Long-Term Seizure Freedom, Resolution of Epilepsy and Perceived Life Changes in Drug Resistant Temporal Lobe Epilepsy With Hippocampal Sclerosis: Comparison of Surgical Versus Medical Management.

BACKGROUND: Outcome of temporal lobe epilepsy associated with hippocampal sclerosis (TLE-HS) has rarely been evaluated exclusively. OBJECTIVE: To compare long-term seizure freedom, resolution of epilepsy, and perceived life changes in patients with drug-resistant TLE-HS who underwent surgery vs those who opted for best medical management. METHODS: In this retrospective longitudinal study, 346 patients with TLE-HS who underwent surgery were compared with 325 who received best medical management. Predictors for long-term remission, resolution of epilepsy, and seizure recurrence were analyzed. RESULTS: The duration of follow-up ranged from 3-18 (mean 12.61) years. The average age of study population was 28.54 ± 12.27 years with 321 (47.8%) women. Age at onset of epilepsy (11.84 ± 8.48 vs 16.29 ± 11.88; P ≤ .001) was lower, and duration of epilepsy (15.65 ± 9.33 vs 12.97 ± 11.44; P < .001) was higher in the surgery group. Seizure freedom at 3 (81.8 vs 19.0%; P < .001), 5 (73% vs 16.1%; P < .001), and 10 years (78.3% vs 18.5; P < .001) and resolution of epilepsy (30.5% vs 0.6%; P < .001) was higher in the surgery group. The overall perceived life changes score was higher in the surgery group (80.96 ± 25.47 vs 66.24 ± 28.13; P < .001). At long-term follow-up (≥10 years), the presence of an aura was the strongest predictor for resolution of epilepsy (ß: 2.29 [95% CI; 1.06-4.93]; P = .035), whereas acute postoperative seizures (APOS) (ß: 6.06 [95% CI 1.57-23.42]; P < .001) and an abnormal postoperative EEG (ß: 0.222 [95% CI 0.100-0.491]; P < .001) were predictors of persistent seizures. Seizure freedom both at 3 and 5 years predicted seizure freedom at 10 years. CONCLUSION: Surgery for drug-resistant TLE-HS was associated with higher rate of long-term seizure-freedom, resolution of epilepsy, and reduction of anti-seizure medications with improvement in perceived life changes compared with best medical management. The presence of an aura was predictor for resolution of epilepsy while APOS and an abnormal postoperative EEG were predictors of persistent seizures.

Endoscopic Management of Lateral Ventricle Arachnoid Cysts-Case Series with Proposed Classification.

BACKGROUND: We present a case series of 7 patients with intraventricular arachnoid cysts of lateral ventricle managed with endoscopic treatment with proposed classification of the cyst based on anatomic extent. METHODS: In all patients, the lateral ventricle arachnoid cyst was primarily located in the trigone and body of the lateral ventricle. Proposed classification is based on extension of the arachnoid cyst. Type 1 is an arachnoid cyst located in the lateral ventricle only, type 2 is a lateral ventricle arachnoid cyst extending to the quadrigeminal cistern, and type 3 is the lateral ventricle arachnoid cyst extending to the velum interpositum cistern. RESULTS: Two patients were managed with multiple fenestration and septostomy, and in 1 patient where the cyst was not adherent to the ventricular wall it was excised completely. Two patients who had a lateral ventricle cyst located in the atrium but extending to quadrigeminal cyst were managed with 3 fenestrations. Two patients with a lateral ventricle arachnoid cyst located into the atrium of lateral ventricle and extending to the velum interpositum cistern through the choroid fissure were managed with 3 endoscopic fenestrations. Postoperatively, patients were followed clinically and by radiologic imaging. None of the patients reported recurrence until the latest follow-up. CONCLUSIONS: Multiple endoscopic fenestrations for lateral ventricle arachnoid cyst according to its location and anatomic extension help to reduce recurrence and good outcome. Cyst excision is recommended only when the cyst wall is easily separable from the lateral ventricle wall. Intraoperative use of thulium light amplification by stimulated emission of radiation helps in achieving early hemostasis and easy perforation of the thick cyst wall.

Contralateral Clipping of Multiple Intracranial Aneurysms.

The reported incidence of multiple intracranial aneurysms (MIA) is approximately 7-35% of all intracranial aneurysms. The primary goal in the management of MIAs is to secure the ruptured aneurysm and to treat as many of the remaining lesions as possible without affecting the outcome of the patient. In recent era endovascular treatment is the preferred treatment of multiple bilateral intracranial aneurysms if all aneurysms are amenable to addressed in single stage. But most often all aneurysms were not possible to addressed due to complexity of different aneurysms, technical limitation and infrastructure. In such scenarios options left were two stage sequential craniotomy on either sides and clipping of bilateral aneurysms or unilateral craniotomy and clipping of bilateral MIA. Bilateral two stage surgery or two stage endovascular treatment caries risk of bleeding from one of the untreated aneurysms, morbidity due to two stage and increase the cost of treatment. In properly selected cases of unilateral craniotomy and clipping of bilateral MIA secure the all aneurysm in one stage and decreased morbidity and cost of treatment. When patient selection done meticulously, clipping of MIA including contralateral side aneurysms is feasible and safe.

