Localisation of eloquent cortex using magnetoencephalography and its clinical implications

OBJECTIVES

This study aimed to localise the eloquent cortex and measure evoked field (EF) parameters using magnetoencephalography in patients with epilepsy and tumours near the eloquent cortex.

METHODS

A total of 41 patients (26 with drug-refractory epilepsy and 15 with tumours), with a mean age of 33 years, were recruited. Visual evoked field (VEF), auditory evoked field (AEF), sensory evoked field (SSEF), and motor-evoked field (MEF) latencies, amplitudes, and localisation were compared with those of a control population. Subgroup analyses were performed based on lobar involvement. Evoked Field parameters on the affected side were compared with those on the opposite side. The effect of distance from the lesion on nearby and distant evoked fields was evaluated.

RESULTS

AEF and VEF amplitudes and latencies were reduced bilaterally (p < 0.05). Amplitude in the ipsilateral SSEF was reduced by 29.27% and 2.16% in the AEF group compared to the contralateral side (p = 0.02). In patients with temporal lobe lesions, the SSEF amplitude was reduced bilaterally (p < 0.02), and latency was prolonged compared with controls. The MEF amplitude was reduced and latency was prolonged in patients with frontal lobe lesions (p = 0.01). EF displacement was 32%, 57%, 21%, and 16% for AEF, MEF, VEF, and SSEF respectively. Patients in the epilepsy group had distant EF abnormalities.

CONCLUSIONS

EF amplitude was reduced and latency was prolonged in the involved hemisphere. Distant EF amplitudes were more affected than latencies in epilepsy. Amplitude and distance from the lesion had negative correlation for all EF. EF changes indicated eloquent cortical displacement which may not be apparent on MRI.

Yield of video electro encephalography for phase 1 pre-surgical evaluation of drug resistant epilepsy in 1200 adults: retrospective study from a tertiary center situated in a lower-middle-income country

INTRODUCTION

Video Electroencephalography (VEEG) is crucial for presurgical evaluation of Drug Refractory Epilepsy (DRE). The yield of VEEG in large volume centers, particularly those situated in Low-and Middle-Income countries (LMIC) is not well studied.

METHODOLOGY

We studied 1200 adults with drug resistant focal epilepsy whose seizures were recorded during VEEG in the epilepsy monitoring unit. VEEG review and analysis was done independently by trained epileptologists. Video EEG and MRI data were examined for concordance in order to generate a hypothesis for the presumed epileptogenic zone.

RESULTS

Analysis of seizure semiology provided information on the symptomatogenic zone in most cases except for 33 (2.75%) patients. A total of 1050 (87.5%) patients showed interictal epileptiform discharges (IEDs) with most (58.3%) showing unilateral IEDs. Most patients (n = 1162, 96.83%) showed ictal EEG discharges of which 951(81.8%) had unilateral ictal onset. Abnormal MRI was seen in 978 (81.5%) patients. Concordance of electroclinical data obtained by analysis of VEEG with MRI abnormality could be established in most patients (63%). Concordance was higher for patients with ictal onset from temporal regions (83.71%) as compared to posterior cortex (55.4%) and frontal regions (43.5%.) CONCLUSION: This study highlights the high yield of VEEG in phase 1 presurgical evaluation in DRE. Systematic evaluation of data from VEEG provided lateralizing and localizing information in most cases. Concordance between VEEG and MRI findings was noted in most patients. These findings support steps to increase referral for pre-surgical evaluation in DRE.

Giant, lamellated colloid cyst: 'Russian-Doll' appearance

Colloid cysts (CCs) are usually small, benign lesions located at the foramen of Monro. They usually grow to a size of 1-3 cms. We have described here a giant colloid cyst of size 6 x 5.2 x 4.4 cm with a unique radiological appearance of multiple concentric layers with different intensities which has not been described before. This unusual appearance is most probably due to the variation of hydration between the different layers with gradually decreasing concentration of protein from centre to periphery, which correlated well with intraoperative and histopathological findings.

