Pioneering Epilepsy Surgery in Cameroon: Outcomes from the First Prospective Cohort of Surgical Patients with Drug-Resistant Epilepsy

Pioneering Epilepsy Surgery in Cameroon: Outcomes from the First Prospective Cohort of Surgical Patients with Drug-Resistant Epilepsy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pioneering Epilepsy Surgery in Cameroon: Outcomes from the First Prospective Cohort of Surgical Patients with Drug-Resistant Epilepsy Ghislain Guea Ngbwa, Oumarou Haman Nassourou, Bekolo Nga Evina, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7941534/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Drug-resistant epilepsy (DRE) represents a public health burden that affects one-third of people with epilepsy and carries a high risk of premature death. Although surgical resection achieves seizure freedom in up to 70% of cases in high-income settings, access to epilepsy surgery in sub-Saharan Africa remains limited. Cameroon initiated an epilepsy surgery program seven years ago, but no prospective outcome data have been reported. Methods: We conducted a single-center, prospective observational cohort of 31 consecutive Cameroonian patients with DRE who underwent epilepsy surgery between January 2018 and March 2024. Collected data included sociodemographic and clinical characteristics, surgical and histopathological findings, postoperative complications, seizure outcomes (Engel classification), neuropsychological performance, and health-related quality of life (QoL) at baseline, 6 months, and 12 months postoperatively. Primary endpoints were seizure freedom (Engel I), cognitive change, and QoL improvement. Survival estimates were computed using Kaplan–Meier analysis and assessed time from surgery to disabling seizure. Results: In this cohort, female was predominant (74.2%), the median age at surgery was 21 years (IQR 14–29), and the median disease duration was 8 years (IQR 5–13). Complex partial seizures comprised 61.3% of cases. Anterior temporal lobectomy was performed in 61.3%; hippocampal sclerosis was the most common pathology (61.3%). At final follow-up, 71% achieved seizure freedom. Postoperative complications were uncommon: 12.9% experienced transient neurologic deficits, and 3.2% had wound infections. Cognitive outcomes varied by laterality: left-side resections showed declines in most domains, whereas right-side surgeries demonstrated improvement in several measures. Seizure-free patients maintained better QoL and neuropsychological performance across all domains (p < 0.05) except for energy level and medication effects. Overall QoL and sum QoL scores rose from a mean of 6.4 to 9.1 (p < 0.001) and 48.8 to 63.18 (p < 0.001), respectively, with significantly greater gains among seizure-free individuals. Mean estimated survival time was 270.4 days (95% CI 217.1–323.8); median survival was not reached. Conclusion: Epilepsy surgery in Cameroon is safe, effective, and yields outcomes comparable to global standards. The procedure significantly enhances seizure control and QoL, though cognitive effects vary by surgical site. These findings underscore the feasibility and importance of expanding surgical epilepsy care in resource-limited settings. Neurosurgery Drug-resistant epilepsy Engel classification anterior temporal lobectomy hippocampal sclerosis Figures Figure 1 Introduction Among epileptic patients, it is estimated that one-third have drug-resistant epilepsy (DRE). A patient is considered to have DRE if a trial of at least two anti-epileptic drugs (AEDs) failed to control his seizure, despite good compliance to the regimen [1]. These patients are particularly vulnerable and sometimes represent a burden for their family. Also, they present a three-fold risk of premature death compared to the general population related to their disease and associated injuries. The exact etiopathogenesis of that condition (DRE) remains unclear; however, some point to a multifactorial origin involving structural abnormalities, genetic defects, and molecular mechanisms such as altered drug targets in the epileptogenic brain [2]. Besides polypharmacy, surgical intervention, neuromodulation, and ketogenic diets have emerged as suitable therapeutic approaches [3, 4, 5]. Among those therapeutic options, surgery represents the best option in terms of effectiveness, with a seizure-free rate of 70% with techniques like anterior temporal lobectomy. On the other hand, neuromodulation interventions tend to reduce seizure frequency without absolute seizure freedom [6]. Regarding the ketogenic diet, data about its benefits have remained dubious, and some cohorts only report seizure reduction for the pediatric population [7]. Therefore, no nonsurgical therapies match the long-term efficacy of resective surgeries. In sub-Saharan Africa, the burden of epilepsy is especially high, and care is severely constrained. It is estimated by WHO that 25 million Africans live with epilepsy [8]. Community studies report a broad prevalence variability with values up to 0.5–10% in some regions, likely underestimates given the stigma associated with epilepsy in Africa. The treatment gap in Africa is enormous; roughly 70–75% of people with epilepsy do not receive appropriate treatment due to factors such as low awareness, social stigma, poverty, and reliance on traditional remedies [9, 10]. Data on DRE are sparse and nonexistent in some regions. One systematic review estimated 211,000 new surgical candidates per year in Africa. Yet only a handful of epilepsy surgery centers have been established. Reported outcomes from existing African cohorts demonstrate that 60–100% of patients achieved good seizure control at one year, comparable to high-income settings [11]. In spite of these successes, the continent’s neurosurgical capacity is extremely limited, and only 1,974 neurosurgeons serve 1.3 billion Africans (about 0.15 per 100,000 population), with almost all being concentrated in a few urban centers [12]. Consequently, specialized epilepsy evaluation and surgery remain inaccessible to most, and the DRE burden in Africa goes largely unmet. Cameroon's situation mirrors the realities experienced by other sub-Saharan countries. Epilepsy is a leading neurological cause of disability in sub-Saharan Africa, and Cameroon has been cited among the most affected countries. For instance, a village study reported a prevalence of 135 per 1000 inhabitants [13]. However, national epidemiology data are unknown because they are scant. Community surveys in Cameroon reveal both high awareness and pervasive stigma, and half of respondents said they would forbid marriage to someone with epilepsy, and many believed epilepsy to be contagious or a form of insanity. About 30% of people in that district would first seek help from a traditional healer rather than medical care [14]. In contrast, respondents from another region supported employment and schooling of persons with epilepsy, illustrating regional heterogeneity [13]. What is clear is that cultural misconceptions and limited resources delay diagnosis and treatment. Critically, Cameroon initiated epilepsy surgery about 6 years ago. The country has about 25 neurosurgeons (0.1 per 100,000 people), and most are based in capitals, leaving most regions without neurosurgical coverage. No prior study has evaluated surgical treatment of DRE in Cameroon, representing a major knowledge gap in how to address the growing burden. To bridge this gap, we established a prospective observational study of Cameroonian patients undergoing epilepsy surgery. The objectives of this study are to evaluate the effectiveness (seizure-control outcomes and quality of life), cognitive well-being, and safety of epilepsy surgery in this setting. Materials and Methods Study Design and Setting This was a prospective observational single-arm cohort study conducted from January 2018 to March 2024 at the Yaoundé General Hospital (YGH) in Cameroon. The study was conducted in the Department of Neurosciences at the Yaoundé General Hospital (YGH). Yaoundé General Hospital is a first-level referral health facility, equipped with a Department of Neurosciences that includes a fully operational neurosurgery unit. The neurosurgical department has a capacity of approximately 25 inpatient beds and performs an estimated 300 surgical procedures annually. The unit currently operates with three consultant neurosurgeons. The Department of Neurosciences also includes three consultant neurologists, some of whom have received subspecialty training in epileptology, as well as a psychiatrist, anesthesiologists/intensivists, and one full professor of neuroradiology. The epilepsy surgery program benefits from close multidisciplinary collaboration with pediatric neurologists, clinical psychologists, and speech and language therapists. The hospital is equipped with a modern intensive care unit that meets international standards in terms of infrastructure and equipment, ensuring adequate postoperative support for neurosurgical patients. YGH also houses a large, fully aseptic surgical theater complex composed of seven operating rooms, including two dedicated microsurgical suites. Among the available equipment is a HAAG STREIT ALLEGRA 700 surgical microscope, fitted with dual adjustable oculars and five illumination modes to enhance visualization of fine tissue structures and optimize surgical performance. The facility is further equipped with essential microsurgical instruments, including bipolar coagulators, assorted dissectors, micro-scissors, and suction cannulae of various diameters. For cranial stabilization and positioning, a Mayfield head clamp is available. Additionally, an ANSPACH EMAX 2 multimodal surgical drill system is used, incorporating craniotomy attachments, saws, and burrs, which facilitate the safe execution of cranial bone flaps. All patients who underwent surgical treatment for epilepsy at YGH during the study period were enrolled. The study design followed a single-center cohort format. The patients were identified at the time of their evaluation for epilepsy surgery and followed longitudinally through their pre-surgical workup, surgery, and post-operative period (03 months, 06 months, and 12 months). Study Population Our study included all age patients with DRE according to International League Against Epilepsy (ILAE) criteria [15]. A total of 67 patients were found eligible for epilepsy surgery during our study period. Among these patients, 34 didn’t adhere to surgical treatment and didn’t initiate any assessment. From those who adhered to surgery, 2 didn’t complete their pre-operative workup and didn’t undergo surgical treatment. Only 31 patients completed the recommended presurgical workup and underwent surgery. All eligible patients and/or their guardians provided written informed consent to participate. Pre-Surgical Evaluation All patients underwent a comprehensive presurgical evaluation by a multidisciplinary epilepsy team prior to surgery. Clinical Assessment: A detailed clinical history was obtained, including age of seizure onset, seizure semiology, and prior treatments. Each patient received a thorough neurological examination and general medical review. High-resolution brain MRI was performed for all patients (T1-weighted and FLAIR images). Only MRI was used for structural imaging, as it was available on-site; no routine CT or PET scans were obtained in this cohort. Each patient underwent scalp electroencephalography (EEG), including prolonged video-EEG monitoring to capture habitual seizures and identify the epileptogenic zone. At minimum, long-term video-EEG was utilized to record and localize ictal events, and MRI was reviewed to detect any lesion corresponding to the EEG focus. Only cases where MRI clearly revealed a lesion were judged candidates for surgery, as advanced functional imaging (PET or SPECT) was not available. Additionally, a comprehensive neuropsychological battery was administered by a neuropsychologist as part of the preoperative workup. For example, patients completed the Boston Naming Test (BNT) for object naming, the Controlled Oral Word Association Test (COWAT) for phonemic verbal fluency, a semantic fluency test (SFT), Trail Making Test Parts A and B (TMT-A and TMT-B) for processing speed and executive function, and an Auditory Verbal Learning Test (AVLT) for episodic memory. Baseline assessments were conducted at the 6-month postoperative period by the neuropsychologist. In our resource setting, the intracarotid amobarbital (Wada) test was not performed. Each case was reviewed in a multidisciplinary epilepsy surgery conference upon completion of the abovementioned evaluation. Based on