Publications by authors named "Sita Jayalakshmi"

42 Publications

Determinants of mortality and long-term outcome in children with refractory and super refractory status epilepticus.

J Clin Neurosci 2022 Mar 11;97:12-16. Epub 2022 Jan 11.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, India.

Aim: To evaluate factors associated with progression of convulsive refractory status epilepticus(RSE) to super refractory status epilepticus(SRSE) and long term outcome in children.

Materials And Methods: In this open cohort study, data of children admitted with convulsive RSE from 2010 to 2018 was retrospectively analyzed. The outcome at two years was graded according to the Glasgow outcome scale(GOS).

Results: Fifty six children formed study population, 24 progressed to SRSE. The mean age of the study population was 9.38 ± 4.28(2-16) years. There was no significant difference for age between SRSE and RSE children (9.53 ± 4.50 years vs. 9.17 ± 4.06 years; p = 0.756). Acute symptomatic aetiology was the most common aetiology for RSE (57.1%) and SRSE (54.2%). There were no differences for aetiology between children who progressed to SRSE and those who did not. Mean length of stay in the NICU was 13.54 ± 17.53 days and children who progressed to SRSE had a longer length of stay in NICU (4.78 ± 3.03 days vs. 25.21 ± 21.77 days; p < 0.001). The mortality was 14.2%. Acidosis was more common in children who died (27.1% vs. 87.5%;p < 0.001). There was no significant difference in the mortality between RSE and SRSE (9.4% vs. 20.8%; p = 0.268). At latest follow up 34 (60.7%) children had good outcome. Poor outcome was more common in children who progressed to SRSE(29.4% vs. 63.6%;p < 0.015).

Conclusion: Acute symptomatic etiology is more frequent in children with RSE and SRSE. Progression to SRSE did not significantly increase mortality but associated with poor GOS outcome. Encouragingly, 60% of children had good outcome.
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http://dx.doi.org/10.1016/j.jocn.2021.12.030DOI Listing
March 2022

A Case of Drug-resistant Epilepsy Associated with Ring Chromosome 20.

Ann Indian Acad Neurol 2021 Sep-Oct;24(5):805-807. Epub 2021 Apr 16.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.4103/aian.AIAN_1292_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8680879PMC
April 2021

Simultaneous Acute Pulmonary Thromboembolism and Stroke - A Management Dilemma.

Neurol India 2021 Sep-Oct;69(5):1371-1373

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

The management of established pulmonary thromboembolism (PTE) coexisting with acute ischemic stroke (AIS) is quite challenging. We report the case of a 52-year-old man with concurrent massive right middle cerebral artery AIS and acute PTE, who was successfully managed despite the contradictory guidelines to manage them simultaneously. The patient underwent decompression craniotomy followed by anticoagulant therapy. The current case report demonstrates that full-dose heparin, despite being relatively contraindicated in an AIS, can achieve a good outcome when given under close monitoring. The transesophageal echo with bubble contrast during the Valsalva maneuver demonstrated patent foramen ovale with a right to left shunt as a cause of AIS and PTE in this patient.
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http://dx.doi.org/10.4103/0028-3886.329553DOI Listing
November 2021

Current practices in epilepsy monitoring units (EMU) in India.

Seizure 2021 Dec 8;93:13-19. Epub 2021 Oct 8.

Department of Neurology, Avitis Institute of Medical Sciences, Kerala, India.

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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http://dx.doi.org/10.1016/j.seizure.2021.10.004DOI Listing
December 2021

Ictal Smile and Fear In A Child With Refractory Epilepsy - An Interesting Electro Clinical Correlation.

Neurol India 2021 Jul-Aug;69(4):1040-1042

Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Ictal fear is a common manifestation with seizures originating from temporal lobe, orbitofrontal region and cingulate cortex. Ictal smile has been described in association with seizures from hypothalamus, cingulate cortex, lateral and prefrontal cortex. Isolated fear or ictal smile has been reported in various published reports in the past in patients with cingulate epilepsy. We report an unusual semiology with ictal smiling along with fear and preserved sensorium during the event, in a four-year-old child; Our hypothesis was that the ictal origin, most likely from the right mesial frontal or cingulate cortex. The child underwent resective surgery after multimodality evaluation and has been seizure free for 6 years post-surgery.
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http://dx.doi.org/10.4103/0028-3886.325357DOI Listing
September 2021

Predictors of surgical outcome in focal cortical dysplasia and its subtypes.

J Neurosurg 2022 Feb 30;136(2):512-522. Epub 2021 Jul 30.

4Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, India.

Objective: The authors analyzed predictors of surgical outcome in patients with focal cortical dysplasia (FCD) and its ILAE (International League Against Epilepsy) subtypes after noninvasive multimodal evaluation and calculated time to first seizure.

Methods: Data of 355 patients with refractory epilepsy, confirmed FCD pathology, and 2-13 years of postsurgical follow-up were analyzed to determine the predictive roles of clinical, EEG, imaging, and surgical factors that influence seizure freedom.