Sleep profile and Polysomnography in patients with drug-resistant temporal lobe epilepsy (TLE) due to hippocampal sclerosis (HS) and the effect of epilepsy surgery on sleep-a prospective cohort study

OBJECTIVES

We analyzed changes in sleep profile and architecture of patients with drug-resistant TLE-HS using three validated sleep questionnaires- Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), NIMHANS Comprehensive Sleep Disorders, and polysomnography (PSG). We studied the effect of epilepsy surgery in a subset of patients.

METHODS

In this prospective observational cohort study, sleep profile of 40 patients with drug-resistant TLE-HS was compared to 40 healthy matched controls. Sleep architecture of 22 patients was studied by overnight PSG and compared to 22 matched controls. Sleep profile was reassessed in 20 patients after a minimum period of three months after epilepsy surgery.

RESULTS

The mean PSQI was higher among patients compared to controls(P=0.0004) while mean ESS showed no difference. NCSDQ showed fewer patients feeling refreshed after a night's sleep compared to controls (p=0.006). PSG revealed a higher time in bed (p=0.0001), longer total sleep time (p=0.006) and more time spent in NREM stage 1 (p=0.001) and stage 2 (p=0.005) while spending less time in stage 3 (p=0.039) among TLE patients. Sleep efficiency was worse in patients on ≥3 ASMs compared to those on 2 ASMs (p-0.044). There was no change in mean ESS (p=0.48) or PSQI (p=0.105) after surgery.

CONCLUSIONS

Patients with drug-resistant TLE-HS have an altered sleep profile and architecture. Patients on ≥3 ASMs have a lower sleep efficiency. Reassessment at short intervals after epilepsy surgery did not reveal significant changes in sleep profile.

Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature

Background  Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators.

Materials and Methods  We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis.

Results  A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up.

Conclusion  Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

Magnetoencephalography imaging of high frequency oscillations strengthens presurgical localization and outcome prediction

In patients with medically refractory epilepsy, resective surgery is the mainstay of therapy to achieve seizure freedom. However, ∼20-50% of cases have intractable seizures post-surgery due to the imprecise determination of epileptogenic zone. Recent intracranial studies suggest that high frequency oscillations between 80 and 200 Hz could serve as one of the consistent epileptogenicity biomarkers for localization of the epileptogenic zone. However, these high frequency oscillations are not adopted in the clinical setting because of difficult non-invasive detection. Here, we investigated non-invasive detection and localization of high frequency oscillations and its clinical utility in accurate pre-surgical assessment and post-surgical outcome prediction. We prospectively recruited 52 patients with medically refractory epilepsy who underwent standard pre-surgical workup including magnetoencephalography (MEG) followed by resective surgery after determination of the epileptogenic zone. The post-surgical outcome was assessed after 22.14 ± 10.05 months. Interictal epileptic spikes were expertly identified, and interictal epileptic oscillations across the neural activity frequency spectrum from 8 to 200 Hz were localized using adaptive spatial filtering methods. Localization results were compared with epileptogenic zone and resected cortex for congruence assessment and validated against the clinical outcome. The concordance rate of high frequency oscillations sources (80-200 Hz) with the presumed epileptogenic zone and the resected cortex were 75.0% and 78.8%, respectively, which is superior to that of other frequency bands and standard dipole fitting methods. High frequency oscillation sources corresponding with the resected cortex, had the best sensitivity of 78.0%, positive predictive value of 100% and an accuracy of 78.84% to predict the patient's surgical outcome, among all other frequency bands. If high frequency oscillation sources were spatially congruent with resected cortex, patients had an odds ratio of 5.67 and 82.4% probability of achieving a favourable surgical outcome. If high frequency oscillations sources were discordant with the epileptogenic zone or resection area, patient has an odds ratio of 0.18 and only 14.3% probability of achieving good outcome, and mostly tended to have an unfavourable outcome (χ2 = 5.22; P = 0.02; φ = -0.317). In receiver operating characteristic curve analyses, only sources of high-frequency oscillations demonstrated the best sensitivity and specificity profile in determining the patient's surgical outcome with area under the curve of 0.76, whereas other frequency bands indicate a poor predictive performance. Our study is the first non-invasive study to detect high frequency oscillations, address the efficacy of high frequency oscillations over the different neural oscillatory frequencies, localize them and clinically validate them with the post-surgical outcome in patients with medically refractory epilepsy. The evidence presented in the current study supports the fact that HFOs might significantly improve the presurgical assessment, and post-surgical outcome prediction, where it could widely be used in a clinical setting as a non-invasive biomarker.