clinical, electrophysiological, and MRI data, the team reached a consensus on the localization of the epileptogenic zone and determined whether the patient was a good candidate for resective surgery. Patients and families were then counseled regarding the proposed surgery, including potential benefits and risks. Surgical Procedures Resective epilepsy surgery was performed for each patient using a tailored approach based on the location of the seizure focus. Three types of surgeries were performed: anterior temporal lobectomy, lesionectomy, and frontal gyral resection. In the operating room, a frameless stereotactic neuronavigation system was employed for all cases to guide the surgeon to the targeted brain region with high precision. Neuronavigation was based on each patient’s MRI and allowed accurate delineation of resection margins. Resections were carried out under general anesthesia using standard microsurgical techniques. The extent of resection aimed to completely remove the epileptogenic zone while preserving adjacent eloquent cortex. In temporal lobectomies, for instance, approximately 3–5 cm of the anterior temporal lobe was removed along with the amygdalohippocampal complex, as per standard practice. All surgeries were performed by the same lead neurosurgeon, a full professor of neurosurgery. Standard anti-epileptic drug therapy was continued in the postoperative period; no patient had immediate discontinuation of medications. After discharge, patients returned for scheduled follow-up visits at approximately 3 months, 6 months, and 12 months post-surgery. Outcome Measures Primary Outcomes The primary efficacy outcome was post-surgical seizure control, categorized using the Engel Epilepsy Surgery Outcome Scale [16]. At the 12-month follow-up (or last follow-up available for each patient), seizure outcome was classified as Engel Class I, II, III, or IV [15]. For subgroup analysis, we defined favorable outcome as Engel Class IA-IB and unfavorable outcome as Engel Classes II–IV. In addition to seizure frequency, we evaluated quality of life as a co-primary outcome. Quality of life was assessed at baseline and at 06 months and 12 months post-surgery using the 31-item Quality of Life in Epilepsy questionnaire (QOLIE-31). An improvement in the QOLIE-31 overall score post-surgery (higher scores indicate better quality of life) was considered a positive outcome. We also examined neuropsychological outcomes by comparing patients’ cognitive performance before and after surgery. At approximately 6–12 months post-op, patients repeated key tests from the neuropsychological battery. Changes in scores were documented to detect any significant post-surgical cognitive decline or improvement. These cognitive outcome measures were descriptive and used to supplement the overall assessment of each patient’s benefit vs. risk from surgery. Secondary Outcomes Secondary outcome measures included surgical safety and long-term epilepsy control metrics. We prospectively recorded any surgical complications, both acute and late. Complications were defined as any deviation from the expected postoperative course, including neurosurgical complications or systemic complications. We also assessed survival time to seizure relapse, which we defined as the time from surgery until the occurrence of a disabling seizure (a seizure that would be classified as Engel Class II or higher). This was essentially a measure of the durability of seizure freedom. Patients who remained in Class I (completely seizure-free or only auras) at last contact were considered not to have reached the event; those who had any recurrent disabling seizure were counted as events, and the interval from surgery to that first seizure was recorded (in days). Data Collection and Management All data were collected prospectively by the study investigators using standardized forms and then entered into a secure database. Clinical information, investigation results, surgical details, and outcomes for each patient were recorded. We utilized a combination of hospital medical records and dedicated research case report forms to ensure comprehensive data capture. Data Sources : Preoperative clinical data were obtained from patient interviews and chart reviews at enrollment. MRI and EEG results were retrieved from the hospital’s radiology and neurophysiology records and summarized on the study forms. Surgical operative notes and discharge summaries provided details on the procedures and immediate outcomes. Follow-up data (seizure frequency, Engel class, QOLIE-31 scores, etc.) were collected during outpatient visits at 3, 6, and 12 months, and from phone interviews if an in-person visit was missed. Data Quality Control : We instituted several measures for data standardization and quality assurance. The data collection forms were pilot-tested on a few initial patients to ensure clarity and consistency in how variables were recorded. Key outcome variables such as Engel classification and complication status were defined explicitly with codes to facilitate consistent interpretation. Each patient was assigned a unique study ID, and all analyses were performed on de-identified data. Access to the data was limited to authorized study personnel only. Physical records (such as consent forms and paper questionnaires) were kept in locked cabinets in the Neurology department research office. All procedures for data handling were in accordance with institutional guidelines and national data protection regulations to ensure patient confidentiality. Statistical Analysis All analyses were performed using SPSS version 23, and a two-tailed α level of 0.05 was considered statistically significant. First, we assessed continuous variables for normality by the Shapiro–Wilk test. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using paired or unpaired Student’s t-tests as appropriate. Non-normally distributed variables are expressed as median (IQR) and were compared by Wilcoxon signed-rank tests for paired samples or Mann–Whitney U tests for independent groups. Categorical variables are reported as counts and percentages. Pre- to post-surgery changes in neuropsychological scores and quality-of-life domains were evaluated with paired tests (paired t-test or Wilcoxon signed-rank) based on the distribution of the data. For between-group comparisons (left- versus right-side surgery; seizure-free versus persistent seizures), we employed independent t-tests or Mann–Whitney U tests for continuous measures. Survival distributions were estimated by the Kaplan–Meier method. Ethical Considerations This study was approved by the institutional ethics review board of the Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon (approval number 0383/UY1/FMSB). All procedures and investigations were conducted in accordance with the ethical standards of our institution and with the Declaration of Helsinki and its later amendments. Written informed consent was obtained from each adult participant, and for pediatric patients, consent was obtained from a parent or legal guardian. Participants were informed about the aims of the study, the procedures involved, and any potential risks or benefits of participation. They were assured that refusal to participate or withdrawal from the study would not affect the quality of their medical care. Confidentiality of patient data was strictly maintained, and no identifying personal information is revealed in this publication. Each patient’s decision for surgery was made on clinical grounds independent of the study; the research component was observational and posed no additional risk beyond standard care. Result Socio-demographic Characteristics This prospective cohort study included 31 patients, who underwent surgical treatment for drug-resistant epilepsy (DRE) in Cameroon. Among them, 23 participants (74.2%) were female. The median age at surgery was 21 years (IQR: 14–29), with seizure onset at a median age of 10 years (IQR: 6–10) and a median disease duration of 8 years (IQR: 5–13). Educational attainment was limited; 25.8% had never attempted higher education, and only 12.9% earned a highest educational degree. Most patients lived with parents (71.0%) and had low socioeconomic engagement, with only 32.3% working full-time. Clinical characteristics The most common seizure type was complex partial seizures (61.3%), followed by generalized (25.8%) and focal motor seizures (12.9%). Preoperative seizure frequency was ≤ 10 episodes/month in 64.5% of patients. A majority (61.3%) had no relevant medical history. Four participants (12.9%) had a history of febrile seizure. Other risk factors such as head trauma, psychiatric illness, CNS infection, and fetal asphyxia were present in two participants (6.5%) each. The average number of antiepileptic drugs (AEDs) taken preoperatively was 1.32 ± 0.6; 74.2% were on two AEDs. Surgical and Histopathological Findings Anterior temporal lobectomy (61.3%) predominated, followed by lesionectomy (25.8%) and frontal gyral resection (12.9%). Most surgeries were conducted in the left temporal lobe (54.8%), 32.3% in the right temporal lobe, and 12.9% in the left frontal lobe. Video-EEG confirmed epileptogenic foci in the left temporal lobe in 61.3% of cases; the right temporal lobe and the left frontal lobe respectively represent 32.4% and 6.4% of epileptogenic foci. Histopathology revealed hippocampal sclerosis in 61.3%, vascular malformations in 29.0%, and low-grade brain tumors in 9.6%. Postoperative Outcomes The median postoperative stay was 11 (IQR: 6–15) days; 4 (12.9%) participants reported postoperative neurologic deficit, and surgical site suppuration was reported in 1 (3.2%) participant. Only one participant reported neurologic sequelae (right-side hemiparesis). Disabling postoperative seizures occurred in 9 (29.0%) patients. At the last follow-up, 22 patients (71%) achieved seizure freedom (Engel class IA–IB). Cognitive Outcomes Postoperative assessments demonstrated mixed cognitive outcomes. Certain domains, such as VC, BNT, TMT-A, COWAT, and AVLT, showed statistically significant declines after surgery. This decline was not significant for TMT B and SFT. Subgroup analysis (right-side surgery and left-side surgery) reported different outcomes. Patients who underwent right-side surgery reported significant improvement in VC, TMT-A, TMT-B, SFT, and BNT, but they declined in COWAT (p = 0.22) and AVLT (p < 0.001). On the other hand, left-side surgery yielded significant declines in all categories except for the COWAT, where the cognitive decline was not significant (p = 0.22). Cognitive outcomes were significantly better among seizure-free patients across all neuropsychological domains. However, there was no significant difference based on surgical type (anterior temporal lobectomy vs. other surgeries). Quality of Life (QoL) QoL metrics significantly improved post-surgery. Overall QoL domain increased from a mean of 6.4 pre-surgery to 9.1 at 12 months (p < 0.001). Seizure worry, emotional well-being, energy, cognition, medication effects, and social functioning all improved significantly from presurgical assessment to 12-month postoperative evaluation. Seizure-free patients reported markedly higher QoL scores than those with persistent seizures across multiple domains. This is highlighted by the substantial difference in mean total score at the 12-month evaluation between the 02 groups (68.5 vs. 50.1; p < 0.001). However, no significant difference in mean was present for energy level (8.4 vs. 7.3; p = 0.13) and medication effects (2.7 vs. 2.6; p = 0.44) between the two groups. Based on surgical type (anterior temporal lobectomy vs. other surgeries), there was no significant difference among QoL domains. Survival Estimates The mean estimated survival time was 270.4 days (95% CI: 217.1–323.8). Median survival time was not reached, indicating favorable survival outcomes within the follow-up period. Table 1 Baseline characteristics of the study population Variable Mean/median or no. Age at seizure onset 10(6–10) Age at surgery 21(14–29) Time between onset and surgery 8(5–13) Female 23(74.2%) Predominant type of seizure Partial complex 19(61.3%) Generalize seizure 8(25.8%) Focal motor 4(12.9%) Occupation Student 18(58.1%) Formal 8(25.8%) Informal 3(9.7%) Unemployed 2(6.5%) Highest education Do not apply 11(35.5%) Did not attempt 8(25.8%) Ongoing 8(25.8%) Finished 4(12.9%) Preoperative seizure frequency ≤10 20(64.5%) 11–20 7(22.9%) ≥20 1(3.2%) Countless 3(9.7%) Medical History Irrelevant 19(61.3%) Febrile seizure 4(12.9%) Fetal asphyxia 2(6.5%) Psychiatric illness 2(6.5%) CNS infection 2(6.5%) Head trauma (mild) 2(6.5%) No. of