Cost-Utility of Video-Electroencephalography Monitoring Followed by Surgery in Adults with Drug-Resistant Focal Epilepsy in Thailand.

OBJECTIVES: This study assessed whether video-electroencephalography (VEEG) monitoring followed by surgery was cost-effective in adult patients with drug-resistant focal epilepsy under Thai health care context, as compared with continued medical treatment without VEEG. METHODS: The total cost (in Thai Baht, THB) and effectiveness (in quality-adjusted life years, QALYs) were estimated over a lifetime horizon, using a decision tree and a Markov model. Data on short-term surgical outcomes, direct health care costs, and utilities were collected from Thai patients in a specialized hospital. Long-term outcomes and relative effectiveness of the surgery over medical treatment were derived, using systematic reviews of published literature. RESULTS: Seizure-free rates at years 1 and 2 after surgery were 79.4% and 77.8%, respectively. Costs of VEEG and surgery plus 1-year follow-up care were 216,782 THB, of which the VEEG and other necessary investigations were the main cost drivers (42.8%). On the basis of societal perspective, the total cost over a 40-year horizon accrued to 1,168,679 THB for the VEEG option, 64,939 THB higher than that for no VEEG. The VEEG option contributed to an additional 1.50 QALYs over no VEEG, resulting in an incremental cost-effectiveness ratio of 43,251 THB (USD 1236) per 1 QALY gained. Changes in key parameters had a minimal impact on the incremental cost-effectiveness ratio. Accounting for uncertainty, there was an 84% probability that the VEEG option was cost-effective on the basis of Thailand's cost-effective threshold of 160,000 THB/QALY. CONCLUSIONS: For patients with drug-resistant epilepsy, VEEG monitoring followed by epilepsy surgery was cost-effective in Thailand. Therefore it should be recommended for health insurance coverage.

Outcomes after temporal lobectomy for temporal lobe epilepsy with hippocampal sclerosis.

OBJECTIVE: Outcome predictors from the pure cohorts of patients with temporal lobe epilepsy (TLE) with hippocampal sclerosis (HS) are limited The aim of the present study was to assess seizure outcomes and predictive factors in groups of well-defined patients with TLE-HS. MATERIAL AND METHOD: One hundred forty eight patients with drug resistant TLE who had magnetic resonance imaging (MRI) that demonstrated unilateral HS underwent temporal lobectomy between 2004 and 2008 by a single neurosurgeon. All patients had completed at least two years of follow-up. Seizure outcome was categorized into seizure-free and not seizure-free. RESULTS: Ninety-five patients (64.2%) were seizure-free after surgery at two years of follow-up. At four years follow-up, 47 patients (77.1%) were seizure-free for at least two years. There was no operative mortality or significant morbidity. No clinical variables are predictive of surgical outcomes at two and four years offollow-up. CONCLUSION: Temporal lobectomy for drug-resistant TLE with HS is safe and effective. The authors did not identify predictive factors of surgical outcomes in TLE-HS.

Outcome of temporal lobectomy for hippocampal sclerosis in older patients.

Patients of 50 years or older account for a small but significant portion of the patient population that receives surgical treatment for epilepsy. There have been few studies reporting surgical outcomes from temporal lobectomy in older patients. We examined seizure outcome and surgical complications after anterior temporal lobectomy for temporal lobe epilepsy with pathological evidence of unilateral hippocampal sclerosis. Two patient groups were compared in this study: patients 50 years or older (mean age 55.5 years old, n=16) and patients less than 50 years old (mean age 32.9 years old, n=184). After a minimum of one year follow up, younger patients (79.4%, n=146) were significantly more likely to be seizure-free (p=0.041) compared to older patients (56.3%, n=9). There was no significant difference (p=0.404) between the two age groups in the percentage of patients withdrawn from medication following surgery. Surgical complications were significantly higher in the older age group compared to the younger age group (p=0.009), although there was no permanent morbidity. Thus, while surgical treatment of temporal lobe epilepsy with unilateral hippocampal sclerosis is still beneficial in older patients who are refractory to medical therapy, surgical treatment should be considered at as early an age as possible, to maximize the chance for a better outcome with fewer complications.

Frameless stereotactic for deep brain stimulation placement: operative technique.

