During a 2-year period, a total of 43 incident cases of central nervous system infections occurred in the adult (aged 15 years and above) population in Benghazi, Libya. This comprised 17 patients with aseptic meningitis, 10 acute... more
During a 2-year period, a total of 43 incident cases of central nervous system infections occurred in the adult (aged 15 years and above) population in Benghazi, Libya. This comprised 17 patients with aseptic meningitis, 10 acute bacterial meningitis, four tuberculous meningitis, five encephalitis, four neurosyphilis, two hydatidosis and one bilharzial myelopathy. The aetiology of the aseptic meningitis and encephalitis could not be established. The annual incidence rates of aseptic, septic and tuberculous meningitis, and encephalitis were 3.4, 2, 0.8 and 1 per 100,000 population, respectively.
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Status epilepticus (SE) is a neurological emergency resulting from prolonged Clinical or electroencephalographic seizure activity. Refractory SE refers to the persistence of seizure activity despite the initiation of first- and... more
Status epilepticus (SE) is a neurological emergency resulting from prolonged Clinical or electroencephalographic seizure activity. Refractory SE refers to the persistence of seizure activity despite the initiation of first- and second-line anticonvulsant therapy. Sinister outcomes are often attributed to the etiology of SE. Despite randomized multicentre trials of established and promising therapeutic options, the management and prognostication in SE are fraught with challenges. Neither the duration of SE nor time-delay to initiation of therapy should discourage the aggressive approach to the management of SE. Neurointensive care of patients with SE consists of an algorithmic approach tailored to the etiology and systemic complications that arise as a consequence. This approach is also driven by the persistence of electrographic seizure activity, which is best followed with continuous EEG monitoring. The extent of patient support has to be augmentative to the degree of encephalopathy/coma and impairment of vital functions. Potential interactions of anticonvulsant drugs with other co-medications need to be considered during the course of treatment. This review discusses the existing literature on the epidemiological aspects, clinical approach, treatment and prognostication of SE.
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Background and aim: To assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with hypoxic ischemic encephalopathy (HIE). Design: Non-randomized case-control observational study. Setting: Tertiary level neurorehabilitation... more
Background and aim: To assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with hypoxic ischemic encephalopathy (HIE). Design: Non-randomized case-control observational study. Setting: Tertiary level neurorehabilitation unit. Population: Twenty-five patients with HIE seen between 1 to 12 months after the injury and having a coma recovery scale-revised (CRS-R) score less than 7 at entry were recruited. Methods: Out of the patients who received HBOT, 20 received 20 sessions of HBOT at two absolute atmosphere pressure (ATA), and two received 60 sessions at 2 ATA over three different treatment intervals. We compared the outcomes between cases (who received HBOT) and controls (who did not receive HBOT).Cases and controls were allocated to three groups based on the time interval after injury following which they were recruited to the study: 1-3 months (9 cases and 16 controls), 4-8 months (9 cases and 9 controls) and 9-12 months (8 cases and 3 controls). Outcome measures: CRS-R, Karnofsky performance scale, and change in disorder of consciousness (DOC) at admission and discharge were assessed. Results: We observed a significant difference in CRS-R favoring the HBOT group at time intervals of 1-3 and 4-8 months. More patients in the HBOT group improved in DOC than the control group. Conclusions: HBOT given in the first nine months post-HIE can result in a better recovery and functional outcome.
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Differentiation between syncope secondary to epileptic seizures and cardiac disease in patients displaying transient loss of consciousness associated with convulsive movements is a diagnostic challenge both for neurologists and... more
Differentiation between syncope secondary to epileptic seizures and cardiac disease in patients displaying transient loss of consciousness associated with convulsive movements is a diagnostic challenge both for neurologists and cardiologists. In such patients, prolonged video-EEG monitoring not only helps in identifying asystole as the cause of syncope, but also in categorizing asystole as primarily cardiac in origin (cardiac asystole) and secondary to epileptic seizures (ictal asystole). We carried out this study to ascertain the prevalence of asystole in an epilepsy monitoring unit, and to contrast the clinical and electrophysiological characteristics between ictal asystole and cardiac asystole. Through a retrospective search, we identified patients who were shown to have had asystole using a database of patients who underwent prolonged video-EEG monitoring during a 68-month period. We compared the data of 18 consecutive patients; five with ictal asystole and 13 with cardiac asyst...
