Posterior temporal epilepsy: Electroclinical features

In the course of evaluating children with posterior temporal lobe epilepsy with subdural electrodes, we observed that their seizures commonly arose from basal rather than convexity foci and that they followed a stereotyped clinical sequence. Seizures characteristically began with behavioral arrest that coincided with basal temporal seizure discharges and progressed to motor signs as the seizure activity spread to the ipsilateral cortical convexity. Behavioral automatisms were observed in approximately half the patients, but were never the first or most prominent ictal manifestation. Focal lesions were identified preoperatively in 7 patients. We performed tailored temporal lobe resections in 14 patients, 10 (71%) of whom were seizure free (N = 9) or had occasional auras (N = 1) at a mean follow-up of 2 years. These findings suggest that in childhood, posterior temporal seizures frequently arise from basal cortex and have a consistent and recognizable ictal and electrographic semiology. In medically refractory patients, tailored temporal resection is an effective therapy.     

Differentiating Clinical Features of Right and Left Temporal Lobe Seizures

Summary: We reviewed 127 seizures in 19 consecutive patients with temporal lobe epilepsy (TLE) documented by EEG/closed-circuit TV (EEG-CCTV) monitoring. Ten patients had seizure onset in the right temporal lobe (RTL, 54 seizures), and 9 had seizure onset in the left temporal lobe (LTL, 73 seizures). We compared the clinical characteristics in the two groups and analyzed the seizures for frequency of auras, seizures secondarily generalized, automatisms, tonic head deviation, focal posturing and jerking, ictal speech, and postical manifestations. Automatisms overall were more common in the RTL group, but individual categories (extremity, head and trunk, oroalimentary) were comparable among the two groups. Contralateral focal jerking and tonic head deviation were more common in LTL lobe seizures, as were secondarily generalized seizures. In addition to focal motor symptoms, three features were most statistically significant in distinguishing the two groups: Postictal aphasia occurred exclusively in the LTL group, whereas well-formed ictal speech and rapid return to baseline postictally were noted only in RTL seizures.     

Clinical and EEG Features of Complex Partial Seizures of Temporal Lobe Origin

Summary: The electrographic and clinical behavioural manifestations of 96 temporal lobe seizures are reviewed from recordings in 19 patients who were submitted to stereotaxic depth electrode implantation in temporal and frontal lobes. Focal onset in hippocampus was recorded in 40% of the seizures. Sixty percent of temporal lobe seizures exhibited a regional seizure onset but in two-thirds of these ictal changes were restricted to amygdaloid and hippocampal structures. Thus, in approximately 80% of seizures, the onset of ictal EEG changes resided in the mesial temporal structures. The main behavioral manifestations observed during seizure discharge restricted to one temporal lobe included warning (67%), motionless stare (24%), automatism (22%), and head-body turning (24%). The predominant ictal behavioural manifestations observed during seizure spread to contralateral temporal and extratemporal structures included warning (3%), motionless stare (36%), automatism (77%), and head-body turning (81%). The direction of head turning did not provide reliable lateralization as to the side of seizure onset.     

Electrophysiology of Bimanual-Bipedal Automatisms

Summary: To determine the localizing value and electrophysiology of bimanual-bipedal automatisms (BBAs), we studied these behaviors in 54 seizures of 8 patients with temporal or frontal lobe seizure onset. BBAs occurred with a frequency of 27% in frontal lobe epilepsy (FLE) and of 7% in temporal lobe epilepsy (TLE). The distribution of electrode sites showing ictal activity during these automatisms was significantly different in the two patient groups (0.0001 Chi-square). Mesioand/or laterotemporal plus orbital frontal areas were involved areas when the behaviors appeared in patients with TLE; dorsolateral and mesiofrontal regions were the most commonly involved when the behaviors occurred during the course of frontal lobe seizures. We concluded that BBAs represent activation of frontal lobe circuitry but are not unique to seizures of frontal lobe origin. Eyelid flutter and repetitive body movements in either the axial or sagittal plane were significantly associated with the frontal lobe group whereas oral-alimentary automatisms were associated with the temporal lobe group. Thus, these associated behaviors may help indicate whether a frontal or temporal lobe seizure onset has occurred when BBAs are observed. A new concept of ictal expression is proposed to conform with the results as well as with other apparently disparate ictal behaviors that may have localizing value.     