Preoperative AEDs 1.32 ± 0.6 2 23(74.2%) 3 6(19.4%) 4 2(6.5%) Surgical site Left temporal lobe 17(54.8%) Right temporal lobe 10(32.3%) Left frontal 4(12.9%) Living Family (parents) 22(71.0%) Family (wife/husband) 5(16.1%) Single 4(12.9%) Socioeconomic status Working full time 10(32.3%) Working part time 7(22.6%) Studying 7(22.6%) No occupation 7(22.6%) Right handedness 31(100%) Postoperative hospital stays 11(6–15) EEG video foci LT 19(61.3%) RT 10(32.3%) LF 2(6.4%) Postoperative disabling seizure 9(29.0%) Histopathology findings Hippocampal sclerosis 19(61.3%) Vascular malformation 9(29.0%) Low grade tumor 3(9.6%) Surgical technique Anterior Temporal lobectomy 19(61.3%) Lesionectomy 8(25.8%) Frontal gyral resection 4(12.9%) Table 2 Cognitive assessment Categories presurgical postsurgical p-value VC 91.71 89.90 0.006 Right 101.4 104.1 < 0.001 Left 87.1 83.1 < 0.001 COWAT 29.10 27.84 < 0.001 Right 30.0 28.9 0.22 Left 28.6 27.3 0.11 TMT A 33.03 34.87 0.002 Right 29.3 27.4 < 0.001 Left 34.8 38.4 < 0.001 TMT B 80.68 82.65 0.07 Right 77.1 71.5 < 0.001 Left 82.3 87.95 < 0.001 SFT 32.35 31.42 0.112 Right 37.5 40.6 < 0.001 Left 29.9 27.05 < 0.001 BNT 46.13 41.65 < 0.001 Right 49.2 51.9 < 0.001 Left 44.6 36.7 < 0.001 AVLT 8.39 6.19 < 0.001 Right 10.7 9.9 < 0.001 Left 7.2 4.4 < 0.001 Table 3 QoL evolution from baseline to 12 months postoperative period Variables Pre-surgical QoL 6 months QoL 12 months QoL p-value Seizure worry 3.09 4.7 5.04 < 0.001 Overall QoL 6.4 8.6 9.1 < 0.001 Emotional wellbeing 5.9 8.4 8.49 < 0.001 Energy 6.6 7.9 8.11 < 0.001 Cognitive 13.99 15.4 14.8 < 0.001 Medication effects 2.02 2.5 2.7 0.035 Social function 10.7 13.8 14.67 < 0.001 Sum QoL 48.8 61.6 63.19 < 0.001 Table 4 QoL and cognitive function comparison based on seizure freedom Variables Engel IA-IB (22) Engel II-V (9) p-value QoL at last assessment Seizure worry 5.3 4.2 0.004 Overall QoL 10.1 6.7 0.004 Emotional wellbeing 9.3 6.5 0.01 Energy 8.4 7.3 0.13 Cognitive 16.4 10.8 < 0.001 Medication effects 2.7 2.6 0.44 Social function 15.8 11.9 0.06 Sum QoL 68.5 50.1 < 0.001 Postoperative Cognitive function VC 95.4 76.4 < 0.001 COWAT 28.7 25.6 0.001 TMT A 33.2 38.7 0.009 TMTB 80.1 88.7 0.01 SFT 33.5 26.3 0.006 BNT 44.2 35.3 0.005 AVLT 6.9 4.3 0.02 Table 5 QoL and cognitive function comparison based on surgical type Variables Anterior temporal lobectomy (19) Other surgeries (12) p-value QoL at last assessment Seizure worry 4.8 5.4 0.12 Overall QoL 8.5 10.0 0.86 Emotional wellbeing 7.9 9.4 0.49 Energy 7.8 8.5 0.11 Cognitive 14.4 15.4 0.53 Medication effects 2.6 2.7 0.54 Social function 13.7 16.1 0.10 Sum QoL 60.3 67.7 0.46 Postoperative Cognitive function VC 87.3 94.0 0.09 COWAT 27.2 28.8 0.89 TMT A 35.0 34.6 0.86 TMTB 82.2 83.3 0.69 SFT 32.2 30.1 0.36 BNT 41.3 42.2 0.76 AVLT 6.3 6.0 0.77 Table 6 Estimate survival function mean Estimate Std. Error 95% CI Lower Bound Upper Bound 270.419 27.210 217.088 323.751 Discussion Demographic and Clinical Context Our cohort from a sub-Saharan African country highlights the considerable burden of DRE in a low-resource setting. The patients were predominantly young, with the median age at surgery being 21, and female (74%) patients were predominant. The median age at seizure onset was 10 years, with a median disease duration of 8 years. This contrasts with some surgical series in other regions that often show a male majority [17], an intriguing difference possibly influenced by sociocultural factors or referral patterns in our setting. Low educational attainment and limited employment (only 32.3% of participants had a full-time occupation before surgery) were common, underscoring the disruptive impact of uncontrolled epilepsy on schooling and livelihood. Similar socio-economic challenges are reported across low- and middle-income countries (LMICs), where many people with epilepsy lack access to adequate treatment [18]. Our findings reinforce that, as in high-income countries (HICs), DRE in LMICs exacts a heavy toll on quality of life and productivity—and that effective interventions are urgently needed to prevent young patients from losing formative educational and work opportunities. Surgical Strategies and Pathology in Perspective Despite the resource-limited context, the surgical approaches and pathologies in our cohort mirror global trends. Anterior temporal lobectomy was the most common procedure (61.3%), reflecting the predominance of mesial temporal lobe epilepsy, followed by lesionectomies and a few frontal gyral resections. This distribution is comparable to both HIC and LMIC reported data, where temporal lobe surgery typically represents the majority of cases [5, 17]. Notably, most surgeries in our series were performed on left temporal foci (54.8%), aligning with video-EEG findings and demonstrating the capability to lateralize and localize seizures even in a new program that lacks crucial tools such as the Wada test. Histopathology results were likewise in line with international data: hippocampal sclerosis was the leading pathology (61.3%), consistent with the well-known prevalence of mesial sclerosis in surgical epilepsy [18, 19]. The remainder were lesional etiologies such as vascular malformations (29%) and low-grade brain tumors (9.6%), which parallels reports from both LMIC and HIC centers that often find a mixture of mesial sclerosis and benign brain lesions [6]. Seizure Outcomes and Safety At 12 months post-surgery, 71% of patients achieved complete seizure freedom (Engel class I), a remarkable outcome that is uniform with results from high-income countries and surpasses many expectations for new programs [20, 21]. For instance, a randomized trial reported 64% one-year seizure freedom after temporal lobectomy [22], and other large series generally show about 60–70% of well-selected patients becoming seizure-free [19]. Our results also fall within the range documented in other LMIC contexts—a recent African review found 80.6% of post-surgical patients initially seizure-free, with about 70.3% maintaining Engel I over 1–5 years [23]. This comparability shows the evidence that epilepsy surgery can be as effective in an LMIC setting as in HICs when a dedicated multidisciplinary approach is involved and well organized. Equally, our safety profile was acceptable and in line with international data: only one patient (3.2%) had a lasting neurological deficit, and one had a surgical site infection postoperatively. The overall postoperative complication rate (neurological deficits in 12.9% and infection in 3.2%) is similar to the 8–15% reported elsewhere [5], and there were no perioperative mortalities. Cognitive Function Post-Surgery Postoperative neuropsychological outcomes in our cohort were mixed, highlighting the well-known cognitive risks of epilepsy surgery as well as the potential benefits of seizure control. Overall, we observed significant declines in certain domains such as verbal comprehension, naming, attention span, and verbal memory after surgery for the overall cohort. This aligns with expectations, especially for dominant hemisphere (mostly left-sided) resections. In fact, patients who underwent left temporal lobe surgery showed broad declines across most cognitive tests—a finding consistent with extensive literature that documents verbal memory and language deficits as a major complication of dominant temporal lobectomy [24]. In contrast, those with right-sided surgeries demonstrated improvements in several cognitive domains (attention/executive function and even naming), likely reflecting relief from chronic seizure burden and possibly practice effects. Notably, our seizure-free patients had significantly better cognitive outcomes than those with persistent seizures, an observation also reported in HIC studies where memory decline is exacerbated in patients who continue to have seizures [25]. These results are encouraging because they suggest that while specific cognitive declines (particularly in verbal functions) can occur—and must be managed with counseling and rehabilitation—the net cognitive and functional status of many patients may improve with successful surgery due to the elimination of seizures and reduction in polypharmacy. Our data therefore parallel findings from both LMIC and HIC settings that emphasize careful patient selection (considering language dominance) and highlight that achieving seizure freedom is key to optimizing cognitive outcomes post-surgery. Quality of Life Improvements Perhaps the most compelling evidence of the value of epilepsy surgery in this context is the marked improvement in patients’ quality of life (QoL) after surgery. All QoL domains assessed (seizure worry, emotional well-being, energy, cognition, social function, and overall health) showed significant gains from baseline to 12 months postoperatively. The mean overall QoL score rose from 6.4 before surgery to 9.1 at the 12-month postoperative evaluation, reflecting a transformation in day-to-day functioning and confidence. These improvements are similar to reports from HICs, where freedom from seizures consistently correlates with better psychosocial outcomes [26]. In our study, seizure-free individuals reported higher QoL scores than those with ongoing seizures (total score 68.5 vs 50.1, p < 0.001), echoing the pattern seen in HIC studies that seizure freedom after surgery is the greatest predictor of QoL improvement in DRE [1, 25, 26, 27]. Encouragingly, even domains like “seizure worry” and “cognition” improved significantly, indicating that patients not only experienced relief from the fear of unpredictable seizures but also experienced cognitive improvement in daily life. This observation is likely related to improved stigma, concentration, and memory with fewer seizures. There were no QoL differences between those who had temporal lobectomy versus other surgeries, suggesting that it is the seizure outcome, not the surgical type, that drives QoL improvement. This reflects findings in other settings and reinforces that the primary goal in epilepsy surgery should be seizure freedom, and the choice of surgery should be focused on the potential benefit this will have on seizure frequency [28, 29]. Overall, the QoL outcomes from our program demonstrate that beyond the clinical metrics, patients’ social and emotional well-being substantially improve after surgery. Implications and Recommendations Our experience reinforces that epilepsy surgery is a feasible, effective, and life-changing intervention for drug-resistant epilepsy in Cameroon, with outcomes similar to those of top international centers. This first prospective study in the country not only achieved seizure freedom rates and safety profiles comparable to both regional LMIC programs and HIC standards but also improved cognitive and quality-of-life outcomes in the majority of patients. These findings should encourage health authorities and neurology/neurosurgery communities in similar resource-limited settings to develop and invest in epilepsy surgery programs. Given the treatment gap (nearly 80% of developing countries lack epilepsy surgery programs [30]), our optimistic findings serve as a persuasive case study for advocacy. We recommend strengthening regional collaborations and training initiatives to build local expertise, as well as early referral of DRE patients for surgical evaluation to maximize benefits while patients are young and before years of seizures exact irreversible psychosocial damage. Limitations This study represents the first prospective surgical study for drug-resistant epilepsy in Cameroon, yet it is not without limitations. Our sample size was relatively small, and the study was conducted in one single center (YGH). This may limit the generalizability of our findings. Neuropsychological evaluations, while comprehensive, lacked culturally validated tools specific to our setting, which may interfere with cognitive outcome interpretation. Lastly, resource constraints limited the availability of advanced imaging, the Wada test, and intraoperative monitoring, potentially affecting surgical precision and outcome optimization. Despite these constraints, the study provides a critical foundation for expanding epilepsy surgery in sub-Saharan Africa and demonstrates the feasibility and efficacy of surgical care in a low-resource context. Conclusion This first prospective study on epilepsy surgery in Cameroon demonstrates that safe and effective surgical treatment for drug-resistant epilepsy is feasible in a low-resource setting. With seizure freedom achieved in over two-thirds of patients, significant improvements in quality of life, and cognitive benefits in selected subgroups, our results are similar to outcomes reported in HICs. Despite infrastructural and socioeconomic challenges, these findings support the integration of epilepsy surgery into national neurology and neurosurgery programs in sub-Saharan Africa. Expanding access to timely surgical evaluation and multidisciplinary care can transform the lives of thousands living with refractory epilepsy across the region. Declarations Competing interests: The authors declare no competing interests. Funding Statement: This prospective single-arm cohort did not receive a grant from any institution in the public, commercial, and not-for-profit-sectors. References Riney K, Bogacz A, Somerville E, et al. International League Against Epilepsy classification and definition of epilepsy syndromes with onset at a variable age: position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia. 2022 Jun;63(6):1443-1474. doi: 10.1111/epi.17240. Epub 2022 May 3. PMID: 35503725. W. Löscher, H. Potschka, S. M. Sisodiya, et al. ‘Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options’, Pharmacological Reviews , vol. 72, no. 3, pp. 606–638, July 2020, doi: 10.1124/pr.120.019539. Raslan EE, Al-Hawas SF, Alghamdi MM, et al. Assessment of the Efficacy of Deep Brain Stimulation (DBS) in Managing Drug-Resistant Epilepsy (DRE): A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs). Cureus. 