Results: The mean ± SD age at surgery was 20.26 ± 12.18 years. In total, 142 (40.0%) patients had daily seizures and 90 (25.3%) had multiple seizure types. MRI showed clear-cut FCD in 289 (81.4%) patients. Pathology suggested type I FCD in 27.3% of patients, type II in 28.4%, and type III in 42.8% of patients. At latest follow-up, 72.1% of patients were seizure free and 11.8% were seizure free and not receiving antiepileptic drugs. Among the subtypes, 88.8% of patients with type III, 69.3% with type II, and 50.5% with type I FCD were seizure free. Multiple seizure types, acute postoperative seizures (APOS), and type I FCD were predictors of persistent seizures, whereas type III FCD was the strongest predictor of seizure freedom. Type I FCD was associated with daily seizures, frontal and multilobar distribution, subtle findings on MRI, incomplete resection, and persistent seizures. Type II and III FCD were associated with clear-cut lesion on MRI, regional interictal and ictal EEG onset pattern, focal pattern on ictal SPECT, complete resection, and seizure freedom. Type III FCD was associated with temporal location, whereas type I and II FCD were associated with extratemporal location. Nearly 80% of patients with persistent seizures, mostly those with type I FCD, had their first seizure within 6 months postsurgery.

Conclusions: Long-term seizure freedom after surgery can be achieved in more than two-thirds of patients with FCD after noninvasive multimodal evaluation. Multiple seizure types, type I FCD, and APOS were predictors of persistent seizures. Seizures recurred in about 80% of patients within 6 months postsurgery.
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http://dx.doi.org/10.3171/2020.12.JNS203385DOI Listing
February 2022

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

Seizure 2021 Mar 8;86:60-67. Epub 2021 Jan 8.

Department of Neurology, Avitis Institute of Medical Sciences, Kerala, India.

Objective: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India.

Methods: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers.

Results: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection.

Conclusions: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.
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http://dx.doi.org/10.1016/j.seizure.2020.12.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837209PMC
March 2021

Adjunctive Brivaracetam in Indian Patients with Uncontrolled Focal Epilepsy: Results from a Pooled Analysis of Two Double-Blind, Randomized, Placebo-Controlled Trials.

Neurol India 2020 Nov-Dec;68(6):1400-1408

UCB Pharma, Raleigh, NC, USA.

Background: Nearly one-third of patients don't achieve seizure control with existing antiepileptic drugs. Brivaracetam (BRV) is a new member of the racetam class of drug, designed to selectively target SV2A, with binding affinity 15- to 30-fold greater than that of levetiracetam.

Objective: This pooled analysis reports efficacy and tolerability data of adjunct BRV (50, 100, and 200 mg/day) compared with placebo in Indian patients with uncontrolled focal epilepsy.

Methods: Data of 104 patients (aged 16-80 years) from 2 studies (N01252 and N01358) were pooled for this analysis. The studies comprised an 8-week prospective baseline period, and a 12-week treatment period. The study endpoints included median percent reduction from baseline in focal seizure frequency/28-days, ≥50% responder rate, and seizure freedom (all seizure types). The safety analysis included treatment-emergent adverse events (TEAEs).

Results: The efficacy population comprised 101 patients. In the Indian sub-group population, median percent reduction from baseline in focal seizure frequency/28-days was greater in the BRV dose groups: 39.7% (p = 0.00868), 46.8% (p = 0.00180) and 48.2% (p = 0.05224), for BRV 50, 100, 200 mg/day, respectively, compared with 20.6% for placebo. Responder rates (≥50%) were 38.1%, 45.7%, and 45.5% for BRV 50, 100, and 200 mg/day, respectively, compared with 11.7% for placebo. Complete seizure freedom was reported by 4.8% (1/21) and 2.9% (1/35) of patients on BRV50 and 100 mg/day, respectively, and none out of the 11 and 34 patients on BRV200 mg/day and placebo, respectively. In the safety population (n = 104), most commonly reported TEAEs (reported by ≥5% of patients taking brivaracetam) were headache and cough; most TEAEs were mild or moderate in intensity.

Conclusion: This pooled analysis has provided evidence that adjunct brivaracetam, was effective and well-tolerated in Indian patients with uncontrolled focal epilepsy.
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http://dx.doi.org/10.4103/0028-3886.304103DOI Listing
June 2021

Inter-ictal EEG patterns in malformations of cortical development and epilepsy.

Clin Neurol Neurosurg 2020 09 15;196:106022. Epub 2020 Jun 15.

Department of Radiology, Krishna Institute of Medical Sciences, Secunderabad, India.

Objectives: Malformations of cortical Development (MCDs) are associated with refractory epilepsy. We evaluated scalp inter-ictal EEG patterns in various types of MCD, and its association with clinical features and seizure control.

Patients And Methods: Retrospective analysis of demographic, clinical, inter-ictal EEG and seizure outcome data of 665 patients with epilepsy and MCD with at least two years follow up was performed.

Results: Average age of study population was 15.95 ± 10.79 years with 291(43.8 %) women. Multiregional spikes were more common in children (22.7 % vs 8.5; p < 0.001), if age of onset of epilepsy was <2 years (21.8 % vs 11.4 %; p = 0.001) and polymicrogyria (12.1 % vs 37.3 %; p < 0.001). Generalized epileptiform discharges were more frequent in patients with developmental delay (24.7 % vs 12.6 %; p < 0.001); and were associated with lissencephaly(14.0 % vs 59.3 %; p < 0.001) and heterotopias(14.5 % vs 34.9 %;p = 0.002). Regional spikes were more common if age of onset of epilepsy is >2 years (26.2 % vs 38.4 %; p = 0.003), and also in FCD (17.1 % vs 42.6 %; p < 0.001). At latest follow-up, 151(22.7 %) patients were seizure free; 401(60.7 %) had refractory epilepsy and the rest had remissions with relapse. No association was found between inter-ictal EEG patterns and seizure control.

