We will go ahead to the next speaker, who is Professor Kamlichi, and this will be a presentation on epilepsy surgery in Africa, the Moroccan experience. Thank you, Madam Chairman, ladies and gentlemen, dear colleagues. It's my pleasure to be here. I would like first to thank the organizers of this symposium for inviting me to share with you this recent experience on epilepsy surgery. As you know, epilepsy is a very severe disease, and it's a worldwide priority health problem. But in Africa, it's really a burden for two main reasons. The first one is that the incidence prevalence is high in Africa because, as you see, the causes of epilepsy are so frequent. And the second reason is that the sociocultural conditions of epileptic patients in Africa are still, in many places, really miserable because of the lack of knowledge and because also of the wrong beliefs, which left patients under traditional treatment before going to see doctors, which create a huge delay in the modern management for epilepsy in this area. So maybe epileptic patients in Africa are those who are more in need for surgical treatment, especially that the surgical treatment is now performed in many centers in developing countries and, of course, could be available in African hospitals. The reason for this development is that the pre-surgical evaluation of the patients in many types of epilepsy could be limited to non-invasive techniques, which are quite simple and can be mastered by a dedicated neurologist. We started our program of epilepsy surgery in Rabat in 2005, starting with a temporal lobe epilepsy, and we operated until now, as you see, 87 patients. A majority of our patients had the same classical technique of anterior temporal lobectomy with amygdalo-hippocampictomy. And the success of this technique, of course, depends on the respect of the different steps I will try to show you through this case of a young lady, 21 years, which has a typical temporal epilepsy with right anterior temporal focus on AEG and video AEG, and you see this mesiotemporal sclerosis on the right side on the MRI. Here is the surgical position of the patients, the skin incision and the cardiotomy, which quite enlarged posteriorly, and you see that the temporal lobectomy is limited to the temporal pole extended to four and a half centimeters. The cortectomy starting in the middle of the T1, and it's going to remove the cortex of T1, T2, T3, and T4, and then follow with the second steps by the removal of the subcortical weight matter of the same gyrus, and then you, of course, do it by paying attention to the sylvian fissure arteries and the vessels. The third step is the opening of the temporal horn of the ventricle, and you see here the hippocampus sulcus, which is very good landmark to remove the external part of the hippocampus with the rest of the T5, and you have to pay attention during these last steps. Of course, if you can manage to keep all these pieces separate and to send them to the pathology to look for the lesion, and here for the hippocampus sclerosis. We are removing now the last part, the internal part of the hippocampus, which is called the ammonia horn with the amygdala. Of course, this part of the surgery is the most delicate and risky because, as you know, the internal hippocampus is directly lying on the brainstem with all the vascular structure here, the carotid bifurcation, the third nerve, the posterior communicating artery, and the posterior cerebral artery, so one should pay attention to this type of surgery. Here is the result of the pathology showing the hippocampus sclerosis. This is the postoperative MRI. This technique used in the hippocampus sclerosis is also used in all temporal epileptic lesions which are large, as you see here, in this gonglioglioma, cortical dysplasia, or dynette, and benign oligodendroglioma. When the lesions are smaller, like in this case of dynette hidden in the sylvian fissure in the right sylvian fissure, or in case of cavernoma, of course, the surgery is limited to the lesionectomy. So here are the techniques used in all our cases of temporal lobe epilepsy, and you see that the majority, 91%, had anterior temporal lobectomy with amygdala or hippocampectomy. Today, in 9%, 8 patients, we performed just a lesionectomy. We extended our program recently to extratemporal epilepsy, and we just operated 15 cases. Of course, the best cases are those secondary to benign lesion, as you see here in this case of gonglioglioma, approached through transcendental approach. The lesion is just behind the broca area, and it was completely removed. An important surgical issue in this paleotogenic benign lesion is to remove them completely with the gliotic area if you want, of course, to cure definitely the seizures of your patients. A second technique we are trying to introduce also is a callosotomy, which is a palliative technique but very useful in severe epilepsy, generalized forms like this one in a young boy, 15 years, with tonic seizures, frequent drop attack. The technique we use is a frontal approach from right side, dissecting the corpus callosum, performing the callosotomy. The main issue in this technique is to try to be in the middle and to try not to open the ventricles by remaining in the cavum of the septum, as you see here. This is the best way to perform this callosotomy. Here is the postoperative control, and you see, of course, this is a CT scan in the immediate postoperative control. Another technique, which is old, one, and complex, is the hemispherotomy, but again, which can give excellent results in severe epilepsy, generalized epilepsy, originating from one whole hemisphere in young children, as you see in this six-year-old girl, which has right hemiparesis with severe epilepsy and left hemisphere atrophy, typically Rasmussen syndrome. And you see here the position, the operative position, a midline approach, frontal midline approach, unilateral. The neuronavigation in this complex surgery is very helpful and mandatory if you want to follow the disconnection from all sides of the atrophic hemisphere. And you see here the frontal midline approach, the dissection of the corpus callosum, and starting with the callosotomy, complete callosotomy, and then the interior disconnection, as you see here, lateral disconnection, and then going into the atrium of the ventricle, as we will see here, and opening the temporal hole, resecting the amygdala, and then complete by the posterior disconnection. Here you see the postoperative CT scan with the anterior disconnection, lateral disconnection, and posterior disconnection. The last technique I'm going to show you is some patients treated with radiosurgery. We had the chance to get our gamma knife