V. P. Singh

Memory and intelligence outcome following surgery for intractable temporal lobe epilepsy: relationship to seizure outcome and evaluation using a customized neuropsychological battery

The main objectives of this prospective study were to (1) assess memory and intelligence outcome following surgery for intractable temporal lobe epilepsy, (2) correlate this with seizure outcome and side of surgery, and (3) perform (1) and (2) using an indigenously developed battery customized to the Indian population. Prior to use in our epilepsy surgery program, the test-retest and interexaminer variance reliability of this battery had been established in both normal and cognitively compromised populations. The memory scores were overall rather than material-specific. The battery was administered to right-handed adults undergoing surgery for intractable temporal lobe epilepsy without any evidence of opposite temporal lobe abnormality, both presurgery and postsurgery at a mean follow-up of 8 months. Twenty-five consecutive patients were included; 13 underwent right and 12 underwent left temporal surgery. Seizure outcome was assessed using Engels classification. Among 13 patients who underwent right temporal surgery, although 4 patients with poor seizure outcome had insignificant changes in scores, 7 of 9 patients with good seizure outcome exhibited considerable (> 20% over preoperative) improvement in their memory and intelligence scores. Statistical analysis using Students t test and the Mann-Whitney test revealed that the patients who underwent right temporal surgery with good seizure outcome had significant improvement in both memory (P = 0.007) and intelligence (P = 0.043) scores compared with those with poor seizure outcome. In contrast, patients who underwent left temporal surgery had no significant change in cognitive scores irrespective of seizure outcome. Cognitive improvement seems to occur in patients with good seizure outcome following nondominant temporal lobe surgery for intractable epilepsy with no evidence of pathology in the opposite temporal lobe. The same finding was not observed in patients undergoing left temporal surgery.

Spontaneous Decompression of a Posterior Fossa Arachnoid Cyst: A Case Report

The authors present a case of spontaneous regression of a posterior fossa, supracerebellar arachnoid cyst causing hydrocephalus in a 7-month-old male child. The patient presented with macrocrania, bulging fontanelle and upgaze paresis of the eyes. There was complete improvement of these symptoms on the morning of the day of surgery without any obvious precipitating factors, including trauma. CT scan showed complete resolution of the cyst and hydrocephalus. The child was doing well at 1 year of follow-up. To the best of our knowledge, this is the first case report of spontaneous resolution of a posterior fossa arachnoid cyst.

Inflammatory granulomas: evaluation with proton MRS

Intracranial inflammatory lesions consisting mainly of tuberculomas (nu2005=u200528), neurocysticercosis (NCC) (nu2005=u200510), and non‐specific inflammatory granulomas (IG) (nu2005=u200522) were evaluated with proton MRS. Water‐suppressed proton spectra were acquired from 60 patients using the STEAM sequence with an echo time of 135u2005ms and metabolite ratios determined from the spectra. Students paired t‐test and χ2‐test were used to analyse the data. Statistically significant differences were observed for the following ratios between the three patient categories: NAA/Cr (pu2005<u20050.0001), NAA/Cho (pu2005=u20050.001) and Cr/Cho (pu2005=u20050.02) for the non‐specific IG and NCC, NAA/Cho (pu2005=u20050.03) for non‐specific IG and tuberculoma, and NAA/Cr (pu2005<u20050.0001) for NCC and tuberculoma. While lipids were seen in 86% of the tuberculomas, they were observed in only 20% of the NCCs (χ2u2005=u20056.81, pu2005=u20050.009), and 21% of the non‐specific IGs (χ2u2005=u200510.75, pu2005=u20050.0001). While the presence of lipid can be used for differentiating tuberculomas from both non‐specific IG and NCC, the extremely low levels of metabolites together with a poor signal/noise ratio could itself act as a marker for NCC. Copyright

Surgical outcome of cortical dysplasias presenting with chronic intractable epilepsy: a 10-year experience.

BACKGROUNDnThere has been sparse description of cortical dysplasias (CDs) causing intractable epilepsy from India.nnnAIMnClinical retrospective study of CDs causing intractable epilepsy that underwent surgery.nnnMATERIALS AND METHODSnFifty-seven cases of CDs reviewed (1995 till July 2006) are presented. All patients had intractable epilepsy, and underwent a complete epilepsy surgery workup (inter ictal electroencephalography (EEG), video EEG, MRI as per epilepsy protocol, SPECT {interictal, ictal with subtraction and co-registration when required}, and PET when necessary). Surgical treatment included a wide exposure of the pathology with a detailed electrocorticography under optimal anesthetic conditions. Mapping of the sensori-motor area was performed where indicated. Procedures included resection either alone or combined with multiple subpial transactions when extending into the eloquent areas.nnnRESULTSnOur study had 28 (49.12%) cases of isolated focal CDs, and 29 (50.67%) with dual pathology. Average age at the time of onset of seizures in our series was 7.04 years (three months to 24 years), and average age at the time of surgery was 10.97 years (eight months to 45 years). Among coexistent pathologies, one had associated MTS, 16 had coexistent gangliogliomas and 12 (dysembryonic neuroepithelial tumor) DNTs. At an average follow-up of 3.035 years (range 5-10 years), three patients were lost to follow-up. Fifty-one per cent (29/57) patients had a good outcome (Engel Grade I) and 26%(15/57) had a Grade II outcome.nnnCONCLUSIONnCortical dysplasias have a good outcome if evaluated and managed with concordant electrical and imaging modalities.