The Trend and Outcomes of Laparoscopic Appendectomy for Complicated Appendicitis in Nepal: A retrospective study from 2014 to 2018 in a University Hospital

Background Globally, appendicitis is the most frequent emergency surgical procedure. Laparoscopic Appendectomy (LA) is recommended as a standard surgical procedure to remove appendix. In Nepal, studies showed improved outcomes of Laparoscopic Appendectomy than Open Appendectomy (OA) in treating acute appendicitis. However, effectiveness of in Complicated Appendicitis (CA) has not yet studied in Nepal. Objective This study aims to assess the temporal trend of Laparoscopic Appendectomy in management of Complicated appendicitis and to compare outcomes with Open Appendectomy. Method The study is a retrospective descriptive study. The outcome measures in the study are age, sex, ethnicity, length of postoperative stay (LOS), and conversion rate. Secondary data of 174 patients with complicated appendicitis were extracted and reviewed from the operation theater records and the discharge summary from the period of 2014 to 2018. Result The mean age of the patients is 33.2 (SD ±19.4). Predominantly increased incidence is observed among male patients (66%). Mean Length of stay was 4.07(SD±2.1) days. Laparoscopic Appendectomy had shorter hospital stays than open and converted cases. The conversion rate was 10.92% for the observation period, and it was in a decreasing trend with the latest of 4.54%. The temporal trend for the percentage of patients who underwent Laparoscopic Appendectomy was increasing in the observation period. Conclusion The utilization of laparoscopic appendectomy in complicated appendicitis is growing in Nepal, and has decreasing conversion rate.

Laparoscopic Cholecystectomy: Conversion Rate and Associated Factors for Conversion

Background Laparoscopic cholecystectomy is the standard surgical treatment of gall bladder disease. However, conversion to open cholecystectomy is inevitable in certain cases. Different centers has reported different conversion rate and factors associated with conversion. Objective To identify the conversion rate, postoperative complication and factors associated with conversion. Method This retrospective study included all laparoscopic cholecystectomy cases attempted in Dhulikhel hospital during the year 2015 and 2016. Records of all patients were reviewed to find out demography of the patients, indications of laparoscopic cholecystectomy, rate of conversion to open, underlying reasons for conversion and postoperative complications. Result Out of 644 cases of laparoscopic cholecystectomy, 452 (70.18%) were female and 192 (29.81%) were male with the mean age of 39 years. Over all conversion rate to open cholecystectomy was 1.86% with the frozen calot's triangle as the most common reason for conversion. The overall postoperative complication was found to be 1.24% with no major bile duct injury. Acute cholecystitis is a significant preoperative predictor for the conversion into open cholecystectomy. Conclusion Laparoscopic cholecystectomy can safely be done with low conversion rate and complication. Appreciation of the predictor factors help the patient and surgeon for appropriate treatment plan.

Where is the Perforation ? Rare Complication of Endoscopic Retrograde Cholangio Pancreatography

Perforation is one of the most feared complications of Endoscopic Retrograde Cholangio Pancreatography (ERCP). ERCP has become important method for treating biliary-pancreatic diseases. Perforation related with Endoscopic Retrograde Cholangio Pancreatography is an infrequent, but if happens is a severe complication. Reported incidence of Edoscopic Retrograde Cholangio Pancreatography related perforation is 0.3-6%. Its mortality is as high as 37.5%. In our hospital since 2010 AD, There were 6 Perforations related to Endoscopic Retrograde Cholangio Pancreatography done in 4787 cases. This is a case of Endoscopic Retrograde Cholangio Pancreatography related perforation with no site of perforation recognized during surgical management.

