Handbook of Clinical Neurology, Vol. 108 (3rd series)Epilepsy, Part IIH. Stefan and W.H. Theodore, Editors# 2012 Elsevier B.V. All rights reserved

Chapter 57

Epilepsy surgery in developing countries

MANUEL G. CAMPOS*

Epilepsy Center and Department of Neurosurgery, Clínica Las Condes, Santiago, Chile

INTRODUCTION

Epilepsy is a common, serious, chronic neurologicalcondition with high prevalence worldwide, but particularlyin developing countries. Data suggest that 80% of the 50million people with epilepsy worldwide live in the develop-ing world (Sander and Shorvon, 1996; Scott et al., 2001;Radhakrishnan, 2009). Chronic epilepsy results in signifi-cant economic costs, especially in cases of medicallyrefractory epilepsy, which requires continued symptomatictreatment. In addition, people’s ability to work and to re-ceive vocational training can be affected, contributing toa significant social and psychological burden for them(Shorvon and Farmer, 1988; Yoon et al., 2009).

In the last two decades, epilepsy surgery programshave been increasingly developed worldwide (Camposet al., 2000; Williamson and Jobst, 2000; Lachhwaniand Radhakrishnan, 2008; Moodley and Khamlichi,2008), since epilepsy surgery is the best treatment forfocal refractory epilepsy, especially when it is associatedwith a focal lesion (Wiebe et al., 2001; Yoon et al., 2003;Radhakrishnan et al., 2008).

In the adult population, at least 25% of people withepilepsy have uncontrolled seizures despite optimal anti-epileptic drug (AED) treatment (Engel et al., 1997;Semah et al., 1998; Brodie et al., 2012); this percentageis even greater in children (Aicardi, 1997). On average,approximately 10% of people with epilepsy could beconsidered good candidates for epilepsy surgery. How-ever, fewer than 4% of potential candidates receive sur-gical treatment, even in developed countries such asGermany and the USA. For example, it is estimated thatonly 2000 of nearly 100000 eligible patients in the USAundergo epilepsy surgical procedures each year(Campos andWiebe, 2008). The number of patients withrefractory epilepsy without surgical alternatives ishigher in developing countries (Williamson and Jobst,

*Correspondence to: Manuel G. Campos, M.D., Centro de Epilep

Chile. Tel: þ56 2 610 4609, Fax: þ56 2 219 0267, E-mail: mcamp

2000; Radhakrishnan et al., 2008) (Table 57.1). In a2006 survey conducted by the International Leagueagainst Epilepsy (ILAE), the Bureau for Epilepsy(IBE), and the World Health Organization (WHO), epi-lepsy surgery was found to be available in only 13% oflow-income countries (Dua et al., 2006).

Appropriate presurgical evaluation is basic to optimizesurgical therapy (Duchowny et al., 1997; NeuroimagingCommission of ILAE, 1998; Binnen and Polkey, 2000;Campos et al., 2008). Detection of magnetic resonanceimaging (MRI) abnormalities and electroencephalo-graphic (EEG) seizure onset are the most important initialsteps for patients being considered for surgery (Berget al., 2003; Campos et al., 2008). MRI has allowed earlyidentification of potential surgical candidates, whichmany investigators feel increases the chance of success,as well as selection of candidates destined to have a post-operative seizure-free outcome (Yoon et al., 2003; Toniniand Beghi, 2004; Jeha et al., 2006).

Twenty years ago, only 10 countries had epilepsy sur-gical programs. By 2000, in contrast, 26 had such pro-grams (Wieser and Silfvenius, 2000), the majority indeveloped countries. Nevertheless, epilepsy surgery re-mains underused, even in developed countries (CamposandWiebe, 2008). Evaluation for epilepsy surgery is oftendelayed, ranging from 8 to 20 years (Wiebe and Gafni,1995; Platt and Sperling, 2002; Campos et al., 2008). Thisis inappropriate if we compare the proven benefits of epi-lepsy surgery against the poorer quality of life and in-creased risk of death for patients with refractory epilepsy.

Several reasons underlie this phenomenon. Becauseof the introduction of many new AEDs over the pasttwo decades, the duration between epilepsy onset andreferral for surgical treatment may have actually in-creased (Engel, 2008). Physicians’ and patients’ percep-tion of the surgery as invasive and irreversible make it a

sias, Clınica Las Condes, Lo Fontecilla 441, Santiago de Chile,

os@clc.cl

Table 57.1

Number of epilepsy surgical procedures per year, in some

Latin American countries, India, Germany, and USA

India 1 per each 3651 173 Habitants (300 surgeries in1095351995 Habitants)

Ecuador 1 per each 1083333 Habitants (12 surgeries in13 million Habitants)

Mexico 1 per each 454545 Habitants (220 surgeries in100 million Habitants)

Colombia 1 per each 390909 Habitants (110 surgeries in

43 million Habitants)Brazil* 1 per each 308000 Habitants (650 surgeries in

200 million Habitants)

Uruguay 1 per each 300000 Habitants (10 surgeries in 3million Habitants)

Chile 1 per each 283333 Habitants (60 surgeries in 17

million Habitants)Germany 1 per each 164000 Habitants (500 surgeries in

82 million Habitants)USA 1 per each 133500 Habitants (2000 surgeries in

267 million Habitants)

*Only cases from epilepsy surgical programs with governmental sup-

port. Private cases are not included, because the information is not

available.

944 M.G. CAM

therapy of last resort (Engel, 1999). In many parts of theworld, especially in developing countries, the determin-ing factor is a lack of resources. In many African coun-tries, for example, even MRI and EEG may beunavailable or too expensive for most patients. Manage-ment of complex cases, for example requiring presurgi-cal evaluation with intracranial EEG, may be beyond thecapabilities and expertise of many countries.