Conclusion: In patients with MCD, generalized epileptiform discharges were associated with developmental delay, lissencephaly and heterotopias. Regional spikes were frequent in FCD while multiregional spikes in children and polymicrogyria. Inter-ictal EEG patterns did not influence seizure outcome.
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http://dx.doi.org/10.1016/j.clineuro.2020.106022DOI Listing
September 2020

Evaluation of factors influencing obesity and the effect of a 12-week home-based exercise program in people with epilepsy - Randomized control trial.

Epilepsy Behav 2020 09 6;110:107148. Epub 2020 Jun 6.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Background: Association of obesity, quality of life (QoL), and physical fitness in people with epilepsy (PWE) is rarely reported. We evaluate the effect of a 12-week home-based exercise program on weight reduction and physical capacity in PWE.

Methods: In 173 PWE, physical fitness was assessed by using six-minute walk test (6MWT) and one-minute step test. Self-reported QoL data was collected using a 12-Item Short Form Survey (SF-12) questionnaire; further physical (PCS) and mental (MCS) component scores were derived. Effect of exercise was evaluated using randomized study of 110 PWE, divided into control and exercise groups of 55 each.

Results: At baseline, mean age of study population was 25.85 ± 9.62 years with 77 (44.5%) women. Average body mass index (BMI) was 29.33 ± 6.17 kg/m. Mean PCS and MCS were 45.95 ± 7.92 and 45.72 ± 10.40 respectively. In 124 (71.7%) PWE with obesity, while high-density lipoprotein (HDL-C) (46.10 ± 12.32 vs. 39.30 ± 10.39 mg/dL; p < .001) was lower, low-density lipoprotein (LDL-C) (101.60 ± 37.51 vs. 113.89 ± 32.65 mg/dL; p = .035) was high. Both the randomized groups were comparable for type and number of antiepileptic drugs (AEDs) used. At 12-week follow-up, PWE in the exercise group reduced 7.65 ± 5.62 kg while control group gained an average of 4.01 ± 4.74 kg (p < .001). Distance walked in 6MWT (293.07 ± 118.73 vs. 464.29 ± 55.33 m; p = .007) and PCS (48.59 ± 8.57 vs. 52.62 ± 4.03; p = .006) were higher in exercise group whereas MCS did not differ between the groups. None of the participants reported seizure during the 12-week follow-up period.

Conclusion: People with epilepsy have low PCS and MCS scores; PWE with obesity have altered metabolic profile when compared to PWE without obesity. A 12-week, home-based exercise program significantly reduces weight and improves physical capacity, irrespective of AEDs used. Trials with larger sample size and longer follow-up are required to validate our findings.
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http://dx.doi.org/10.1016/j.yebeh.2020.107148DOI Listing
September 2020

Response to Letter to Editor: Metabolic issues in people with epilepsy.

Epilepsy Behav 2020 07 15;108:107089. Epub 2020 Apr 15.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.1016/j.yebeh.2020.107089DOI Listing
July 2020

Metabolic syndrome in people with epilepsy.

Epilepsy Behav 2020 05 10;106:106992. Epub 2020 Mar 10.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Background: Little is known about the association of metabolic syndrome (MetS) and quality of life (QoL) in people with epilepsy (PWE). We evaluate the trends of MetS in PWE across various age groups. We also evaluate the association of MetS and QoL in PWE.

Methods: Clinical and seizure data were collected in 173 people with controlled epilepsy. Physical fitness was assessed by using the six-minute walk test and one-minute step test. Self-reported SF-12 questionnaire, was used to derive physical (PCS) and mental (MCS) component scores.

Results: The average age of the study population was 25.85 ± 9.62 years, and MetS was observed in 91 (52.6%). Obesity was seen in 153 (88.4%). Average distance walked in the six-minute walk test was 385.55 ± 71.52 m. Mean PCS and MCS were 45.95 ± 7.92 and 45.72 ± 10.40, respectively. More number of women had MetS (47.6% vs. 62.6%; p = 0.049) and women in the study population had lower high-density lipoprotein (HDL)-C (44.34 ± 11.60 vs. 38.65 ± 10.13 mm Hg; p < 0.001). Except for the variables that define MetS, none of the clinical characteristics were associated with MetS. Across age groups, prevalence of MetS was consistently at 50.0% although prevalence of hypertension showed a linear increase with age. While low HDL-C was seen highest (61.5%) in ≤20 years age, impaired fasting blood sugar (FBS) was highest in PWE aged >40 years.

Conclusion: Metabolic syndrome is seen in more than half of PWE, and this increased prevalence is not associated with the number of antiepileptic medicines. While prevalence of MetS was stable at 50.0% across all age groups, components of MetS have varying prevalence across age groups hence, suggesting their varied contribution across age groups.
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http://dx.doi.org/10.1016/j.yebeh.2020.106992DOI Listing
May 2020

Ictal FDGPET and SPECT in hemifacial seizures due to cerebellar epilepsy-Case report.

