Epilepsy in neurofibromatosis type 1

ObjectivesTo describe the characteristics of epilepsy in patients with Neurofibromatosis type 1 (NF1).MethodsAnalysis of a cohort of consecutive NF1 patients seen in our NF1 clinic during a three-year period.ResultsOf the 184 NF1 patients seen during that period, 26 had epilepsy and three had febrile seizures. Of the 26, 17 (65%) had localization-related epilepsy, seven of whom (41%) were drug resistant. Six (23%) had apparently primary generalized epilepsy (0/6 drug resistant), two (8%) Lennox-Gastaut syndrome, and one (4%) West syndrome (all three were drug-resistant). As compared to the patients with no epilepsy, those with epilepsy were more likely to have MRI findings of mesial temporal sclerosis (MTS) (23% vs. 5%, p = 0.0064), and cerebral hemisphere tumors (31% vs. 10%, p = 0.0079), but not of the other MRI findings including neurofibromatosis bright objects, or optic gliomas. Three of the six patients with MTS underwent temporal lobectomy with subsequent control of their seizures with confirmation of MTS on pathology in 3/3 and presence of coexisting focal cortical dysplasia (FCD) in 2/3. We also have observed three additional patients outside the above study with the association of NF1, MTS, and intractable epilepsy.SignificanceEpilepsy is relatively common in NF1, often occurs in patients with brain tumors or with MTS which can coexist with FCD, can be associated with multiple types of epilepsy syndromes, and when localization-related is often drug-resistant. Patients with NF1 and MTS can respond to medial temporal lobectomy and may have coexisting medial temporal lobe cortical dysplasia.     

Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy

PurposeThe aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit.MethodsPatients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again.ResultsA significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p < 0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p = 0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p = 0.016).DiscussionPatient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.     

Surgical outcome in adolescents with mesial temporal sclerosis: Is it different?

There are extensive studies evaluating mesial temporal sclerosis (MTS) in adults and limited studies in children, with adolescents being included within both patient populations. Our aim was to evaluate predictors of surgical outcome solely in adolescent patients with MRI- and pathology -proven MTS.The Yale Epilepsy Surgery Database was reviewed from 1987 to 2012 for adolescent patients with confirmed MTS on MRI and pathology who underwent temporal lobectomy and had greater than two-year postsurgical follow-up. Clinical and electrographic data were reviewed. Eighteen patients were identified.Eleven patients (61%) were seizure-free. All seven patients (39%) who were not seizure-free free were found to have lateralized ictal onset within one hemisphere involving two or more lobes on scalp EEG (p < 0.001). Of the 7 patients who were not seizure-free, 4 had a history of status epilepticus (compared to 1/11 seizure-free patients; p = 0.047), and 4 had lateralized hypometabolism involving two or more lobes within a hemisphere seen on PET (compared to 0/8 seizure-free patients; p = 0.002).A novel finding in our study was that lateralized (rather than localized) ictal onset on scalp EEG, lateralized hypometabolism on PET, and history of status epilepticus were risk factors for not attaining seizure freedom in adolescents with MTS who underwent temporal lobectomy.     

Temporal lobe asymmetry in FDG-PET uptake predicts neuropsychological and seizure outcomes after temporal lobectomy