Frontal lobe epilepsy manifesting with seizures consisting of isolated vocalization.

Vocalizations may occur in focal epileptic seizures, which typically arise from frontal and temporal regions. They are commonly associated with other motor phenomena such as automatisms, tonic posturing, or head version. We report on a patient whose seizures were documented by video-EEG monitoring, but in whom the observable ictal semiology consisted solely of a brief, monotonous vocalization. Ictal EEGs showed left frontal seizure patterns. Isolated vocalizations can constitute an ictal epileptic event and may be the only observable clinical manifestation of a left frontal lobe epilepsy. [Published with video sequences].     

Differentiation of Temporal Lobe Ictal Behavior Associated with Hippocampal Sclerosis and Tumors of Temporal Lobe

Summary: Ictal behavioral characteristics may reflect seizure spread patterns and provide a clue to seizure onset location, between or within specific cerebral lobes. Sequential symptomatology might therefore distinguish patients with hippocampal sclerosis from patients with temporal lobe tumors. To determine ictal behavioral differences in patients of these groups, we analyzed 145 seizures of 33 patients with hippocampal sclerosis (group I) and 79 seizures of 22 patients with temporal lobe tumors (group 11). First appearance of a variety of ictal behavioral characteristics was determined in three phases (first 5 s, 5–60 s, and from 60 s to mental clearing) for patients in both groups. Ipsilateral hand automatisms were significantly more frequent in the first 60 s in group I (p < 0.005). Onset of contralateral head turning was observed in the first 5 s only in group Il (p < 0.05). First appearance of leg automatisms in group I and of oral automatisms in group Il were very rare in phase 2 (p < 0.01, p < 0.005). Time of onset of other ictal behavioral characteristics and duration of seizures were not statistically different between the two groups. Ictal behavioral characteristics varied among and within patients and patient groups, but certain behavioral characteristics were helpful in differentiating these two groups of temporal lobe epilepsy (TLE) patients.     

Localizing and lateralizing features of auras and seizures

The symptomatology of auras and seizures is a reflection of activation of specific parts of the brain by the ictal discharge, the location and extent of which represent the symptomatogenic zone. The symptomatogenic zone is presumably, though not necessarily, in close proximity to the epileptogenic zone, the area responsible for seizure generation, the complete removal or disconnection of which is necessary for seizure freedom. Knowledge about the symptomatogenic zone in focal epilepsy is acquired through careful video/EEG monitoring and behavioral correlation of seizures and electrical stimulation studies. Ictal symptomatogy provides important lateralizing and/or localizing information in the presurgical assessment of epilepsy surgery candidates. As the initial symptoms of epileptic seizures, many types of auras have highly significant localizing or lateralizing value. Similarly, motor signs during focal and secondary generalized seizures, language manifestations, and autonomic features offer reliable clues to the delineation of the epileptogenic zone. Some focal epilepsies (e.g., neocortical temporal lobe epilepsy, insular lobe epilepsy, temporal-plus epilepsies, and parieto-occipital lobe epilepsy) generate seizure manifestations that mimic temporal lobe epilepsy, potentially contributing to surgical failure. To optimize surgical outcome, careful interpretation of ictal symptomatology in conjunction with other components of the presurgical evaluation is required.     

Genital and sexual manifestations in drug-resistant partial epilepsy.

Genital and sexual manifestations represent rare clinical phenomena during or after focal seizures. The semiology of these types of automatisms is controversial. In particular, it is unclear whether temporal or frontal structures are involved in their generation and whether these clinical manifestations have a potential lateralizing value. In this view, from a population of 212 consecutive patients with drug resistant focal epilepsy referred to us for presurgical assessment, we retrospectively identified 24 patients with genital ictal manifestations. We evaluated the incidence of these behaviours, the clinical semiology, the associated symptoms/signs with the corresponding ictal EEG findings and their potential role in lateralizing the epileptogenic zone. Our results indicate that ictal genital automatisms are possible in seizures originating from temporal lobe and they cannot be attributed exclusively to frontal lobe seizures. In particular, the most frequent genital automatisms consist in subtle phenomena while hypermotoric behaviour, such as pelvic rhythmic movements are quite rare. No lateralizing value for genital automatisms was disclosed.     

