Revising the ICD-10 codes for epilepsy and seizures.

The World Health Organization is currently revising the International Classification of Disease, 10th Revision (ICD-10). A Neurology Task Force Advisory Group [TAG] has been charged with producing a revision that reflects scientific advances and new concepts of pathophysiology since 1992. The ICD codes are used globally to report mortality and morbidity statistics, and they play a vital role in health care planning, training, and allocation of health care resources in many countries. Although used by physicians and hospitals at all levels, the primary users of the ICD codes are primary health care providers, which, particularly in low income countries, include nurses, clinical assistants, and health officers. The TAG, which consists of representatives of major international subspecialty groups such as the International League Against Epilepsy (ILAE), has published draft codes that are available online for public comment.

Medically intractable temporal lobe epilepsy in patients with normal MRI: surgical outcome in twenty-one consecutive patients.

INTRODUCTION: Abnormal MRI findings localizing to the mesial temporal lobe predict a favorable outcome in temporal lobe epilepsy surgery. The purpose of this study is to summarize the surgical outcome of patients who underwent a tailored antero-temporal lobectomy (ATL) with normal 1.5 T MRI. Specifically, factors that may be associated with favorable post-surgical seizure outcome are evaluated. METHODS: A retrospective analysis of the Rush University Medical Center surgical epilepsy database between 1992 and 2003 was performed. Patients who underwent an ATL and had a normal MRI study documented with normal volumetric measurements of hippocampal formations and the absence of any other MRI abnormality were selected for this study. Demographic information was collected on all patients. Seizure outcomes were evaluated using Engel's classification. A two-sided Fisher exact test with Bonferroni correction was performed in statistical analyses. RESULTS: Twenty-one (21) patients met the inclusion criteria of normal 1.5 T MRI and underwent a tailored temporal lobectomy. Mean age at time of surgery was 28 years (SD=8.1, range 11-44) and mean duration of the seizure disorder was 13.4 years (range 2-36). Risk factors for epilepsy included head injury (n=4), encephalitis (n=3), febrile seizures (n=2), and 12 patients had no risk factors. Pathological evaluation of resected tissue revealed no abnormal pathology in 12/21 patients (57%). After a mean 4.8 years follow-up post-surgical period, 15/21 (71%) patients were free of disabling seizures (Engel I outcome). At 8.3 years follow-up, 13/21 (62%) patients had similar results. Absence of prior epilepsy risk factors was the only statistically significant predictor of an Engel class I outcome (p<0.0022). CONCLUSION: Patients with medically intractable epilepsy and normal MRI appear to benefit from epilepsy surgery. Absence of prior epilepsy risk factors may be a positive prognostic factor.

Intractable epilepsy in patients treated for childhood acute lymphocytic leukemia.

PURPOSE: In the 1970s and 80s, standard treatment for childhood acute lymphocytic leukemia (ALL) included both intrathecal methotrexate and whole-brain irradiation. During acute treatment, seizures were not uncommon. The development of intractable epilepsy years after treatment, however, has not been well described in the literature. We describe five patients who were treated for acute lymphocytic leukemia as children, who later developed intractable epilepsy. RESULTS: All of the patients were diagnosed with leukemia before age seven. Treatment included both whole-brain irradiation and intrathecal chemotherapy. All five received intrathecal methotrexate; in addition, two also received intrathecal cytosine arabinoside. The first seizure occurred at a mean of 7.5 years after diagnosis. Four patients have multiple seizure types, and all patients have been on multiple antiepileptic drugs. All five patients are cognitively impaired. CONCLUSIONS: Successful treatment for childhood leukemia may be followed by signs of late cerebral injury including intractable epilepsy. We propose that neurotoxicity resulting from exposure to intrathecal methotrexate and cranial irradiation may have contributed to the intractable epilepsy seen in our five patients.

Effects of poverty on cognitive function: a hidden neurologic epidemic.

Mental retardation is one of the most prevalent neurologic disorders globally. Surveys in high-income countries show 3 to 5 per 1,000 with severe intellectual disability, i.e., IQ below 55. Estimates from developing countries, however, have found prevalence rates from 5 to as much as 22 per 1,000. Protein-energy malnutrition, dietary micronutrient deficiencies, environmental toxins, and lack of early sensory stimulation or the ability to profit from it may contribute to neurodevelopmental disabilities. Tropical diseases such as parasitosis with resultant anemia, malaria, and other infections are major contributory causes. Reduction of poverty and its effects would reduce the present and future burden of mental retardation and cognitive dysfunction, especially in developing countries.

Postmortem study of deep brain stimulation of the anterior thalamus: case report.