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580 Multiple studies across different regions of India have shown huge treatment gap for epilepsy ranging from 50%–90%.[1,2] There have been little sincere attempts to investigate the reasons for this wide treatment gap and to improve the... more
580 Multiple studies across different regions of India have shown huge treatment gap for epilepsy ranging from 50%–90%.[1,2] There have been little sincere attempts to investigate the reasons for this wide treatment gap and to improve the situation. Various medical and social factors including limited access to medical care and unavailability and unaffordability of basic antiepileptic drugs (AEDs) contribute to this wide treatment gap.[3] A longitudinal follow-up study from West Bengal reported that 620 (43%) of the 1450 patients with epilepsy discontinued their treatment within one year after initiation. The main reasons for discontinuing the treatment were financial overburden (90%), unemployment (29%), frustration and despair (21%), nonavailability of medicines locally (20%), and superstitions about epilepsy (17%).[4] With the improvement in country’s economy and health care cover in rural areas, it is assumed that treatment gap would have improved in India.
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Surgical treatment for epilepsy remains highly underutilized: in the United States, there has been no increase in the number of surgical procedures performed annually since 19901; for most patients referred, the average duration of... more
Surgical treatment for epilepsy remains highly underutilized: in the United States, there has been no increase in the number of surgical procedures performed annually since 19901; for most patients referred, the average duration of epilepsy is 22 years2; and there has been no change in this delay to surgery3, despite two randomized controlled trials4, 5 and an American Academy of Neurology practice parameter that recommended surgery as the treatment of choice for medically refractory temporal lobe epilepsy6. This session addressed issues relevant to increasing the availability of epilepsy surgery, particularly in countries with limited resources.
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The objective of this work is to design a patient independent system using time domain measures to detect the electrical onset of seizure in patients with temporal lobe epilepsy (TLE). We utilized the EEG data from 29 seizures of 18... more
The objective of this work is to design a patient independent system using time domain measures to detect the electrical onset of seizure in patients with temporal lobe epilepsy (TLE). We utilized the EEG data from 29 seizures of 18 patients who underwent multi-day video-scalp EEG monitoring as part of their presurgical evaluation. Seven time domain measures – signal energy, approximate entropy (ApEn), sample entropy (SampEn), mean, variance, skewness and kurtosis were calculated for each windowed signal. Among them, signal energy was selected as significant feature to discriminate normal and seizure condition. The performance of five classifiers – Linear Discriminant Algorithm (LDA), Naive Bayes (NB), Decision Tree (DT), Support Vector Machine (SVM) and k-Nearest Neighbour (KNN) using signal energy feature were analysed to test the suitability for automated seizure detection. Among the five, LDA and NB classifiers detected the unknown samples with sensitivity (specificity) of 44% (95%), 54% (90%) respectively. The other two, DT and KNN classifiers performed with sensitivity (specificity) of 74% (73%), and 74% (67%) respectively. The SVM classifier performed with sensitivity and specificity of 64% and 82% is found suitable for the design of generalized system to detect the onset of seizure.
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Objective: To investigate the association between serum albumin level and functional outcome following acute ischemic stroke. Method: We included 101 patients of acute ischemic stroke in the anterior circulation, functional outcome was... more
Objective: To investigate the association between serum albumin level and functional outcome following acute ischemic stroke. Method: We included 101 patients of acute ischemic stroke in the anterior circulation, functional outcome was measured with Barthel score on day 7 of stroke and 3 months following acute ischemic stroke and compared with baseline serum albumin level. Result: The relation between admission Serum albumin and Barthel score were measured using unpaired student ‘t’ test at 7 th day of onset and 3 rd month following the onset of acute ischemic stroke. The mean SD of admission Serum Albumin among the patient with total/severe dependency(mean 4.26 S.D 0.41) and patients with moderate or slight dependency(mean 4.57 with S.D 0.36) in Barthel score at 7th day of Stroke was not significantly different (p=0.098). However at 3 rd month following the acute ischemic stroke, the mean SD of admission Serum Albumin among the patient with total/severe dependency (mean 4.02 S...
