Outcome of epilepsy surgery in lesional epilepsy: Experiences from a developing country.

BACKGROUND: Our aim was to report the postoperative seizure outcome and associated factors in patients with lesional epilepsy, in a low-income setting. METHODS: This longitudinal prospective study included patients who underwent epilepsy surgery at Kashani Comprehensive Epilepsy Center between 2014 and 2019. Post-surgical outcomes were reported according to the Engel score, and patients were classified into two groups of seizure free (SF) and not-seizure free (NSF). RESULTS: A total of 148 adult patients, with a mean age of 30.45 ±â€¯9.23 years were included. The SF outcome was reported in 86.5% of patients and antiepileptic drugs (AEDs) were reduced or discontinued in 45.9%. The mean follow-up duration was 26.7 ±â€¯14.9 months. Temporal lobe lesions (76.3%) and mesial temporal sclerosis (MTS) (56.7%) were the most frequent etiologies. Temporal lesion (Incidence relative risk (IRR): 1.76, 95% CI [1.08-2.87], p = 0.023), prior history of CNS infection (IRR:1.18, 95% CI [1.03-1.35], p = 0.019), use of intra-operative ECoG (IRR:1.73, 95% CI [1.06-2.81], p = 0.028), and absence of IEDs in postoperative EEG (IRR: 1.41, 95% CI [1.18-1.70], p < 0.001) were positive predictors for a favorable outcome. CONCLUSION: Many patients with drug-resistant lesional epilepsy showed a favorable response to surgery. We believe that resective epilepsy surgery in low-income settings is a major treatment option. The high frequency of patients with drug-resistant epilepsy in developing countries is associated with high rates of morbidity and mortality. Hence, strategies to increase access to epilepsy surgery in these settings are urgently needed.

Risk factors associated with intensive care unit (ICU) admission and in-hospital death among adults hospitalized with COVID-19: a two-center retrospective observational study in tertiary care hospitals.

BACKGROUND: The COVID-19 pandemic is straining the health care systems worldwide. Therefore, health systems should make strategic shifts to ensure that limited resources provide the highest benefit for COVID-19 patients. OBJECTIVE: This study aimed to describe the risk factors associated with poor in-hospital outcomes to help clinicians make better patient care decisions. MATERIAL AND METHODS: This retrospective observational study enrolled 176 laboratory-confirmed COVID-19 patients. Demographic characteristics, clinical data, lymphocyte count, CT imaging findings on admission, and clinical outcomes were collected and compared. Two radiologists evaluated the distribution and CT features of the lesions and also scored the extent of lung involvement. The receiver operating characteristic (ROC) curve was used to determine the optimum cutoff point for possible effective variables on patients' outcomes. Multivariable logistic regression models were used to determine the risk factors associated with ICU admission and in-hospital death. RESULT: Thirty-eight (21.5%) patients were either died or admitted to ICU from a total of 176 enrolled ones. The mean age of the patients was 57.5 ± 16.1 years (males: 61%). The best cutoff point for predicting poor outcomes based on age, CT score, and O2 saturation was 60 years (sensitivity: 71%, specificity: 62%), 10.5 (sensitivity: 73%, specificity: 58%), and 90.5% (sensitivity: 73%, specificity: 59%), respectively. CT score cutoff point was rounded to 11 since this score contains only integer numbers. Multivariable-adjusted regression models revealed that ages of ≥ 60 years, CT score of ≥ 11, and O2 saturation of ≤ 90.5% were associated with higher worse outcomes among study population (odds ratio (OR): 3.62, 95%CI: 1.35-9.67, P = 0.019; OR: 4.38, 95%CI: 1.69-11.35, P = 0.002; and OR: 2.78, 95%CI: 1.03-7.47, P = 0.042, respectively). CONCLUSION: The findings indicate that older age, higher CT score, and lower O2 saturation could be categorized as predictors of poor outcome among COVID-19-infected patients. Other studies are required to prove these associations.

The Relationship between Aura and Postoperative Outcomes of Epilepsy Surgery in Patients with Mesial Temporal Sclerosis.

BACKGROUND: We conducted a study to evaluate the relationship between aura types and postoperative outcomes in patients with mesial temporal sclerosis (MTS) to predict the prognosis of patients, accordingly. MATERIALS AND METHODS: In this cross-sectional study, 99 patients with MTS-temporal lobe epilepsy were enrolled based on inclusion and exclusion criteria. The types of aura were evaluated, and the outcomes were categorized according to the Engel scale. Preoperative and postoperative results of patients were compared and analyzed with the Kruskal-Wallis test. RESULTS: About 73.7% of patients had seizure-free after their surgeries. The most of patients (n = 81) were in Class I of Evaluating Engel criteria. About 36.3% had not experienced any aura before their seizures, and among those with aura, the most prevalent aura was abdominal aura in 29 patients (29.3%) followed by other types of aura and affective aura. Most of the patients in Class I, II, III, and IV of Engel scale had an abdominal aura, without aura, effective aura, and abdominal aura, respectively, but this difference was not statistically significant (P = 0.691). CONCLUSION: According to this study, the type of aura cannot predict postoperative outcomes in MTS patients. More studies are needed to evaluate this relation in better-planned studies with greater sample size.