ObjectiveThe objective of this study was to determine whether preoperative [¹⁸F]fludeoxyglucose (FDG)-positron emission tomography (PET) asymmetry in temporal lobe metabolism predicts neuropsychological and seizure outcomes after temporal lobectomy (TL).MethodsAn archival sample of 47 adults with unilateral temporal lobe epilepsy who underwent TL of their language-dominant (29 left, 1 right) or nondominant (17 right) hemisphere were administered neuropsychological measures pre- and postoperatively. Post-TL seizure outcomes were measured at 1 year. Regional FDG uptake values were defined by an automated technique, and a quantitative asymmetry index (AI) was calculated to represent the relative difference in the FDG uptake in the epileptic relative to the nonepileptic temporal lobe for four regions of interest: medial anterior temporal (MAT), lateral anterior temporal (LAT), medial posterior temporal (MPT), and lateral posterior temporal (LPT) cortices.ResultsIn language-dominant TL, naming outcomes were predicted by FDG uptake asymmetry in the MAT (r = − 0.38) and LPT (r = − 0.45) regions. For all patients, visual search and motor speed outcomes were predicted by FDG uptake asymmetry in all temporal regions (MPT, r = 0.42; MAT, r = 0.34; LPT, r = 0.47; LAT, r = 0.51). Seizure outcomes were predicted by FDG uptake asymmetry in the MAT (r = 0.36) and MPT (r = 0.30) regions. In all of these significant associations, greater hypometabolism in regions of the epileptic temporal lobe was associated with better postoperative outcomes.ConclusionsOur results support the conclusion that FDG uptake asymmetry is a useful clinical tool in assessing risk for cognitive changes in patients being considered for TL.     

Interictal serum brain-derived neurotrophic factor level reflects white matter integrity,epilepsy severity,and cognitive dysfunction in chronic temporal lobe epilepsy

ObjectiveMost patients with temporal lobe epilepsy (TLE) have epileptic foci originating from the medial temporal lobe, particularly the hippocampus. Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophin growth factor mainly expressed in the hippocampus, though it is not known whether the circulating level of BDNF reflects cognitive performance or white matter structural changes in chronic TLE.MethodsThirty-four patients with TLE and 22 healthy controls were enrolled for standardized cognitive tests, diffusion tensor imaging, and serum BDNF measurement. The patients were further divided into a subgroup with unilateral TLE (n = 23) and a subgroup with bilateral TLE (n = 11) for clinical and neuroimaging comparisons.ResultsThere were significantly lower BDNF levels in the patients with TLE compared with the controls, with significance contributed mainly from the subgroup with bilateral TLE, which also had more frequent seizures. The BDNF levels correlated with epilepsy duration (σ = − 0.355; p = 0.040) and fractional anisotropy (FA) in the left temporal lobe, left thalamus, and right hippocampus. Using a regression model, BDNF level predicted verbal memory score. Further, design fluency scores were predicted by serum BDNF level via the interactions with left temporal FA.ConclusionsSerum BDNF levels reflected longer epilepsy duration, impaired white matter integrity, and poor cognitive function in patients with chronic TLE.     

Developmental stage affects cognition in children with recently-diagnosed symptomatic focal epilepsy

This study explored the impact of developmental stage on cognitive function in children with recently-diagnosed epilepsy. In keeping with a neurodevelopmental framework, skills in a critical developmental period were expected to be more vulnerable than those stable at the time of seizure onset. We studied children with early-onset (EO) symptomatic focal epilepsy (onset: 3–5 years; n = 18) and compared their performance with that of the group with late-onset (LO) epilepsy (onset: 6–8 years performance of; n = 8) on a range of cognitive tasks. Performance of both groups was compared with normative standards. ‘Critical’ and ‘stable’ classifications were based on developmental research. Nonparametric analyses revealed that skills in a critical developmental period for the group with EO epilepsy fell below normative standards (Phonological Processing: p = .007, Design Copying: p = .01, Visuomotor Precision:, p = .02) and fell below the performance of the group with LO epilepsy (Design Copying: p = .03, Visuomotor Precision: p = .03). There were no differences between the group with EO epilepsy and the group with LO epilepsy on measures of receptive vocabulary and memory, which were proposed to be in a stable developmental period across both groups. Auditory span, as measured by Word Order, was reduced for both the group with EO epilepsy (p = .02) and the group with LO epilepsy (p = .02) relative to normative standards, but the groups did not differ from each other. These results are consistent with a prolonged period of critical development for this skill. These findings support the notion that skills in a critical phase of development are particularly vulnerable following the onset of symptomatic focal epilepsy in childhood.     