Deep brain stimulation (DBS) has been shown to be a safe and effective method for the treatment of refractory Parkinson's disease and other movement disorders. Traditionally, frame-based stereotactic have been the standard technique commonly used for DBS surgery. With the development of image-guided neurosurgical systems, frameless stereotactic has been increasingly used for tumor resection or biopsy without the use of stereotactic frame. Frameless stereotactic for functional surgery has been recently developed with the accuracy comparable to frame-based stereotactic surgery. The authors report the surgical technique of frameless functional stereotactic for the treatment of movement disorders.

Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of two cases.

Hemorrhage occurring at regions remote from the operative site is an infrequent complication. Although the mechanism remains unclear, previous reports implicate over drainage of cerebrospinal fluid as the predominant mechanism. The authors report two cases of cerebellar hemorrhage after supratentorial surgery. Two young patients underwent left hemispherectomy and fronto-temporal resection for the treatment of refractory hemispheric and multiregional epilepsy. The hemorrhage manifested early in the immediate postoperative period as delayed awakening. The diagnosis was established by computed tomography. Treatment consisted in external ventricular drainage in case 1 and conservative treatment in case 2. Both patients recovered without major neurological deficits. Early detection and awareness of this complication may help to avoid further neurological morbidity and mortality.

Long-term seizure outcome in reoperation after failure of epilepsy surgery.

OBJECTIVE: Treatment of patients who fail epilepsy surgery is problematic. Selected patients may be candidates for further surgery, potentially leading to a significant decrease in the frequency and severity of seizures. We present our long-term outcome series of highly investigated patients who failed resective epilepsy surgery and subsequently underwent reoperative resective procedures. METHODS: We performed a retrospective consecutive analysis of patients who underwent reoperative procedures because of medically intractable epilepsy at our institution from 1990 to 2001. Seventy patients underwent reoperative epilepsy surgery, with 57 patients having a minimum follow-up period of 2 years. We assessed the relationship between seizure outcome and categorical variables using chi2 and Fisher's exact tests, and the relationship between outcome and continuous variables using a Wilcoxon rank-sum test. Statistical significance was set at a P value of 0.05. RESULTS: Of the 57 patients (29 male and 28 female patients), the age of seizure onset ranged from 3 months to 39 years (mean, 10.7 +/- 10.3 yr; median, 7 yr). The mean age at reoperation was 24.7 +/- 12 years (range, 4-50 yr). The interval between first and second resection was 7 days to 16 years. The follow-up period ranged from 24 to 228 months (mean, 128 mo; mode, 132 mo). Seizure outcome was classified according to Engel's classification. Fifty-two percent of the patients had a favorable outcome (38.6% were Class I and 14.0% were Class II). Patients with tumors as their initial pathology had better outcome compared with patients with focal cortical dysplasia and mesial temporal sclerosis (P < 0.05). CONCLUSION: Reoperation should be considered in selected patients failing epilepsy resective surgery because approximately 50% of patients may have benefit. Patients with cortical dysplasia and mesial temporal sclerosis are less likely to improve after reoperation.

The first invasive EEG monitoring for surgical treatment of epilepsy in Thailand.

The authors report the first invasive electroencephalography (EEG) monitoring in Thailand in a patient who had intractable left temporal lobe epilepsy. The seizure origin and functioning cortices were identified The corresponding epileptogenic zone was resected without functional deficit. The patient has become seizure free 1 year since surgery. Subdural EEG monitoring with cortical stimulation have been developed at this tertiary epilepsy center The technique provides essential evidence for the surgical decision so that the best post operative outcome can be achieved.

Quality of life after successful epilepsy surgery: evaluation by occupational achievement and income acquisition.