2024 Oct 13;16(10):e71348. doi: 10.7759/cureus.71348. PMID: 39534832; PMCID: PMC11555489. Y. Ng, A. L. McGregor, D. C. Duane, et al. ‘Childhood Mesial Temporal Sclerosis’, J Child Neurol , vol. 21, no. 6, pp. 512–517, June 2006, doi: 10.1177/088307380602100601. W. Löscher, H. Potschka, S. M. Sisodiya, et al. ‘Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options’, Pharmacological Reviews , vol. 72, no. 3, pp. 606–638, July 2020, doi: 10.1124/pr.120.019539. H. Dong, J. Shi, P. Wei, et al. ‘Comparative Efficacy of Surgical Strategies for Drug-Resistant Epilepsy: A Systematic Review and Meta-Analysis’, World Neurosurgery , vol. 195, p. 123729, Mar. 2025, doi: 10.1016/j.wneu.2025.123729. Falsaperla R, D'Angelo G, Praticò AD, et al. Ketogenic diet for infants with epilepsy: A literature review. Epilepsy Behav. 2020 Nov;112:107361. doi: 10.1016/j.yebeh.2020.107361. Epub 2020 Sep 28. PMID: 33181904. P. N. Banerjee, D. Filippi, and W. Allen Hauser, ‘The descriptive epidemiology of epilepsy—A review’, Epilepsy Research , vol. 85, no. 1, pp. 31–45, July 2009, doi: 10.1016/j.eplepsyres.2009.03.003. Angwafor SA, Bell GS, Ngarka L, et al. Epilepsy in a health district in North-West Cameroon: Clinical characteristics and treatment gap. Epilepsy Behav. 2021 Aug;121(Pt A):107997. doi: 10.1016/j.yebeh.2021.107997. Epub 2021 May 11. PMID: 33994085. P. Antwi, K. B. Padron, A.-E. K. Ukachukwu, et al. ‘Surgery for Medication Refractory Epilepsy in Africa: A Review of Seizure Freedom Outcomes’, World Neurosurgery , vol. 193, pp. 1126–1132, Jan. 2025, doi: 10.1016/j.wneu.2024.12.017. P. Antwi, K. B. Padron, A.-E. K. Ukachukwu, et al. ‘Surgery for Medication Refractory Epilepsy in Africa: A Review of Seizure Freedom Outcomes’, World Neurosurgery , vol. 193, pp. 1126–1132, Jan. 2025, doi: 10.1016/j.wneu.2024.12.017. Ukachukwu AK, Still MEH, Seas A, et al. Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030. J Neurosurg. 2022 Aug 12;138(4):1102-1113. doi: 10.3171/2022.2.JNS211984. PMID: 35962968. S. A. Angwafor, G. S. Bell, A. K. Njamnshi, et al. ‘Parasites and epilepsy: Understanding the determinants of epileptogenesis’, Epilepsy & Behavior , vol. 92, pp. 235–244, Mar. 2019, doi: 10.1016/j.yebeh.2018.11.033. A. K. Njamnshi, S. A. Angwafor, E. N. Tabah, et al.‘General public knowledge, attitudes, and practices with respect to epilepsy in the Batibo Health District, Cameroon’, Epilepsy & Behavior , vol. 14, no. 1, pp. 83–88, Jan. 2009, doi: 10.1016/j.yebeh.2008.09.012. Drees C, Sillau S, Brown MG, et al. Preoperative evaluation for epilepsy surgery: Process improvement. Neurol Clin Pract. 2017 Jun;7(3):205-213. doi: 10.1212/CPJ.0000000000000357. PMID: 30107011; PMCID: PMC6081968. Kwan P, Arzimanoglou A, Berg AT, et al. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia. 2010 Jun;51(6):1069-77. doi: 10.1111/j.1528-1167.2009.02397.x. Epub 2009 Nov 3. Erratum in: Epilepsia. 2010 Sep;51(9):1922. PMID: 19889013. Engel J Jr, Wiebe S, French J, et al. Practice parameter: temporal lobe and localized neocortical resections for epilepsy. Epilepsia. 2003 Jun;44(6):741-51. doi: 10.1046/j.1528-1157.2003.48202.x. PMID: 12790886. M. Tripathi, ‘Predictors of refractory epilepsy in North India: A case–control study’, Seizure , vol. 20, no. 10, pp. 779–783, Dec. 2011, doi: 10.1016/j.seizure.2011.07.010. Wiebe S, Blume WT, Girvin JP, et al. Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001 Aug 2;345(5):311-8. doi: 10.1056/NEJM200108023450501. PMID: 11484687. Tiefes AM, Hartlieb T, Tacke M, et al. Mesial Temporal Sclerosis in SCN1A-Related Epilepsy: Two Long-Term EEG Case Studies. Clin EEG Neurosci. 2019 Jul;50(4):267-272. doi: 10.1177/1550059418794347. Epub 2018 Aug 17. PMID: 30117335. J. Liu, B. Liu, and H. Zhang, ‘Surgical versus medical treatment of drug-resistant epilepsy: A systematic review and meta-analysis’, Epilepsy & Behavior , vol. 82, pp. 179–188, May 2018, doi: 10.1016/j.yebeh.2017.11.012. K. M. Fiest, T. T. Sajobi, and S. Wiebe, ‘Epilepsy surgery and meaningful improvements in quality of life: Results from a randomized controlled trial’, Epilepsia , vol. 55, no. 6, pp. 886–892, June 2014, doi: 10.1111/epi.12625. A. Paul, D. Adeloye, R. George-Carey, et al. ‘An estimate of the prevalence of epilepsy in Sub–Saharan Africa: A systematic analysis’, J Glob Health , vol. 2, no. 2, Dec. 2012, doi: 10.7189/jogh.02.020405. S. Baxendale, ‘The impact of epilepsy surgery on cognition and behavior’, Epilepsy & Behavior , vol. 12, no. 4, pp. 592–599, May 2008, doi: 10.1016/j.yebeh.2007.12.015. de Tisi J, Bell GS, Peacock JL, et al. The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study. Lancet. 2011 Oct 15;378(9800):1388-95. doi: 10.1016/S0140-6736(11)60890-8. PMID: 22000136. C. Helmstaedter, M. Kurthen, S. Lux, et al. ‘Chronic epilepsy and cognition: A longitudinal study in temporal lobe epilepsy’, Annals of Neurology , vol. 54, no. 4, pp. 425–432, Oct. 2003, doi: 10.1002/ana.10692. Spyrantis A, Conradi N, Mann C, et al. Impact of seizure outcome and extent of neocortical resection on emotional well-being in patients with epilepsy one year after temporal lobe surgery. Epilepsy Behav. 2024 Dec;161:110061. doi: 10.1016/j.yebeh.2024.110061. Epub 2024 Sep 21. PMID: 39306983. D. J. Englot, J. D. Rolston, D. D. Wang, et al. ‘Seizure outcomes after temporal lobectomy in pediatric patients: A systematic review’, PED , vol. 12, no. 2, pp. 134–141, Aug. 2013, doi: 10.3171/2013.5.PEDS12526. Michael L Bell, Satish Rao, Elson L So, et al. "Epilepsy surgery outcomes in temporal lobe epilepsy with a normal MRI." Epilepsia 50.9 (2009): 2053-2060. https://doi.org/10.1111/j.1528-1167.2009.02079.x Qiu, Jane. "Epilepsy surgery: challenges for developing countries." The Lancet Neurology 8.5 (2009): 420-421. 10.1016/S1474-4422(09)70096-1 External Link Additional Declarations The authors declare no competing interests. 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1","display":"","copyAsset":false,"role":"figure","size":10855,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003esurvival function using the Kaplan Meier’s method\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7941534/v1/4a71893c250f32ec09d02a7a.png"},{"id":94672071,"identity":"bf23e60b-ee13-4072-85cf-e70c8f776688","added_by":"auto","created_at":"2025-10-29 13:38:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1403258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7941534/v1/dcb0cd1e-66dc-40d5-9a77-398b1d8e9402.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePioneering Epilepsy Surgery in Cameroon: Outcomes from the First Prospective Cohort of Surgical Patients with Drug-Resistant Epilepsy\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAmong epileptic patients, it is estimated that one-third have drug-resistant epilepsy (DRE). A patient is considered to have DRE if a trial of at least two anti-epileptic drugs (AEDs) failed to control his seizure, despite good compliance to the regimen [1]. These patients are particularly vulnerable and sometimes represent a burden for their family. Also, they present a three-fold risk of premature death compared to the general population related to their disease and associated injuries. The exact etiopathogenesis of that condition (DRE) remains unclear; however, some point to a multifactorial origin involving structural abnormalities, genetic defects, and molecular mechanisms such as altered drug targets in the epileptogenic brain [2].\u003c/p\u003e\u003cp\u003eBesides polypharmacy, surgical intervention, neuromodulation, and ketogenic diets have emerged as suitable therapeutic approaches [3, 4, 5]. Among those therapeutic options, surgery represents the best option in terms of effectiveness, with a seizure-free rate of 70% with techniques like anterior temporal lobectomy. On the other hand, neuromodulation interventions tend to reduce seizure frequency without absolute seizure freedom [6]. Regarding the ketogenic diet, data about its benefits have remained dubious, and some cohorts only report seizure reduction for the pediatric population [7]. Therefore, no nonsurgical therapies match the long-term efficacy of resective surgeries.\u003c/p\u003e\u003cp\u003eIn sub-Saharan Africa, the burden of epilepsy is especially high, and care is severely constrained. It is estimated by WHO that 25\u0026nbsp;million Africans live with epilepsy [8]. Community studies report a broad prevalence variability with values up to 0.5\u0026ndash;10% in some regions, likely underestimates given the stigma associated with epilepsy in Africa. The treatment gap in Africa is enormous; roughly 70\u0026ndash;75% of people with epilepsy do not receive appropriate treatment due to factors such as low awareness, social stigma, poverty, and reliance on traditional remedies [9, 10]. Data on DRE are sparse and nonexistent in some regions. One systematic review estimated 211,000 new surgical candidates per year in Africa. Yet only a handful of epilepsy surgery centers have been established. Reported outcomes from existing African cohorts demonstrate that 60\u0026ndash;100% of patients achieved good seizure control at one year, comparable to high-income settings [11]. In spite of these successes, the continent\u0026rsquo;s neurosurgical capacity is extremely limited, and only 1,974 neurosurgeons serve 1.3\u0026nbsp;billion Africans (about 0.15 per 100,000 population), with almost all being concentrated in a few urban centers [12]. Consequently, specialized epilepsy evaluation and surgery remain inaccessible to most, and the DRE burden in Africa goes largely unmet.\u003c/p\u003e\u003cp\u003eCameroon's situation mirrors the realities experienced by other sub-Saharan countries. Epilepsy is a leading neurological cause of disability in sub-Saharan Africa, and Cameroon has been cited among the most affected countries. For instance, a village study reported a prevalence of 135 per 1000 inhabitants [13]. However, national epidemiology data are unknown because they are scant. Community surveys in Cameroon reveal both high awareness and pervasive stigma, and half of respondents said they would forbid marriage to someone with epilepsy, and many believed epilepsy to be contagious or a form of insanity. About 30% of people in that district would first seek help from a traditional healer rather than medical care [14]. In contrast, respondents from another region supported employment and schooling of persons with epilepsy, illustrating regional heterogeneity [13]. What is clear is that cultural misconceptions and limited resources delay diagnosis and treatment. Critically, Cameroon initiated epilepsy surgery about 6 years ago. The country has about 25 neurosurgeons (0.1 per 100,000 people), and most are based in capitals, leaving most regions without neurosurgical coverage. No prior study has evaluated surgical treatment of DRE in Cameroon, representing a major knowledge gap in how to address the growing burden.\u003c/p\u003e\u003cp\u003eTo bridge this gap, we established a prospective observational study of Cameroonian patients undergoing epilepsy surgery. The objectives of this study are to evaluate the effectiveness (seizure-control outcomes and quality of life), cognitive well-being, and safety of epilepsy surgery in this setting.