Neurol India 2019 Jan-Feb;67(1):169-172

Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

The role of cerebellum in seizure generation is debatable. Semiology and electroencephalography (EEG) findings are non-specific and sometimes misleading, posing further difficulty in proving the epileptogenicity in pre-surgical workup. We report two cases of cerebellar lesions who presented with hemifacial seizures since the neonatal period and were refractory to antiepileptic drugs (AEDs). Both inter-ictal and ictal EEGs were non-contributory. Magnetic resonance imaging (MRI) showed a lesion in the cerebellum, in proximity to cerebellar peduncle in both the patients. (18) F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and ictal single photon emission computed tomography (SPECT) showed focal hypermetabolism and hyperperfusion respectively, corresponding to the lesion on MRI in both the cases. Intraoperative electrocorticography showed rhythmic spikes confirming the epileptogenic nature of the lesion. Both patients were operated with a favorable surgical outcome. Histopathology was suggestive of a ganglioglioma in one child and a low-grade glioma in the other. Both cases illustrate that FDG-PET and SPECT can act as surrogate markers for invasive recordings to prove the epileptogenicity of cerebellar lesions, especially in resource limited settings.
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http://dx.doi.org/10.4103/0028-3886.253622DOI Listing
December 2019

Migraine and Mood Disorders: Prevalence, Clinical Correlations, and Disability.

J Neurosci Rural Pract 2019 Jan-Mar;10(1):1-2

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.4103/jnrp.jnrp_323_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338002PMC
February 2019

Gelastic seizures due to inferior frontal gyrus cavernoma.

Neurol India 2018 Sep-Oct;66(5):1503-1505

Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.4103/0028-3886.241351DOI Listing
September 2019

Quantifying dementia in normal pressure hydrocephalus: Precision versus pitfalls.

Neurol India 2017 Jul-Aug;65(4):732-733

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.4103/neuroindia.NI_520_17DOI Listing
July 2019

Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography.

Indian J Ophthalmol 2017 May;65(5):354-357

Department of Ophthalmology, Krishna Institute of Medical Sciences, Hyderabad, Telangana, India.

Purpose: The purpose of the study is to present anterior segment optical coherence tomography (AS-OCT) as an alternative method of evaluating Kayser-Fleischer (KF) ring in Wilson disease (WD) not only by ophthalmologists but also by other clinicians dealing with WD.

Materials And Methods: This was a retrospective case series of six WD patients with KF ring. Evaluation of KF ring was done by naked eye examination using torch light, slit lamp biomicroscopy (SL), and AS-OCT. SL examination was done using a narrow slit of the superior cornea. AS-OCT was done using the Optovue RTvue PremierTM device (Fremont, CA, USA).

Results: AS-OCT revealed KF ring as an intense hyperreflective band at the level of Descemet membrane (DM). Color scale of AS-OCT showed KF ring as greenish/greenish yellow/orange yellow/yellowish/red band. Validation of AS-OCT findings was done by second ophthalmologist, medical gastroenterologist, surgical gastroenterologist, and neurophysician. After seeing the first observation, they could identify the AS-OCT features in all pictures with ease.

Conclusions: This is the first observation of KF ring in WD on AS-OCT. On AS-OCT, KF ring is visualized as intense hyperreflectivity at the level of DM in the peripheral cornea. Further, studies are needed to evaluate the usefulness of AS-OCT in WD management.
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http://dx.doi.org/10.4103/ijo.IJO_400_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565897PMC
May 2017

Epilepsy surgery in children.

Neurol India 2017 May-Jun;65(3):485-492

Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Approximately 60% of all patients with epilepsy suffer from focal epilepsy syndromes. In approximately 15% of these patients, the seizures are not adequately controlled with anticonvulsive drugs, and such patients are potential candidates for surgical treatment and majority are children. Epilepsy surgery in children, who have been carefully chosen, can result in either seizure freedom or a marked (>90%) reduction in seizures in approximately two-third of children with intractable seizures. In the multimodality presurgical evaluation approach, sufficient concordance should be established among various independent investigations, thus identifying the location and extent of the epileptogenic zone with a high degree of confidence. Early surgery improves the quality of life and cognitive and developmental outcome of the child. Surgically remediable epilepsies in children should be identified early and include temporal lobe epilepsy with focal lesions, lesional extratemporal epilepsies, hemispherical epilepsies, and gelastic epilepsy with hypothalamic hamartoma, and can be treated by resective or disconnection surgery. Palliative procedures include corpus callosotomy and vagal nerve stimulation for children with diffuse and multifocal epilepsies, who are not candidates for resective surgery. Deep brain stimulation in patients with epilepsy is still under evaluation. For children with "surgically remedial epilepsy," surgery should be offered as a procedure of choice rather than as a treatment of last resort.
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http://dx.doi.org/10.4103/neuroindia.NI_1033_16DOI Listing
July 2019

Legal challenges in neurological practice.