OBJECTIVES: A comprehensive epilepsy surgery program has been developed at Chulalongkorn University Hospital, Thailand to reach an international standard level, rendering patients good surgical outcomes comparable to developed countries. After successful operation, seizure free patients have become independent, self earning or employed. However, quality of life (QOL) in terms of occupational achievement and income acquisition after epilepsy surgery has never been studied. These indicators reflect the ultimate QOL in the aspects of actual independency, intact brain functions, mental health and psycho-social interactions. The authors therefore conduct the study on improvement of QOL after successful epilepsy surgery using these parameters. MATERIAL AND METHOD: One hundred and eleven intractable epilepsy who have become seizure free to worthwhile improved (Engel class I to III) after standard presurgical evaluation and epilepsy surgery from January 2002 to December 2004 were evaluated. The patients were followed up for 3 years. The occupational status and incomes were categorized according to the ranking of the patients' functioning levels. The pre and post surgery work abilities, employment and incomes were interviewed and compared. Mc Nemar test and paired t-test were used for statistical analyses. RESULTS: The average age of the 111 adults (54 males and 57 females) was 33.7 +/- 9.2 years. Eighty two percent of the patients had temporal lobe epilepsy (TLE) with mesial temporal sclerosis (MTS) and underwent standard anterior temporal lobectomy. The rest had tumors, cortical dysplasia or scar and received lesionectomy or cortical resection assisted by intra-operative or intra-cranial EEG. The overall seizure free rate is 83.8%. The occupational status of the subjects was shown to improve significantly after surgery from unemployed to higher categories of professional achievement (p < 0.001). The number of unemployed and no income individuals decreased from 66 to 25 cases (62.1% reduction rate) after surgery (p < 0. 001). Reciprocally, the number of persons who achieved professional jobs with regular incomes or salaries increase from 30 to 53 cases (43.4% increasing rate) (p < 0.001). The patients who have not acquired any income increment showed improvement in working ability after epilepsy surgery. The average annual incomes per capita shows the increasing rate of 45.08%, from 55,657.85 Baht (approximately U.S. dollars 1390) to 80,748.15 Baht (approximately U.S. dollars 2018), with strong statistical significance (p < 0.001). The improvement is best seen in seizure free than in non-seizure free subjects. CONCLUSION: The present study, to the authors 'knowledge, is the first to use work abilities, professional achievement and income acquisition to assess the ultimate QOL after epilepsy surgery. Most subjects have been shown to significantly improve their postoperative lives in terms of occupational accomplishment and income increment, especially in seizure free individuals. The need for expansion of epilepsy surgery is emphasized.

Failure of gamma knife radiosurgery for mesial temporal lobe epilepsy: report of five cases.

OBJECTIVE: We sought to determine the efficacy of gamma knife radiosurgery (GKRS) in controlling mesial temporal lobe epilepsy. METHODS: From August 1999 to January 2001, five patients with drug-resistant mesial temporal lobe epilepsy due to hippocampal sclerosis underwent GKRS amygdalohippocampectomy. All of the patients underwent standard epilepsy preoperative evaluation at the comprehensive epilepsy center of the Cleveland Clinic Foundation. A marginal dose of 20 Gy to the 50% isodose line was delivered to the mesial temporal structures in all patients. Postoperative follow-up included serial neurological examinations, neuroimaging studies, and neuropsychological evaluations. RESULTS: None of the patients were seizure-free after GKRS. Two patients died, 1 month and 1 year after the procedure, as a result of complications related to recurrent seizures. At 1 year, T2-weighted magnetic resonance imaging changes were noted in all three patients, which suggested radiational changes. None of the three surviving patients had any seizure reduction, so 18, 20, and 22 months after GKRS, they underwent temporal lobectomy, which resulted in complete seizure control in all patients. CONCLUSION: GKRS at the 20-Gy dose level did not lead to seizure control in patients with mesial temporal lobe epilepsy due to hippocampal sclerosis.

Seizure outcome after temporal lobectomy in temporal lobe cortical dysplasia.

PURPOSE: To identify the temporal lobe cortical dysplasia (CD) histopathology classification subtype and determine the seizure outcome of patients who underwent temporal lobectomy with coincident CD. METHODS: We reviewed the data of 28 patients with temporal lobe epilepsy who underwent surgery with pathologically verified CD at our institution from 1990 to 2000. The seizure outcome was assessed at a minimum of 1 year after surgery according to Engel's classification. RESULTS: Of 28 patients who underwent surgery, nine (32.1%) had isolated CD, and 19 (67.9%) had CD and hippocampal sclerosis (CD&HS). Twenty-six (92.9%) patients had histopathology subtype Ia (architectural abnormalities). Twenty (71.4%) patients were seizure free (Engel class I). Favorable seizure outcome (Engel class I, II) was achieved in 26 (92.9%) patients. No difference in seizure outcome was noted between patients with CD and CD&HS. CONCLUSIONS: The most common histopathologic subtype in patients with temporal lobe CD is type Ia (architectural abnormalities). Temporal lobectomy in temporal lobe epilepsy patients with CD can achieve favorable seizure outcome.