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis was a prospective observational single-arm cohort study conducted from January 2018 to March 2024 at the Yaoundé General Hospital (YGH) in Cameroon. The study was conducted in the Department of Neurosciences at the Yaoundé General Hospital (YGH).\u003c/p\u003e\u003cp\u003eYaoundé General Hospital is a first-level referral health facility, equipped with a Department of Neurosciences that includes a fully operational neurosurgery unit. The neurosurgical department has a capacity of approximately 25 inpatient beds and performs an estimated 300 surgical procedures annually. The unit currently operates with three consultant neurosurgeons.\u003c/p\u003e\u003cp\u003eThe Department of Neurosciences also includes three consultant neurologists, some of whom have received subspecialty training in epileptology, as well as a psychiatrist, anesthesiologists/intensivists, and one full professor of neuroradiology.\u003c/p\u003e\u003cp\u003eThe epilepsy surgery program benefits from close multidisciplinary collaboration with pediatric neurologists, clinical psychologists, and speech and language therapists.\u003c/p\u003e\u003cp\u003eThe hospital is equipped with a modern intensive care unit that meets international standards in terms of infrastructure and equipment, ensuring adequate postoperative support for neurosurgical patients.\u003c/p\u003e\u003cp\u003eYGH also houses a large, fully aseptic surgical theater complex composed of seven operating rooms, including two dedicated microsurgical suites. Among the available equipment is a HAAG STREIT ALLEGRA 700 surgical microscope, fitted with dual adjustable oculars and five illumination modes to enhance visualization of fine tissue structures and optimize surgical performance. The facility is further equipped with essential microsurgical instruments, including bipolar coagulators, assorted dissectors, micro-scissors, and suction cannulae of various diameters. For cranial stabilization and positioning, a Mayfield head clamp is available. Additionally, an ANSPACH EMAX 2 multimodal surgical drill system is used, incorporating craniotomy attachments, saws, and burrs, which facilitate the safe execution of cranial bone flaps.\u003c/p\u003e\u003cp\u003eAll patients who underwent surgical treatment for epilepsy at YGH during the study period were enrolled. The study design followed a single-center cohort format. The patients were identified at the time of their evaluation for epilepsy surgery and followed longitudinally through their pre-surgical workup, surgery, and post-operative period (03 months, 06 months, and 12 months).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eOur study included all age patients with DRE according to International League Against Epilepsy (ILAE) criteria [15]. A total of 67 patients were found eligible for epilepsy surgery during our study period. Among these patients, 34 didn’t adhere to surgical treatment and didn’t initiate any assessment. From those who adhered to surgery, 2 didn’t complete their pre-operative workup and didn’t undergo surgical treatment. Only 31 patients completed the recommended presurgical workup and underwent surgery. All eligible patients and/or their guardians provided written informed consent to participate.\u003c/p\u003e\n\u003ch3\u003ePre-Surgical Evaluation\u003c/h3\u003e\n\u003cp\u003eAll patients underwent a comprehensive presurgical evaluation by a multidisciplinary epilepsy team prior to surgery. Clinical Assessment: A detailed clinical history was obtained, including age of seizure onset, seizure semiology, and prior treatments. Each patient received a thorough neurological examination and general medical review. High-resolution brain MRI was performed for all patients (T1-weighted and FLAIR images). Only MRI was used for structural imaging, as it was available on-site; no routine CT or PET scans were obtained in this cohort. Each patient underwent scalp electroencephalography (EEG), including prolonged video-EEG monitoring to capture habitual seizures and identify the epileptogenic zone. At minimum, long-term video-EEG was utilized to record and localize ictal events, and MRI was reviewed to detect any lesion corresponding to the EEG focus. Only cases where MRI clearly revealed a lesion were judged candidates for surgery, as advanced functional imaging (PET or SPECT) was not available. Additionally, a comprehensive neuropsychological battery was administered by a neuropsychologist as part of the preoperative workup. For example, patients completed the Boston Naming Test (BNT) for object naming, the Controlled Oral Word Association Test (COWAT) for phonemic verbal fluency, a semantic fluency test (SFT), Trail Making Test Parts A and B (TMT-A and TMT-B) for processing speed and executive function, and an Auditory Verbal Learning Test (AVLT) for episodic memory. Baseline assessments were conducted at the 6-month postoperative period by the neuropsychologist. In our resource setting, the intracarotid amobarbital (Wada) test was not performed. Each case was reviewed in a multidisciplinary epilepsy surgery conference upon completion of the abovementioned evaluation. Based on clinical, electrophysiological, and MRI data, the team reached a consensus on the localization of the epileptogenic zone and determined whether the patient was a good candidate for resective surgery. Patients and families were then counseled regarding the proposed surgery, including potential benefits and risks.\u003c/p\u003e\n\u003ch3\u003eSurgical Procedures\u003c/h3\u003e\n\u003cp\u003eResective epilepsy surgery was performed for each patient using a tailored approach based on the location of the seizure focus. Three types of surgeries were performed: anterior temporal lobectomy, lesionectomy, and frontal gyral resection. In the operating room, a frameless stereotactic neuronavigation system was employed for all cases to guide the surgeon to the targeted brain region with high precision. Neuronavigation was based on each patient’s MRI and allowed accurate delineation of resection margins. Resections were carried out under general anesthesia using standard microsurgical techniques. The extent of resection aimed to completely remove the epileptogenic zone while preserving adjacent eloquent cortex. In temporal lobectomies, for instance, approximately 3–5 cm of the anterior temporal lobe was removed along with the amygdalohippocampal complex, as per standard practice. All surgeries were performed by the same lead neurosurgeon, a full professor of neurosurgery. Standard anti-epileptic drug therapy was continued in the postoperative period; no patient had immediate discontinuation of medications. After discharge, patients returned for scheduled follow-up visits at approximately 3 months, 6 months, and 12 months post-surgery.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe primary efficacy outcome was post-surgical seizure control, categorized using the Engel Epilepsy Surgery Outcome Scale [16]. At the 12-month follow-up (or last follow-up available for each patient), seizure outcome was classified as Engel Class I, II, III, or IV [15]. For subgroup analysis, we defined favorable outcome as Engel Class IA-IB and unfavorable outcome as Engel Classes II–IV. In addition to seizure frequency, we evaluated quality of life as a co-primary outcome. Quality of life was assessed at baseline and at 06 months and 12 months post-surgery using the 31-item Quality of Life in Epilepsy questionnaire (QOLIE-31). An improvement in the QOLIE-31 overall score post-surgery (higher scores indicate better quality of life) was considered a positive outcome. We also examined neuropsychological outcomes by comparing patients’ cognitive performance before and after surgery. At approximately 6–12 months post-op, patients repeated key tests from the neuropsychological battery. Changes in scores were documented to detect any significant post-surgical cognitive decline or improvement. These cognitive outcome measures were descriptive and used to supplement the overall assessment of each patient’s benefit vs. risk from surgery.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eSecondary outcome measures included surgical safety and long-term epilepsy control metrics. We prospectively recorded any surgical complications, both acute and late. Complications were defined as any deviation from the expected postoperative course, including neurosurgical complications or systemic complications. We also assessed survival time to seizure relapse, which we defined as the time from surgery until the occurrence of a disabling seizure (a seizure that would be classified as Engel Class II or higher). This was essentially a measure of the durability of seizure freedom. Patients who remained in Class I (completely seizure-free or only auras) at last contact were considered not to have reached the event; those who had any recurrent disabling seizure were counted as events, and the interval from surgery to that first seizure was recorded (in days).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Collection and Management\u003c/h2\u003e\u003cp\u003eAll data were collected prospectively by the study investigators using standardized forms and then entered into a secure database. Clinical information, investigation results, surgical details, and outcomes for each patient were recorded. We utilized a combination of hospital medical records and dedicated research case report forms to ensure comprehensive data capture.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Sources\u003c/b\u003e: Preoperative clinical data were obtained from patient interviews and chart reviews at enrollment. MRI and EEG results were retrieved from the hospital’s radiology and neurophysiology records and summarized on the study forms. Surgical operative notes and discharge summaries provided details on the procedures and immediate outcomes. Follow-up data (seizure frequency, Engel class, QOLIE-31 scores, etc.) were collected during outpatient visits at 3, 6, and 12 months, and from phone interviews if an in-person visit was missed. Data \u003cb\u003eQuality Control\u003c/b\u003e: We instituted several measures for data standardization and quality assurance. The data collection forms were pilot-tested on a few initial patients to ensure clarity and consistency in how variables were recorded. Key outcome variables such as Engel classification and complication status were defined explicitly with codes to facilitate consistent interpretation. Each patient was assigned a unique study ID, and all analyses were performed on de-identified data. Access to the data was limited to authorized study personnel only. Physical records (such as consent forms and paper questionnaires) were kept in locked cabinets in the Neurology department research office. All procedures for data handling were in accordance with institutional guidelines and national data protection regulations to ensure patient confidentiality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed using SPSS version 23, and a two-tailed α level of 0.05 was considered statistically significant. First, we assessed continuous variables for normality by the Shapiro–Wilk test. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using paired or unpaired Student’s t-tests as appropriate. Non-normally distributed variables are expressed as median (IQR) and were compared by Wilcoxon signed-rank tests for paired samples or Mann–Whitney U tests for independent groups. Categorical variables are reported as counts and percentages.\u003c/p\u003e\u003cp\u003ePre- to post-surgery changes in neuropsychological scores and quality-of-life domains were evaluated with paired tests (paired t-test or Wilcoxon signed-rank) based on the distribution of the data. For between-group comparisons (left- versus right-side surgery; seizure-free versus persistent seizures), we employed independent t-tests or Mann–Whitney U tests for continuous measures. Survival distributions were estimated by the Kaplan–Meier method.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study was approved by the institutional ethics review board of the Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon (approval number 0383/UY1/FMSB). All procedures and investigations were conducted in accordance with the ethical standards of our institution and with the Declaration of Helsinki and its later amendments. Written informed consent was obtained from each adult participant, and for pediatric patients, consent was obtained from a parent or legal guardian. Participants were informed about the aims of the study, the procedures involved, and any potential risks or benefits of participation. They were assured that refusal to participate or withdrawal from the study would not affect the quality of their medical care. Confidentiality of patient data was strictly maintained, and no identifying personal information is revealed in this publication. Each patient’s decision for surgery was made on clinical grounds independent of the study; the research component was observational and posed no additional risk beyond standard care.