Feasibility of Tailored Unilateral Disconnection vs Callosotomy for Refractory Epilepsy in Patients with Bilateral Parieto-Occipital Gliosis Following Perinatal Insult.

Background: Patients with perinatal hypoxia (PH) and drug-refractory epilepsy (DRE) often have bilateral parieto-occipital gliosis. Surgical management of such patients is a dilemma. Objective: To identify preoperative determinants for unilateral disconnection vs callosotomy, and analyze the surgical outcome in such patients. Methods and Material: This was a retrospective analysis of patients with DRE and history of PH, with MRI abnormalities restricted to bilateral posterior quadrants. Preoperative semiology, epilepsy duration and seizure frequency were recorded. Based on the concordance between the results of non-invasive tests, patients underwent either posterior quadrant disconnection (PQD) or corpus callosotomy (CC). Preoperative variables were analyzed and corelated to the postoperative seizure freedom. Results: Fourteen patients were identified, 6 underwent PQD and 8 underwent CC. At follow up of 39.17 ± 23.75 months, 66.66% of patients (4/6) in the PQD subgroup had an ILAE Class I outcome. While none in the CC group attained seizure freedom, 87.5% (7/8) had more than 50% reduction in seizure frequency (follow up: 42 ± 27.31 months). Patients with a poor outcome had significantly greater seizure frequency (P = 0.05) and history of drop attacks (P = 0.04) in both the groups. Magnetoencephalography (MEG) accurately localized the epileptogenic zone in all of the patients with good outcome (P = 0.015). Concordance with single photon emission tomography (SPECT) was also a predictor of favorable outcome (P = 0.041). Conclusions: A history of drop attacks with high seizure frequency is associated with poor postoperative seizure outcome. Unilateral PQD is feasible and leads to superior seizure-free outcomes, even in cases with widespread and bilateral imaging and electrical abnormalities, provided the other preoperative investigations are concordant in localizing the epileptogenic zone.

Robotic thermocoagulative hemispherotomy: concept, feasibility, outcomes, and safety of a new "bloodless" technique.

OBJECTIVE: The authors present a new "bloodless" technique for minimally invasive robotic thermocoagulative hemispherotomy (ROTCH). Such a method is being described in the literature for the first time. METHODS: A robotic system was used to plan five sets of different trajectories: anterior disconnection, middle disconnection, posterior disconnection, corpus callosotomy, and temporal stem and amygdalar disconnection. A special technique, called the "X" technique, allowed planar disconnection. Registration was performed with surface landmarks (n = 5) and bone fiducials (n = 1). Coregistration with O-arm images was performed one or two times to confirm the trajectories (once for middle disconnection, and once for disconnection of the temporal stem and amygdala or body of the corpus callosum). Impedance measured before ablation allowed for minor adjustments. Radiofrequency ablation was performed at 75°C-80°C for 60 seconds. Surgical procedures were performed with multiple twist drills. After removal of the electrode, glue was used to prevent CSF leak, and a single stitch was applied. Follow-up CT and MRI were immediately performed. RESULTS: The pathologies included Rasmussen's encephalitis (n = 2), hemispheric cortical dysplasia (n = 2), posttraumatic encephalomalacia (n = 1), and perinatal insult (n = 1). The mean ± SD (range) age was 6.7 ± 3.6 years (5 months to 10.2 years), and the right side was affected in 4 patients. The mean ± SD seizure frequency was 7.4 ± 5.6 seizures per day (1 patient had epilepsia partialis continua). The mean ± SD number of trajectories was 15.3 ± 2.5, and the mean ± SD number of lesions was 108 ± 25.8. The mean ± SD maximum numbers of trajectories and lesions required for middle disconnection were 7.1 ± 1.7 and 57.5 ± 18.4, respectively. All but 1 patient had class 1 outcomes according to the International League Against Epilepsy Outcome Scale at a mean ± SD (range) follow-up of 13.5 ± 1.6 (12-16) months; the remaining patient had a class 2 outcome. The estimated blood loss was < 5 ml for all patients. Complications included repeat surgery (after 2 weeks) for a "skip" area (n = 1) and a small temporal hematoma (n = 1), which resolved. CONCLUSIONS: ROTCH seems to be a safe, feasible, and bloodless procedure, with a very low morbidity rate and promising outcomes.

Autologous intravenous bone marrow mononuclear cell therapy for patients with subacute ischaemic stroke: a pilot study.