Unfortunately, information about epilepsy surgery indeveloping countries is limited. The majority of paperscome from a small number of developing countries andtend to emphasize economic aspects, rather than dis-cussing diagnostic and treatment approaches that mightbe most effective in limited resource settings. This chap-ter presents an analysis of the information currentlyavailable.

EPILEPSYSURGERY: DIFFERENCESBETWEENDEVELOPEDANDDEVELOPING COUNTRIES

Access to epilepsy surgery

The problems surrounding increasing costs of treatingepilepsy are magnified in developing countries wherehealthcare resources are scarce. Excellent neurologyand neurosurgery services exist throughout Asia andSouth and Central America but they tend to be concen-trated in major cities. Public or private health insurancesystems are not as prevalent or comprehensive in

developing countries as in Western Europe and NorthAmerica, and many patients who could benefit fromtreatment cannot receive it. This “treatment gap” is duein part to economic factors such as relatively low averageper capita income and expenditure on health (Shorvon andFarmer, 1988; World Health Organization, 2004; Camposand Wiebe, 2008; Qiu, 2009; Radhakrishnan, 2009)(Table 57.2).

However, political, social and organizational factorsare also highly relevant. A good example is LatinAmerica,where the number of surgeries has been limited, despiteexcellent facilities and personnel in some countries, andrelatively low surgical cost especially for temporal lobeepilepsy (TLE) (Table 57.3). In this region, only Brazilhas a national epilepsy surgery program with govern-mental support. The plan, spearheaded by Brazil’s HealthMinistry, includes standardizing protocols for diagnosis,assessment, and surgery, establishing special epilepsy/surgery centers, and sending medical staff to developedcountries for training, leading to increased surgeries(Fig. 57.1). However, in 2009, under pressure from neuro-surgeons, the government increased epilepsy surgical cen-ters from eight to 30, despite an inadequate number ofphysicians trained in presurgical evaluation and epilepsysurgery (see below).

Resources

HUMAN RESOURCES

Presurgical evaluation and surgery requires a well-trainedmultidisciplinary team of specialists in epileptology (pedi-atric and adult neurologists), clinical neurophysiology,neurosurgery, neuroradiology, neuroanesthesiology, andintensive care medicine as well as pediatrics, psychiatry,neuropathology, psychology, and other fields, since allrisks need to be carefullyweighed and onlyminor newneu-rological deficits should be acceptable (Binnen and Polkey,2000; Wiebe, 2004; Asadi-Pooya and Sperling, 2008;Campos et al., 2008; Malekpour and Sharifi, 2009). Butphysicians with good training are usually difficult to findin developing countries. The situation is extreme in somenations; for example, in Africa many countries have onlya few neurologists and neurosurgeons for millions ofpeople; psychiatrists often treat people with epilepsy(Lachhwani and Radhakrishnan, 2008; Moodley andKhamlichi, 2008). LatinAmerica and someAsian countriesare better served, but the number of epilepsy specialistsremains limited. For many developing countries epilepsysurgery is still some distance away from being possible.

MATERIAL RESOURCES (TECHNOLOGY)

Minimal technological requirements for establishing anepilepsy center in developing countries include MRI,video-EEG, and computed tomography (CT) (which still

POS

Table 57.2

Per capita gross domestic product (GDP) in international dollars (ID), total expenditure on health as a percentage of GDP,

and per capita total expenditure on health in ID (2006), in representative countries of each continent

Country GDP*

Total expenditure on health

as % of GDP

Per capital total expenditure on health at

average exchange rate (US$){

USA 43915 15.3 6719

Luxembourg 89123 7.3 6506France 35791 11 3937Germany 35075 10.6 3718Australia 37954 8.7 3302

Japan 34062 8.1 2759Israel 20938 8 1675Republic of Korea 18250 6.4 1168

Mexico 7985 6.6 527Lebanon 5614 8.8 494Chile 8925 5.3 473

Brazil 5693 7.5 427South Africa 5313 8 425Russian Federation 6925 5.3 367

Peru 3386 4.4 149Georgia 1750 8.4 147China 2043 4.6 94Egypt 1460 6.3 92

Philippines 1368 3.8 52Senegal 759 5.8 44Haiti 500 8.4 42

Sudan 974 3.8 37Nigeria 868 3.8 33Cambodia 508 5.9 30

India 806 3.6 29Democratic Republicof the Congo

147 6.8 10

Liberia 146 4.8 7

*According to the World Bank, 103 of 209 countries (49.3%) belong to the resource poor category.{Total health expenditure per capita is the per capita amount of the sum of Public Health Expenditure and Private Expenditure on Health. The

international dollar is a common currency unit that takes into account differences in the relative purchasing power of various currencies.

Figures expressed in international dollars are calculatedusing purchasing power parity,which accounts for differences inprice level between countries.

Source: World Health Organization (http://www.who.int/en/).

EPILEPSY SURGERY IN DEVELOPING COUNTRIES 945

play an important role when parasitic infections are en-demic, in order to detect calcified lesions). It is impor-tant to offer patients the best available techniques fordetection and delineation of epileptogenic tissue, andclinical comorbidity. However, it must be stressed thatbudgetary considerations during equipment acquisitionmust include not only the initial, but also maintenanceand operational costs. If equipment is working, it maybe a mistake to replace it by state-of-the-art technology,which is later very difficult to maintain, owing to costand dependence on expertise not available locally.

The low cost ofmethodologies such as standardMRI isreducing the technological “gap” between developed anddeveloping regions and will certainly help the establish-ment of new basic epilepsy surgery centers in the wholeworld (Campos et al., 2000; Williamson and Jobst,

2000). However, the majority of the epilepsy surgical pro-cedures in the public health system in developing countriesare noninvasive or noncomplicated cases. The cost of sub-dural or depth electrodes and lack of equipment, such asadvanced MRI (3 T, postprocessing, spectroscopic, etc.),single photon emission computed tomography, positronemission tomography,magnetoencephalography, precludeinvestigation of most “nonlesional” epilepsy.