\u003c/p\u003e"},{"header":"Result","content":"\u003ch2\u003eSocio-demographic Characteristics\u003c/h2\u003e\u003cp\u003eThis prospective cohort study included 31 patients, who underwent surgical treatment for drug-resistant epilepsy (DRE) in Cameroon. Among them, 23 participants (74.2%) were female. The median age at surgery was 21 years (IQR: 14–29), with seizure onset at a median age of 10 years (IQR: 6–10) and a median disease duration of 8 years (IQR: 5–13).\u003c/p\u003e\u003cp\u003eEducational attainment was limited; 25.8% had never attempted higher education, and only 12.9% earned a highest educational degree. Most patients lived with parents (71.0%) and had low socioeconomic engagement, with only 32.3% working full-time.\u003c/p\u003e\u003ch2\u003eClinical characteristics\u003c/h2\u003e\u003cp\u003eThe most common seizure type was complex partial seizures (61.3%), followed by generalized (25.8%) and focal motor seizures (12.9%). Preoperative seizure frequency was ≤ 10 episodes/month in 64.5% of patients. A majority (61.3%) had no relevant medical history. Four participants (12.9%) had a history of febrile seizure. Other risk factors such as head trauma, psychiatric illness, CNS infection, and fetal asphyxia were present in two participants (6.5%) each. The average number of antiepileptic drugs (AEDs) taken preoperatively was 1.32 ± 0.6; 74.2% were on two AEDs.\u003c/p\u003e\u003ch2\u003eSurgical and Histopathological Findings\u003c/h2\u003e\u003cp\u003eAnterior temporal lobectomy (61.3%) predominated, followed by lesionectomy (25.8%) and frontal gyral resection (12.9%). Most surgeries were conducted in the left temporal lobe (54.8%), 32.3% in the right temporal lobe, and 12.9% in the left frontal lobe. Video-EEG confirmed epileptogenic foci in the left temporal lobe in 61.3% of cases; the right temporal lobe and the left frontal lobe respectively represent 32.4% and 6.4% of epileptogenic foci. Histopathology revealed hippocampal sclerosis in 61.3%, vascular malformations in 29.0%, and low-grade brain tumors in 9.6%.\u003c/p\u003e\u003ch2\u003ePostoperative Outcomes\u003c/h2\u003e\u003cp\u003eThe median postoperative stay was 11 (IQR: 6–15) days; 4 (12.9%) participants reported postoperative neurologic deficit, and surgical site suppuration was reported in 1 (3.2%) participant. Only one participant reported neurologic sequelae (right-side hemiparesis).\u003c/p\u003e\u003cp\u003eDisabling postoperative seizures occurred in 9 (29.0%) patients. At the last follow-up, 22 patients (71%) achieved seizure freedom (Engel class IA–IB).\u003c/p\u003e\u003ch2\u003eCognitive Outcomes\u003c/h2\u003e\u003cp\u003ePostoperative assessments demonstrated mixed cognitive outcomes. Certain domains, such as VC, BNT, TMT-A, COWAT, and AVLT, showed statistically significant declines after surgery. This decline was not significant for TMT B and SFT. Subgroup analysis (right-side surgery and left-side surgery) reported different outcomes. Patients who underwent right-side surgery reported significant improvement in VC, TMT-A, TMT-B, SFT, and BNT, but they declined in COWAT (p = 0.22) and AVLT (p \u0026lt; 0.001). On the other hand, left-side surgery yielded significant declines in all categories except for the COWAT, where the cognitive decline was not significant (p = 0.22).\u003c/p\u003e\u003cp\u003eCognitive outcomes were significantly better among seizure-free patients across all neuropsychological domains. However, there was no significant difference based on surgical type (anterior temporal lobectomy vs. other surgeries).\u003c/p\u003e\u003ch2\u003eQuality of Life (QoL)\u003c/h2\u003e\u003cp\u003eQoL metrics significantly improved post-surgery. Overall QoL domain increased from a mean of 6.4 pre-surgery to 9.1 at 12 months (p \u0026lt; 0.001). Seizure worry, emotional well-being, energy, cognition, medication effects, and social functioning all improved significantly from presurgical assessment to 12-month postoperative evaluation. Seizure-free patients reported markedly higher QoL scores than those with persistent seizures across multiple domains. This is highlighted by the substantial difference in mean total score at the 12-month evaluation between the 02 groups (68.5 vs. 50.1; p \u0026lt; 0.001). However, no significant difference in mean was present for energy level (8.4 vs. 7.3; p = 0.13) and medication effects (2.7 vs. 2.6; p = 0.44) between the two groups.\u003c/p\u003e\u003cp\u003eBased on surgical type (anterior temporal lobectomy vs. other surgeries), there was no significant difference among QoL domains.\u003c/p\u003e\u003ch2\u003eSurvival Estimates\u003c/h2\u003e\u003cp\u003eThe mean estimated survival time was 270.4 days (95% CI: 217.1–323.8). Median survival time was not reached, indicating favorable survival outcomes within the follow-up period.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the study population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean/median or no.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at seizure onset\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(6–10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(14–29)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTime between onset and surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(5–13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23(74.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePredominant type of seizure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartial complex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(61.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneralize seizure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(25.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFocal motor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(58.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(25.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(9.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHighest education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo not apply\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(35.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDid not attempt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(25.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOngoing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(25.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinished\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePreoperative seizure frequency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≤10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(64.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11–20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(22.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e≥20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(3.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCountless\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(9.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedical History\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIrrelevant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(61.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFebrile seizure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFetal asphyxia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatric illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCNS infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead trauma (mild)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNo. of Preoperative AEDs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.32 ± 0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23(74.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(19.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical site\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft temporal lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(54.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight temporal lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(32.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft frontal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLiving\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily (parents)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22(71.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily (wife/husband)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(16.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocioeconomic status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking full time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(32.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking part time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(22.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudying\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(22.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo occupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(22.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRight handedness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31(100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative hospital stays\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(6–15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEEG video foci\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(61.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(32.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative disabling seizure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(29.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHistopathology findings\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHippocampal sclerosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(61.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVascular malformation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(29.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow grade tumor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(9.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical technique\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnterior Temporal lobectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19(61.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLesionectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(25.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrontal gyral resection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(12.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCognitive assessment\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003epresurgical\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003epostsurgical\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e91.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e101.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e104.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCOWAT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTMT A\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTMT B\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e82.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSFT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBNT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAVLT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQoL evolution from baseline to 12 months postoperative period\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-surgical QoL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 months QoL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 months QoL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeizure worry\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall QoL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmotional wellbeing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnergy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCognitive\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedication effects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocial function\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSum QoL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e63.