vs. unprovoked, and timing and number of recurrences), imparted fourfold to sevenfold increased hazards for continued seizures beyond the first postoperative year. Although patients with complex partial seizures with or without secondary generalized tonic-clonic seizures (CPS/GTCS) had a sixfold increased risk, those with auras alone had only a borderline risk for seizures beyond the first postoperative year. In the multivariate model, CPS/GTCS as the predominant seizure type and three or more seizure recurrences during the first postoperative year independently predicted unfavorable long-term seizure outcome.Significance: Our study provides valuable information that is helpful in prognosticating and counseling patients, and in making rational decisions on the withdrawal of antiepileptic drugs following surgery. Our findings enhance the general understanding of the etiopathogenesis of surgical failure.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 Polytherapy increases the risk of infertility in women with epilepsy(NEUROLOGY, 2010)Background: Reproductive capability is an important concern for women with epilepsy (WWE). We aimed to ascertain the magnitude of infertility in a cohort of WWE who were anticipating pregnancy.Methods: A prospective cohort of WWE enrolled in the Kerala Registry of Epilepsy and Pregnancy (1998-2007) in the preconception stage. The endpoint was occurrence of pregnancy. They were divided into those who remained infertile (IG group) and those who had become pregnant during the follow-up period (FG).Results: Out of 375 women followed up for 1-10 years, 231 had pregnancy and 144 remained infertile (38.4%). Pregnancy occurred within 2 years of follow-up for most patients in the FG group. The IG group had higher mean age, lower education, and longer follow-up when compared to the FG group. Infertility was least (7.1%) for those with no antiepileptic drug (AED) exposure and higher (p = 0.001) with AED exposure (31.8% with 1 AED, 40.7% with 2 AED, and 60.3% with 3 or more AED exposure). Those exposed to phenobarbital had significant risk of infertility, but no such trend was observed with valproate or other drugs. On multiple logistic regression, use of 3 AEDs or more (odds ratio [OR] 17.9; 95% confidence interval [CI] 2.14-149.48), older age (OR 1.32; 95% CI 0.84-2.09), and low education (OR 2.91; 95% CI 1.82-4.65) remained as the important predictors of infertility.Conclusion: More than a third (38.4%) of WWE had infertility. The important predictors of infertility were exposure to multiple AEDs, older age, and lower education. Neurology (R) 2010;75:1351-1355Item Primary care doctors' management behavior with respect to epilepsy in Kerala, southern India(EPILEPSY & BEHAVIOR, 2011)Although a majority of persons with epilepsy in developing countries are diagnosed, treated, and followed up by primary care doctors, few efforts have been made to examine their understanding with respect to epilepsy management. Through a questionnaire survey, we gathered information about the epilepsy management behavior of 500 primary care doctors distributed across the south Indian state of Kerala. Very few of them ever had diagnosed focal seizures, and the majority of them overutilize EEGs, prescribe continuous antiepileptic drug (AED) prophylaxis for febrile convulsions, use relatively expensive AEDs often in combination and in suboptimal doses, and did not know about alternate management options for AED-resistant epilepsies. A substantial proportion of the current large treatment gap in epilepsy in developing countries could be minimized by educating the primary care physicians about the diagnosis of epileptic seizures, cost-effective AED treatment, and need-based referral for specialized care. (C) 2011 Elsevier Inc. All rights reserved.Item Risk factors for epilepsy: A population-based case-control study in Kerala, southern India(EPILEPSY & BEHAVIOR, 2009)We undertook a community-based case-control study on persons with active epilepsy residing in Kerala, southern India. Using a standardized questionnaire, we collected information from 362 cases and 362 controls. In the final multivariate model, family history of epilepsy (odds ratio = 7.8, 95% confidence interval = 3.2-18.8, P = 0.000), antecedent history of febrile seizures (7.7, 4.3-14.0, 0.000), birth by complicated delivery (6.8, 2.1-21.8. 0.001), and neonatal seizures (7.8, 1.7-35.4, 008) emerged as strong independent predictors of epilepsy, followed in decreasing order by mental retardation, prematurity, maternal age >= 30, perinatal distress, and incomplete immunization. There were more similarities than differences in the distribution of risk factors between generalized and localization-related epilepsy syndromes. Our findings suggest interplay between genetic and acquired factors in the pathogenesis of epilepsies, and underscore the need for improvement in obstetric and neonatal care to minimize the epilepsy burden in low-income countries. (c) 2009 Elsevier Inc. All rights reserved.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 Utility of susceptibility-weighted MRI in differentiating Parkinson's disease and atypical parkinsonism(NEURORADIOLOGY, 2010)Neuropathological studies report varying patterns of brain mineralization in Parkinson's diseases (PD), progressive supranuclear palsy (PSP), and Parkinson variant of multiple system atrophy (MSA-P). Susceptibility-weighted imaging (SWI) is the ideal magnetic resonance imaging (MRI) technique to detect mineralization of the brain. The purpose of this study was to test if SWI can differentiate PD, PSP, and MSA-P.Eleven patients with PD, 12 with PSP, 12 with MSA-P, and 11 healthy controls underwent SWI of the brain. Hypointensity of putamen, red nucleus, substantia nigra, and dentate nucleus in all groups were measured using an objective grading scale and scored from 0 to 3.In PSP, hypointensity score of red nucleus was higher than that in MSA-P (p = 0.001) and PD (p = 0.001), and a score of a parts per thousand yen2 differentiated the PSP group from the PD and MSA-P groups. Putaminal hypointensity score was higher in PSP when compared to that in PD (p = 0.003), and a score of a parts per thousand yen2 differentiated PSP from PD groups. SWI hypointensity scores of red nucleus and putamen had an excellent intrarater and interrater correlation. Substantia nigra hypointensity score of the PSP group was higher than that of the MSA-P (p = 0.004) and PD (p = 0.006) groups, but the scores had only a moderate intrarater and interrater correlation.SWI shows different patterns of brain mineralization in clinically diagnosed groups of PD, PSP, and MSA-P and may be considered as an additional MR protocol to help differentiate these conditions.Item Women with onset of epilepsy prior to marriage: Disclose or conceal?(EPILEPSIA, 2007)We inquired reasons for concealment/disclosure of the history of epilepsy during marriage negotiations and marriage outcomes of 82 consecutive women attending a tertiary referral center based epilepsy clinic in Kerala, southern India. At the time of marriage, 55% concealed and 45% disclosed the history of epilepsy. Majority of those who concealed admitted that they did so fearing breakup of marriage negotiations, and majority of those who disclosed did so to forestall the consequences after marriage of concealing. Compared to those who disclosed, the prevalence of divorce, separation and disturbed marriages were significantly higher among those who concealed. Honest prospective communication during marriage negotiations about epilepsy is important for preserving subsequent married life.