Role of intraoperative dynamic magnetic resonance myelogram in management of giant dorsolumbar spinal extradural arachnoid cyst: case report

Giant dorsolumbar spinal arachnoid cysts are a complex, poorly understood, and difficult to manage clinical entity. Traditional CT myelography is technically difficult to use in these cases to detect the site of leakage preoperatively. The authors report a novel technique for detecting the site of the leak by using sequential, dynamic intraoperative MR myelography. To the authors' knowledge, there is no other similar report in the literature.

Clinico-Pathological Correlation of Colorectal Diseases by Colonoscopy and Biopsy

Background Colonoscopy is a simple, safe and well tolerated procedure, the visualization of the mucosa of the entire colon and terminal ileum to detect intestinal abnormalities and obtain biopsy leads to the early detection of the pathologic process and institution of appropriate therapy. Objective To find out the correlation between clinical and histopathological diagnosis of colorectal diseases. Method A cross-sectional study was conducted at Department of Pathology, Dhulikhel Hospital, Kathmandu University Hospital from Jan. 2015 - Jan. 2016. Altogether, 95 colonoscopic biopsies were examined and recorded clinical data using pre-designed pro forma. The specimens were grossed, processed and embedded using standard procedures, stained with Hematoxylin and Eosin stain and were analyzed using light microscope. Special stains Ziehl Neelsen, and Periodic Acid-Schiff were used whenever necessary. Result Analyses of 95 cases of colonoscopic biopsies were done. The most common clinical diagnosis was polyp in 49 cases (51.57%) and the common histopathological diagnosis was non-neoplastic polyps 31(32.63%). There was no correlation in cases for suspected infectious colitis, microscopic colitis and hemorrhoids. Conclusion Colonoscopy is incomplete without biopsy and histopathology is the gold standard for the diagnosis of colorectal lesions. The clinico-pathological correlation for neoplastic lesions was excellent. However, correlation was poor in non-neoplastic lesion.

A comparative study between extracorporeal shock wave lithotripsy and ureterorenoscopic lithotripsy in the management of upper ureteric calculus

Introduction and Objective: A stone in the ureter usually comes from the kidney. Urolithiasis is the third most common disease of the urinary tract which is surpassed only by urinary tract infections and pathologic conditions of prostate. There are some controversies on the effectiveness of extracorporeal shock wave lithotripsy (ESWL) and ureteroscopic lithotripsy (URSL) in ureteral stones. We aim to compare the efficacy of ESWL and URSL in the management of upper ureteric stones in terms of stone clearance.Materials and Methods: This prospective hospital based study included patients with upper ureteric calculus managed with URSL with DJ stenting or ESWL at Dhulikhel Hospital-Kathmandu University Hospital from August 2014 to December 2015. Stone size, stone clearance, number of sittings, complications and need of other procedure were recorded.Results: Total number of patients undergone ESWL was 49 and URSL was 48. There was no difference in male/ female ratio, age and stone diameter between two groups (P>0.05). Total stone-free ratio was 85.71%(42/49) for ESWL and 81.25%(39/48) for URSL, partial fragmentation requiring shift of modality of treatment was 12.24%(6/49) for ESWL and 12.5%(6/48) for URSL, failed procedure was 2.04%(1/49) for ESWL and 6.25%(3/48%) for URSL(P= 0.577).Conclusion: ESWL is as effective as URSL in the management of upper ureteric calculus with no significant difference in age, male/female ratio, stone diameter and stone free ratio

Laparoscopic cholecystectomy: Conversion rate and complcation

Introduction and Objective: Laparoscopic Cholecystectomy is the standard surgical treatment for gallbladder disease. However, conversion to open surgery is not the complication. Different centers have reported different conversion rates and post operative complications. The objective of this study is to identify conversion rate and post operative complication of laparoscopic cholecystectomyMaterials and Methods: This retrospective study included all laparoscopic cholecystectomies attempted in Dhulikhel hospital during the year 2015. Files of all patients were reviewed to find out the demography of the patients and the indication of Laparoscopic cholecystectomy. The rate of conversion to open cholecystectomy, the underlying reasons for conversion and postoperative complications were analyzed.Results: Out of 324 cases attempted laparoscopic cholecystetomies, two cases with the history of previous laparotomy were excluded to rule out the bias in the result. Out of 322 cases 226(70.18%)were female and 96(29.81%) were male . The mean age was 38 years. Over all conversion rate to open cholecystetomy was 1.86% with frozen calot’s triangle as the most common reason for conversion. The over all postoperative complication was 1.24% with no major bile duct injury.Conclusion: Laparoscopic cholecystectomy can safely be done with low conversion rate and complication.

