Cost-effectiveness of HARNESS-MRI protocol in focal drug-resistant epilepsy in a limited-resources country: An Egyptian study.

OBJECTIVES: The international league against epilepsy (ILAE) recommended the harmonized neuroimaging of epilepsy structural sequences (HARNESS-MRI) to improve the detection of epileptogenic lesions in patients with focal drug-resistant epilepsy (DRE). The application of this protocol is still limited in low-resource countries, mainly due to apparent high costs. We aimed to evaluate the cost-effectiveness of the HARNESS-MRI protocol in Egypt and highlighted our experience. METHODS: Patients diagnosed with focal DRE at Cairo University epilepsy clinic underwent both conventional MRI (c-MRI) and HARNESS-MRI. Electro-clinical data were collected and analyzed. After the radiologists' initial diagnosis, a multidisciplinary team re-evaluated the MRI. Lesion detection rate and cost for detecting an extra lesion by HARNESS-MRI protocol were calculated. RESULTS: The study included 230 patients with focal DRE (146, 62% males and 91, 38% females), with a mean age of 20.5 years. Epileptogenic lesions detected by c-MRI and HARNESS-MRI before and after the board meeting were 40, 106, and 131 lesions, respectively (P < 0.001). Sixty-nine percent of the lesions detected by HARNESS-MRI were missed on c-MRI; most commonly were mesial temporal sclerosis (MTS) and Malformations of cortical development (MCDs). Thirty-seven MTS and 32 MCDs were detected with HARNESS-MRI, compared to only 6 and 3, respectively, detected on c-MRI (P < 0.001). HARNESS-MR protocol is more cost-effective than c-MRI in detecting MRI lesions; it can save about 42$ for detecting an extra lesion in MRI. CONCLUSION: The HARNESS-MRI protocol was cost-effective and highly recommended even in limited-resource countries for patients with focal DRE.

Resective epilepsy surgery in a limited-resource settings: A cohort from a multi-disciplinary epilepsy team in a developing country.

Background: Multidisciplinary pre-surgical evaluation is vital for epilepsy surgery decision and outcomes. Resective epilepsy surgery with assisted monitoring is currently a standard treatment for focal drug resistant epilepsy (DRE). In resource-limited countries, lack of epilepsy surgery center is a huge challenge. We presented and illustrated how to create a multidisciplinary protocol with resource-limited settings in a developing country and epilepsy surgery outcome using brain mapping and monitoring techniques for ensuring satisfactory resection. Methods: We created multicentric incomplete but complementary units covering all epilepsy-related sub-specialties and covering a wide geographical area in our country. Then, we conducted a prospective and multicentric study with low resource settings on patients with focal DRE, who underwent resective epilepsy surgery and were followed up for at least 12 months and were evaluated for postoperative seizure outcome and complications if present. Preoperative comprehensive clinical, neurophysiological, neuropsychological, and radiological evaluations were performed by multidisciplinary epilepsy team. Intraoperative brain mapping including awake craniotomy and direct stimulation techniques, neurophysiological monitoring, and electrocorticography was carried out during surgical resection. Results: The study included 47 patients (18 females and 29 males) with mean age 20.4 ± 10.02 years. Twenty-two (46.8%) patients were temporal epilepsy while 25 (53.2%) were extra-temporal epilepsy. The epilepsy surgery outcome at the last follow up was Engel Class I (seizure free) in 35 (74.5%), Class II (almost seizure free) in 8 (17%), Class III (worthwhile improvement) in 3 (6.4%), and Class IV (no worthwhile improvement) in 1 patient (2.1%). Conclusion: With low resource settings and lack of single fully equipped epilepsy center, favorable outcomes after resective surgery in patients with focal DRE could be achieved using careful presurgical multidisciplinary selection, especially with using intraoperative brain mapping and electrocorticography techniques.

An international study of the effects of the COVID-19 pandemic on characteristics of functional seizures.

OBJECTIVE: We investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with functional seizure (FS) (at the time of diagnosis) in a large multicenter international study. METHODS: This was a retrospective study. We investigated all patients with FS, who were admitted at the epilepsy monitoring units at six centers in the world: 1. Shiraz, Iran; 2. Salzburg, Austria; 3. Nancy, France; 4. Atlanta, USA; 5. Kuwait City, Kuwait; and 6. Cairo, Egypt. Patients were studied during two time periods: admitted in 2018-2019 (pre-COVID era) and 2020-2021 (COVID era). RESULTS: Three hundred and twenty-six patients were studied. Two hundred and twenty-four (68.7%) patients were diagnosed before and 102 (31.3%) persons during the COVID-19 pandemic. Only, a history of family dysfunction was significantly associated with the COVID-19 pandemic era (Odds Ratio: 1.925, 95% Confidence Interval: 1.099-3.371; p = 0.022). A low level of education might also be associated with FS during the COVID-19 pandemic, at least in some cultures (e.g., the Middle-East). CONCLUSION: The COVID-19 pandemic has not affected the clinical characteristics of patients with FS (at the time of diagnosis). However, a history of family dysfunction was significantly more frequently associated with FS during the COVID-19 pandemic. Multiagency integration of law enforcement responses, social services, and social awareness is recommended to address family dysfunction and domestic violence and support the victims during this pandemic.