Intractable seizures of frontal lobe origin: clinical characteristics, localizing signs, and results of surgery

PURPOSE: We analyzed the clinical characteristics of seizures of frontal lobe (FL) origin with particular emphasis on establishing different categories and determining if these categories had any localizing or lateralizing value. In addition, results of surgery are reported. METHODS: Seizure characteristics were established by historical review and electroencephalographic/videotape analysis of 449 seizures in 26 adult patients with refractory seizures of FL origin. RESULTS: No outstanding risk factor was identified for seizures of FL origin. Seizures were frequent (7.1 per week), brief (mean duration, 48.3 seconds), and had a nocturnal preponderance in 58% of the patients. Status epilepticus was reported in 54%, and generalized convulsions as a prominent seizure type were reported in 26% of patients. The most common reported aura was a nonspecific sensation, often localized to the head (35%). Early forced head and eye deviation was not a consistent lateralizing sign, whereas late head and eye deviation always occurred contralateral to the site of seizure origin. Early asymmetric tonic posturing occurred consistently contralateral to the side of seizure origin. Clinical seizure patterns did not consistently localize to specific regions of the frontal lobe, although there were some noticeable trends: focal clonic seizures were associated with seizure origin in the frontal convexity; tonic seizures were most often associated with origin in the supplementary motor area but also occurred with origin in other parts of the frontal lobe; seizures resembling typical temporal lobe seizures with oroalimentary automatisms were observed with seizure origin in the orbitofrontal region; and seizures with hyperactive, frenetic automatisms were not associated with any specific region within the frontal lobes. Eighty percent of patients had favorable seizure outcome after surgery (class I/II). CONCLUSION: Although certain clinical features are characteristic for seizures of frontal lobe origin and some have lateralizing value, they do not localize to specific areas within the FL. After careful presurgical evaluation, both lesional and nonlesional patients benefit from epilepsy surgery.     

Localizing Value of Seizure Manifestations of Temporal Lobe Epilepsies and the Consequence of Analyzing Their Sequential Appearance

We investigated the localizing and lateralizing value of principal seizure manifestations in temporal lobe epilepsies (signal symptoms, oroalimentary automatisms, somatomotor manifestations, unilateral dystonic posturing, ictal speech, motionless stare) of 223 complex partial seizures in 50 patients. All the patients had invasive long-term monitoring with the combined implantation of intracerebral electrodes in and subdural electrodes on the bilateral temporal lobes. Postoperative freedom from seizures was ascertained for longer than one year. We found that 35 patients had amygdalohippocampal seizures and 15 had lateral temporal seizures. The value of the manifestations was established in relation to the site and side of seizure origin and to the progression of seizure discharges within the unilateral temporal lobe or to the contralateral cerebral hemisphere. Several signs among the manifestations were found to be reliable in predicting the site or side of the temporal lobe seizure focus. We emphasized the importance of investigating sequential changes of seizure manifestations in relation to ictal EEG findings by means of simultaneous recording.     

A detailed analysis of symptomatic posterior cortex seizure semiology in children younger than seven years

PURPOSE: To analyze the semiology of seizure onset and evolution in young children with posterior cortex epilepsy (PCE), compare this with adult reports, and assess age-related differences. METHODS: We videotaped and analyzed 110 seizures from 18 patients with PCE, aged 3-81 months. All had a good prognosis after posterior epileptogenic zone removal. Ictal events were categorized by behavioral, consciousness, autonomic, and sensory features, as well as motor patterns, which included myoclonic, tonic, clonic, unclassified motor seizures, and epileptic spasm. A time-scaled data sheet was developed to record each epileptic event as onset, very early, early, or late manifestation. RESULTS: Patients had a high seizure frequency with < or =100 attacks/day; one third of them showed a cluster tendency. The mean duration of seizures was 67 s. The most common seizure components were motor manifestations (with myoclonic and tonic seizures), but psychomotor (automotor), hypomotor attacks, and isolated auras also were frequently observed. Clinical seizure spread was frequent; auras and visual sensory signs were difficult to record in this age. Typical phenomena during seizures included behavioral changes, ictal vocalization, smile, flush, head nod, oculomotor features, and late-appearing oral automatisms, whereas hypermotor and secondarily generalized tonic-clonic seizures were not seen. CONCLUSIONS: Our results suggest that PCE in infants and young children is very heterogeneous but shows important age-related features. Compared with adults, children with PCE have shorter but more frequent seizures; they rarely report aura or visual sensory signs, only sporadically develop hypermotor and secondarily generalized tonic-clonic seizures, whereas ictal smile, flush, head nod, and behavioral change are typical features at this age. Because of frequent subtle ictal phenomena, long-term video-EEG monitoring is a useful diagnostic tool with infants and young children with PCE.     