Successful selection of patients with intractable extratemporal epilepsy using non-invasive investigations

PURPOSEnPatients with intractable epilepsy, operated for extratemporal epileptogenic foci, have often been found to have poorer surgical outcome compared with those with temporal lobe foci. The objective of this study is to assess the surgical outcome in patients with extratemporal foci, operated at the All India Institute of Medical Sciences (AIIMS), New Delhi.nnnMETHODSnPatients of intractable epilepsy with extratemporal foci on detailed investigation constituted the study group. They were evaluated by the Comprehensive Epilepsy Care Team at the AIIMS with detailed clinical assessment, interictal EEGs, video-EEG studies, magnetic resonance imaging (MRI) with special sequences tailored for evaluation of the temporal lobes and for cortical dysplasias and single photon emission computerised tomography (SPECT) studies. Intraoperative electrocorticography was obtained in some patients. Outcome was assessed on follow-up, and graded according to Modified Engels Grading System.nnnRESULTSnTwenty-five patients (18 males, 7 females) with a mean age of 19.7 years (age range 7-45 years) were operated and assessed during the study period, for surgical outcome with a mean follow-up of 16.8 months (range 3 months to 6.5 years). Twenty patients (87%) were found to have a good outcome (Modified Engels grades I and II), while three had poor outcome, one died and one was lost to follow-up.nnnCONCLUSIONnWe found a good seizure outcome in patients who underwent resection of extratemporal epileptogenic foci, one of the reasons being presence of a lesion in all patients. Careful patient selection even with non-invasive investigations can aid in obtaining a good outcome in this group of patients.

MRS characterization of central neurocytomas using glycine

This study reports in vivo MRS findings in 11 patients with histologically diagnosed central neurocytomas, which are rare intraventricular tumors of neuronal origin. Single‐voxel 1H MRS was carried out prior to surgery using a point‐resolved spectroscopy sequence with TRu2009=u20096u2009s, TEu2009=u2009135u2009ms and 128 scans. In vitro high‐resolution 1H spectroscopy was also carried out on two surgically excised samples. The striking features of the spectra from the central neurocytomas were the presence of high glycine, decreased N‐acetylaspartate, increased choline and alanine. Retrospective, blind analysis of the spectra by two independent observers correctly identified all but one central neurocytoma based on the presence of glycine. The presence of glycine and prominent choline in the 1H MR spectrum is a characteristic feature of the central neurocytomas, and could be used to characterize and differentiate them from other brain tumors. Copyright

In vivo MRS study of intraventricular tumors.

To evaluate the role of MR spectroscopy (MRS) as a noninvasive tool for characterization of intraventricular brain tumors.

Meningioangiomatosis with meningioma: an uncommon association of a rare entity—report of a case and review of the literature

IntroductionMeningioangiomatosis (MA) is a rare lesion, probably of malformative origin, consisting of meningovascular proliferation and leptomeningeal calcification. Patients with MA usually present with seizures or persistent headaches. Neurofibromatosis may be associated in a variable proportion of patients, while in others it may be sporadic. Surgical treatment is usually recommended, and is gratifying in most cases. Rarely, MA has been described coexisting with meningiomas, arteriovenous malformations, encephaloceles, oligodendrogliomas, meningeal haemangiopericytomas and orbital erosion. Among these, meningiomatosis with meningioma is the most frequent combination.Case reportWe report a case of MA with meningioma in an 18-month-old girl, who presented with recurrent seizures.Discussion In these situations, it is extremely important for the pathologist to be aware of this entity and to distinguish it from other lesions, like cortical invasion by a meningioma, intraparenchymal meningioma and intracerebral schwannoma, which it may mimic.

The need for developing comprehensive epilepsy surgery units in India

This journal took shape as a result of a natural need required for an academic and research platform for the work done by the neurosurgical community of India. India currently has about 2000 neurosurgeons. Apart from the academic curriculum from the major institutes, there are a number of smaller hospitals which cater to diploma courses in neurosurgery. It is expected that by 2020, the neurosurgical community would cross about 7000, bringing it to an equivalent platform as many other medical specialties.