Cost (price)

Because of the high initial costs of presurgical evalua-tion and epilepsy surgery, it is important to understandthe long-term costs incurred with various treatmentmodalities. Also, an assessment of direct, indirect,and intangible costs provides a necessary framework

Table 57.3

Cost for temporal lobe epilepsy with noninvasive

presurgical evaluation in Latin America*, India, andChina

(these last two countries together contribute almost 20% of

the people with epilepsy worldwide)

Average/Latin America US$8400 (year 2008)India US$1500 (year 2009; Qiu, 2009)

China US$8500 (year 2009; Qiu, 2009)

*Latin America (Brazil, Colombia, Chile, Ecuador, Mexico and

Uruguay):

Population (six countries): 359 million hours

Epilepsy prevalence: 1.25�100 hours

Epilepsy surgeries per year: 854

Centers: 24

Average/surgeries per center: 35.6

Data from Spanish Symposium: “Presurgical Evaluation of Epilepsy:

Cost Effective Practice” at the Congress of American Epilepsy

Society, December 2007, Philadelphia (http://www.aesnet.org/go/

professional-development/educational-opportunities/archived-aes-

symposia?module¼2007/spanish/index.cfm).

946 M.G. CAM

for assessing the costs of epilepsy surgery. The cost ofintractable epilepsy is eight times higher than that ofwell-controlled epilepsy (King et al., 1997; Silfvenius,2000). The 25% of patients constituting the most resis-tant epilepsy cases account for 79% of the total cost ofincident cases (Begley et al., 2000). Several studies havecompared the costs of epilepsy surgery with those ofmedical treatment (Wiebe and Gafni, 1995; King et al.,1997; Langfitt, 1997; Begley et al., 2000; Silfvenius,2000; Boon et al., 2002; Platt and Sperling, 2002). Thesestudies demonstrate that, despite the high initial cost ofpresurgical evaluation and surgery, the benefits achievedin terms of clinical improvements and reduced require-ments for medications and medical services outweighthe costs of surgery in the long term.

1994 1995

Cas

es p

er y

ear

1996 1997 1998

Y

0

100

200

300

400

500

600

700

Fig. 57.1. Epilepsy surgery in Brazil (1994–2008). Eight centers pData from the Spanish Symposium: “Presurgical Evaluation of Ep

Epilepsy Society, December 2007, Philadelphia, USA (with perm

A cost effectiveness study from France comparedsurgical and medical therapies in a 14-centre prospectivecohort of intractable patients with epilepsy who werecandidates for resective surgery (Picot et al., 2004).The mean cost of presurgical evaluation was €8364(25th; 75th percentiles¼€3286; €12027). The meancost of presurgical evaluation and surgery was€20772 (25th; 75th percentile¼€15000; €25310). Ananalysis of projected costs over several years concludedthat epilepsy surgery became cost-effective within 9years after surgery, i.e., surgery became a cheaper alter-native than medical therapy. These results were based ondirect costs only and on an assumption of seizure-freerates of 77% of patients at 2 years. Interestingly, theseauthors replicated the findings of an earlier Canadianstudy, which found that, although the costs of epilepsysurgery were higher up front (during the first year), sur-gery became cheaper than medical therapy after 8.5years because of averted costs of medical care owingto the high rate of seizure-free patients with surgery(Wiebe and Gafni, 1995). In the USA, the estimated pay-back time for epilepsy surgery is approximately 6 years(Gumnit, 2001). Whereas the Canadian study (Wiebe andGafni, 1995) comprised both intracranial and non-invasive presurgical evaluations, the USA figures applyparticularly to noninvasive, not complicated temporallobe resections. This figure is important because it is es-timated that approximately 60% of all epilepsy surgeriesneeded in developing countries at this point require nointracranial or complex evaluation. Therefore, thesedata provide strong support for establishing andexpanding epilepsy surgery programs in developingcountries. The cost difference in presurgical evaluationinvolving intracranial EEG versus scalp recording onlyis substantial. A communication from the USA showedthat the cost of patients requiring intracranial recordings

POS

1999 2000

ears

2001 2002 2003 2008

erformed epilepsy surgeries for almost 200 million inhabitants.

ilepsy: Cost Effective Practice” at the Congress of American

ission from Dr. Americo Sakamoto).

DEVELOPING COUNTRIES 947

($72032) was almost twice that of those requiring onlyscalp recordings ($40912) (p<0.01) (Gumnit, 2001;Langfitt et al., 2005). In this study, seizure freedomwas associated with a significant reduction in totalhealthcare costs from year 1. By year 2 after evaluation,the total cost in seizure-free patients had declined toroughly half that of patients who continued to have seiz-ures. This decline was due to a reduction in the numberof inpatient admissions and AEDs prescribed, particu-larly the newer, more expensive medications (Langfittet al., 2005).

A few reports have compared the cost of epilepsysurgery between developed and developing countries.Some studies show that the costs of epilepsy surgeryvary by a factor of up to 10 between developing anddeveloped countries. One study compared the directcosts of epilepsy surgery programs in Colombia andSwitzerland (Tureczek et al., 2000), and showed thatthe average epilepsy surgery costs per patient inColombia were a mere 5.5% of those in Switzerland.In the health care system, an epilepsy surgery withoutinvasive investigations costs between $5000 and$10000 in Chile or Brazil (Campos et al., 2000;Cendes, 2004), and it may be even cheaper inColombia or India (Rao and Radhakrishnan, 2000;Tureczek et al., 2000; Radhakrishnan, 2009) (Table 57.3).The same surgical procedure can be 8–10 timesmore costlyin the USA and 6–8 times more costly in Germany(Campos, 2004). Thus, epilepsy surgery can be a relativelyinexpensive and efficient treatment option for patientswith epilepsy in developing countries. Although empiricaldata are not available (Carpio and Hauser, 2009), it wouldappear that in developing countries epilepsy surgery mayeven be considered as an earlier therapeutic alternativefor patients who cannot afford the lifetime costs ofmedical therapy. The pertinent question at this point iswhatexplains such wide between-country variability in costs.