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Lennox–Gastaut syndrome (LGS) is an epileptic encephalopathy characterized by delayed mental development and intractable multiple seizure types, predominantly tonic. Drop attacks are the commonest and the most disabling type of seizures.... more
Lennox–Gastaut syndrome (LGS) is an epileptic encephalopathy characterized by delayed mental development and intractable multiple seizure types, predominantly tonic. Drop attacks are the commonest and the most disabling type of seizures. Resective surgery is often not possible in LGS as the electroencephalogram (EEG) abnormalities are usually multifocal and generalized, and magnetic resonance image is often either normal or multilesional. We report a case of LGS with bilateral parieto-occipital gliosis where EEG before and after callosotomy demonstrated synchronized bilateral interictal epileptiform discharges and ictal discharges becoming desynchronized and running down. This phenomenon emphasizes the role of the corpus callosum in secondary bilateral synchrony.
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AIM As an initial step to develop guidelines for epilepsy monitoring units (EMUs) appropriate for developing countries, we inquired the existing practices in EMUs in India. METHODS After checking for the content and face validity as well... more
AIM As an initial step to develop guidelines for epilepsy monitoring units (EMUs) appropriate for developing countries, we inquired the existing practices in EMUs in India. METHODS After checking for the content and face validity as well for clarity, we sent a 52-item online non-anonymized questionnaire to all the 52 EMUs in India. RESULTS The questionnaire was completed by 51 of the 52 EMUs (98% response rate). The majority of the EMUs are located in major cities and 51% are located in non-governmental corporate hospitals. There are total of 122 prolonged video-EEG monitoring (PVEM) beds in India and 70% EMUs have ≤2 beds. Approximately two-thirds of the EMUs have defined protocols for pre-procedure consent and risk assessment, management of seizure clusters and status epilepticus, continuous observation of patients, and peri‑ictal testing. Only one-third of the EMUs have protocols for management of post-ictal psychosis, anti-suffocation pillows, and protected environment within bathrooms. The waiting period for PVEM is more (49.9 ± 101 vs. 4.9 ± 10.9 days; p = 0.04) and mean cost for 3-day PVEM is less (INR 8311 ± 9021 vs. 30,371 ± 17,563; p <0.0001) in public as compared to private hospitals. There was a negative correlation between cost of PVEM and the waiting period (r=-0.386; p = 0.01). Safety practices are similar in public and private hospitals. CONCLUSIONS Although practices in EMUs in India vary widely, they are comparable to those in developed countries. India has severe shortage of EMUs and long waiting lists for affordable PVEM.
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ABSTRACT:Cellular telephones are becoming increasingly common; their small size and portability means that they may be unrevealed when a patient has an EEG. They contain radio-frequency receivers and transmitters, and may produce EEG... more
ABSTRACT:Cellular telephones are becoming increasingly common; their small size and portability means that they may be unrevealed when a patient has an EEG. They contain radio-frequency receivers and transmitters, and may produce EEG artifacts by several mechanisms. We have ascertained three patterns of EEG artifact that may be generated by cellular telephones: an “autonomous registration” artifact that may occur with the telephone turned on, but not otherwise being used, and “sending” and “receiving” artifacts which may be seen with use of the cellular telephone. The artifacts have a characteristic appearance. Awareness of these artifacts should prompt the technologist to determine if a cellular telephone is present in or near the recording room.