Computerized Cognitive Testing in Epilepsy (CCTE): A new method for cognitive screening

PurposeOptimized therapy in epilepsy should include individual care for cognitive functions. Here we introduce a computerized screening instrument, called “Computerized Cognitive Testing in Epilepsy” (CCTE), which allows for time-efficient repetitive assessment of the patient's cognitive profile regarding the domains of memory and attention, which are frequently impaired due to side effects of antiepileptic medication.MethodsThe CCTE battery takes 30 min and covers tasks of verbal and figural memory, cognitive speed, attention and working memory. The patient's results are displayed immediately in comparison to age-related normative data. For evaluation of psychometrics and clinical correlations, data from patients of a tertiary referral epilepsy center (n = 240) and healthy subjects (n = 83) were explored.ResultsCCTE subtests show good reliability and concurrent validity compared to standard neuropsychological tests (p < 0.01). Adverse cognitive effects of antiepileptic medication can be detected (p < 0.05), e.g. significant negative effects of increasing drug load. Specific epilepsy subgroups, e.g. focal versus primary generalized epilepsy or right versus left mesial temporal lobe epilepsy, showed different CCTE profiles.ConclusionCCTE appears valuable for early detection of individual cognitive alterations related to medication. In addition, it displays interesting differences between epilepsy syndromes. The CCTE battery provides a standardized, time- and personnel-efficient assessment of cognitive functions open to a large number of patients and applicable for clinical and scientific use in epilepsy.     

Short-term neurocognitive outcomes following anterior temporal lobectomy

Changes in cognitive function are a well established risk of anterior temporal lobectomy (ATL). Deficits in verbal memory are a common postoperative finding, though a small proportion of patients may improve. Postoperative evaluation typically occurs after six to 12 months. Patients may benefit from earlier evaluation to identify potential needs; however, the results of a formal neuropsychological assessment at an early postoperative stage are not described in the literature. We compared pre- and postoperative cognitive function for 28 right ATL and 23 left ATL patients using repeated measures ANOVA. Changes in cognitive function were compared to ILAE seizure outcome. The mean time to postoperative neuropsychological testing was 11.1 weeks (SD = 6.7 weeks). There was a side × surgery interaction for the verbal tasks: immediate memory recall (F(1,33) = 20.68, p < 0.001), short delay recall (F(1,29) = 4.99, p = 0.03), long delay recall (F(1,33) = 10.36, p = 0.003), recognition (F(1,33) = 5.69, p = 0.02), and naming (F(1,37) = 15.86, p < 0.001). This indicated that the left ATL group had a significant decrement in verbal memory following surgery, while the right ATL group experienced a small but significant improvement. For the right ATL group, there was a positive correlation between ILAE outcome and improvement in immediate recall (r = − 0.62, p = 0.02) and long delay recall (r = − 0.57, p = 0.03). There was no similar finding for the left ATL group. This study demonstrates that short-interval follow-up is effective in elucidating postoperative cognitive changes. Right ATL was associated with improvement in verbal memory, while left ATL resulted in a decrement in performance. Improvement in the right ATL group was related to improved seizure outcome. Short-interval follow-up may lend itself to the identification of patients who could benefit from early intervention.     

Visual field defects following different resective procedures for mesiotemporal lobe epilepsy

IntroductionOne of the most common side effects of mesiotemporal lobe resection in patients with medically intractable epilepsy are visual field defects (VFD). While peripheral defects usually remain unnoticed by patients, extended VFD influence daily life activities and can, in particular, affect driving regulations. This study had been designed to evaluate frequency and extent of VFD following different surgical approaches to the mesiotemporal area with respect to the ability to drive.Materials and methodsThis study comprises a consecutive series of 366 patients operated at the Epilepsy Center in Freiburg for intractable mesiotemporal lobe epilepsy from 1998 to 2016. The following procedures were performed: standard anterior temporal lobectomy (ATL: n = 134; 37%), anterior temporal or keyhole resection (KH: n = 53; 15%), and selective amygdalohippocampectomy via the transsylvian (tsAHE: n = 145; 40%) and the subtemporal (ssAHE: n = 34; 9%) approach. Frequency and extent of postoperative VFD were evaluated in relation to different surgical procedures. According to the German driving guidelines, postoperative VFD were classified as driving-relevant VFD with the involvement of absolute, homonymous central scotoma within 20° and driving-irrelevant VFD with either none or exclusively minor VFD sparing the center.ResultsPostoperative visual field examinations were available in 276 of 366 cases. Postoperative VFD were observed in 202 of 276 patients (73%) and were found to be driving-relevant in 133 of 276 patients (48%), whereas 69 patients (25%) showed VFD irrelevant for driving. Visual field defects were significantly less likely following ssAHE compared with other temporal resections, and if present, they were less frequently driving-relevant (p < 0.05), irrespective of the side of surgery.ConclusionSubtemporal sAHE (ssAHE) caused significantly less frequently and less severely driving-relevant VFD compared with all other approaches to the temporal lobe, irrespective of the side of surgery.     