Comparison of Tzanakis Score vs Alvarado Score in the Effective Diagnosis of Acute Appendicitis

Background Acute appendicitis is the most frequent surgical emergency encountered worldwide. This study was conducted to compare the efficacy of Tzanakis score and Alvarado score in diagnosing acute appendicitis.Objectives The aim of this study is to compare the efficacy of Tzanakis scoring system with Alvarado scoring system in diagnosing AA.Methods This was a retrospective and nonrandomized observational study conducted in Dhulikhel hospital. It included 200 clinically diagnosed cases of acute appendicitis who underwent emergency open or laparoscopic appendectomy during the year 2012. Final diagnosis of acute appendicitis was based on histological findings given by pathologist.Results The sensitivity, specificity, positive predictive value and negative predictive value of Tzanakis score was 86.9%, 75.0, 97.5% and 33.3% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score was 76.0%, 75.0%, 97.2% and 21.4% respectively. Negative appendectomy was 8.0%. Conclusion Tzanakis scoring system is an effective scoring system in diagnosing acute appendicitis.Kathmandu University Medical Journal Vol.12(1) 2014: 48-50

The predictive value of pre-operative symptoms including upper gastrointestinal endoscopy before laparoscopic cholecystectomy for elective symptomatic cholecystolithiasis

BACKGROUND

It has always been a challenge to distinguish between upper gastrointestinal symptoms due to gall stones or any other causes. The persistence of abdominal symptoms even after cholecystectomy is highly discouraging for surgeons.

OBJECTIVE

To evaluate the value of preoperative (UGE) as a routine investigative tool in patients with gall stone disease and to assess the outcome of cholecystectomy in patients with gallstones on preoperative abdominal symptoms.

METHODS

This is a prospective study conducted on 96 cases at the Department of Surgery, Dhulikhel Hospital among ultrasonographically proven gall bladder stones irrespective of age and sex. After the examination, all the patients were subjected to UGE, and biopsy were obtained for histopathology if required. The statistical analysis were performed using spss version 16.

RESULTS

Out of total patients, 84(87.5%) were females and 12(12.5%) were males with a M: F ratio of 1:7. Both the sexes were comparable in age groups. Out of total 96 patients, 53(55.2%) presented with typical pain and 43(44.8%) presented with atypical pain. All the patients were subjected to upper gastrointestinal endoscopy (UGE) and 53(55.2%) had normal findings and 43(44.8%) had various lesions. Patients with typical pattern of pain had normal endoscopic findings and those with atypical pain had pathology in upper gastroendoscopy (p<0.001). Serious pathology resulting to change of the planned treatment was found in three cases (3.12%). Among them two had gastric carcinoma and one had active peptic ulcer disease. The relief rate after the cholecystectomy was significant in patients with typical pain than among those with atypical pain (p<0.001). The commenest post cholecystectomy symptoms were heart burn (10%), abdominal discomfort (9%) and dyspepsia (7%).

CONCLUSION

Presence of atypical pain in patients with gall stones is highly likely to have other coexisting upper gastrointestinal pathologies. Hence, upper gastrointestinal endoscopy prior to elective cholecystectomy in patients with gall stones can be clinically helpful.

Laparoscopic cholecystectomy complication and conversion rate

BACKGROUND

Laparoscopic cholecystectomy has become standard method for treating gallstone. However, different centres have reported different complications and conversion rate. The objective of this study was to evaluate complications and conversion of laparoscopic cholecystectomy into open cholecystectomy in Dhulikhel Hospital, Kathmandu University, Nepal.

