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So do we know all the answers when it comes to epilepsy with single small CT enhancing lesion (SSCTEL)? The answer is an empathetic no. In 1985, we were the first to draw attention to these lesions in a publication titled “Appearing and disappearing CT abnormalities and seizures” [1]. Our small series of 11 patients aroused considerable interest nationally and internationally in these lesions. The patient reported were treated with no specific medicines except anticonvulsants and in all these, lesions disappeared spontaneously after a variable periods of 2-3 months. Prior to our publication, due to high incidence of tuberculosis in our population and response of these lesions to anti-tubercular therapy (ATT) it was widely believed that these lesions were tuberculomas. In absence of any biopsy in our series, by a process of exclusion, we thought that these lesions represented some sort of spontaneously resolving infection, peculiar to the Indian subcontinent and referred to it as a “focal encephalitis”. In hind sight the choice of our word was inappropriate and a better term would have been “focal encephalitides”. Following our publication others reported presumptive diagnoses of these lesions as tuberculoma, cysticercosis, sarcoidosis, larva migrans, transient viral encephalitis, microabscess, post ictal enhancement and even vascular lesions. Rajshekhar documented stereotactic biopsy findings in 6 such cases. In all cases the biopsy was reported as “non specific chronic inflammatory lesions” or “focal encephalitides” [2]. Five of these lesions were followed up with anti-convulsant therapy and in all of them the lesion reportedly disappeared in three months. The authors disagreed with policy regarding starting these patients on ATT preferring to treat only with anti-convulsants as advised by us. A subsequent paper published in 1991 which included stereotactic biopsy in some of the cases, it was concluded that in Indian epileptic patients with SSECTL, cysticercosis is the commonest etiology. A critical analysis of Chandy’s and Rajshekhar’s paper reveals that in a significant number of their patients, the lesion disappeared or turned into calcific dots with no specific therapy. The authors concluded that disappearing lesions are nothing but a manifestation of a “very benign form of neurocysticercosis” [3]. While the disappearance or death and calcification of these parasites in the brain is a natural event in the evolution of most types of benign cerebral cysticercosis, the process can take anywhere from 18 months to 10 years from the time of manifestation. The rapid resolution of the granulomas (disappearance in 4 to 6 weeks) in some patients and the long duration of symptoms in others is difficult to explain except by postulating that this is determined by the individual host immune status and the host-parasite reaction. A point to ponder here is that why in cases reported from the Indian subcontinent 60 to 80% of SSECT lesions disappear while in South America, where neurocysticercosis is rampant, disappearing lesions have not been commonly reported. How do we explain this paradox?

Epilepsy with Single Small CT Scan Enhancing Lesion in India-Do we know all the Answers Yet?