Surgical Outcome of Pharmaco Refractory Epilepsy in the National Epilepsy Center of Sri Lanka.

BACKGROUND: The National Epilepsy Center (NEC) in Sri Lanka was established in 2017. Seizure outcome, effects on quality of life (QOL) and surgical complications among nonpediatric patients who underwent epilepsy surgery from October 2017 to February 2023 are described. METHODS: Nineteen patients (≥14 years) underwent epilepsy surgery at the NEC. We used Engel classification and Quality of Life in Epilepsy 31 (QOLIE-31) questionnaire to assess seizure outcome and QOL respectively. Surgical complications were categorized into neurological and complications related to surgery. RESULTS: Nine female and 10 male patients underwent surgery (mean age 27.5 years (range 14-44 years). The mean follow-up duration was 10.5 months (range 6-55 months). Twelve patients underwent temporal lobe resections. At 6-months follow-up, 83.3% (10/12) had favorable seizure outcomes with Engel class I/II. At 1-year follow-up 6/8 patients (75.0%) and at 2-year follow-up, 5/7 patients (71.4%) had a favorable outcome. Seven patients had extra-temporal lobe surgeries and one defaulted. Seizure freedom was observed in 6/6 at 6 months, 3/3 at 1-year, and 2/2 at 2-year follow-up. Five patients (26.3%) experienced minor post-operative surgical site infection. Two (11.1%) had persistent quadrantanopia. Meaningful improvement in QOL (change in QOLIE-31 score ≥11.8) was observed irrespective of seizure outcome or type of surgery (P < 0.001). CONCLUSIONS: Epilepsy surgery is effective in developing countries. Seizure outcomes in our patients are comparable to those worldwide. Clinically important QOL improvement was observed in our series. This is the first published data on epilepsy surgery outcomes in nonpediatric patients from Sri Lanka.

Recurrent intramedullary endometriosis of the conus medullaris: A case report of diagnostic pitfalls and a review of literature.

INTRODUCTION: Endometriosis is a common gynaecologcial disorder and is characterized by the presence and implantation of endometrial epithelium and glandular stroma in an extrauterine location Intraspinal endometriosis can involve the intramedullary, subarachnoid, intradural-extramedullary, and extradural compartments, including the vertebral bodies. Symptoms due to intraspinal endometriosis will vary depending on the location and degree of compression of neural structures and will fluctuate with the menstrual cycle. PRESENTATION OF CASE: A 20-year-old Sri Lankan female with recurrent catamenial backpain, presented to the neurosurgical clinic with acute cauda equina syndrome. She had a history of cyclical lower back pain and lower limb radiculopathy and had undergone spinal decompression and excision of a haemorrhagic cyst in the conus medullaris on three occasions over the past three years. Clinical, radiological and histological discordance meant that the diagnosis of intraspinal endometriosis was missed previously. She underwent repeat spinal decompression on this occasion with histology confirming an endometrial cyst. DISCUSSION: Intramedullary spinal cord haematomas are rarely encountered in neurosurgery. Vascular or neoplastic causes are common with endometriosis being extremely rare. The lack of clinical suspicion, radiological imaging supporting an alternate diagnosis, along with lack of histological confirmation led to the initial diagnostic dilemma and delays in starting long term endometrial suppression therapy. CONCLUSION: Intraspinal endometriosis is a rare but important differential diagnosis in the evaluation of a female in the reproductive age group with cyclical lower back pain and neurological symptoms. One must have a high degree of suspicion regarding it, in order to prevent protracted morbidity.

Air rifle wound to the chest and pellet embolism to the intracranial internal carotid artery with a middle cerebral artery territory infarct: A case report and review of literature.

INTRODUCTION: Traumatic embolization of pellets into the cerebral circulation is a rare complication following gunshot wounds to the neck, chest and abdomen. Foreign bodies enter the circulation from early direct puncture or delayed erosion of an artery or vein or directly through the heart. PRESENTATION OF CASE: A previously well 13-year-old Sri Lankan boy who presented 2 h following an air rifle injury to the lower sternum with chest pain, developed seizures and left hemiparesis. Contrast CT angiogram showed the pellet at the base of the skull at the right carotid canal, with a middle cerebral artery (MCA) thrombus and evidence of MCA infarction. Decompressive craniectomy was performed. Cerebral angiography confirmed complete occlusion of the intracranial internal carotid artery (ICA) by the pellet, without cross circulation from the left ICA. Attempts at endovascular pellet retrieval failed. Open pellet embolectomy was not performed and the patient was managed conservatively. DISCUSSION & CONCLUSION: Air rifle injury to the chest causing pellet embolism from the left ventricle to the right intracranial ICA with associated right MCA thrombus is a rare phenomenon. Missile embolism must be suspected when neurological findings are not in concordance with the site of injury especially in the absence of an exit wound and an inability to locate the pellet in the vicinity of the entry wound. Radiographs, CT and cerebral angiography are indicated to locate the pellet and associated injuries. The decision on surgical embolectomy, endovascular retrieval or expectant management is an individualized decision dependent on many factors.

Removal of a low clival chordoma in a teenager by dorsolateral suboccipital transcondylar approach.

Chordomas are rare midline tumors of the central nervous system which arise from the remnants of the primitive notochord and have unique diagnostic and management challenges. Although recommended treatment for chordoma is radical resection, this may require extended skull base approaches. We report a case of low clival chordoma in a teenage patient which was successfully treated by dorsolateral suboccipital transcondylar approach.