Ann Indian Acad Neurol 2016 Oct;19(Suppl 1):S3-S8

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Clinical neuroscience has made tremendous advances over the last century. Neurology as a discipline is still considered challenging and at times risky due to the natural history and progressive course of few of the neurological diseases. Encouragingly, the patient and their caregivers are now increasingly willing to be actively involved in making decisions. The patients' relationship with the doctor is a reflection of the society. A society that is orienting itself toward "rating" and "feedback" has made this doctor-patient relationship, a consumer-service provider relationship. This perhaps is due to commercialization of health that usually accompanies globalization. Moreover, a rapid influx of information from potential erroneous sources such as the Internet has also made patient and caregivers not being hesitant to taking legal course in the case of adverse events during treatment or simply because of dissatisfaction. The purpose of the legal process initiated by patients with neurological ailments is more often to compensate for the income lost, physical and psychological anguish that accompanies disease and its treatment, and to fund treatment or rehabilitation requirements. However, it is not clearly established if monetary benefits acquired lead to better opportunities for recovery of the patient. The consumer protection act and commercialization of medical services may well have an adverse effect on the doctor and patient relationship. Hence, there is a great need for all medical professionals to mutually complement and update each other. This review examines legal (litigation) processes with special interest on medicolegal system in patients with neurological ailments and the challenges faced by the neurologist during day-to-day clinical practice.
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http://dx.doi.org/10.4103/0972-2327.192888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109758PMC
October 2016

Neuropsychological implications of white matter microstructural lesions determined by diffusion tensor imaging in magnetic resonance imaging-negative temporal lobe epilepsy.

Neurol India 2016 Nov-Dec;64(6):1243-1244

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

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http://dx.doi.org/10.4103/0028-3886.193764DOI Listing
November 2018

Complications of Epilepsy Surgery: A Single Surgeon's Experience from South India.

World Neurosurg 2016 Jul 29;91:16-22. Epub 2016 Mar 29.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.

Objective: Epilepsy surgery is largely underused in developing counties as a result of many misconceptions. The current study evaluates complications of epilepsy surgery performed by a single surgeon from South India.

Methods: A retrospective analysis was performed of 697 consecutive patients who underwent epilepsy surgery. Complications were classified as minor and major medical, neurologic, and psychiatric complications. The study population was divided into groups of surgery for temporal lobe epilepsy (TLE), extratemporal lobe epilepsy (ETLE), and other procedures. Incidence of complications was compared in children aged ≤12 years and those aged >12 years. Engel class I and IIA was classified as favorable outcomes.

Results: The average age of the cohort was 21.9 ± 11.15 years, with 300 (42.8%) females. The mortality was 0.14%. Medical complications were observed in 2%: minor in 10 patients (1.43%) and major in 4 patients (0.57%). In patients with TLE (n = 467), minor and major neurologic complications were observed in 18 patients (3.9%) and 4 patients (0.9%), respectively, and 14 patients (2.9%) had psychiatric complications. In 175 patients with ETLE, the lesion was in noneloquent area in 108; no patients had major and 20 patients (18.5%) had minor neurologic complications. In the remaining 67 patients with ETLE with eloquent area surgery, 29 patients (43.2%) had neurologic deficits as expected, and 12 (17.9%) had major neurologic deficit. Age did not influence complications. Engel favorable outcome was reported in 400 patients with TLE (85.7%) and 116 patients with ETLE (65.2%).

Conclusions: In the current study, risk of mortality was 0.1% and rate of overall major complications was 1.4%. Epilepsy surgery should be increasingly used in developing countries.
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http://dx.doi.org/10.1016/j.wneu.2016.03.068DOI Listing
July 2016

Clinical profile and outcome of refractory convulsive status epilepticus in older children from a developing country.

Seizure 2016 Mar 1;36:31-35. Epub 2016 Feb 1.

Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, India.

Purpose: The current study evaluates the etiology, clinical course and outcome of refractory convulsive status epilepticus (CSE) in older children.

Methods: Retrospective analysis of data of 73 children with CSE, aged ≥2 and ≤12 years was performed. Odds ratios were calculated between variables for clinical course and outcome. Mortality of the group was analyzed using survival analysis.

Results: Thirty three (45.2%) children progressed to refractory status epilepticus (RSE). The most common etiology for CSE was acute symptomatic in 44 (60.3%) of which 37 had presumed CNS infections. The odds of progressing to RSE were higher in children with acute symptomatic etiology (OR 2.62; CI - 95%; 0.99-7.14; p=0.041). Progression to RSE increased the chances of severe sepsis by six times (OR 6.08; CI - 95%; 1.19-31.02; p=0.036) and acidosis by nearly 15 times (OR 14.77; CI - 95%; 1.19-31.02; p=0.020). Overall mortality was 13.7%, higher in RSE (21.2% vs.7.5%). Amongst the 63 surviving children followed for 1 year from discharge, progression to RSE increased the odds of disability by seven times (OR 7.08; CI 29.31; p=0.004).

Conclusion: Acute symptomatic etiology was the commonest cause of CSE among older children from developing country and increased the odds of progressing to RSE. RSE was significantly associated with disability at 1 year from discharge.
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http://dx.doi.org/10.1016/j.seizure.2016.01.014DOI Listing
March 2016

Causes and outcomes of new onset status epilepticus and predictors of refractoriness to therapy.

J Clin Neurosci 2016 Apr 25;26:89-94. Epub 2016 Jan 25.