EPILEPSY SURGERY IN

WHY ARE COSTS DIFFERENT AMONG COUNTRIES?

To answer this question we need to consider several vari-ables that play a role in this discrepancy:

● Price of instruments: the cost of instruments such as

MRI and video-EEG equipment, before taxes, issimilar to that in the place of origin, usually a devel-oped country. The price of equipment at the point ofuse varies owing to a number of factors, such astransportation, insurance, or national taxes. Theseelements play a small role in the overall between-country price variation and do not fully explain it,although exchange rates and the availability of for-eign currency may affect purchase decisions. On theother hand, the price of an examination using these

technologies varies tremendously by country andwithin countries. For instance, the cost of an MRIscan in Santiago de Chile is $400, whereas inMiami (USA) it is $3438, i.e., nine times morecostly. This difference can be explained becausethe examination in Miami incurs higher overheads,salary, research, maintenance, or renewal expenses,and no less important, the requirement of highprofitability.

● Medical supplies and technology: this is an impor-

tant factor underpinning the vast cost differencesin epilepsy surgery between developed and develop-ing countries. It reflects the elevated cost ofhigh-end technologies, which are the gold standardin developed countries, but only exceptionally usedin the average epilepsy surgery centers in developingcountries.

● Professional salaries: in general, the salaries of phy-

sicians in university and publicly funded hospitalsare low in developing countries. This stands in starkcontrast to the situation of their peers in developedcountries. As a result, most doctors in developingcountries need to complement their meager salariesby working in private practice settings. This has im-portant implications for analyses of the cost of ep-ilepsy surgery. First, the cost disparities betweensurgical procedures performed in public versus pri-vate settings are apparent. Second, an increasingnumber of graduating physicians and specialistscan drive the supply–demand curve in directionsthat may increase the cost and provision of medicaland surgical services. Medicine may be unique in itsreversal of the usual relationship between the costand availability of services. Physicians can generatedemand for their services, which already are stres-sing the resources even of the richest countriesand could overwhelm nations undergoing rapid de-velopment such as Brazil. It will be important forregulatory bodies to create and implement epilepsysurgery guidelines to avoid the potential problem ofsurgery performed with suboptimal expertise, forquestionable or inappropriate indications, or with-out sufficient investigations to allow optimal patientselection.

● Malpractice insurance: this is another important

aspect contributing to the differences in surgicalcosts between developed and developing countries.For example, in the USA, an average neurosurgeonrequires malpractice insurance that costs about$84 151 a year, a sum many times higher than thatrequired by their peers in developing countries.

● Administration cost: the administration costs

are difficult to assess but in general they arefairly low.

948 M.G. CAM

ARE SURGICALRESULTSDIFFERENTIN DEVELOPINGCOUNTRIESAND

DEVELOPEDCOUNTRIES?

The general answer is “no” in relation to seizure-free pa-tients. Analysis of the evidence shows that surgical resultsinEurope,USA,LatinAmerica, orAsia are practically thesame.A systematic review foundnodifference in surgicalresults for common procedures across large worldregions (Engel et al., 2003). The simplest explanation isthat medical skills are similar worldwide.

The majority of epilepsy surgical cases in developingcountries are performed in TLE with hippocampal sclero-sis or structural lesions (Campos et al., 2000; Paglioli-Netoet al., 2004) and lesional extratemporal cases (Rao andRadhakrishnan, 2000; Radhakrishnan et al., 2008). Somedeveloping countries, especially in private institutions,can do almost all types of surgical procedures includingcomplicated cases (nonlesional, focus, or lesion in elo-quent cortex, invasivemonitoring), but this is exceptional.

Information about neuropsychological outcomes afterepilepsy surgery is very limited in developing countries;there are some reports ofTLE in the dominant hemispherewithout the Wada test and good results (Campos et al.,2000) and also improvement of verbal memory scoresin dominant temporal lobe surgery (Paglioli et al., 2006).

An important challenge facing clinicians in developedcountries is globalization. Conceivably, the surgical man-agement of epilepsy patients in the future will see privatehealth insurance companies paying for patients to travelto selected centers in developing countries for epilepsysurgery. This phenomenon has already been observedin cardiac surgery.

SOLUTIONSOR ALTERNATIVEWAYSFOR DEVELOPING COUNTRIES

Education

Education about epilepsy surgery is an effective treatmentfor refractory epilepsy. The educationmust be directed to-ward physicians treating people with epilepsy, includinggeneral practitioners, pediatricians, and psychiatrists aswell as neurologists, through education in the medicalschool and continuing medical education (symposiums,conferences, etc). In developing countries most physicianswho treat patients with epilepsies have little knowledgeabout epilepsy surgery (Qiu, 2009). Patients themselvescould be reached through the press, radio, or TV.

Development of different typesof epilepsy centers

In order to perform rational evaluation and treatment ofpatients with intractable epilepsy in the developing world,itmaybehelpful toestablish twodifferent levelsofepilepsy

surgical centers (Campos et al., 2008). One would meetrequirements for an entry-level or basic epilepsy surgerycenterwhile the otherwould havemore extensive facilities,and the expertise needed to treat more complex cases(Tables 57.4 and 57.5). In practice, many centers aroundthe world will fall between these categories. However, inplanning a national epilepsy care system, a few basic sur-gerycenters could serveas satellitesofoneor twofull treat-ment facilities. Epilepsy surgical programsmust always bepart of a comprehensive epilepsy program and should notbecome an isolated issue in a medical institution.