METHODS

Files of all patients who had laparoscopic cholecystectomy from January 2005 to December 2009 were reviewed. Out of 119 laparoscopic cholecystectomy cases, 102 were included in the study as complete information was lacking in the rest.

RESULTS

Out of 102 cases, 80 were female. Symptomatic cholelithiasis were 76.47%. The mean hospital stay was 2.48 days. Postoperative complications occurred in 5.88% patients. Conversion rate to open cholecystectomy was 3.92%.

CONCLUSIONS

Laparoscopic cholecystectomy is a reliable and safe surgery. With growing experience in laparoscopic technique, it is possible to bring complications and conversion rate to minimum. However, there will be no significant improvements once learning curve is reached. Rather, the nature of biliary injury may become more severe.

Acute postoperative seizures following anterior temporal lobectomy for intractable partial epilepsy

Recurrence of seizures immediately following epilepsy surgery can be emotionally devastating, and raises concerns about the chances of successfully attaining long-term seizure control. The goals of this study were to investigate the frequency of acute postoperative seizure (APOS) occurring in the 1st postoperative week following anterior temporal lobectomy (ATL) to identify potential risk factors and to determine their prognostic significance.

One hundred sixty consecutive patients who underwent an ATL for intractable nonlesional temporal lobe epilepsy were retrospectively studied. Acute postoperative seizures occurred in 32 patients (20%). None of the following factors were shown to be significantly associated with the occurrence of APOS: age at surgery, duration of epilepsy, side of surgery, extent of neocortical resection, electrocorticography findings, presence of mesial temporal sclerosis, and hippocampal volume measurements (p > 0.05). Patients who suffered from APOS overall had a lower rate of favorable outcome with respect to seizure control at the last follow-up examination than patients without APOS (62.5% compared with 83.6%, p < 0.05). The type of APOS was of prognostic importance, with patients whose APOS were similar to their preoperative habitual seizures having a significantly worse outcome than those whose APOS were auras or were focal motor and/or generalized tonic-clonic seizures (excellent outcome: 14.3%, 77.8%, and 75%, respectively, p < 0.05). Only patients who had APOS similar to preoperative habitual seizures were less likely to have an excellent outcome than patients without APOS (14.3% compared with 75%, p < 0.05). Timing of the APOS and identification of a precipitating factor were of no prognostic importance.

The findings of this study may be useful in counseling patients who suffer from APOS following ATL for temporal lobe epilepsy.

Acute postoperative seizures following anterior temporal lobectomy for intractable partial epilepsy

OBJECT

Recurrence of seizures immediately following epilepsy surgery can be emotionally devastating, and raises concerns about the chances of successfully attaining long-term seizure control. The goals of this study were to investigate the frequency of acute postoperative seizures (APOS) occurring in the 1st postoperative week following anterior temporal lobectomy (ATL) to identify potential risk factors and to determine their prognostic significance.

METHODS

One hundred sixty consecutive patients who underwent an ATL for intractable nonlesional temporal lobe epilepsy were retrospectively studied. Acute postoperative seizures occurred in 32 patients (20%). None of the following factors were shown to be significantly associated with the occurrence of APOS: age at surgery, duration of epilepsy, side of surgery, extent of neocortical resection, electrocorticography findings, presence of mesial temporal sclerosis, and hippocampal volume measurements (p > 0.05). Patients who suffered from APOS overall had a lower rate of favorable outcome with respect to seizure control at the last follow-up examination than patients without APOS (62.5% compared with 83.6%, p < 0.05). The type of APOS was of prognostic importance, with patients whose APOS were similar to their preoperative habitual seizures having a significantly worse outcome than those whose APOS were auras or were focal motor and/or generalized tonic-clonic seizures (excellent outcome: 14.3%, 77.8%, and 75%, respectively, p < 0.05). Only patients who had APOS similar to preoperative habitual seizures were less likely to have an excellent outcome than patients without APOS (14.3% compared with 75%, p < 0.05). Timing of the APOS and identification of a precipitating factor were of no prognostic importance.

CONCLUSIONS

The findings of this study may be useful in counseling patients who suffer from APOS following ATL for temporal lobe epilepsy.