Challenges in the management of epilepsy associated with posterior gliosis secondary to perinatal brain injury

Posterior gliosis is a major substrate underlying drug resistant epilepsy (DRE) in children and young adults in low-middle income countries. Neonatal hypoglycemia and prolonged partial asphyxia either isolated or combined are major risk factors for posterior gliosis. The epilepsy associated with posterior gliosis has a spectrum of severity with early onset drug resistant epileptic encephalopathies with disabling co-morbidities at one end and pharmaco-responsive focal epilepsy in a normal child at the other. Intermediate severity syndromes are common. Disabling co-morbidities are typically cognitive and visual with sparing of motor skills. The imaging spectrum consist of bilateral symmetric or asymmetric parieto-occipital gliosis though unilateral occipital lesions are not uncommon. EEG too has a wide range of abnormalities but is of limited benefit in localisation and lateralisation. Standard management strategies for posterior gliosis associated epilepsy offer unique challenges in low-middle income countries where more DRE is encountered. Issues in anti-seizure medication (ASM) treatments and ketogenic diet are highlighted. Resective surgery for unilateral/asymmetric bilateral gliosis has an established place. Challenges remain in predicting post-operative visual deficits. The use of resting state fMRI is discussed. Seizure freedom is achievable in ∼25 % of medically managed patients, though ASM discontinuation fails in the majority.