Focus on special groups

TEMPORAL LOBE EPILEPSY

TLE associated with mesial temporal sclerosis is themost common and intractable type of epilepsy. Also,unilateral medial temporal lobe resections have the bestpostsurgical seizure outcome (Zentner et al., 1995; Wieseret al., 2000;Wiebe et al., 2001; Tellez-Zenteno et al., 2005;Cukiert et al., 2009; Malekpour and Sharifi, 2009).In adults, 70–80% of epilepsy surgeries are performedin the temporal lobe (Berg et al., 2003; McIntosh et al.,2004; Tellez-Zenteno et al., 2005; Lachhwani andRadhakrishnan, 2008; Cukiert et al., 2009), while around80% of these patients do not need invasive presurgicalevaluation, which means that approximately 60–70% ofall the resective epilepsy surgeries can be performed ina basic epilepsy surgery center. Some TLE patients wouldmeet exclusion criteria for a basic epilepsy surgery center,but can be evaluated in advanced epilepsy surgery centers(Table 57.6).

EXTRATEMPORAL LOBE EPILEPSY

Extratemporal lobe epilepsy (ETLE) is associated withseveral specific problems with respect to epilepsysurgery. Frequently the origins of seizures may not belimited to a circumscribed anatomical region and sei-zures can be widespread within the same lobe or hemi-sphere and even on the contralateral side. Anotherproblem is eloquent cortex (motor, sensory, language,etc.), which could surround or be part of the epilepto-genic zone. Some patients with ETLE need precise map-ping of eloquent cortex through invasive presurgicalevaluation with subdural electrodes or complex func-tional techniques such as functional MRI; these casesmust be treated at advanced epilepsy surgery centers.Neocortical extratemporal and temporal lesional epilep-sies associated with focal lesions not involving eloquentcortex can generally be evaluated and treated at basicepilepsy surgery centers as well as advanced epilepsysurgery centers (Engel, 1999, 2008; Campos et al.,2008). A patient with refractory epilepsy and a focal

POS

Table 57.4

Minimum requirements for basic and advanced epilepsy surgery centers

Basic epilepsy surgery center Advanced epilepsy surgery center

Patients Children InfantsAdolescents ChildrenAdults Adolescents

AdultsTypes of surgeries Temporal lobectomies Temporal lobectomies

Extratemporal (extralimbic) lesionalresections, excluding eloquent areas

Callosotomies

Extratemporal (extralimbic) lesional/nonlesionalresections, including eloquent cortex, functional

hemispherectomies, hemispherotomies,callosotomies, multiple subpial transections, specialsurgical techniques (vagus nerve stimulation)

Video-EEGmonitoring

Digital EEG – minimum of 32 channels Digital EEG – minimum of 64 channels24-hour monitoring 24-hour monitoringNoninvasive monitoring

(additionalþ sphenoidal)

Noninvasive monitoring (additionalþ sphenoidal)

“Less invasive” monitoring (foramenovale)

Invasive monitoring (foramen ovale, subdural stripsand grids, epidural electrodes, depth electrodes)

Structural imaging High-resolution 1.5-T equipment(0.5–1.0 T acceptable)

High-resolution 1.5-T equipment or moreMRI volumetric quantification

Advanced MRItechniques*

MRI spectroscopyFunctional MRI

T2 relaxometry3D reconstructionCurvilinear reconstruction

Coregistration and experimental techniquesFunctional imaging{ SPECT (optional study) SPECT (interictal/ictal studies)

PET

MSIMEG

Electrocorticography Intraoperative (optional) IntraoperativeCortical stimulation Intraoperative (optional) Intraoperative

ExtraoperativeNeuropsychologicaltests

Children ChildrenAdults Adults

Wada test Optional YesAED monitoring Yes Yes

*MRI, magnetic resonance imaging; 3-D, three dimensional.{MEG,magnetoencephalography; MRSI, magnetic resonance spectroscopic imaging; PET, positron emission tomography; SPECT, single-photon

emission computerized tomography.

AED, antiepileptic drug; EEG, electroencephalography.

Source: Campos et al. (2008).

EPILEPSY SURGERY IN DEVELOPING COUNTRIES 949

lesion on MRI not located in a functionally importantarea, with concordant EEG, might to go to surgery with-out other studies. However, the role of the basic epilepsycenter will be to ensure comprehensive epilepsy care,while a department of neurosurgery might simply ap-proach the patient as someone with a resectable lesion.

CHILDREN WITH INTRACTABLE EPILEPSY

Epilepsy surgery must be considered very soon (6–12months) in children with uncontrolled seizures, because

many brain functions are affected by refractory epi-lepsy, such as maturation, cognitive development, andbrain plasticity. Special attention should be given to in-fants and younger children with catastrophic epilepsy,who require careful selection for presurgical evaluation,which should define cortical abnormalities and assessfunctional capacity. Pediatric epilepsy surgery shouldonly be performed in advanced epilepsy surgery centers,especially for babies and young children, and all mem-bers of the team ought to meet the established standardsfor advanced epilepsy surgery centers.