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OBJECTIVE To determine treatment responses to various antiseizure medicines (ASMs) in patients with drug resistant juvenile myoclonic epilepsy (DRJME) METHODS: We reviewed records of all JME patients attending epilepsy clinics at 5... more
OBJECTIVE To determine treatment responses to various antiseizure medicines (ASMs) in patients with drug resistant juvenile myoclonic epilepsy (DRJME) METHODS: We reviewed records of all JME patients attending epilepsy clinics at 5 centers during a 5-year period. We used International Consensus Criteria to diagnose JME and International League Against Epilepsy Criteria to define drug resistance and sustained seizure freedom. We only used broad spectrum medicines which included valproate, lamotrigine, topiramate, levetiracetam, clobazam, phenobarbitone, clonazepam, and zonisamide. We considered an ASM successful if patient achieved seizure freedom within 3 months of attaining maintenance dose. RESULTS We studied 116 patients (61 males) with DRJME. At terminal followup, 82 (70.7%) patients had achieved sustained seizure freedom with a mean followup of 3.2 ± 1.3 years after last dose change. In patients where valproate failed as first- or second-line ASM (n=70; 60.3%), 49(70%) became seizure-free. In this group, 33(67%) patients became seizure-free after addition of lamotrigine. Success rate of lamotrigine and valproate combination was 69% as compared to 9% with all other combinations (p = 0.001). In patients who were not exposed to valproate as initial therapy (n=46), 33 (71.7%) became seizure-free, 30 (91%) after adding valproate. At last follow-up, 75 (90%) seizure-free patients were receiving valproate including 45 (55%) patients with a combination of valproate and lamotrigine. Only one of 24 patients became seizure-free after failing valproate and lamotrigine combination. CONCLUSION Seizure freedom can be achieved in two-thirds of patients with DRJME. A combination of valproate and lamotrigine is the most effective duotherapy.
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Epilepsy surgery in India has seen remarkable advances over the last twenty years. Presently 39 centers are undertaking epilepsy surgeries in India on a regular basis. Out of these, 18 centers have become operational in the last five... more
Epilepsy surgery in India has seen remarkable advances over the last twenty years. Presently 39 centers are undertaking epilepsy surgeries in India on a regular basis. Out of these, 18 centers have become operational in the last five years. Many of them are well equipped with high end technologies and have expertise to undertake all kinds of epilepsy surgeries. Till July 31st, 2016, approximately 7143 epilepsy surgeries have been performed in India. Presently, 734 epilepsy surgeries are carried out in India every year representing an increase of approximately 58% over the last three and a half years as compared to the previous years. The reported postoperative outcomes from all these centers are comparable to those reported from the well-established centers in high income countries. Still, only 2 in 1000 eligible patients In India undergo epilepsy surgery, because of which, the enormous surgical treatment gap continues to persist. To tackle this, by the year 2020, India should have at least 60 state-level epilepsy surgery centers (with each undertaking at least 50 surgeries per year) and 6 national centers of excellence. Here, we discuss the current prevalence and practice of epilepsy surgery in India and suggest pragmatic steps and solutions to make epilepsy surgery affordable and widely available. The steps also include a framework for the development of a national epilepsy surgery program.
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While there are over one million people with drug-resistant epilepsy in India, today, there are only a handful of centers equipped to undertake presurgical evaluation and epilepsy surgery. The only solution to overcome this large surgical... more
While there are over one million people with drug-resistant epilepsy in India, today, there are only a handful of centers equipped to undertake presurgical evaluation and epilepsy surgery. The only solution to overcome this large surgical treatment gap is to establish comprehensive epilepsy care centers across the country that are capable of evaluating and selecting the patients for epilepsy surgery with the locally available technology and in a cost-effective manner. The National Epilepsy Surgery Support Activity (NESSA) aims to provide proper guidance and support in establishing epilepsy surgery programs across India and in neighboring resource-poor countries, and in sustaining them.
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In order to understand whether the antiseizure mechanism of ketogenic diet (KD) is mediated through its anti-inflammatory effect, we measured the serum concentrations of cytokines IL- 1β and IL-6 in 21 children with drug-resistant... more
In order to understand whether the antiseizure mechanism of ketogenic diet (KD) is mediated through its anti-inflammatory effect, we measured the serum concentrations of cytokines IL- 1β and IL-6 in 21 children with drug-resistant epilepsy. We found a significant reduction in the levels of serum IL- 1β and IL-6 levels at one-year of KD therapy compared to baseline. However, we did not find any correlation between decrease in the serum concentrations of these interleukins with the reduction in seizure frequency at one-year of KD therapy, which may be due to the small sample size and heterogeneous patient population we studied. Future studies should try to overcome these limitations.