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQoL and cognitive function comparison based on seizure freedom\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEngel IA-IB (22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEngel II-V (9)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoL at last assessment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeizure worry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall QoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional wellbeing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnergy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedication effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSum QoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative Cognitive function\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e95.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOWAT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTMT A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTMTB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e88.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSFT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBNT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQoL and cognitive function comparison based on surgical type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnterior temporal lobectomy (19)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOther surgeries (12)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoL at last assessment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeizure worry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall QoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional wellbeing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnergy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedication effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSum QoL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative Cognitive function\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOWAT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTMT A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTMTB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSFT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBNT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAVLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEstimate survival function mean\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStd. Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003cp\u003eLower Bound Upper Bound\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e270.419\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e217.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e323.751\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eDemographic and Clinical Context\u003c/h2\u003e\u003cp\u003eOur cohort from a sub-Saharan African country highlights the considerable burden of DRE in a low-resource setting. The patients were predominantly young, with the median age at surgery being 21, and female (74%) patients were predominant. The median age at seizure onset was 10 years, with a median disease duration of 8 years. This contrasts with some surgical series in other regions that often show a male majority [17], an intriguing difference possibly influenced by sociocultural factors or referral patterns in our setting. Low educational attainment and limited employment (only 32.3% of participants had a full-time occupation before surgery) were common, underscoring the disruptive impact of uncontrolled epilepsy on schooling and livelihood. Similar socio-economic challenges are reported across low- and middle-income countries (LMICs), where many people with epilepsy lack access to adequate treatment [18]. Our findings reinforce that, as in high-income countries (HICs), DRE in LMICs exacts a heavy toll on quality of life and productivity\u0026mdash;and that effective interventions are urgently needed to prevent young patients from losing formative educational and work opportunities.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSurgical Strategies and Pathology in Perspective\u003c/h2\u003e\u003cp\u003eDespite the resource-limited context, the surgical approaches and pathologies in our cohort mirror global trends. Anterior temporal lobectomy was the most common procedure (61.3%), reflecting the predominance of mesial temporal lobe epilepsy, followed by lesionectomies and a few frontal gyral resections. This distribution is comparable to both HIC and LMIC reported data, where temporal lobe surgery typically represents the majority of cases [5, 17]. Notably, most surgeries in our series were performed on left temporal foci (54.8%), aligning with video-EEG findings and demonstrating the capability to lateralize and localize seizures even in a new program that lacks crucial tools such as the Wada test. Histopathology results were likewise in line with international data: hippocampal sclerosis was the leading pathology (61.3%), consistent with the well-known prevalence of mesial sclerosis in surgical epilepsy [18, 19]. The remainder were lesional etiologies such as vascular malformations (29%) and low-grade brain tumors (9.6%), which parallels reports from both LMIC and HIC centers that often find a mixture of mesial sclerosis and benign brain lesions [6].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eSeizure Outcomes and Safety\u003c/h2\u003e\u003cp\u003eAt 12 months post-surgery, 71% of patients achieved complete seizure freedom (Engel class I), a remarkable outcome that is uniform with results from high-income countries and surpasses many expectations for new programs [20, 21]. For instance, a randomized trial reported 64% one-year seizure freedom after temporal lobectomy [22], and other large series generally show about 60\u0026ndash;70% of well-selected patients becoming seizure-free [19]. Our results also fall within the range documented in other LMIC contexts\u0026mdash;a recent African review found 80.6% of post-surgical patients initially seizure-free, with about 70.3% maintaining Engel I over 1\u0026ndash;5 years [23]. This comparability shows the evidence that epilepsy surgery can be as effective in an LMIC setting as in HICs when a dedicated multidisciplinary approach is involved and well organized. Equally, our safety profile was acceptable and in line with international data: only one patient (3.2%) had a lasting neurological deficit, and one had a surgical site infection postoperatively. The overall postoperative complication rate (neurological deficits in 12.9% and infection in 3.2%) is similar to the 8\u0026ndash;15% reported elsewhere [5], and there were no perioperative mortalities.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eCognitive Function Post-Surgery\u003c/h2\u003e\u003cp\u003ePostoperative neuropsychological outcomes in our cohort were mixed, highlighting the well-known cognitive risks of epilepsy surgery as well as the potential benefits of seizure control. Overall, we observed significant declines in certain domains such as verbal comprehension, naming, attention span, and verbal memory after surgery for the overall cohort. This aligns with expectations, especially for dominant hemisphere (mostly left-sided) resections. In fact, patients who underwent left temporal lobe surgery showed broad declines across most cognitive tests\u0026mdash;a finding consistent with extensive literature that documents verbal memory and language deficits as a major complication of dominant temporal lobectomy [24]. In contrast, those with right-sided surgeries demonstrated improvements in several cognitive domains (attention/executive function and even naming), likely reflecting relief from chronic seizure burden and possibly practice effects. Notably, our seizure-free patients had significantly better cognitive outcomes than those with persistent seizures, an observation also reported in HIC studies where memory decline is exacerbated in patients who continue to have seizures [25]. These results are encouraging because they suggest that while specific cognitive declines (particularly in verbal functions) can occur\u0026mdash;and must be managed with counseling and rehabilitation\u0026mdash;the net cognitive and functional status of many patients may improve with successful surgery due to the elimination of seizures and reduction in polypharmacy. Our data therefore parallel findings from both LMIC and HIC settings that emphasize careful patient selection (considering language dominance) and highlight that achieving seizure freedom is key to optimizing cognitive outcomes post-surgery.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eQuality of Life Improvements\u003c/h2\u003e\u003cp\u003ePerhaps the most compelling evidence of the value of epilepsy surgery in this context is the marked improvement in patients\u0026rsquo; quality of life (QoL) after surgery. All QoL domains assessed (seizure worry, emotional well-being, energy, cognition, social function, and overall health) showed significant gains from baseline to 12 months postoperatively. The mean overall QoL score rose from 6.4 before surgery to 9.1 at the 12-month postoperative evaluation, reflecting a transformation in day-to-day functioning and confidence. These improvements are similar to reports from HICs, where freedom from seizures consistently correlates with better psychosocial outcomes [26]. In our study, seizure-free individuals reported higher QoL scores than those with ongoing seizures (total score 68.5 vs 50.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), echoing the pattern seen in HIC studies that seizure freedom after surgery is the greatest predictor of QoL improvement in DRE [1, 25, 26, 27]. Encouragingly, even domains like \u0026ldquo;seizure worry\u0026rdquo; and \u0026ldquo;cognition\u0026rdquo; improved significantly, indicating that patients not only experienced relief from the fear of unpredictable seizures but also experienced cognitive improvement in daily life. This observation is likely related to improved stigma, concentration, and memory with fewer seizures. There were no QoL differences between those who had temporal lobectomy versus other surgeries, suggesting that it is the seizure outcome, not the surgical type, that drives QoL improvement. This reflects findings in other settings and reinforces that the primary goal in epilepsy surgery should be seizure freedom, and the choice of surgery should be focused on the potential benefit this will have on seizure frequency [28, 29]. Overall, the QoL outcomes from our program demonstrate that beyond the clinical metrics, patients\u0026rsquo; social and emotional well-being substantially improve after surgery.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eImplications and Recommendations\u003c/h2\u003e\u003cp\u003eOur experience reinforces that epilepsy surgery is a feasible, effective, and life-changing intervention for drug-resistant epilepsy in Cameroon, with outcomes similar to those of top international centers. This first prospective study in the country not only achieved seizure freedom rates and safety profiles comparable to both regional LMIC programs and HIC standards but also improved cognitive and quality-of-life outcomes in the majority of patients. These findings should encourage health authorities and neurology/neurosurgery communities in similar resource-limited settings to develop and invest in epilepsy surgery programs. Given the treatment gap (nearly 80% of developing countries lack epilepsy surgery programs [30]), our optimistic findings serve as a persuasive case study for advocacy. We recommend strengthening regional collaborations and training initiatives to build local expertise, as well as early referral of DRE patients for surgical evaluation to maximize benefits while patients are young and before years of seizures exact irreversible psychosocial damage.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study represents the first prospective surgical study for drug-resistant epilepsy in Cameroon, yet it is not without limitations. Our sample size was relatively small, and the study was conducted in one single center (YGH). This may limit the generalizability of our findings. Neuropsychological evaluations, while comprehensive, lacked culturally validated tools specific to our setting, which may interfere with cognitive outcome interpretation. Lastly, resource constraints limited the availability of advanced imaging, the Wada test, and intraoperative monitoring, potentially affecting surgical precision and outcome optimization. Despite these constraints, the study provides a critical foundation for expanding epilepsy surgery in sub-Saharan Africa and demonstrates the feasibility and efficacy of surgical care in a low-resource context.