Abstracts

RATIONALE: Epilepsy surgery is a well established treatment for selected patients with medically refractory epilepsy. Epilepsy surgery was considered, till recently, an expensive high-tech therapy restricted to the industrialized world. The recent recognition that a majority of patients with medically refractory partial seizures have surgically remediable syndromes that can be identified by relatively simple non-invasive studies has resulted in the evolution of epilepsy surgery programs in developing countries. During the last six years, the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India has developed a comprehensive program for the evaluation and management of persons with medically refractory epilepsy. Based on this program, we wish to report our experience with determination of surgical candidacy for epilepsy surgery and propose a pragmatic cost effective strategy applicable to developing regions of the world. At the end of this presentation the participants should be able to assess the quality and cost effectiveness of a non-invasive presurgical evaluation and understand the development of epilepsy surgery program in a country with limited resources.
METHODS: From March 1995 through December 2001, 358 patients underwent anterior temporal lobectomy. These patients were selected for ATL based on non-invasive protocol, comprising history, interictal scalp EEG, MRI, ictal video scalp EEG and neuropsychological data. Information obtained through neuropsychological assessment and Wada test were considered complimentary. All patients underwent craniotomy and standard ATL, which included 5-6 cms of lateral neocortical resection, anterior two-thirds of hippocampus and lateral two-thirds of the amygdala along with uncus and parahippocampal gyrus under general anesthesia without electro-corticography. We determined the siezure outcome using seizure outcome scoring for each 12 month period after surgery. Psychological, psychiatric, educational and employment status were also evaluated.
RESULTS: The 358 ATL patients comprised 183 men 175 women, mean age 25.6 years, median duration of epilepsy 15 years. The pre-operative MRI and/or histopathology of the resected specimens among the first 300 cases revealed mesial temporal sclerosis in 240, neoplastic lesions in 28, and dysplastic and non-specific changes in 32 patients. Among the 213 patients who completed two-year follow-up, 77.9% had Engel Class I outcome. The quality of life remarkably improved in seizure-free patients. The average cost per patient for presurgical evaluation and ATL was Indian Rupees 47,000 (US$ 1200). Comparable post operative changes in the neuropsychology and quality of life were seen.
CONCLUSIONS: Our experience from a comprehensive epilepsy surgery center from a developing region indicates that epilepsy surgery is not only possible but can be undertaken in a cost effective way. The epilepsy surgery centers in developing countries should initially restrict their surgical candidacy to patients who can be selected using locally available relatively inexpensive and non-invasive technologies and in whom an excellent post-opeartive outcome can be predicted.
[Supported by: SCTIMST]