Outcome of lesional epilepsy surgery: Report of the first comprehensive epilepsy program in Iran.

BACKGROUND: We investigated the utility of epilepsy surgery and postoperative outcome in patients with lesional epilepsy in Iran, a relatively resource-poor setting. METHODS: This prospective longitudinal study was conducted during 2007-2017 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with a diagnosis of intractable focal epilepsy, with MRI lesions, who underwent epilepsy surgery and were followed up ≥ 24 months, were included and evaluated for postoperative outcome. RESULTS: A total of 214 patients, with a mean age of 26.90 ± 9.82 years (59.8% men) were studied. Complex partial seizure was the most common type of seizure (85.9%), and 54.2% of the cases had auras. Temporal lobe lesions (75.2%) and mesial temporal sclerosis (48.1%) were the most frequent etiologies. With a mean follow-up of 62.17 ± 19.33 months, 81.8% of patients became seizure-free postoperatively. Anticonvulsants were reduced in 86% of the cases and discontinued in 40.7%. In keeping with previous studies, we found that seizure freedom rates were lower among patients with longer follow-up periods. CONCLUSIONS: We found high rates of seizure freedom after surgery in lesional epilepsy patients despite limited facilities and infrastructure; antiepileptic medications were successfully tapered in almost half of the patients. Considering the favorable outcome of epilepsy surgery in our series, we believe that it is a major treatment option, even in less resource-intensive settings, and should be encouraged. Strategies to allow larger scale utility of epilepsy surgery in such settings in the developing world and dissemination of such knowledge may be considered an urgent clinical need, given the established mortality and morbidity in refractory epilepsy.

Evaluation of dual pathology among drug-resistant epileptic patients with hippocampal sclerosis.

PURPOSE: Dual pathology (DP) is defined as simultaneous presence of hippocampal sclerosis (HS) and any other pathology in the brain. Since this is a less probed concept, we aimed to evaluate the frequency and characteristics of DP among drug-resistant epileptic patients with HS. METHODS: This is a cross-sectional study conducted during 2007-2016 in Kashani Comprehensive Epilepsy Center, Isfahan, Iran. Patients with diagnosis of drug-resistant epilepsy and HS were enrolled in the study, and demographic data, seizure semiology, EEG findings, and MRI findings were collected. We compared these variables between three groups of DP, unilateral HS, and bilateral HS. RESULTS: Of the 200 enrolled cases, 29 patients (14.5%) had DP and 21 patients (10.5%) had bilateral HS; the remaining patients had unilateral HS. The average age of patients with DP was 30.03, and 65.5% of them were male. Patients with DP had more EEG discharges from regional and multi-focal sites compared to unilateral HS (P value < 0.001). Also, complex partial seizure (CPS) was more commonly presented in patients with unilateral HS (96.8%). Comparison of disease characteristics between DP and bilateral HS showed no difference in most categories (P > 0.05). CONCLUSIONS: We found DP among 14.5% of our drug-resistant epileptic patients with HS. DP patients mostly presented with CPS and had high proportion of ictal and interictal EEG discharges from regional and multi-focal areas. Gliosis and focal cortical dysplasia were the most common pathologies among DP patients. Patients with DP showed a similar behavior to bilateral HS in many features.

An Undiagnosed Case of Hypothalamic Hamartoma with a Rare Presentation.

Background. Hypothalamic hamartomas (HHs) are rare tumor-like malformations that may present with complex partial seizures refractory to anticonvulsants in adulthood. The condition may be misdiagnosed because of rarity. Case Presentation. We report a 25-year-old man with complaint of seizures presented by falling, tonic spasm of limbs, oral automatism, vocalization, and hypermotor activities. His seizures started at the age of one month and presented as eye deviation and upper limbs myoclonic jerk, followed by frequent seizures with variable frequency. The patient had delayed developmental milestones and was mentally retarded. He was hospitalized and underwent video-EEG monitoring and neuroimaging, and the diagnosis of HH was made. The patient became candidate for surgery after that. Conclusion. In this case, the underlying etiology of seizures was diagnosed after 25 years. HH is a rare condition and neurologists may encounter very small number of these cases during their practice. Therefore, they should consider it in patients who present with suspected signs and symptoms.

