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Perspectives of epilepsy surgery in resource-poor countries: a study in Georgia

  • Clinical Article - Functional
  • Published:
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Abstract

Background

To identify patients with concordant seizure semiology, interictal epileptiform discharges on standard EEG and brain MRI changes to define the patients with pharmacoresistant epilepsy (PRE) who would be suitable for epilepsy surgery according to non-invasive protocol.

Methods

The medical records of the patients with epilepsy seen in Epilepsy Center of Institute of Neurology and Neuropsychology (ECINN) (Tbilisi, Georgia) were reviewed retrospectively. The diagnostic work-up included neurological examination, standard EEG, and MRI. The degree of concordance of the seizure semiology, EEG, and neuroimaging was used to determine the potential candidates for surgery. The probability of seizure freedom rate was estimated based on known predictive values of anatomical, electrophysiological, and semiological characteristics.

Results

A total of 83 (25 %) patients met the criteria of PRE. Fourteen (17 %) patients had complete concordance of seizure semiology, MRI, and EEG. Out of these patients, 11 had mesial temporal sclerosis on MRI and three had focal cortical dysplasia (FCD). Estimated seizure-free surgical success rate in this group was 75–95 % without the need for further investigations. Out of 25 (30 %) non-lesional MRI cases, the concordance of seizure semiology and EEG was in nine patients with probable success rate up to 60 %. Thirteen patients (16 %) had discordant EEG and MRI data and were not suitable for surgery without further testing.

Conclusions

A significant portion of PRE patients with concordant anatomical, electrophysiological, and semiological characteristics can be treated surgically in resource-limited countries. Nevertheless, most patients will still require further investigation for proper localization of epileptogenic focus.

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Acknowledgments

The study was performed within the frame of the Shota Rustaveli National Science Foundation’s Grant “Epidemiology and risk factors of pharmacoresistant epilepsy in Georgia” (Project number DI/40/8-313/11). We are grateful to G. Kutchuchidze, T. Tchintcharauli, T. Kobulashvili, D. Kvernadze, K. Geladze, and M. Khvadagiani for providing support for the implementation of the project. We are grateful to M. Okujava for reviewing the MRIs.

Ethical standards

The study was scrutinized and approved by the National Committee of Bioethics and was carried with full adherence to the principles of the Declaration of Helsinki, 1964. Before inclusion in the study, all participants gave informed consent.

Conflict of interest

The funding source has not been involved in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. GL, GJ and SK were paid for their job within the grant DI/40/8-313/11. None of other authors have conflict of interest to declare.

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Authors and Affiliations

  1. Institute of Neurology and Neuropsychology, 83/11 Vazha-Pshavela Ave., Tbilisi, 0186, Georgia

    Sofia Kasradze, Maia Alkhidze, Giorgi Lomidze & Giorgi Japaridze

  2. Iv. Javakhishvili Tbilisi State University, 0179, Tbilisi, Georgia

    Maia Alkhidze & Aleksander Tsiskaridze

  3. Virtua Neuroscience, 08043, Voorhees, NJ, USA

    Andro Zangaladze

Authors
  1. Sofia Kasradze
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  2. Maia Alkhidze
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  3. Giorgi Lomidze
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  4. Giorgi Japaridze
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  5. Aleksander Tsiskaridze
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  6. Andro Zangaladze
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Corresponding author

Correspondence to Maia Alkhidze.

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Comments

This study is trying to establish arguments to overcome the problem of establishing an epilepsy surgery center in a country where resources to create new cost-intensive treatments is difficult. It is well known that presurgical evaluation can frequently be expensive due to the necessity to have video EEG places with round-the-clock monitoring personnel. In addition, a whole group of experts is needed, such as EEG technicians, epileptologists, experienced EEG readers, neuropsychologists, a modern era MRI, and, as another source of high expense, the technology of implanted electrode evaluations. This problem is certainly not restricted to Georgia; there are other countries in Europe and around the world that are in the same situation.

The authors have done a good job of carefully reviewing the literature and using the data obtained from the literature to identify potential candidates for epilepsy surgery from their annual patient load. They were able to identify 83 potential candidates with drug-resistant epilepsy who in theory would deserve to be evaluated if they are suitable candidates for epilepsy surgery. The paper is obviously written with the intention to convince the local authorities to invest the money for the creation of an epilepsy surgery service. The calculations are based on good data. The study was carefully done, and I think the conclusions are correct. The numbers they found are in accordance with the percentages known from other countries. The study was performed by a neurology group specialized in epileptology and is indirectly related to neurosurgery by pointing out that even with limited resources, for example no intracranial electrode placement, it is still possible to identify surgical candidates. This was done in a convincing fashion.

These arguments may be useful for other joint neurology/neurosurgery groups who want to convince their administrations to establish an epilepsy surgery center.

Johannes Schramm

Bonn, Germany

The authors present a study looking to justify the setting up of an epilepsy surgery program for Georgia (population of 4 million) based on seizure semiology, inter-ictal EEG, and MRI. Temporal lobe epilepsy remains the “mainstay” of adult epilepsy surgery and the authors estimate a “pool” of over 400 cases of MTS in the country, many of which will be potential surgical candidates. Considering that surgery for MTS is one of the few neurosurgical procedures for which there is class I evidence, and with a high chance of rendering the patients seizure free (and hence being highly cost effective), this is the obvious cohort on which to initially develop the service. It is surprising that this study did not identify more glioneuronal tumors—another cohort of lesional epilepsy cases, which are potentially good surgical candidates. For left mesial temporal lesions, some form of memory assessment would add to the pre-evaluation work-up. To undertake non-lesional work on the basis of such a limited assessment may prove more challenging and less rewarding—especially when one considers the Mayo Clinic experience where only 11 % of extra-temporal non-lesional cases had an excellent outcome.

Interestingly, the rate of MTS appears to be decreasing in most developed counties and, despite guidelines, the numbers of patients receiving surgery has always fallen well short of the predicted numbers of patients who might benefit from such surgery. While the authors have supplied good evidence for the need of a service in Georgia, we suspect that once the “backlog” of cases (resulting in a high prevalence) is dealt with, the incidence of new cases coming to surgery will be more modest than that predicted by the authors.

Paul Chumas

Leeds, UK

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Kasradze, S., Alkhidze, M., Lomidze, G. et al. Perspectives of epilepsy surgery in resource-poor countries: a study in Georgia. Acta Neurochir 157, 1533–1540 (2015). https://doi.org/10.1007/s00701-015-2496-3

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  • DOI: https://doi.org/10.1007/s00701-015-2496-3

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