The effects of temporal lobe epilepsy on scene encoding

Forty-four patients with temporal lobe epilepsy (TLE) (25 left) and 40 healthy control participants performed a complex visual scene-encoding fMRI task in a 4-T Varian scanner. Healthy controls and left temporal lobe epilepsy (LTLE) patients demonstrated symmetric activation during scene encoding. In contrast, right temporal lobe (RTLE) patients demonstrated left lateralization of scene encoding which differed significantly from healthy controls and LTLE patients (all p ≤ .05). Lateralization of scene encoding to the right hemisphere among LTLE patients was associated with inferior verbal memory performance as measured by neuropsychological testing (WMS-III Logical Memory Immediate, p = 0.049; WMS-III Paired Associates Immediate, p = 0.036; WMS-III Paired Associates Delayed, p = 0.047). In RTLE patients, left lateralization of scene encoding was associated with lower visuospatial memory performance (BVRT, p = 0.043) but improved verbal memory performance (WMS-III Word List, p = 0.049). These findings indicate that, despite the negative effects of epilepsy, memory functioning is better supported by the affected hemisphere than the hemisphere contralateral to the seizure focus.     

Language and central temporal auditory processing in childhood epilepsies

Because of the relationship between rolandic, temporoparietal, and centrotemporal areas and language and auditory processing, the aim of this study was to investigate language and central temporal auditory processing of children with epilepsy (rolandic epilepsy and temporal lobe epilepsy) and compare these with those of children without epilepsy. Thirty-five children aged between eight and 14 years old were studied. Two groups of children participated in this study: a group with childhood epilepsy (n = 19), and a control group without epilepsy or linguistic changes (n = 16). There was a significant difference between the two groups, with the worst performance in children with epilepsy for the gaps-in-noise test, right ear (p < 0.001) and left ear (p < 0.001) tests, and duration pattern test — naming (p = 0.002) and humming (p = 0.002). In auditory P300, there was no significant difference in latency (p = 0.343) and amplitude (p = 0.194) between the groups. There was a significant difference between the groups, with the worst performance in children with epilepsy, for the auditory-receptive vocabulary (PPVT) (p < 0.001) and phonological working memory (nonwords repetition task) tasks (p = 0.001). We conclude that the impairment of central temporal auditory processing and language skills may be comorbidities in children with rolandic epilepsy and temporal lobe epilepsy.     

Clinical and sociodemographic variables associated with interictal dysphoric disorder and interictal personality in patients with drug-resistant temporal lobe epilepsy: A controlled study