Prognostic value of ictal onset patterns in postsurgical outcome of temporal lobe epilepsy.

Background: To investigate ictal onset patterns (IOP) in scalp electroencephalography (EEG) of patients with temporal lobe epilepsy (TLE) and their prognostic effect on the postoperative outcome. Methods: We conducted a retrospective cohort study between 2011 and 2015 in our referral Epilepsy Surgery Center enrolling adult patients with refractory TLE and a visible epileptogenic lesion in magnetic resonance imaging (MRI), who underwent epilepsy surgery. Demographic, clinical and MRI findings were collected and ictal findings during video-EEG monitoring were reviewed in detail. The correlation between preoperative findings and the postsurgical outcome was analyzed. Results: We reviewed 303 seizures in 93 patients. Rhythmic theta and rhythmic spike/sharp and wave were respectively the most common initial ictal pattern and late significant discharges. Engel class I outcome was observed in 88.2% of patients. Female sex, aura, the absence of secondary generalization, rhythmic theta as initial ictal pattern and concordance of ictal-interictal EEG findings were correlated with favorable 1-year postsurgical outcome. Conclusion: Preoperative clinical and EEG findings can provide valuable information regarding postsurgical prognosis in TLE patients.

Hippocampal volume and hippocampal angle (a more practical marker) in mild cognitive impairment: A case-control magnetic resonance imaging study.

BACKGROUND: Mild cognitive impairment (MCI) accompanies brain atrophy in neuroimaging investigations. The aim of this study was to compare MCI patients with the normal population for hippocampal volume (HV) and hippocampal angle (HA), and to assess the correlation between HV and HA. MATERIALS AND METHODS: In a case-control study on 2014, in Kashani Hospital (Isfahan, Iran), 20 MCI patients were compared with 20 normal controls for HV and HA. Subjects were diagnosed with MCI or normal control, based on neuropsychiatry interview, which was confirmed by neuropsychiatry unit cognitive assessment tool (NUCOG). All magnetic resonance imaging scans were processed using the Free-Surfer software package for HV assessment. The HA was measured on the most rostral slice in which the uncal sulcus could be identified on a coronal plane. The data were analyzed using multiple analysis of co-variance and Pearson correlation. RESULTS: The mean (standard deviation [SD]) score of NUCOG in control and case group were 91.05 (3.01) and 82.42 (3.57), respectively. Comparison of HV and HA scores in two groups, showed that mean (SD) HV and HA were not different between control and case groups, significantly, (P = 0.094 and P = 0.394, respectively). There was a negative correlation between the adjusted HV and the HA in case (r = -0.642, P = 0.004), and control groups (r = -0.654, P = 0.003). CONCLUSION: HV and HA were not different between MCI patients and normal controls; however, HA is correlated with HV negatively and may be used as an alternative factor because of more feasibility and availability in clinical settings in compared to HV.

A case report of osteochondroma with unusual clinical and imaging presentation.

Osteochondroma or exostosis is a bony developmental anomaly, which arises from exophytic outgrowth on bone surfaces in a characteristic manner. Osteochondroma is asymptomatic and grows away from the nearby joint. This paper reports an unusual presentation of osteochondroma in which the patient was surprisingly completely symptomatic. The lesion grew toward the nearby joint and the radiographic findings were not compatible with surgical findings.

Azygos vein aneurysm as a posterior mediastinal mass discovered after minor chest trauma.

Azygos vein aneurysm is a rare cause of a posterior or paratracheal mediastinal mass. Trauma or conditions causing elevated flow or pressure in the azygos system, such as cardiac failure or cirrhosis of the liver are secondary causes of aneurysm of the azygos vein. We report a case of asymptomatic saccular aneurysm of the azygos vein in a 45-year-old man with blunt minor chest trauma. The azygos vein aneurysm was managed by conservative treatment.

Prevalence of hippocampal morphologic variants between healthy elderly subjects and patients with Alzheimer's disease.

BACKGROUND: Alzheimer's disease (AD) is a neurodegenerative disease with atrophic changes in the temporal lobe. Enlargement of cerebrospinal fluid (CSF) spaces, hippocampal sulcus (HS) enlargement, or an increase in the number or size of hippocampal cavities (HCs) could be associated with medial temporal lobe atrophy (MTA). In this study, we assessed the relation of these CSF spaces with AD. MATERIALS AND METHODS: A total 36 demented patients with diagnosis of Alzheimer (Mini-Mental State Examination (MMSE) ≤25) and 36 non-demented elderly individuals were referred for basic magnetic resonance imaging (MRI) before initiating anti-dementia therapy in the demented group. Two observers assessed the maximal HS width, as well as the occurrence, number, and size of HCs, and the visual rating score of MTA on magnified coronal high-resolution T1-weighted MR images. RESULTS: The findings of our study indicate that the presence of hippocampal cavity (HC) (especially in the left side) and medial temporal lobe atrophy in demented patients was significantly higher in comparison with non-demented elderly subjects (P ≤ 0.05). There was a significant relationship between MTA and HS width (P = 0.003, r = 0.00323), and it also had a trend to be significant with size of HCs (P = 0.08, r = 0.00314). A correlation between MTA and number of HCs was not detected. CONCLUSION: HS width is associated with MTA in patients with AD. It may serve as a measure to evaluate MTA for identifying individuals at particularly high risk for Alzheimer progression, and could be employed for selecting subjects for clinical trials or for treatment decisions.