radiosurgery unit since more than 10 years. And you see here, for example, this large hypothalamic hematoma, which was treated in 2012. And look, this huge shrinkage of the lesion, and the young boy, nine years, is completely free of seizures. These are our results in this retrospective study of 102 cases. Some postoperative complications, no mortality, morbidity, quite slight morbidity in 11 cases, all treated without any long-term consequences. One epidural hematoma, surgically treated. Four cases of infection, two local infection, and two meningitis, well-managed. Four cases of transitory depressive syndrome, and then two cases of hemiparesis, which resolved in three to six months. You see here the result in temporal lobe epilepsy. The INGL-1 group, patients with no seizures, 92%. But this is just during the first year, between three months and first year. This result will decrease, of course, with a long-time follow-up. And if we look to our patients, 56, who were controlled more than five years, between five and 12 years, we see that this group one, INGL group one, is decreasing to 68%. However, very important thing is that even if there is a decrease in a group of patients who are completely seizure-free, we had no patients with complete recurrence or worsening after surgery. In the extratemporal lobe epilepsy, of course, the result, the INGL-1, is 78%. But as you see, our series of experience is recent, and the series of patients is smaller. And what we can say regarding this extratemporal lobe epilepsy is that the best results belong to the group of patients with, of course, benign lesions, which were completely removed, the group of patients with Rasmussen syndrome treated with hemispherotomy, and the group of patients with hypothalamic aparthoma treated with radiosurgery. So in conclusion, our first experience on epilepsy surgery is encouraging. Anterior lobectomy with amygdala hippocampictomy gives a very good result, according to our series, 92% INGL-1, which is going to be stabilized. Around 70% after at least five-year follow-up. For the extratemporal epilepsy, the INGL-1 group represents 70% after surgery. Of course, more effort must be directed in the future in our center to improve the development of presurgical invasive techniques of evaluation in order to be able to operate all surgical type of epilepsy. I would like, of course, to thank all people who helped and supported this program, my colleague in Rabat, and some colleagues from St. Anne Hospital in Paris, from All India Institute of Medical Sciences in Delhi, and from Marseille, Latimonde, France, who visited us as a visiting professor and helped us, of course, to introduce all this technique I have shown to you. Thank you for your attention. Thank you. Questions for the speaker? So you mentioned the sort of patient obstacles in Africa to setting up such a program and the reluctance to come in for medical therapy. Can you speak a bit about the challenges you face with setting up such a program in terms of hospital administration and finding the resources that you've needed? Yeah, of course, the challenges are numerous. I mentioned the one which is concerning the epidemiological aspect of the disease in the continent. What is, of course, make all African neurosurgeons today optimistic is the development of neurosurgery itself. Because, you know, 30 years ago, there have been very, very limited centers in the continent. Today, there are almost at least one group of neurosurgeon in almost all African countries. And the second, I think, optimistic aspect is the fact I mentioned that today to perform epilepsy surgery, we don't need a high technology. What we need is a dedicated neurologist first and dedicated neurosurgeon. This is exactly what happened for us, for example, in Rabat. You know, we had the chance to have a very nice hospital which was dedicated to head specialties since more than 40 years, which gathers, since that time, neurologists, neurosurgeons, neuroradiologists, neurophysiologists, and so on. But we had to wait until to have, I must say, yes, some improving in technology and techniques, but to have dedicated people to start this surgery. So I think that today, this what I am trying to repeat in different meeting for my African colleagues and also for all colleagues in developing country, this surgery can be made. As you have seen, all techniques I have shown doesn't need any high technology. Of course, maybe MRI, but they need a very good clinician and dedicated clinician. They need just what I mentioned, the pre-surgical evaluation with very, I mean, standard steps, clinical evaluation with EEG, video EEG, MRI examination, psychological test, exploration, and in very few cases since we get the PET scan 10 years ago, had also a PET scan exploration, but in general don't need to have it. I mean, in most of the cases, mainly the temporal lobe epilepsy. Along the same lines, these patients that you see, are they mostly coming from a dedicated epilepsy neurologist or are they being referred from a general practitioner? Is there a growth now of epilepsy neurology that parallels the growth of your surgical program? I must say, all of them came from neurology. Those who are sent by general practitioners, we sent them first because we have a chance now, since we started in 2005, to have a dedicated neurologic service, which is called a service of clinical neurophysiology. So, all patients went there, they have their interictal repeated EEG, they have a clinical evaluation. Of course, the main issue is also to be sure about the qualification or quality of intractable epilepsy, which is very important, and just a neurologist can do it. And then they have MRI, of course, with special protocol. We have, of course, colleagues now with experience in neuroradiology to do that. And then they came, of course, we have every week a meeting, multidisciplinary team, to discuss these patients. And all patients I operated, really all of them were selected by this multidisciplinary team. Any other questions? Yes. I just want to ask my colleague, how would it be for a neurologist to refer to neurosurgical services throughout the country, not just in the capital region? I think that, I must say that our colleague in the country, they know now that we have a group of neurologists and neurosurgeons who are starting this surgery. We are trying with other colleagues, neurosurgeons, of course, to develop it in other centers. But these neurologists from all the countries, they send the patients to the same hospital today. But we hope, of course, that this will be developed more.

epilepsy surgery

Africa

Moroccan experience

surgical treatment

temporal lobe epilepsy

presurgical evaluation