OBJECTIVE: As new clinical applications for deep brain stimulation (DBS) emerge and the number of patients with DBS systems continues to grow, lead technology will also advance. To direct improvement of these leads, improved understanding of the effects of the DBS electrodes and stimulation parameters on the surrounding brain parenchyma is necessary. We present a postmortem evaluation of a patient who had previously undergone bilateral DBS of the anterior thalamic nucleus. CLINICAL PRESENTATION: A 21-year-old, right-handed man with a 2-year history of epilepsy secondary to encephalitis underwent bilateral DBS of the anterior nucleus of the thalamus. He died 8 months after surgery, and his death was classified as a sudden, unexpected, unexplained death as a result of epilepsy. INTERVENTION: Microscopic examination and immunohistochemical analysis using glial fibrillary acidic protein, CD11b, CD45, and CD 68 were performed. The thalami of this patient were then compared with brain tissue obtained from a 45-year-old patient who died as a result of a myocardial infarction and had no history of neurological disease and no surgical intervention. There were no differences in the microscopic and histochemical evaluation of the thalami between patients, other than immediately around the electrode tract. Minimal tissue damage, mild astrocytosis, and mild inflammation surrounding the electrode termination site were observed. CONCLUSION: We report the first postmortem examination after bilateral DBS of the anterior nucleus of the thalamus for epilepsy. A comparison with control tissue showed no significant difference other than mild inflammation along the lead track.

Epidural cylinder electrodes for presurgical evaluation of intractable epilepsy: technical note.

BACKGROUND: This is a technical report describing a different technique for the insertion of epidural electrodes in the preoperative evaluation of epilepsy surgery. Our experience in 67 cases using this technique is analyzed. METHODS: Cylinder electrodes with multiple recording nodes spaced 1 cm apart along a Silastic core are placed into the epidural space under general anesthesia through single or multiple burr holes. We reviewed the data on 67 cases of medically intractable epilepsy requiring intracranial monitoring that had epidural cylinder electrodes placed. The electrodes were placed bilaterally or contralateral to subdural grids in 64 of the 67 cases. Continuous monitoring was performed from 1 to 3 weeks. RESULTS: This method was most useful when used bilaterally or contralateral to subdural grids. Definitive surgery was rendered in 48 of 67 cases. After monitoring, all electrodes were removed at bedside or upon return to the operating room for definitive surgery. There were no mortalities, infections, cerebrospinal fluid leaks, neurologic deficits, or electrode malfunctions. Two patients (2/67, 3%) did develop subdural hematomas early in our series after dural injury near the pterion; however, these patients did not sustain permanent deficit. CONCLUSIONS: Epidural cylinders are another option for preoperative monitoring, useful for determining lobe or laterality of seizure genesis. They offer an alternate method to EPEs in cases where epidural recording is desirable. The cylinder electrodes are easy to place and can be removed without a return to the operating theater. The electrodes' minimal mass effect allows them to be safely placed bilaterally or contralateral to subdural grids. The epidural cylinders can monitor cortex with a greater density of nodes and can access regions not amenable to EPEs.

Neurology training programs worldwide: a world federation of neurology survey.

This World Federation of Neurology (WFN) project was aimed at collecting data about the number and nature of neurology residency programs in different countries. A survey was sent to delegates from the neurology societies belonging to the World Federation of Neurology. Over 6200 physicians graduating from neurology training programs each year were identified. Many regions of the world, including those with the highest prevalence of disorders of the nervous system, have few or no post-graduate neurology training programs. Adequate teaching in psychiatry, neuroradiology, and neuropathology is lacking in many programs. Training in a large number of countries is hampered by inadequate access to books, journals, and the internet. The global distribution of postgraduate neurology training programs is unrelated equally to the burden of neurological diseases or to the need for their treatment and prevention.

Nervous system disorders: a global epidemic.

Major new epidemiological analyses are focusing attention on disorders of the nervous system as important causes of death and disability around the world. One in every 9 individuals dies of a disorder of the nervous system. Stroke outweighs all other neurological disorders combined as a cause of mortality. Most disorders of the nervous system occur in developing countries. Developmental disability due to malnutrition, and cognitive dysfunction associated with parasitic infections are the most common neurological disorders. As the world's population ages and the effects of infectious disease decline, the relative effects of many disorders of the nervous system, including stroke and dementia, are increasing. The disorders of the nervous system causing the highest rates of death and disability are preventable and treatable. Increased awareness of the global effects of neurological disorders should help health care planners and the neurological community set appropriate priorities in research, prevention, and management of these conditions.