BACKGROUND & OBJECTIVES: Bone marrow mononuclear cell therapy has emerged as one of the option for the treatment of Stroke. Several preclinical studies have shown that the treatment with mononuclear cell (MNCs) can reduce the infarct size and improve the functional outcome. We evaluated the feasibility, safety and clinical outcome of administering bone marrow mononuclear cell (MNCs) intravenously to patients with subacute ischaemic stroke. METHODS: In a non-randomized phase-I clinical study, 11 consecutive, eligible and consenting patients, aged 30-70 yr with ischaemic stroke involving anterior circulation within 7 to 30 days of onset of stroke were included. Bone marrow was aspirated from iliac crest and the harvested mononuclear cells were infused into antecubital vein. Outcomes measured for safety included immediate reactions after cell infusion and evidence of tumour formation at one year in whole body PET scan. Patients were followed at week 1, 4-6, 24 and 52 to determine clinical progress using National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), modified Rankin Scale (mRS), MRI, EEG and PET. Feasibility outcomes included target-dose feasibility. Favourable clinical outcome was defined as mRS score of 2 or less or BI score of 75 to 100 at six months after stem cell therapy. RESULTS: Between September 2006 and April 2007, 11 patients were infused with bone-marrow mononuclear cells (mean 80 million with CD-34 + mean 0.92 million). Protocol was target-dose feasible in 9 patients (82%). FDG-PET scan at 24 and 52 wk in nine patients did not reveal evidence of tumour formation. Seven patients had favourable clinical outcome. INTERPRETATION & CONCLUSIONS: Intravenous bone marrow mononuclear cell therapy appears feasible and safe in patients with subacute ischaemic stroke. Further, a randomized controlled trial to examine its efficacy is being conducted.

Mobilization of Stem Cells Using G-CSF for Acute Ischemic Stroke: A Randomized Controlled, Pilot Study.

Background. There is emerging evidence to support the use of granulocyte colony-stimulating factor (G-CSF) therapy in patients with acute ischemic stroke. Aims. To explore feasibility, safety, and preliminary efficacy of G-CSF therapy in patients with acute ischemic stroke. Patients and Method. In randomized study, 10 patients with acute ischemic stroke were recruited in 1 : 1 ratio to receive 10 µg/kg G-CSF treatment subcutaneously daily for five days with conventional care or conventional treatment alone. Efficacy outcome measures were assessed at baseline, one month, and after six months of treatment included Barthel Index (BI), National Institute of Health Stroke Scale, and modified Rankin Scale. Results. One patient in G-CSF therapy arm died due to raised intracranial pressure. No severe adverse effects were seen in rest of patients receiving G-CSF therapy arm or control arm. No statistically significant difference between intervention and control was observed in any of the scores though a trend of higher improvement of BI score is seen in the intervention group. Conclusion. Although this study did not have power to examine efficacy, it provides preliminary evidence of potential safety, feasibility, and tolerability of G-CSF therapy. Further studies need to be done on a large sample to confirm the results.

Surgery for medically intractable epilepsy due to postinfectious etiologies.

Medically intractable epilepsy (MIE) resulting from postinfectious etiologies requiring surgery have been uncommonly reported. A series of 28 cases are presented (hospital prevalence 5.7%). The mean duration of epilepsy prior to surgery was 8.2 +/- 2.1 years. The mean time of onset of epilepsy after central nervous system infection was 1.4 +/- 0.9 years (range 0-19 years). The pathologies included postpyogenic meningitic/encephalitic sequel (8), neurocysticercosis (6), tuberculomas/posttuberculous etiology (4), postpyogenic abscess of otogenic etiology (4), posttraumatic abscess-related gliosis (2), and gliosis of unknown infectious etiology (4) cases. Surgery included mesial temporal (11), lateral temporal (4), frontal (9), parietal (2) resections and hemispherotomy (1). Hippocampal sclerosis was seen in nine cases (4 neurocysticercosis) and this occurred in younger persons as compared to neocortical epilepsies. Good outcome (Engel class I and II) was seen in 23 of 28 cases (Engel class I in 17).

Laparascopic cholecystectomy: cystic duct occlusion with titanium clips or ligature? A prospective randomized study.

During laparoscopic cholecystectomy (LC), cystic duct occlusion can be done with titanium clips or laparoscopically tied knots. However, till date, there is no randomized, controlled study reported in the literature that has prospectively compared the outcome using either of these methods. In the present study, 105 patients who were to undergo LC were randomly assigned to two groups. Group I comprised patients undergoing cystic duct occlusion with clips while group II comprised those undergoing cystic duct occlusion with knots. Our aim was to compare the postoperative outcome in both the cases. The incidence of overall bile leak following LC was 4 out of 105 (3.8%) while the leak rate following cystic duct occlusion with clips was 2 out 52 (3.9%), and that following ligature was 2 out of 53 (3.8%). The procedure using ligature took slightly longer time than that using clips. There was no significant difference in the postoperative outcome in either group. The use of ligature is a feasible, safe and cost-effective alternative to the use of titanium clips for cystic duct occlusion during LC.