Contralateral motor automatisms in neocortical temporal lobe epilepsy

BACKGROUND: The lateralizing value of the motor automatisms is generally doubted in most patients with temporal lobe epilepsy. However, subgroup analysis of the seizures of temporal lobe origin suggests a role for motor automatisms in discriminating seizures of neocortical versus mesial temporal lobe origin. METHODS: Video-EEG of a patient with well-defined neocortical temporal lobe epilepsy was reviewed to assess the localizing value of motor automatisms. RESULTS: We report a patient with left upper extremity motor automatisms and clonic movements of the proximal left lower extremity with altered awareness as the sole manifestations of right temporal neocortical seizures. CONCLUSION: Early onset unilateral motor automatisms without dystonic posturing can localize the seizure origin to the contralateral temporal lobe neocortex.     

Semiology of hyperkinetic seizures of frontal versus temporal lobe origin

Aims. Hyperkinetic seizures are usually associated with frontal lobe epilepsy. However, some patients have hyperkinetic seizures of temporal lobe origin. The semiological differences in hyperkinetic seizures between frontal and temporal lobe epilepsy have not been well studied. Here, we retrospectively assessed ictal semiology in order to distinguish between hyperkinetic seizures of frontal lobe origin and those of temporal lobe origin. Methods. We retrospectively reviewed data on patients who had undergone surgery for hyperkinetic seizures of temporal or frontal lobe origin and achieved favourable seizure outcomes (Engel Class I) with a minimum postoperative follow‐up of 24 months. We reviewed seizure histories, imaging reports, video‐EEG monitoring data, operative records, and pathological findings. We analysed and compared the hyperkinetic semiology of video‐recorded seizures of temporal lobe origin and those of frontal lobe origin. Results. Forty hyperkinetic seizures in eight patients (seven adult patients and one 12‐year‐old patient) with temporal lobe epilepsy and 45 hyperkinetic seizures in nine patients (eight adult patients and one 16‐year‐old patient) with frontal lobe epilepsy were analysed. Emotional facial expressions (such as fear, laughing, or anger), bilateral forceful elbow flexion, bilateral forceful grasping, facial flushing, and bilateral facial contraction were observed significantly more frequently in seizures of frontal lobe origin. Oroalimentary automatisms, seizures during wakefulness, salivation, and bilateral drop of the corners of the mouth were observed significantly more frequently in seizures of temporal lobe origin. Conclusions. Observation of a number of signs during hyperkinetic manifestations may help to predict whether a seizure originates from the frontal lobe or the temporal lobe.     

Insular-opercular seizures manifesting with sleep-related paroxysmal motor behaviors: a stereo-EEG study

Purpose: Sleep‐related complex motor seizures are a common feature of nocturnal frontal lobe epilepsy. Nevertheless, recent studies also suggest that sleep‐related hypermotor seizures can originate in the insula. The present study describes the electroclinical features of eight drug‐resistant epileptic patients with insular‐opercular seizures manifesting with nocturnal complex motor seizures. Methods: Patients underwent a comprehensive presurgical evaluation, which included history, interictal electroencephalography (EEG), scalp video‐EEG monitoring, high‐resolution magnetic resonance imaging (MRI), and intracerebral recording by stereo‐EEG. Key Findings: Almost all patients reported an initial sensation consisting of viscerosensitive or somatosensory symptoms. Ictal clinical signs were represented by tonic–dystonic asymmetric posturing and/or hyperkinetic automatisms, including bimanual/bipedal activity and ballistic movements. Some patients exhibited dysarthric speech, hypersalivation, and apnea. Interictal and ictal EEG provided lateralizing information in the majority of patients. In three patients, MRI showed a focal anatomical abnormality in the insular‐opercular region. Stereo‐EEG ictal recordings demonstrated that the epileptic discharge involved simultaneously the insular cortex and the opercular region. Complex motor manifestations appeared when the ictal discharge showed an extrainsular spreading to frontomesial regions (cingulum, superior frontal gyrus, and supplementary motor area) and/or to internal and neocortical temporal lobe structures. Six patients received an insular‐opercular cortical resection; three of them are seizure free (minimum follow‐up 24 months) and in one a marked reduction in seizure frequency was obtained. Two patients have been operated on recently. Histology revealed a focal cortical dysplasia in three patients. One patient excluded from surgery died for sudden unexpected death in epilepsy during sleep. Significance: Our data strengthen the concept that sleep‐related complex motor attacks can originate in the insula, and provide useful electroclinical information to differentiate this localization from those with similar clinical characteristics. Furthermore, this study indicates that in these drug‐resistant patients, surgical treatment represents a highly effective treatment option.     