Risk Stratification in Low Grade Glioma: A Single Institutional Experience.

BACKGROUND: Low grade gliomas (LGG) are most often noted with the unpredictable overall survival and progression to higher grades. Objective: In the present study, we analyze the clinicopathological features influencing the prognostic outcomes and compared the features with criteria developed by EORTC. MATERIALS AND METHODS: We observed the 130 LGG clinical cases in single institute and maintained the follow-up for more than 5 years. In addition, the molecular details were confirmed with markers as IDH, 1p/19q codeletion, p53 and ATRX mutations. RESULTS: The mean age of patients as 37.67 years and male population contributing to 70%. We observed biased incidence among the male population with dominating occurrence at frontal and parietal lobes in the brain. 40.8% patients had oligodendroglioma, 33.8% astrocytoma, 19.2% oligoastrocytoma and 2.3% gemistocytic astrocytoma pathology. Patients who were subjected to chemotherapy and radiotherapy were noted with average survival of 29 months. Oligodendroglial tumors were found with progression free survival (PFS) of 25 months, oligoastrocytoma cases with 32 months, diffuse astrocytoma cases with 23 months while the gemistocytic astrocytoma cases had 22 months. The PFS for LGG cases was 4.7 years while the overall survival was 4.9 years. Mean survival of patients with KPS score <70 and >70 was 1.5 & 4.9 years respectively. 64 patients were observed with the tumor size >5 cm. In total, 72.3% of the patients were underwent GTR, 23.3% STR and 3.8% underwent biopsy. CONCLUSION: Taken together, the clinical symptoms, expression of molecular markers and the prognosis details provided by our results can help for better management of LGG cases. We further propose to use following five factors to accurately describe the prognosis and tumor recurrence: 1) Age >50 years, 2) tumor size >5 cm, 3) MIB index >5%, 4) KPS score < 70 and 5) gemistocytic pathology.

Current Status of Surgery in Management of Prolactinomas.

Prolactinomas are a complex neuroendocrine challenge for the neurosurgeon. Management of prolactinoma patients requires centres that include neuroendocrinologists, neurosurgeons, neuroradiologists. Although dopamine agonists are the current mainstay of management of prolactinomas, surgery was often preferred management option prior to 1980, before the advent of dopamine agonists. Importantly, all patients with neurologic symptoms suspected due to the lesion, and those risk of adverse effects of medical management, treatment failure, resistance to dopamine agonists and those planning pregnancy, should be referred to a neurosurgeon at the earliest possible. When selected after meticulous evaluation, in patients with neurological deficits like acute visual loss, intolerance to medical therapy, or treatment failures, surgical intervention could come to rescue. Encouragingly, when carefully selected, surgical remission rates are high. In the current review, we review the existing literature and share the experience at our centre in the surgical management of prolactinomas.

Surgical Resection of Insular Gliomas and Roles of Functional Magnetic Resonance Imaging and Diffusion Tensor Imaging Tractography-Single Surgeon Experience.

OBJECTIVE: In gliomas located in proximity to eloquent areas, near total resection and subsequent radiotherapy is often preferred to avoid postoperative neurologic complications. Preoperative functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) tractography provide new insights into surgeries of insular gliomas. In this study we report our experience of surgical management of insular gliomas and the role of fMRI and DTI tractography in planning the resection. METHODS: We retrospectively compared the clinical and outcome variables of 61 patients who underwent surgical resection of insular gliomas. The study population was divided into 2 groups according to the use of fMRI and DTI tractography in planning the resection. RESULTS: The average age of the study population was 44.1 ± 12.6 years with 21 (34.4%) of the patients women. Nearly two thirds of them (40, or 65.6%) had World Health Organization grade II tumors, and 16 patients (26.2%) had grade IV tumors. The most common tumor was glioblastoma, observed in 16 patients (26.2%). In 10 (16.4%) patients, fMRI and DTI tractography were used. The overall mortality in the study population was 15 (24.6%). None of the patients where fMRI and DTI were used for planning the surgery died (29.4% vs. 0.0%; P = 0.05), and all of them had normal functioning (70.5% vs. 100.0%; P = 0.05) at 3 months' follow-up. CONCLUSION: Surgical resection of insular gliomas remains a challenge to the neurosurgeon and demands good knowledge of anatomic landmarks. Use of fMRI and DTI tractography may help achieve a good outcome.