Department of Neurology, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Secunderabad 500003, Telangana, India.

We aimed to evaluate the determinants of outcome in new onset refractory status epilepticus (SE). A retrospective analysis of patients with new onset SE admitted between May 2005 and October 2013 was performed. Regression analysis was used to determine factors that affect progression of new onset SE to refractory status epilepticus (RSE) and mortality. Among 114 patients with new onset SE, 52 patients progressed to RSE. Sixty seven (58.7%) were men. New onset RSE patients were younger than new onset SE patients (mean 35.9 ± standard deviation18.2 versus 28.7 ± 20.2 years; p=0.050). Cryptogenic aetiology was the most significant determinant of progression of new onset SE to RSE (Exp [β]=5.68; p=0.001). The overall mortality in the entire group was 23.7%, significantly higher in new onset RSE group (40.4% versus 9.7%; p<0.0001). New onset RSE patients with symptomatic and cryptogenic etiology did not differ for clinical characteristics and outcome. Acidosis was the strongest predictor of mortality in the entire cohort (Exp [β]=8.72; p=0.005). Nearly half of the patients with new onset SE progressed to RSE. While cryptogenic aetiology determined progression of new onset SE to RSE, acidosis was associated with mortality. The outcome was similar between symptomatic and cryptogenic new onset RSE.
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http://dx.doi.org/10.1016/j.jocn.2015.06.032DOI Listing
April 2016

Psychiatric disorders among 165 patients with juvenile myoclonic epilepsy in India and association with clinical and sociodemographic variables.

Epilepsy Behav 2015 Dec 28;53:37-42. Epub 2015 Oct 28.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India. Electronic address:

Objective: The current study evaluated the association between clinical variables and psychiatric disorders (PDs) in patients with juvenile myoclonic epilepsy (JME).

Methods: Consecutive patients with JME who had at least two years of regular follow-up from May 2011 to April 2014 formed the study population. The association between clinical and sociodemographic data with psychiatric evaluation on structured clinical interview and quality of life in epilepsy - 31 (QOLIE-31) was evaluated using logistic regression analysis.

Results: Out of 165 patients in the current study, 77 (46.6%) patients were diagnosed with PDs; while 50 were categorized to having anxiety disorders, 27 patients had depressive disorders. The mean age of the study population was 25.35 ± 7.6 years with 37.52% women. Patients with PDs had lower overall QOLIE score (55.84 ± 13.07 vs 68.70 ± 11.23, p<0.001) and lower social function score (80.95 ± 19.22 vs 91.09 ± 14.74, p<0.001). Being married was the strongest predictor of depressive disorders (β=8.59; 95% CI, 1.44-51.28; p=0.018); whereas, lower emotional well-being (β=0.942; 95% CI, 0.907-0.978; p=0.002) was the only variable associated with anxiety disorders. Patients with depressive disorders had longer duration of PDs (11.85 ± 8.68 years vs 7.75 ± 6.70 years, p=0.039), and a majority of them were married (66.7% vs 26.0%, p=0.001). Patients with depressive disorders scored low on emotional well-being (50.81 ± 14.62 vs 61.02 ± 13.05, p=0.002), energy levels (52.78 ± 11.71 vs 62.80 ± 10.84, p<0.001), and social function (70.96 ± 20.69 vs 86.34 ± 16.16, p=0.001). Depressive disorders were more prevalent among married patients above 35 years of age (5.2% vs 36.8%, p=0.042).

Significance: Nearly half of the patients with JME had coexisting PDs. The psychological profile of anxiety disorders was different from depressive disorders in patients with JME. Depressive disorders were more prevalent among older patients with JME, and marriage was strongly associated with depressive disorders.
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http://dx.doi.org/10.1016/j.yebeh.2015.09.024DOI Listing
December 2015

Aetiology and outcome of generalized convulsive status epilepticus in elderly.

Seizure 2015 Jul 11;29:104-8. Epub 2015 Apr 11.

Department of Neurology, Krishna Institute of Medical Sciences, Hyderabad, India.

Purpose: Convulsive status epilepticus (CSE) is a common neurologic emergency in elderly people. The current study elaborates the clinical characteristics and outcome of CSE in elderly patients.

Methods: Analysis of data of generalized CSE patients, aged 60 years and above admitted at the neurointensive care unit (NICU) was performed. The primary outcome for analysis was in-hospital mortality. The study population was divided into groups based on progression of CSE and mortality to analyze difference in study variables. Mortality of the group was analyzed using life tables.

Results: A total of 33 patients satisfied the inclusion criteria from medical records of 212 patients with CSE. Mean age of the study population was 67.0 ± 6.8 years; 69.7% were men. Acute symptomatic aetiology was the commonest cause of CSE (60.6%); nine (27.3%) patients progressed to refractory status epilepticus (RSE) of which five patients had prolonged RSE. The overall mortality was 18.2%. Complications of mechanical ventilation and mean age were higher in patients who died. Though vascular aetiology was the leading cause of CSE (39.3%), it was not associated with progression to RSE or mortality. Acute symptomatic aetiology accounted for five out of the six deaths in the entire cohort.