Cephalic auras of supplementary motor area origin: an ictal MEG and SAM(g2) study

Although a nonspecific cephalic sensation, the so-called "cephalic aura," is a common sensory aura, particularly in frontal lobe seizures, but is rarely is the entire sensory seizure event. The unusual presentation of cephalic sensations in isolation representing supplementary motor area (SMA) seizures, which are commonly unaccompanied by ictal electroencephalography (EEG) changes, can easily lead to misdiagnosis of nonepileptic psychogenic seizures. We illustrate the case of a 36-year-old male patient with frontal lobe epilepsy who presented with isolated cephalic auras described as a nonvertiginous sense of head movement without observable clinical signs after his habitual partial motor seizures were controlled with pharmacotherapy. Video/EEG recordings showed no recognizable epileptic discharges time-locked to the onset of the isolated cephalic auras. Ictal magnetoencephalography (MEG) with synthetic aperture magnetometry-kurtosis (SAM(g(2))) analysis demonstrated the SMA onset of the cephalic auras; thus, MEG was essential in differentiating these isolated auras from nonepileptic psychogenic events.     

Complex Partial Seizures of Temporal Lobe Origin in Children of Different Age Groups

Summary: The semiology of complex partial seizures(CPS) of temporal lobe origin in adults is well known and is important in establishing seizure localization in patients considered for epilepsy surgery. In contrast, the behavioral features of temporal lobe seizures (TLS) in children described in the literature have not been consistent. In the present study, we investigated children with TLS to compare their attacks to TLS occurring in adults. The study was based on video recordings of 29 children with TLS aged 18 months to 16 years. Children were included, if they became seizure-free after temporal lobectomy (except 4 children with a marked reduction in seizure frequency and 1 with isolated auras), and if clear unitemporal seizure onset in ictal EEG-recordings, unilateral radiological lesions, and corresponding histopathological findings were detected. Children aged >6 years had TLS with features similar to those of adults. In younger children, typical semiology included symmetric motor phenomena of the limbs, postures similar to frontal lobe seizures in adults, and head nodding as in infantile spasms. We concluded that the clinical features of TLS in younger children can be misleading and should therefore be considered with caution in selecting patients for surgical procedures on the temporal lobe.     

Lateralisation value of lower limb behaviors in complex partial seizures of temporal lobe origin: a video-EEG analysis.

PURPOSE: To determine the lateralising value of leg behaviors in complex partial seizures (CPS) of temporal lobe onset. METHODS: Videotapes of 123 seizures from 38 patients who were seizure-free after temporal lobectomy were reviewed. Ictal behaviors including head turning, limb automatisms, tonic/dystonic postures and the latent time for ictal behavior were analysed for their lateralising value. RESULTS: Contralateral versive head turning, ipsilateral arm automatisms, contralateral arm tonic/dystonic posturing, and contralateral arm clonic posturing were found to have high predictive value of lateralisation. As for the lower limbs, meaningful leg behaviors were recorded in 38 (31%) of 123 seizures, far less than behaviors of the upper limbs (79%). The predictive value from leg behaviors were similar to that from upper limbs. Among the leg behaviors, dystonic behaviors were always contralateral to the ictal side. Tonic behaviors were 94% contralateral to the ictal side. Dystonia and clonic movement were always contralateral to the ictal side. Automatisms were 86% ipsilateral to the ictal side. CONCLUSIONS: Although incidences were low, leg behaviors could provide useful lateralising value of the seizure foci. Clinicians as well as investigators should recognize the value of lower limbs behavior in studies of ictal semiology.     