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People with epilepsy frequently experience problems in marriage including reduced marital prospects, poor marital outcomes and diminished quality of married life. Conversely, marriage might impact epilepsy self-management and quality of... more
People with epilepsy frequently experience problems in marriage including reduced marital prospects, poor marital outcomes and diminished quality of married life. Conversely, marriage might impact epilepsy self-management and quality of life in people with epilepsy. There is little in published literature on marriage and epilepsy, so there is a need for psycho-behavioral research. Here, we focus on arranged marriages which, although now rare in western cultures, are widely prevalent in South Asian communities. Arranged marriages, in which families rather than individuals choose marital partners, are particularly problematic because epilepsy is frequently hidden during marital negotiations as well as later. From the psycho-behavioral perspective, marital prospects, outcomes and satisfaction should be examined in relation to the type of marriage (arranged vs. love) and whether or not epilepsy is hidden. Additionally, culturally-relevant tools to appraise marital quality and epilepsy s...
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Isolated intracranial hypertension is a common manifestation of intracranial sino-venous thrombosis (ISVT). Markedly elevated intracranial tension presents with unusual features including cranial neuropathies and radiculopathy. We report... more
Isolated intracranial hypertension is a common manifestation of intracranial sino-venous thrombosis (ISVT). Markedly elevated intracranial tension presents with unusual features including cranial neuropathies and radiculopathy. We report two cases with ISVT, which presented with headache, papilledema, progressive visual loss, complete ophthalmoplegia and flaccid areflexic quadriparesis along with a normal sensorium. Magnetic resonance imaging (MRI) of the brain and cervical spinal cord showed no lesions that could account for the neurological deficits. Markedly elevated lumbar CSF pressure was noted in both cases. Nerve conduction study favored radiculopathy in one case and was normal in the other. Raised intracranial pressure was found to be the sole cause for the clinical manifestations. Visual impairment persisted in one patient despite lumbo-peritoneal shunting while the other died of septicemia. To our knowledge there are no previous reports of a syndrome comprising blindness, ...
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Status epilepticus (SE) is a neurological emergency resulting from prolonged Clinical or electroencephalographic seizure activity. Refractory SE refers to the persistence of seizure activity despite the initiation of first- and... more
Status epilepticus (SE) is a neurological emergency resulting from prolonged Clinical or electroencephalographic seizure activity. Refractory SE refers to the persistence of seizure activity despite the initiation of first- and second-line anticonvulsant therapy. Sinister outcomes are often attributed to the etiology of SE. Despite randomized multicentre trials of established and promising therapeutic options, the management and prognostication in SE are fraught with challenges. Neither the duration of SE nor time-delay to initiation of therapy should discourage the aggressive approach to the management of SE. Neurointensive care of patients with SE consists of an algorithmic approach tailored to the etiology and systemic complications that arise as a consequence. This approach is also driven by the persistence of electrographic seizure activity, which is best followed with continuous EEG monitoring. The extent of patient support has to be augmentative to the degree of encephalopath...
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Background: Focal cortical dysplasia (FCD) is often associated with epilepsy. Identification of FCD can be difficult due to subtle magnetic resonance imaging (MRI) changes. Though fluid-attenuated inversion recovery (FLAIR) sequence... more
Background: Focal cortical dysplasia (FCD) is often associated with epilepsy. Identification of FCD can be difficult due to subtle magnetic resonance imaging (MRI) changes. Though fluid-attenuated inversion recovery (FLAIR) sequence detects the majority of these lesions, smaller lesions may go unnoticed while larger lesions may be poorly delineated. Purpose: To determine the ability of a specialized epilepsy protocol in visualizing and delineating the extent of FCD. Material and Methods: We compared the imaging findings in nine patients with cortical malformation who underwent routine epilepsy MR imaging as well as a specialized epilepsy protocol. All imaging was done on a 1.5T MR unit. The specialized epilepsy protocol included 3D FLAIR in the sagittal plane as well as proton density (PD) and high-resolution T2-weighted (T2W) images in the transverse plane. Results: In all nine patients, the specialized protocol identified lesion anatomy better. In three patients in whom routine MR...