Table 57.5

Minimum qualifications of epilepsy surgery center multiprofessional team

Key personnel Basic epilepsy surgery center Advanced epilepsy surgery center (AESC)

Epileptologist Board-certified neurologist (or equivalentqualification) with 1 year special training in anAESC

Board-certified adult neurologist (or equivalentqualification) with 1 year of special training inan AESC

Board-certified pediatric epileptologist (orequivalent qualification) with 1 year of specialtraining in an AESC

Clinical

neurophysiologist*

Board-certified clinical neurophysiologist (or

equivalent qualification) with training inconventional EEG, evoked potentials, andvideo-EEG monitoring (should have at least

1 year of special training in an AESC)

Board-certified clinical neurophysiologist (or

equivalent qualification) with training inconventional EEG, evoked potentials, andvideo-EEG monitoring (should have at least

1 year of special training in an AESC)Neurosurgeon Board-certified neurosurgeon (or equivalent

qualification) with 6 months of special training

in an AESC)

Board-certified neurosurgeon (or equivalentqualification) with 12 months of special training

in an AESC)Neuropsychologist 3 months of special training in neuropsychological

methodologies in an AESC6 months of special training in neuropsychologicalmethodologies in an AESC

Neuroradiologist{ Board-certified neuroradiologist (or equivalentqualification) ideally with 3 months of trainingin an AESC

Board-certified neurologist (or equivalentqualification) with special training in advancedimaging techniques

Anesthesiologist Board-certified anesthesiologist (or equivalent

qualification) with experience inneuroanesthesiology

Board-certified neurologist (or equivalent

qualification) with experience inneuroanesthesiology

Psychiatrist Board-certified psychiatrist (or equivalent

qualification)

Board-certified psychiatrist (or equivalent

qualification)Nurses Preferentially trained in an AESC Preferentially trained in an AESCEEG technician Preferentially trained in an AESC Preferentially trained in an AESC

Other supportpersonnel

Integrated in the multidisciplinary team Integrated in the multidisciplinary team (socialworker, psychologist, family therapist, etc.)

*In many centers, a neurologist is trained and board certified in both epileptology and neurophysiology.{In selected centers, neurologists are trained and board certified in neuroradiology.

EEG, electroencephalography.

Source: Campos et al. (2008).

950 M.G. CAMPOS

INTERICTAL ELECTROENCEPHALOGRAPHY

There are some reports from Brazil of successfulepilepsy surgery in patients with refractory TLE and pre-surgical evaluation only with interictal EEG (Cendeset al., 2000; Cukiert et al., 2009). This could be an alter-native approach in countries with extremely limited eco-nomic resources and access to continuous video-EEG.However, it should be used only by highly experiencedprofessional teams.

SUPPORT OF DEVELOPED COUNTRIES (EPILEPSYCENTERS) FOR DEVELOPING COUNTRIES

Several countries in Latin America have received sup-port from the North American commission of the ILAEto the Latin American Commission through the “Visiting

Professor Program and Partnering Epilepsy Centers inthe Americas.” There are also partnering programs be-tween epilepsy surgical programs in Canada (Montrealto Uganda (Boeling et al., 2009), Ontario to Peru),France to Tunisia (Mrabet et al., 2010), and so on. Ex-pansion of these programs will allow epilepsy surgerycenters in developed countries to foster epilepsy surgeryin developing countries.

EARLY LESIONAL EPILEPSY SURGERY

The presence of a structural lesion, as well as histo-pathological findings, particularly in the mesial tempo-ral lobe, leads to the best results in epilepsy surgery(Zentner et al., 1995, 1996; Yoon et al., 2003; Wieshmannet al., 2008; Tellez-Zenteno et al., 2010). Based onhistorical data, such as febrile seizures, MRI, clinical

Table 57.6

Recommendations of exclusion criteria for temporal lobe

epilepsy in basic epilepsy surgery centers

● Controlled epilepsy● Progressive medical disease● Patient or family who is not interested in surgery● Uncertain ictal onsets on scalp electroencephalography*● Language involved in epileptogenic zone*● Normal magnetic resonance image*● Memory ipsilateral to the mesial temporal sclerosis*

*Note: the last four exclusion criteria are not meant for advanced

epilepsy surgical centers.

EPILEPSY SURGERY IN DE

semiology, and EEG, it is possible to define a subgroupof patients who are likely to have refractory epilepsy,but who also do well after surgery. Early surgery, foreither TLE or lesional epilepsy, may be a particularlyvaluable approach in the developing world, where med-ical treatment resources are limited, and delaying sur-gery in hopes of remission exposes patients toeducational, social, and economic disadvantages evenworse than might be experienced in the developed world.

CONCLUSIONS

Data about epilepsy surgery in developing countries arelimited. Epilepsy surgery is cost-effective in patientswith refractory focal epilepsy, especially in patients withfocal lesions on MRI, and probably should be per-formed early in the patient’s course. There is an enor-mous gap between the number of patients who couldbenefit from epilepsy surgery and those who actuallyreceive this treatment.

It might seem somewhat paradoxical, in countrieswhere low income is not limited to the patients butextends to young professionals as well, to state thatestablishing a much needed epilepsy center requires in-tegration of a multidisciplinary group of experiencedand trained professionals, when resources, includingoverall gross domestic product health expenditures,are so limited. Thus, all advanced epilepsy surgery cen-ters should include a well-designed and certified trainingprogram. We suggest the creation of an ILAE taskforce, and collaboration with established institutions,to address the regulation and certification of trainingprograms for epilepsy neurologists and neurosurgeons.Because of the variety of surgical procedures availabletoday and the need to tailor resections and techniques toeach individual case and evidence-based delimitation ofepileptogenic tissue, a neurosurgeon’s specialty trainingexperience in an advanced epilepsy surgery centershould last at least 12 months.

These suggestions are possible now for manydeveloping countries, particularly in Latin Americaand Asia, where economic progress is occurring. Collab-oration between developed and developing nations willhave important benefits for the former as well. Lessresource-intensive approaches to epilepsy surgery maybe important for countries such as the USA, where manypatients are uninsured, and medical costs are becominga severe national economic burden. In a world of traveland migration, experience in different medical environ-ments may improve physicians’ understanding of theculturally diverse patients they encounter at home.