Age-dependent seizure semiology in temporal lobe epilepsy

OBJECTIVE: To examine the effects of age on different aspects of temporal lobe seizure semiology. METHODS: We performed a video analysis of 605 archived seizures from 155 consecutive patients (age 10 months to 49 years) selected by seizure freedom after temporal lobectomy. Eighty patients had hippocampal sclerosis (HS). Beside semiological seizure classification, we assessed age dependency of several axes of seizure semiology: (1) aura, (2) number of different lateralizing signs, occurrence of ictal (3) emotional signs, (4) autonomic symptoms, (5) automatisms, and (6) secondary generalization as well as (7) the ratio of motor seizure components. RESULTS: From the 155 patients, 117 reported aura, 39 had ictal emotional signs, 51 had autonomic symptoms, 130 presented automatisms, while 18 patients showed secondary generalization at least once during their seizures. Altogether 369 (median: 2/patient) different lateralizing signs were recorded. Frequency of HS (p < 0.001), ictal automatisms (p < 0.001), secondary generalization (p = 0.014), number of different lateralizing signs (p < 0.001) increased while the ratio of motor seizure component (p = 0.007) decreased by age. Auras, emotional symptoms, and autonomic signs occurred independently of patients' ages. Hippocampal sclerosis adjusted linear models revealed that the frequency of automatisms and secondarily generalized seizures as well as the number of different lateralizing signs are HS-independent significant variables. CONCLUSION: Our findings support that brain maturation significantly influences the evolution of some important aspects (motor seizures, lateralizing signs) of temporal lobe seizure semiology. Conversely, other aspects (aura, emotional, and autonomic signs) are independent of the maturation process. This is the first report investigating age dependency of epileptic seizure semiology comparing all age groups.     

Ictal Characteristics of Cryptogenic Partial Epilepsies in Infancy

Twenty-three patients with onset of partial seizures (PS) during the first 2 years of life were collected in a single neuropediatric center and ictal events were analyzed. All patients initially had normal developmental and neurologic examinations, negative etiologic investigations, and at least two nonfebrile PS of a single type. Mean follow-up from first seizure to the last contact with the patient was 51 months (SEM 8.17 months). Ictal semiology was characterized by three types of seizures: simple PS with motor signs, complex partial seizures (CPS) with impairment of consciousness at onset followed by motor manifestations, and CPS with motor activity at onset. Versive phenomena, oroalimentary automatisms, and vegetative manifestations were frequently associated. The topography of the ictal discharges and the elementary ictal events, suggested involvement of the temporal lobe and somatomotor area. The diagnosis of PS can be difficult during the first year of life since some patients beginning with generalized seizures may evolve into partial seizures. The prognosis is guarded with regard to seizure persistence, but the neurologic outcome is better as a whole than is reported for infancy-onset epilepsies.     

Somatosensory auras in focal epilepsy: a clinical, video EEG and MRI study.

PURPOSE: To determine the clinical characteristics of somatosensory auras (SSA) and analyse features of seizure semiology predictive for localization in focal neocortical and limbic epilepsy. METHODS: This study analyses the clinical, video-EEG and MRI imaging features of 75 consecutive patients with focal epilepsy who described somatosensory auras at seizure onset to determine the frequency and localising value of SSAs in different types of focal epilepsy. Sensory characteristics, somatotopic distribution, evolution of the auras and subsequent ictal features in relation to MRI and EEG findings were analysed. RESULTS: The incidence of SSAs in 600 patients with focal epilepsy was 12%. Seventy-five patients were studied further: 77% reported tingling. Pain, thermal changes and a sense of movement or pulling were also reported. Distal unilateral auras in the hand and arm (46%) were most frequent and associated with a contralateral centroparietal focus. Contralateral auras were reported in 62% of lesional cases, focal cortical dysplasia was the commonest pathology in operated cases. Bilateral auras were associated with more diffuse pathologies or parasagittal foci. Evolution was centrifugal, somatotopic and usually unilaterally confined. Subsequent motor semiology was postural tonic, unilateral clonic, psychomotor or secondary generalized. CONCLUSION: SSA are highly correlated with centroparietal epilepsy but may occur in temporal lobe, mesial frontal and multifocal epilepsy. A lesional etiology including discrete dysplasias, tumours, ischemic and postencephalitic gliosis is likely.