Relieving the burden of intractable epilepsy in India and other developing countries: the case for two tier epilepsy centers

India, with a population of over 1 billion, is likely to have more than a million patients with intractable epilepsy of whom 1/3 to 1/2 are likely to be benefited by Epilepsy Surgery. However, the total number of patients operated till date would not be very much more than 1,200. The Indian situation more or less mirrors the developing country scenario with approximately only 26 of 142 developing countries having at least one epilepsy surgery center. The major reason behind this dismal situation is the unavailability of epilepsy surgery in most parts of the country because epilepsy surgery is deemed to be possible only in massive institutions. One way to overcome this is to have a two-tiered epilepsy surgery program. The first tier would consist of multiple small epilepsy surgery centers equipped with only a high-quality MRI, inter-ictal scalp EEG, standard microneurosurgical facilities and staffed with well-trained epilepsy surgeons and epileptologists. These centers should be able to deal with unilateral temporal lobe epilepsy and single structural lesions in non-eloquent cortex which constitute around 70% of cases suitable for epilepsy surgery in developing countries. The rest of the 30% can be referred to the few advanced centers. This strategy would popularize epilepsy surgery and make it more available at a lower cost. The proposal is based on the belief that a high-quality MRI in itself is adequate pre-operative evaluation for clear-cut unilateral temporal lobe epilepsy and single structural lesions. THE ENORMITY OF THE “SURGICAL