REFERENCES

Asadi-Pooya AA, Sperling MR (2008). Strategies for surgical

treatment of epilepsies in developing countries. Epilepsia

49: 381–385.Begley CE, Famulari M, Annegers JF et al. (2000). The

cost of epilepsy in the United States: an estimate from popu-

lation-based clinical and survey data. Epilepsia 41: 342–351.Berg AT, Vickrey BG, Langfitt JT et al. (2003). The multicen-

ter study of epilepsy surgery: recruitment and selection for

surgery. Epilepsia 44: 1425–1433.Binnen CD, Polkey CE (2000). Commission on neurosurgery

of ILAE 1993–1997: recommended standards. Epilepsia

41: 1346–1349.Boeling W, Palade A, Wabulya A et al. (2009). Surgery for

pharmacoresistant epilepsy in developing world: a pilot

study. Epilepsia 50: 1256–1261.Boon P, D’Have M, Van Walleghem P et al. (2002). Direct

medical costs of refractory epilepsy incurred by three

different treatment modalities: a prospective assessment.

Epilepsia 43: 96–102.Brodie MJ, Barry SJ, Bamagous GA et al. (2012). Patterns of

treatment response in newly diagnosed epilepsy. Neurol-

ogy 15;78: 1548–1554.

Campos MG (2004). Costs in epilepsy surgery: Latin

American versus Europe. Epilepsia 45: 189–190.

Campos MG, Wiebe S (2008). Epilepsy surgery: access, cost

and quality of life. In: H L€uders (Ed.), Textbook of

Epilepsy Surgery. Informa, London, pp. 223–229.

Campos MG, Godoy J, Mesa T et al. (2000). Temporal lobe

epilepsy with limited resources: results and economic

considerations. Epilepsia 41: 18–21.Campos MG, Pomata H, Sakamoto A et al. (2008). Essentials

for the establishment of an epilepsy surgery program. In:

H L€uders (Ed.), Textbook of Epilepsy Surgery. Informa,

London, pp. 1537–1544.

Carpio A, Hauser WA (2009). Epilepsy in developing world.

Curr Neurol Neurosci Rep 9: 319–326.Cendes F (2004). Resultados de la cirugıa de la epilepsia en

Brasil. Libro de resumenes, III Congreso Latinoamericano

de Epilepsia, Mexico.

Cendes F, Li LM, Watson C et al. (2000). Is ictal recording

mandatory in temporal lobe epilepsy? Not when the inter-

ictal electroencephalogram and hippocampal atrophy coin-

cide. Arch Neurol 57: 497–500.

VELOPING COUNTRIES 951

952 M.G. CAMPOS

Cukiert A, Cukiert CM, Argentoni M et al. (2009). Outcome

after corticoamigdalohippocampectomy in patients with

refractory temporal lobe epilepsy and mesial temporal lobe

sclerosis without preoperative ictal recording. Epilepsia

50: 1371–1376.Dua T, de Boer H, Prilipko LL et al. (2006). Epilepsy care in

the word: results of an ILAE/IBE/WHO global campaign

against epilepsy survey. Epilepsia 47: 1225–1231.DuchownyMS, Harvey S, SperlingMR et al. (1997). Indications

and criteria surgical interventions. In: J Engel Jr, TA Pedley

(Eds.), Epilepsy: A Comprehensive Textbook. Lippincott-

Raven Publishers, Philadelphia, pp. 1677–1685.

Engel J Jr (1999). The timing of surgical intervention for

mesial temporal lobe epilepsy: a plan for a randomized

clinical trial. Arch Neurol 56: 1338–1341.Engel J Jr (2008). Editorial: surgical treatment for epilepsy.

Too little, too late. JAMA 300: 2548–2550.

Engel J Jr, Wieser HG, Spencer D (1997). Overview: surgical

therapy. In: J Engel Jr, TA Pedley (Eds.), Epilepsy: A

Comprehensive Textbook. Lippincott-Raven Publishers,

Philadelphia, pp. 1673–1676.

Engel J, Wiebe S, French J et al. (2003). Practice parameter:

temporal lobe and localized neocortical resections for

epilepsy. Neurology 60: 538–547.Gumnit RJ (2001). Cost, accessibility, and quality of life is-

sues in surgery of epilepsy. In: HO Luders, YG Comair

(Eds.), Epilepsy Surgery. 2nd edn. Lippincott Williams

& Wilkins, Philadelphia, pp. 75–78.

Jeha LE, Najm IM, Bingaman WE et al. (2006). Predictors of

outcome after temporal lobectomy for the treatment of in-

tractable epilepsy. Neurology 66: 1938–1940.King JT Jr, Sperling MR, Justice AC et al. (1997). A

cost-effectiveness analysis of anterior temporal lobectomy

for intractable temporal lobe epilepsy. J Neurosurg 87:20–28.

Lachhwani DK, Radhakrishnan K (2008). Epilepsy surgery in

India. In: H L€uders (Ed.), Textbook of Epilepsy Surgery.

Informa, London, pp. 134–144.

Langfitt JT (1997). Cost-effectiveness of anterotemporal lo-

bectomy in medically intractable complex partial epilepsy.

Epilepsia 38: 154–163.Langfitt J,HollowayRG,McDermottMP et al. (2005). Changes

in health care use and cost after evaluation for epilepsy

surgery: a US multi-center study. Epilepsia 46: 242.Malekpour M, Sharifi G (2009). Surgical treatment for

epilepsy in developing countries. JAMA 301: 1769–1770.

McIntosh AM, Kalnins RM, Mitchell LA et al. (2004).

Temporal lobectomy: long-term seizure outcome, late re-

currence and risks for seizure recurrence. Brain 127:2018–2030.

Moodley MF, Khamlichi EL (2008). Epilepsy surgery in

Africa. In: H L€uders (Ed.), Textbook of Epilepsy Surgery.Informa, London, pp. 125–129.