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis first prospective study on epilepsy surgery in Cameroon demonstrates that safe and effective surgical treatment for drug-resistant epilepsy is feasible in a low-resource setting. With seizure freedom achieved in over two-thirds of patients, significant improvements in quality of life, and cognitive benefits in selected subgroups, our results are similar to outcomes reported in HICs. Despite infrastructural and socioeconomic challenges, these findings support the integration of epilepsy surgery into national neurology and neurosurgery programs in sub-Saharan Africa. Expanding access to timely surgical evaluation and multidisciplinary care can transform the lives of thousands living with refractory epilepsy across the region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Statement:\u003c/h2\u003e\u003cp\u003eThis prospective single-arm cohort did not receive a grant from any institution in the public, commercial, and not-for-profit-sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRiney K, Bogacz A, Somerville E, et al. International League Against Epilepsy classification and definition of epilepsy syndromes with onset at a variable age: position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia. 2022 Jun;63(6):1443-1474. doi: 10.1111/epi.17240. Epub 2022 May 3. PMID: 35503725.\u003c/li\u003e\n\u003cli\u003eW. L\u0026ouml;scher, H. Potschka, S. M. Sisodiya, et al. \u0026lsquo;Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options\u0026rsquo;, \u003cem\u003ePharmacological Reviews\u003c/em\u003e, vol. 72, no. 3, pp. 606\u0026ndash;638, July 2020, doi: 10.1124/pr.120.019539.\u003c/li\u003e\n\u003cli\u003eRaslan EE, Al-Hawas SF, Alghamdi MM, et al. Assessment of the Efficacy of Deep Brain Stimulation (DBS) in Managing Drug-Resistant Epilepsy (DRE): A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs). Cureus. 2024 Oct 13;16(10):e71348. doi: 10.7759/cureus.71348. PMID: 39534832; PMCID: PMC11555489.\u003c/li\u003e\n\u003cli\u003eY. Ng, A. L. McGregor, D. C. Duane, et al. \u0026lsquo;Childhood Mesial Temporal Sclerosis\u0026rsquo;, \u003cem\u003eJ Child Neurol\u003c/em\u003e, vol. 21, no. 6, pp. 512\u0026ndash;517, June 2006, doi: 10.1177/088307380602100601.\u003c/li\u003e\n\u003cli\u003eW. L\u0026ouml;scher, H. Potschka, S. M. Sisodiya, et al. \u0026lsquo;Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options\u0026rsquo;, \u003cem\u003ePharmacological Reviews\u003c/em\u003e, vol. 72, no. 3, pp. 606\u0026ndash;638, July 2020, doi: 10.1124/pr.120.019539.\u003c/li\u003e\n\u003cli\u003eH. Dong, J. Shi, P. Wei, et al. \u0026lsquo;Comparative Efficacy of Surgical Strategies for Drug-Resistant Epilepsy: A Systematic Review and Meta-Analysis\u0026rsquo;, \u003cem\u003eWorld Neurosurgery\u003c/em\u003e, vol. 195, p. 123729, Mar. 2025, doi: 10.1016/j.wneu.2025.123729.\u003c/li\u003e\n\u003cli\u003eFalsaperla R, D\u0026apos;Angelo G, Pratic\u0026ograve; AD, et al. Ketogenic diet for infants with epilepsy: A literature review. Epilepsy Behav. 2020 Nov;112:107361. doi: 10.1016/j.yebeh.2020.107361. Epub 2020 Sep 28. PMID: 33181904.\u003c/li\u003e\n\u003cli\u003eP. N. Banerjee, D. Filippi, and W. Allen Hauser, \u0026lsquo;The descriptive epidemiology of epilepsy\u0026mdash;A review\u0026rsquo;, \u003cem\u003eEpilepsy Research\u003c/em\u003e, vol. 85, no. 1, pp. 31\u0026ndash;45, July 2009, doi: 10.1016/j.eplepsyres.2009.03.003.\u003c/li\u003e\n\u003cli\u003eAngwafor SA, Bell GS, Ngarka L, et al. Epilepsy in a health district in North-West Cameroon: Clinical characteristics and treatment gap. Epilepsy Behav. 2021 Aug;121(Pt A):107997. doi: 10.1016/j.yebeh.2021.107997. Epub 2021 May 11. PMID: 33994085.\u003c/li\u003e\n\u003cli\u003eP. Antwi, K. B. Padron, A.-E. K. 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Njamnshi, et al. \u0026lsquo;Parasites and epilepsy: Understanding the determinants of epileptogenesis\u0026rsquo;, \u003cem\u003eEpilepsy \u0026amp; Behavior\u003c/em\u003e, vol. 92, pp. 235\u0026ndash;244, Mar. 2019, doi: 10.1016/j.yebeh.2018.11.033.\u003c/li\u003e\n\u003cli\u003eA. K. Njamnshi, S. A. Angwafor, E. N. Tabah, et al.\u0026lsquo;General public knowledge, attitudes, and practices with respect to epilepsy in the Batibo Health District, Cameroon\u0026rsquo;, \u003cem\u003eEpilepsy \u0026amp; Behavior\u003c/em\u003e, vol. 14, no. 1, pp. 83\u0026ndash;88, Jan. 2009, doi: 10.1016/j.yebeh.2008.09.012.\u003c/li\u003e\n\u003cli\u003eDrees C, Sillau S, Brown MG, et al. Preoperative evaluation for epilepsy surgery: Process improvement. Neurol Clin Pract. 2017 Jun;7(3):205-213. doi: 10.1212/CPJ.0000000000000357. PMID: 30107011; PMCID: PMC6081968.\u003c/li\u003e\n\u003cli\u003eKwan P, Arzimanoglou A, Berg AT, et al. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia. 2010 Jun;51(6):1069-77. doi: 10.1111/j.1528-1167.2009.02397.x. Epub 2009 Nov 3. Erratum in: Epilepsia. 2010 Sep;51(9):1922. PMID: 19889013.\u003c/li\u003e\n\u003cli\u003eEngel J Jr, Wiebe S, French J, et al. Practice parameter: temporal lobe and localized neocortical resections for epilepsy. Epilepsia. 2003 Jun;44(6):741-51. doi: 10.1046/j.1528-1157.2003.48202.x. PMID: 12790886.\u003c/li\u003e\n\u003cli\u003eM. Tripathi, \u0026lsquo;Predictors of refractory epilepsy in North India: A case\u0026ndash;control study\u0026rsquo;, \u003cem\u003eSeizure\u003c/em\u003e, vol. 20, no. 10, pp. 779\u0026ndash;783, Dec. 2011, doi: 10.1016/j.seizure.2011.07.010.\u003c/li\u003e\n\u003cli\u003eWiebe S, Blume WT, Girvin JP, et al. Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001 Aug 2;345(5):311-8. doi: 10.1056/NEJM200108023450501. PMID: 11484687.\u003c/li\u003e\n\u003cli\u003eTiefes AM, Hartlieb T, Tacke M, et al. Mesial Temporal Sclerosis in SCN1A-Related Epilepsy: Two Long-Term EEG Case Studies. Clin EEG Neurosci. 2019 Jul;50(4):267-272. doi: 10.1177/1550059418794347. Epub 2018 Aug 17. PMID: 30117335.\u003c/li\u003e\n\u003cli\u003eJ. Liu, B. Liu, and H. Zhang, \u0026lsquo;Surgical versus medical treatment of drug-resistant epilepsy: A systematic review and meta-analysis\u0026rsquo;, \u003cem\u003eEpilepsy \u0026amp; Behavior\u003c/em\u003e, vol. 82, pp. 179\u0026ndash;188, May 2018, doi: 10.1016/j.yebeh.2017.11.012.\u003c/li\u003e\n\u003cli\u003eK. M. Fiest, T. T. Sajobi, and S. Wiebe, \u0026lsquo;Epilepsy surgery and meaningful improvements in quality of life: Results from a randomized controlled trial\u0026rsquo;, \u003cem\u003eEpilepsia\u003c/em\u003e, vol. 55, no. 6, pp. 886\u0026ndash;892, June 2014, doi: 10.1111/epi.12625.\u003c/li\u003e\n\u003cli\u003eA. Paul, D. Adeloye, R. George-Carey, et al. \u0026lsquo;An estimate of the prevalence of epilepsy in Sub\u0026ndash;Saharan Africa: A systematic analysis\u0026rsquo;, \u003cem\u003eJ Glob Health\u003c/em\u003e, vol. 2, no. 2, Dec. 2012, doi: 10.7189/jogh.02.020405.\u003c/li\u003e\n\u003cli\u003eS. Baxendale, \u0026lsquo;The impact of epilepsy surgery on cognition and behavior\u0026rsquo;, \u003cem\u003eEpilepsy \u0026amp; Behavior\u003c/em\u003e, vol. 12, no. 4, pp. 592\u0026ndash;599, May 2008, doi: 10.1016/j.yebeh.2007.12.015.\u003c/li\u003e\n\u003cli\u003ede Tisi J, Bell GS, Peacock JL, et al. The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study. Lancet. 2011 Oct 15;378(9800):1388-95. doi: 10.1016/S0140-6736(11)60890-8. PMID: 22000136.\u003c/li\u003e\n\u003cli\u003eC. Helmstaedter, M. Kurthen, S. Lux, et al. \u0026lsquo;Chronic epilepsy and cognition: A longitudinal study in temporal lobe epilepsy\u0026rsquo;, \u003cem\u003eAnnals of Neurology\u003c/em\u003e, vol. 54, no. 4, pp. 425\u0026ndash;432, Oct. 2003, doi: 10.1002/ana.10692.\u003c/li\u003e\n\u003cli\u003eSpyrantis A, Conradi N, Mann C, et al. Impact of seizure outcome and extent of neocortical resection on emotional well-being in patients with epilepsy one year after temporal lobe surgery. Epilepsy Behav. 2024 Dec;161:110061. doi: 10.1016/j.yebeh.2024.110061. Epub 2024 Sep 21. PMID: 39306983.\u003c/li\u003e\n\u003cli\u003eD. J. Englot, J. D. Rolston, D. D. Wang, et al. \u0026lsquo;Seizure outcomes after temporal lobectomy in pediatric patients: A systematic review\u0026rsquo;, \u003cem\u003ePED\u003c/em\u003e, vol. 12, no. 2, pp. 134\u0026ndash;141, Aug. 2013, doi: 10.3171/2013.5.PEDS12526.\u003c/li\u003e\n\u003cli\u003eMichael L Bell, Satish Rao, Elson L So, et al. \u0026quot;Epilepsy surgery outcomes in temporal lobe epilepsy with a normal MRI.\u0026quot; \u003cem\u003eEpilepsia\u003c/em\u003e 50.9 (2009): 2053-2060. https://doi.org/10.1111/j.1528-1167.2009.02079.x \u003c/li\u003e\n\u003cli\u003eQiu, Jane. \u0026quot;Epilepsy surgery: challenges for developing countries.\u0026quot; \u003cem\u003eThe Lancet Neurology\u003c/em\u003e 8.5 (2009): 420-421. 10.1016/S1474-4422(09)70096-1 External Link\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1 ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Drug-resistant epilepsy, Engel classification, anterior temporal lobectomy, hippocampal sclerosis","lastPublishedDoi":"10.21203/rs.3.rs-7941534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7941534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eDrug-resistant epilepsy (DRE) represents a public health burden that affects one-third of people with epilepsy and carries a high risk of premature death. Although surgical resection achieves seizure freedom in up to 70% of cases in high-income settings, access to epilepsy surgery in sub-Saharan Africa remains limited. Cameroon initiated an epilepsy surgery program seven years ago, but no prospective outcome data have been reported.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a single-center, prospective observational cohort of 31 consecutive Cameroonian patients with DRE who underwent epilepsy surgery between January 2018 and March 2024. Collected data included sociodemographic and clinical characteristics, surgical and histopathological findings, postoperative complications, seizure outcomes (Engel classification), neuropsychological performance, and health-related quality of life (QoL) at baseline, 6 months, and 12 months postoperatively. Primary endpoints were seizure freedom (Engel I), cognitive change, and QoL improvement. Survival estimates were computed using Kaplan\u0026ndash;Meier analysis and assessed time from surgery to disabling seizure.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eIn this cohort, female was predominant (74.2%), the median age at surgery was 21 years (IQR 14\u0026ndash;29), and the median disease duration was 8 years (IQR 5\u0026ndash;13). Complex partial seizures comprised 61.3% of cases. Anterior temporal lobectomy was performed in 61.3%; hippocampal sclerosis was the most common pathology (61.3%). At final follow-up, 71% achieved seizure freedom. Postoperative complications were uncommon: 12.9% experienced transient neurologic deficits, and 3.2% had wound infections. Cognitive outcomes varied by laterality: left-side resections showed declines in most domains, whereas right-side surgeries demonstrated improvement in several measures. Seizure-free patients maintained better QoL and neuropsychological performance across all domains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) except for energy level and medication effects. Overall QoL and sum QoL scores rose from a mean of 6.4 to 9.1 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 48.8 to 63.18 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively, with significantly greater gains among seizure-free individuals. Mean estimated survival time was 270.4 days (95% CI 217.1\u0026ndash;323.8); median survival was not reached.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eEpilepsy surgery in Cameroon is safe, effective, and yields outcomes comparable to global standards. The procedure significantly enhances seizure control and QoL, though cognitive effects vary by surgical site. These findings underscore the feasibility and importance of expanding surgical epilepsy care in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Pioneering Epilepsy Surgery in Cameroon: Outcomes from the First Prospective Cohort of Surgical Patients with Drug-Resistant Epilepsy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 06:28:14","doi":"10.21203/rs.3.rs-7941534/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39104176-eeb5-4bd1-9faf-2a718eea0349","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56839552,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2025-10-29T06:28:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 06:28:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7941534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7941534","identity":"rs-7941534","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}