Presurgical Evaluation of Epilepsy Surgery

Drug-resistant epilepsy (DRE) is defined as failure of two adequate trials of appropriately chosen and administered antiepileptic drugs. Approximately about 30% of epilepsy patients are drug resistant. Accountable reasons to treatment failure including failure to recognize epilepsy syndrome, poor drug compliance, lifestyle factors, etc. In modern era of medicine, DRE patient should be encouraged to have early referral to tertiary epilepsy centre for presurgical evaluation. Comprehensive neurophysiology, structural neuroimaging, and neuropsychological and psychiatric assessment are regarded as essential elements. Invasive electroencephalography (EEG) monitoring in terms of subdural electrodes, depth electrodes, foramen ovale electrodes, and more advanced technique using stereoelectroencephalography (SEEG) are strong armamentarium for epilepsy surgeon. Epilepsy surgery in terms of resection, disconnection, or neuro-modulation should be recommended after a multi-disciplinary agreement

Overview of Radiosurgery for Intracranial Meningiomas

Meningiomas are the second common Central Nervous System (CNS) neoplasm, and are the most common benign intracranial tumor. They approximately constitute up to 30% of all intracranial tumors. They arise from the arachnoidal coverings of brain. Presentation varies and depends on size, number and location of tumors. Symptoms include those related to increased in intracranial pressure, local irritative features including seizure and local pressure effect to eloquent areas, white matter tracts and cranial nerves. Management of meningiomsa is always challenging and multi-disciplinary approaches includes surgery, radiotherapy and possible chemotherapy and immunotherapy. Among radiation therapy treatment, stereotactic radiosurgery (SRS) or stereotactic radiosurgery (SRT) is getting the popularity compared to traditional conformal radiotherapy with comparable tumor control rate

Emerging Trends in the Management of Cryptogenic Epilepsy

Cryptogenic epilepsy, accounting for ~40% of adult-onset epilepsies and a lesser proportion in paediatrics, is defined as epilepsy of presumed symptomatic nature in which the cause has not been identified. It has a higher prevalence of refractory seizures when compared to those with idiopathic epilepsy (40 vs. 26%). These patients are usually treated with multiple anti-epileptic drugs, yet the total number of which used is inversely proportional to their efficacy. Moreover, these children may have significantly worse behavioural problems and can result in substantial cognitive impairments when older. Luckily, the number of cryptogenic epilepsy cases is diminishing due to better diagnostic abilities in recent years. We aim to divide this chapter into three parts. First, we hope to discuss our working algorithm and explain the use and advantages of different imaging modalities including high-field 3-Tesla MRI with morphological analysis for accurate localisation of the epileptogenic foci. We shall then elaborate the concept of the epileptogenic circuit and explore the selection criteria for more invasive approaches, such as depth electrodes and SEEG. Last but not the least, we aim to discuss the surgical treatments, including VNS and DBS, and their outcomes in these patients

Light at the End of the Tunnel - Video

A 24-year-old Chinese man presented with 1-year history of progressive blurring of vision of the right eye. He had no significant past ocular nor medical history except moderate myopia and migraine. On ophthalmologic examination, his corrected visual acuity at distance was 20/100 OD and 20/30 OS. Ishihara OD failed test plate, OS 3/14. Ocular examination, including intraocular pressure, was normal, except the finding of bilateral disc pallor with enlarged cup-disc ratio of 0.9 OD and 0.7 OS. Visual field examination showed OD general depression and OS tunnel vision. OCT retinal nerve fiber layer analysis confirmed optic atrophy OU. MRI brain and orbit with contrast did not show any optic nerve abnormalities, but there were abnormal T2 hyperintensities at the genu of corpus callosum and the adjacent white matter, which were commented as highly suggestive of demyelinating disease. Other investigations including C-reactive protein, anti-nuclear antibody, rheumatoid factor, vitamin B12, folate levels were all normal. Neuromyelitis optica antibody was not found. Lumber puncture showed CSF white cell count of 13 (99% lymphocyte), and oligoclonal bands were present. Alpha-fetoprotein (AFP) and beta- human chorionic gonadotropin (b-HCG) levels, in serum and CSF, were normal. Multiple sclerosis was suspected, and intravenous steroid therapy was considered, but withheld since the diagnosis was not certain and there was no definite evidence of acute deterioration. When reviewed 2 months after initial presentation, his visual acuity had dropped to 20/400 OS and 20/100 OS. In view of the rapidly deteriorating visual acuity, the MRI was reviewed. It was felt the nodular ependymal and hypothalamus/ pituitary stalk lesions were atypical for demyelination. A diagnostic procedure was performed.VBintracranialtumor