Assessment of Intracranial Collateral Circulation Using Novel TCCS Grading System in Patients With Symptomatic Carotid Occlusion.

Objectives: To establish a novel transcranial color-coded sonography (TCCS) grading system for collateral circulation in cases of symptomatic chronic total carotid occlusion (TCO), and to correlate this new grading system with cerebrovascular reserve capacity (CVR) measured by SPECT. Methods: Thirty-four patients with symptomatic chronic TCO recruited from the neurovascular ultrasound laboratory of the department of Neurology at Cairo University Hospital during 3 years' time period and diagnosed by color-coded duplex were subjected to: clinical assessment, grading of cerebral collaterals using a proposed TCCS criteria, Brain SPECT studies at rest and with dipyridamole stress. Results: The new grading system for cerebral collateral circulation showed a significant positive correlation with CVR (P < 0.001 and Spearman correlation coefficient 0.686). Conclusion: The current study showed that this new TCCS grading system for cerebral collaterals is a reliable indicator for cerebral perfusion and reserve capacity in cases of chronic symptomatic TCO.

Insights into sleep-related hyper-motor epilepsy: an Egyptian case series.

Objective: Sleep-related hypermotor epilepsy (SHE) is a sleep-related focal epilepsy which is often misdiagnosed. Despite active pharmacological therapy in the management of this disorder, satisfactory seizure control still cannot be achieved. Therefore, the aim of the present study was to identify this disorder among people who were seeking medical advice at Cairo University Epilepsy Unit (CUEU), characterizing its clinical, electroencephalographic and imaging features besides identifying possible indicators of inadequate seizure control on drug-therapy. Patients and methods: This study was carried out on 26 patients with SHE who were subjected to detailed history taking and examination in addition to home video recording, video electroencephalographic (EEG) monitoring and brain imaging. Ictal semiology and EEGs were reviewed and analyzed by experienced neurologists. Results: SHE is an uncommon sleep-related focal epilepsy. In our series, median age of the patients was 18.5 years. It is characterized by being sporadic, with often frontal lobe seizure onset (14/26, 53.8%) and with occasional occurrence in wakefulness. Adolescence age at disease onset (11 years, 6-15), duration less than 1 min, clustering, lack of auras and often uninformative brain imaging (22/25, 88%) are all documented features. Moreover, it has a relatively poor outcome on pharmacological therapy (16/26, 61.5%). Longer disease duration (>4.5 years) was a significant feature of the patients exhibiting inadequate seizure control. Conclusions: Our data show relatively poor prognosis of SHE on medical therapy. Its outcome is significantly related to disease duration at the time of diagnosis. Abbreviation: SHE = Sleep related hypermotor epilepsy.

Predictors of poor cerebral collaterals and cerebrovascular reserve in patients with chronic total carotid occlusion.

BACKGROUND: This study aims to investigate the relationship between cerebrovascular reserve (CVR) capacity, as measured by single-photon emission computed tomography (SPECT) and collateral blood flow, according to a transcranial colour-coded duplex(TCCD), in patients with symptomatic total carotid occlusion (TCO). Additionally, the study aims to determine whether vascular risk factors have an effect on collateral blood flow, as well as on the CVR. METHODS: Thirty-four patients with chronic TCO, diagnosed by carotid duplex scanning and confirmed by other vascular imaging modalities, who had ischaemic symptoms either as stroke or transient ischaemic attack, were subjected to clinical assessment, SPECT under dipyridamole stress, and grading of cerebral collateral blood flow using TCCD. Demographics and vascular risk factors were correlated with SPECT and TCCD findings. RESULTS: CVR showed a significant positive correlation with the intensity of collaterals with P value <0.001 and a Spearman correlation coefficient of 0.686. Hypertension was the only predictor of poor collaterals (p value =0.049; OR =11.5 with 95% CI 1.01-131.16).Smoking was predictive of poor CVR as measured by qualitative SPECT (p value =0.02; OR =13.2 with 95% CI 1.4-120.6). CONCLUSION: Cerebral collaterals have an important role in the maintenance of CVR in patients with TCO. Preventive measures should be directed towards hypertension and smoking to preserve cerebral collateral patency and consequently improve CVR in patients with TCO.