Conclusion: Less than one-third of elderly patients with CSE progressed to RSE. Vascular aetiology, the leading cause of generalized CSE in elderly, was not associated with progression to RSE and mortality. Acute symptomatic aetiology was associated with high mortality.
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http://dx.doi.org/10.1016/j.seizure.2015.03.011DOI Listing
July 2015

An observational study on outcome of hemispherotomy in children with refractory epilepsy.

Int J Surg 2016 Dec 4;36(Pt B):477-482. Epub 2015 Jun 4.

Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, 03 Telangana, India.

Introduction: The current study aimed to evaluate the clinical characteristics and outcome of hemispherotomy in children with refractory hemispherical epilepsy.

Methods: Retrospective analysis of data in twenty one children aged ≤12 years who underwent hemispherotomy and had at least two years post surgery follow-up was performed. Sixteen children underwent Delalande's vertical para-sagittal hemispherotomy (VPH), while lateral peri-insular functional hemispherotomy was performed in the rest.

Results & Discussion: The average age of onset for epilepsy in the study population was 2.9 ± 2.4 years; the average duration of epilepsy was 4.0 ± 2.9 years. The mean age at surgery of the study population was 6.8 ± 2.8 years. Six (28.5%) children were girls. Gliosis due to presumed childhood infarct was most common etiology, observed in 13 (62.0%) of the children, followed by Rasmussen's encephalitis in six (28.5%). There was no significant difference between the surgery groups for the reported acute post operative seizures (APOS) (20.0% vs. 25.0%; p = 1.000). At last follow up 90.5% patients were seizure free; there was no difference between the groups for seizure freedom (60.0% vs. 87.5%; p = 0.228). When analyzed for outcome between the etiologies, seizure freedom was similar for gliosis due to infarct (76.9%), Rassmussens encephalitis (83.3%) and malformations of cortical development (MCD) (100.0%). Moreover, improved quality of life in epilepsy (QOLIE) scores was observed in 80.0% of the lateral peri-insular functional hemispherotomy group and 87.5% children in VPH group at the last follow-up.

Conclusion: Gliosis due to presumed childhood infarct was the leading cause of medically refractory epilepsy caused by hemispheric lesions in the current study. Encouragingly, hemispherotomy offers seizure freedom (in 90.5% patients) and improvement in QOLIE scores at two years follow up.
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http://dx.doi.org/10.1016/j.ijsu.2015.05.049DOI Listing
December 2016

Outcome of surgery for temporal lobe epilepsy in adults - A cohort study.

Int J Surg 2016 Dec 12;36(Pt B):443-447. Epub 2015 May 12.

Department of Neurosurgery, Krishna Institute of Medical Sciences, Minister Road, Secunderabad - 03, Telangana, India.

Introduction: The aim of the current study was to evaluate the factors associated with post-operative outcome in patients with temporal lobe epilepsy (TLE) undergoing Surgery.

Methods: We analyzed data of 288 consecutive patients operated for drug-resistant TLE. All the patients had at least one year post surgery follow-up. Logistic regression model was used to evaluate the predictive value of different factors for outcome.

Results: The mean age at onset of epilepsy of the study population was 15.51 ± 9.79 years; whereas the mean age at surgery was 32.16 ± 9.45 years, with 125 (43.4%) women. The age at surgery was significantly lower in the patients with favourable outcome (30.26 ± 9.05 vs. 34.06 ± 9.85 years; p = 0.007). The mean duration of epilepsy with age of onset below 12 years was higher than the rest (19.84 ± 7.30 vs. 13.00 ± 8.45 years; p < 0.001). The histopathology showed hippocampal sclerosis in 203 (70.4%) of the patients; isolated focal cortical dysplasia was associated with unfavourable outcome (9.3% vs.2.6%; p = 0.036). The duration of follow up ranged from 1 to 10.3 years. Three patients died late in the follow up. At the last follow 73% were seizure free and Engel's favourable outcome was noted in 82%. Duration of epilepsy greater than ten years (β = 6.997; 95%CI; 2.254-21.715; p = 0.01), younger age of onset of epilepsy (β = 1.07; 95%CI; 1.014-1.132; p = 0.015) and acute post operative seizures (APOS) (β = 4.761; 95%CI; 1.946-11.649; p = 0.001) were the predictors of unfavourable outcome.

Conclusion: Following surgery for TLE, 73% were seizure free and Engel's favourable outcome was noted in 82%. The predictors of unfavourable outcome were younger age of onset, pronged duration and of epilepsy and APOS.
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http://dx.doi.org/10.1016/j.ijsu.2015.05.006DOI Listing
December 2016

Pediatric ischemic stroke due to dengue vasculitis.

Pediatr Neurol 2014 Oct 1;51(4):570-2. Epub 2014 Jul 1.

Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India.

Background: Dengue infection is an important arboviral infection in southeast Asia, especially in India. Neurological manifestations of dengue are increasingly recognized.

Methods: We report an ischemic stroke due to dengue vasculitis in an 8-year-old child.

Patient: We present a girl with a short febrile illness followed by episodic severe headache, with gradually progressive hemiparesis and visual impairment. Her brain magnetic resonance imaging revealed multiple infarctions in the anterior and posterior circulation. The magnetic resonance angiogram revealed irregular narrowing of bilateral middle cerebral arteries, right anterior cerebral artery, left posterior cerebral, and bilateral vertebral arteries suggestive of vasculitis. Her dengue serology was strongly positive for immunoglobulin M with 68.9 panbio units. The rest of the evaluation for pediatric stroke was unremarkable. She was treated with intravenous followed by oral corticosteroids and recovered totally with resolution of vasculitis on magnetic resonance angiogram over the next 3 months.