Mrabet Khiari H, Khemiri E, Parain D et al. (2010). Epilepsy

surgery program in Tunisia: an example of a Tunisian

French collaboration. Seizure 19: 74–78.

Neuroimaging Commission of ILAE (1998). Recommenda-

tions for neuroimaging of persons with refractory epilepsy.

Epilepsia 39: 1375–1376.

Paglioli-Neto E, Azambuja N, Palmini A et al. (2004). Survival

analysis of surgical outcome of temporal lobe epilepsy due

to hippocampal sclerosis. Epilepsia 45: 1383–1391.Paglioli E, Palmini A, Portuguez M et al. (2006). Seizure and

memory outcome following temporal lobe surgery: selec-

tive compared with nonselective approaches for hippocam-

pal sclerosis. J Neurosurg 104: 70–78.

Picot MC, Neveu D, Kahane P et al. (2004). Cost-

effectiveness of epilepsy surgery in a cohort of patients

with medically intractable partial epilepsy-preliminary re-

sults. Rev Neurol (Paris) 160: 5S354–5S367.Platt M, Sperling MR (2002). A comparison of surgical and

medical costs for refractory epilepsy. Epilepsia 43: 25–31.Qiu J (2009). Epilepsy surgery: challenges for developing

countries. Lancet Neurol 8: 420–421.Radhakrishnan K (2009). Challenges in the management of

epilepsy in resource-poor countries. Nat Rev Neurol 5:

323–330.Radhakrishnan K, Fried I, Cascino GD (2008). Lesionectomy:

management of substrate-directed epilepsies. In: J Engel,

TA Pedley (Eds.), Epilepsy. A Comprehensive Textbook.

LippincottWilliams&Wilkins, Philadelphia, pp. 1891–1905.

Rao MB, Radhakrishnan K (2000). Is epilepsy surgery

possible in countries with limited resources? Epilepsia

41: 31–34.Sander JW, Shorvon SD (1996). Epidemiology of the epilep-

sies. J Neurol Neurosurg Psychiatry 61: 433–443.

Scott RA, Lhatoo SD, Sander JW (2001). The treatment of ep-

ilepsy in developing countries: where do we go from here?

Bull World Health Organ 79: 344–351.

Semah F, Picot MC, Adam C et al. (1998). Is the underlying

cause of epilepsy a major prognostic factor recurrence?

Neurology 51: 1256–1262.

Shorvon SD, Farmer PJ (1988). Epilepsy in developing coun-

tries: a review of epidemiological, socio-cultural, and

treatment aspects. Epilepsia 29: 36–54.

Silfvenius H (2000). Intractable focal epilepsy. In: J Oxbury,

C Polkey, M Duchowny (Eds.), The Health Economics of

Epilepsy Surgery. WB Saunders, London, pp. 849–864.

Tellez-Zenteno JF, Dhar R, Wiebe S (2005). Long-term

seizure outcomes following epilepsy surgery: a systematic

review and meta-analysis. Brain 128: 1188–1198.Tellez-Zenteno JF, Hernandez Ronquillo L, Moien-Afshari F

et al. (2010). Surgical outcomes in lesional and non-

lesional epilepsy: a systematic review and meta-analysis.

Epilepsy Res 89: 310–318.

Tonini C, Beghi E (2004). Predictors of epilepsy surgery out-

come: a meta-analysis. Epilepsy Res 62: 75–87.Tureczek IE, Fandino-Franky J, Wieser HG (2000). Compar-

ison of the epilepsy surgery programs in Cartagena,

Colombia, and Zurich, Switzerland. Epilepsia 41: 35–40.Wiebe S (2004). Effectiveness and safety of epilepsy surgery:

what is the evidence? CNS Spectr 9: 120–122.

Wiebe S, Blume WT, Girvin JP et al. (1995). An economic

evaluation of surgery for temporal lobe epilepsy. J Epi-

lepsy 8: 227–235.

Wiebe S, Blume WT, Girvin JP et al. (2001). A randomized,

controlled trial of surgery for temporal lobe epilepsy. N

Engl J Med 345: 311–318.

EPILEPSY SURGERY IN DEVELOPING COUNTRIES 953

Wieser HG, Silfvenius H (2000). Overview: epilepsy surgery

in developing countries. Epilepsia 41: 3–9.WieserHG,HajekM,GoossAet al. (2000).Mesial temporal lobe

epilepsy syndromewith hippocampal and amygdala sclerosis.

In: JOxbury,CPolkey,MDuchowny (Eds.), IntractableFocal

Epilepsy. WB Saunders, London, pp. 131–158.

Wieshmann UC, Larkin D, Varma T et al. (2008). Predictors

of outcome after temporal lobectomy for refractory tempo-

ral lobe epilepsy. Acta Neurol Scand 118: 306–312.Williamson PD, Jobst BC (2000). Epilepsy surgery in devel-

oping countries. Epilepsia 41: 4–8.WorldHealthOrganization. (2004).Epilepsy in theWHOAfrica

Region, Bridging the Gap: The Global Campaign against

Epilepsy “Out of the Shadows”. WHO Press, Geneva.

Yoon HH, Kwon HL, Mattson RH et al. (2003). Long-term

seizure outcome in patients initially seizure-free after

resective epilepsy surgery. Neurology 61: 445–450.Yoon D, Frick KD, Carr DA et al. (2009). Economic

impact of epilepsy in the United States. Epilepsia 50:2186–2191.

Zentner J, Hufnagel A, Wolf HK et al. (1995). Surgical treat-

ment of temporal lobe epilepsy: clinical, radiological, and

histopathological findings in 178 patients. J Neurol Neuro-

surg Psychiatry 58: 666–673.

Zentner J, Hufnagel A, Ostertun B et al. (1996). Surgical

treatment of extratemporal epilepsy: clinical, radiologic

and histopathologic findings in 60 patients. Epilepsia 37:1072–1080.