The comparative study on diagnostic validity of cerebral aneurysm by computed tomography angiography versus digital subtraction angiography after subarachnoid hemorrhage.

BACKGROUND: In order to declare the preoperative diagnostic value of brain aneurysms, two radiological modalities, computed tomographic angiography and digital subtraction angiography were compared. METHODS: In this descriptive analytic study, diagnostic value of computed tomographic angiography (CTA) was compared with digital subtraction angiography (DSA). Sensitivity, specificity, positive and negative predictive values were calculated and compared between the two modalities. All data were analyzed with SPSS software, version 16. RESULTS: Mean age of patients was 49.5 ± 9.13 years. 57.9 % of subjects were female. CTA showed 89% sensitivity and 100% specificity whereas DSA demonstrated 74% sensitivity and 100% specificity. Positive predictive value of both methods was 100%, but negative predictive value of CTA and DSA was 85% and 69%, respectively. CONCLUSIONS: Based on our data, CTA is a valuable diagnostic modality for detection of brain aneurysm and subarachnoid hemorrhage.

The role of ultrasonography in primary congenital hypothyroidism.

BACKGROUND: The aim of this study was to compare the usefulness of ultrasonography and scintigraphy in diagnosing the etiology of primary congenital hypothyroidism (CH). METHODS: The newborns that were examined by both thyroid scintigraphy and ultrasonography during CH screening program in Isfahan were included in this study. The ultrasonographic findings were compared with the scintigraphic findings and the sensitivity and specificity of the ultrasonography was determined. RESULTS: During this study, 102 CH newborns were studied. According to the ultrasonographic results, 61.8%, 26.5%, 2.9% and 8.8% of them had normal thyroid gland, agenesia, ectopia and hypoplasia, respectively, and according to scintigraphic results, 55.9%, 35.3% and 8.8% of them had normal thyroid gland, agenesia and ectopia, respectively. Ultrasound detected sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 77%, 92%, 89%, 84%, 9.6 and 0.25, respectively. The sensitivity and specificity of ultrasonography compared with thyroid scintigraphy in diagnosis of thyroid gland ectopia was 33% and 100%, respectively. CONCLUSIONS: Though thyroid ultrasonography failed to diagnose 67% of ectopic cases and nonfunctioning thyroid gland, it had the ability to determine the anatomy of thyroid gland. So, considering some limitations of scintigraphy, we concluded that ultrasonography is a relatively appropriate imaging tool for diagnosing CH etiologies, especially in the initial phase of CH screening.

Sonographic assessment of congenitally hypothyroid children in Iran.

INTRODUCTION: Considering the high prevalence of congenital hypothyroidism (CH) in Isfahan, it seems that it is necessary to investigate the aetiology of the disorder and its related factors. The aim of this study was to determine the aetiology of CH among children in Isfahan province. MATERIAL AND METHODS: In this cross-sectional study, the aetiology of CH and the volume of the thyroid was assessed using neck ultrasonography. The results of thyroid function screening tests were additionally recorded. The correlation between ultrasonographic findings and the level of TSH and as well as T4 was determined. RESULTS: During this study 385 CH patients aged 0-3 years were studied. According to ultrasonographic findings, in 19.9% of patients the aetiology of CH was dysgenesis (agenesis, ectopy, and hemiagenesis) and 80.1% had normal thyroid. Mean thyroid gland volume in all studied patients was 0.78 ± 0.44 mL. The prevalence of ultrasonographic findings was as follows: normal 80.1%, agenesis 12.7%, hemiagenesis 5.8%, and ectopy 1.4%. There was a significant correlation between thyroid volume and TSH and T4 and as well as between TSH and ultrasonographic findings (p 〈 0.05). CONCLUSIONS: In spite of the limitations of ultrasonography in the field of determining the aetiology of CH, it is an appropriate imaging tool for determining the volume of the thyroid gland in children. Considering that the rate of goitrous gland was low, it seems that iodine deficiency could not be responsible for the high rate of CH in this region.