Conclusion: This child illustrates possible immune-mediated vasculitis caused by dengue infection which is rather a rare presentation in a child who subsequently recovered well. One should consider dengue in childhood strokes in endemic regions.
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http://dx.doi.org/10.1016/j.pediatrneurol.2014.06.019DOI Listing
October 2014

Determinants and predictors of outcome in super refractory status epilepticus--a developing country perspective.

Epilepsy Res 2014 Nov 30;108(9):1609-17. Epub 2014 Aug 30.

Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad 03, Andhra Pradesh, India.

Importance: Super refractory status epilepticus (SRSE) is a recent entity. There is limited information about the etiology and outcome of SRSE from developing countries.

Objective: We evaluated determinants and predictors of outcome in patients with convulsive SRSE in Indian population.

Methods: In this open cohort study, data of patients with convulsive SE admitted in neurointensive care unit (NICU) from 2005 to 2013 was retrospectively analyzed. Regression and survival analysis was done for outcome of patients divided into non refractory SE (NRSE), refractory SE (RSE), and SRSE groups.

Main Outcome Measure: The primary outcome for analysis was in hospital mortality. Also functional outcome at 6 months was graded according to the Glasgow outcome scale (GOS), and classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome groups.

Results: Out of 177 patients with SE, 105 (59.3%) had NRSE; 72 (40.7%) had RSE of which 30 (16.9% of 177) were sub-classified as SRSE. SRSE was frequent (39%) in children (p<0.01), elderly (21.7%; p<0.003), and in incident SE (82.1%, p=0.05). Encephalitis was the commonest etiology in RSE (30.9%, p=0.015), SRSE (66.7%, p<0.001) than NRSE (12.3%). Encephalitis (β=8.250 (1.8-37.82); p=0.007) was the determinant of the progression of SE to SRSE. Overall mortality was 19.2%, highest in SRSE (40.0%) followed by RSE (35.7%), both significantly (p<0.001) higher than NRSE (6.7%). Mortality was high in patients with encephalitis than other etiologies (39.1% vs. 12.1%; p=0.001). Acidosis predicted mortality in the entire cohort (β=7.313 (1.6-32.58); p=0.009); however none of the variables predicted mortality in SRSE patients. At 6 months follow up only 33.3% of patients with SRSE were in GOS good outcome group when compared to RSE (33.3% vs. 57.1%; p=0.055), and NRSE (33.3% vs. 79.1%; p<0.0001).

Conclusions And Relevance: SRSE is common in children, elderly, and incident SE. Encephalitis was the determinant of progression of SE to SRSE. None of the variables predicted mortality in SRSE patients. Sixty percent of patients with SRSE survived and one third had good outcome. Therefore one should continue the care inspite of weeks of SE.
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http://dx.doi.org/10.1016/j.eplepsyres.2014.08.010DOI Listing
November 2014

Prognosis and predictors of outcome of refractory generalized convulsive status epilepticus in adults treated in neurointensive care unit.

Clin Neurol Neurosurg 2014 Nov 21;126:7-10. Epub 2014 Aug 21.

Department of Neurology, Krishna Institute of Medical Sciences, Minister Road, Secunderabad500 003, Andhra Pradesh, India.

Objective: To evaluate the etiological profile, clinical characteristics and outcome of patients with refractory generalized convulsive status epilepticus treated in Neurological Intensive Care Unit (NICU).

Methods: In this open cohort study, data of 126 patients, aged 18 years and above, with convulsive status epilepticus (SE) admitted in NICU was collected. Status epilepticus was defined as seizures lasting for more than five minutes without regaining consciousness. Refractory SE (RSE) was defined as SE refractory to 2 antiepileptic drugs and requiring anesthetic agents for seizure control. Survival and regression analysis were done to analyze the outcome and factors predicting outcome respectively in the study population.

Results: Out of 126 patients, 81 patients had non -refractory status epilepticus (NRSE); 45 (35.7%) had RSE. Acute symptomatic etiology was noted in 58.6% of entire cohort. Significantly higher percentage of patients with RSE had an etiology of CNS infections than NRSE group (44.4% vs. 23.5%; P=0.0171). Amongst the CNS infections, viral encephalitis was significantly higher in RSE than NRSE patients (31% vs. 6.2%; P=0.0004). All the patients with RSE required mechanical ventilation. Overall mortality was 19%. The mortality in RSE was 42% (19 out of 45), significantly higher when compared to NRSE where only 6% (5 out of 81) died. On logistic regression, the only predictor of death was fever with an odds ratio of 8.55 (P=0.024).

Conclusion: CNS infections, especially viral encephalitis and complications of mechanical ventilation were significantly higher in adult RSE patients. Although mortality is higher in adult patients with RSE, etiology does not contribute to mortality; however fever predicts mortality in these patients. Aggressive management of underlying etiology and prevention of systemic complications may improve outcome in adult RSE patients.
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http://dx.doi.org/10.1016/j.clineuro.2014.07.038DOI Listing
November 2014
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