Light at the End of the Tunnel - Abstract

A 24-year-old Chinese man presented with 1-year history of progressive blurring of vision of the right eye. He had no significant past ocular nor medical history except moderate myopia and migraine. On ophthalmologic examination, his corrected visual acuity at distance was 20/100 OD and 20/30 OS. Ishihara OD failed test plate, OS 3/14. Ocular examination, including intraocular pressure, was normal, except the finding of bilateral disc pallor with enlarged cup-disc ratio of 0.9 OD and 0.7 OS. Visual field examination showed OD general depression and OS tunnel vision. OCT retinal nerve fiber layer analysis confirmed optic atrophy OU. MRI brain and orbit with contrast did not show any optic nerve abnormalities, but there were abnormal T2 hyperintensities at the genu of corpus callosum and the adjacent white matter, which were commented as highly suggestive of demyelinating disease. Other investigations including C-reactive protein, anti-nuclear antibody, rheumatoid factor, vitamin B12, folate levels were all normal. Neuromyelitis optica antibody was not found. Lumber puncture showed CSF white cell count of 13 (99% lymphocyte), and oligoclonal bands were present. Alpha-fetoprotein (AFP) and beta- human chorionic gonadotropin (b-HCG) levels, in serum and CSF, were normal. Multiple sclerosis was suspected, and intravenous steroid therapy was considered, but withheld since the diagnosis was not certain and there was no definite evidence of acute deterioration. When reviewed 2 months after initial presentation, his visual acuity had dropped to 20/400 OS and 20/100 OS. In view of the rapidly deteriorating visual acuity, the MRI was reviewed. It was felt the nodular ependymal and hypothalamus/ pituitary stalk lesions were atypical for demyelination. A diagnostic procedure was performed.VBintracranialtumor

Light at the End of the Tunnel - Slides

A 24-year-old Chinese man presented with 1-year history of progressive blurring of vision of the right eye. He had no significant past ocular nor medical history except moderate myopia and migraine. On ophthalmologic examination, his corrected visual acuity at distance was 20/100 OD and 20/30 OS. Ishihara OD failed test plate, OS 3/14. Ocular examination, including intraocular pressure, was normal, except the finding of bilateral disc pallor with enlarged cup-disc ratio of 0.9 OD and 0.7 OS. Visual field examination showed OD general depression and OS tunnel vision. OCT retinal nerve fiber layer analysis confirmed optic atrophy OU. MRI brain and orbit with contrast did not show any optic nerve abnormalities, but there were abnormal T2 hyperintensities at the genu of corpus callosum and the adjacent white matter, which were commented as highly suggestive of demyelinating disease. Other investigations including C-reactive protein, anti-nuclear antibody, rheumatoid factor, vitamin B12, folate levels were all normal. Neuromyelitis optica antibody was not found. Lumber puncture showed CSF white cell count of 13 (99% lymphocyte), and oligoclonal bands were present. Alpha-fetoprotein (AFP) and beta- human chorionic gonadotropin (b-HCG) levels, in serum and CSF, were normal. Multiple sclerosis was suspected, and intravenous steroid therapy was considered, but withheld since the diagnosis was not certain and there was no definite evidence of acute deterioration. When reviewed 2 months after initial presentation, his visual acuity had dropped to 20/400 OS and 20/100 OS. In view of the rapidly deteriorating visual acuity, the MRI was reviewed. It was felt the nodular ependymal and hypothalamus/ pituitary stalk lesions were atypical for demyelination. A diagnostic procedure was performed.VBintracranialtumor

Mimicking multiple sclerosis - Ghost tumor that comes and goes in different parts of the brain without any treatment

Lesions that spontaneously come and go in central nervous system without any treatment at different time points and at different locations (CNS) usually lead ones to think of the possibilities of multiple sclerosis. However, sometimes there are exceptions. Surgical biopsy remains an important tool for definitive diagnosis in difficult cases. We report a case of intracranial diffuse large B cell lymphoma that spontaneously disappeared without any treatment and then reappeared at different time points and different locations

Letter to the Editor: Broader trauma: Considerations for COVID-19 psychosocial interventions in Hong Kong

Work published in Asian Journal of Psychiatry