Psychiatric disorders (PD) have an elevated prevalence and an important negative impact on patients with epilepsy (PWE) since they are associated with lower quality of life and clinical refractoriness. However, it is also necessary to identify behavioral conditions possibly associated with epilepsy that are not part of the standard psychiatric classifications, such as Interictal Dysphoric Disorder (IDD) and Interictal Personality (IP). The frequency of IDD and IP in patients with drug-resistant temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS) was assessed. The Brazilian versions of the Neurobehavioral Inventory (NBI) and Interictal Dysphoric Disorder Inventory (IDDI) were applied to patients and to a control group. Psychiatric standard assessment was conducted through the Diagnostic and Statistical Manual for Psychiatric Disorders – 5th edition (DSM-5). The value of p considered significant was < 0.05. Ninety-five patients (51 women; 53.6%) and 50 controls (29 women; 58.0%) were assessed. Axis I PD were observed in 41 patients (43.1%). Interictal Dysphoric Disorder was observed in 18 patients (18.4%) and IP in 36 (37.9%). Interictal Dysphoric Disorder was associated with left-sided MTS (OR = 3.22; p = 0.008), previous psychiatric treatment (OR = 4.29; p = 0.007), and more than one AED used (OR = 2.73; p = 0.02) while presence of bilateral MTS (OR = 3.27; p = 0.008), longer disease duration (OR = 3.39; p = 0.006), and presence of Major Depressive Disorder (OR = 4.73; p = 0.004) were associated with IP. In the present study, there was a high prevalence of IDD and IP in patients with drug-resistant TLE-MTS; studies should be conducted to identify the presence of behavioral conditions that are not present in the conventional psychiatric classifications.     

Psychosocial impairments in children with epilepsy depend on the side of the focus

This article explores the idea that epileptic activity may interfere with psychosocial functions and development in children. In an adult population with epilepsy, left hemispheric seizure focus predicts worse psychosocial functioning. The developmental aspects of these disturbances require further studies. We studied self-report measures of cognitive (locus of control) and emotional (Beck Youth Inventories of Emotional and Social Impairment) functions in 30 children with partial epilepsy (6–15 years) and 60 healthy matched controls. Multivariate statistics revealed significant lateralization effects, with left-sided foci (n = 15) leading to more external locus of control. Opposite to adults, the children with right hemispheric foci (n = 15) exhibited more emotional impairments (anger, disruptive behavior) than the left hemispheric group. The cognitive and emotional dysfunctions in epilepsy may result from the interaction of focus lateralization and brain development. The cognitive disturbances beginning in childhood may lead to the stronger emotional impairments observed in adults with left hemispheric seizures.     

Long-term seizure and psychosocial outcomes after resective surgery for intractable epilepsy

Resective surgery is considered an effective treatment for refractory localization-related epilepsy. Most studies have reported seizure and psychosocial outcomes of 2–5 years postsurgery and a few up to 10 years. Our study aimed to assess long-term (up to 15 years) postsurgical seizure and psychosocial outcomes at our epilepsy center. The Henry Ford Health System Corporate Data Store was accessed to identify patients who had undergone surgical resection for localization-related epilepsy from 1993 to 2011. Demographics including age at epilepsy onset and surgery, seizure frequency before surgery, and pathology were gathered from electronic medical records. Phone surveys were conducted from May 2012 to January 2013 to determine patients' current seizure frequency and psychosocial metrics including driving and employment status and use of antidepressants. Surgical outcomes were based on Engel's classification (classes I and II = favorable outcomes). McNemar's tests, chi-square tests, two sample t-tests, and Wilcoxon two sample tests were used to analyze the relationships of psychosocial and surgical outcomes with demographic and surgical characteristics. A total of 470 patients had resective epilepsy surgery, and of those, 50 (11%) had died since surgery. Of the remaining, 253 (60%) were contacted with mean follow-up of 10.6 ± 5.0 years (27% of patients had follow-up of 15 years or longer). Of the patients surveyed, 32% were seizure-free and 75% had a favorable outcome (classes I and II). Favorable outcomes had significant associations with temporal resection (78% temporal vs 58% extratemporal, p = 0.01) and when surgery was performed after scalp EEG only (85% vs 65%, p < 0.001). Most importantly, favorable and seizure-free outcome rates remained stable after surgery over long-term follow-up [i.e., < 5 years (77%, 41%), 5–10 years (67%, 29%), 10–15 years (78%, 38%), and > 15 years (78%, 26%)]. Compared to before surgery, patients at the time of the survey were more likely to be driving (51% vs 35%, p < 0.001) and using antidepressants (30% vs 22%, p = 0.013) but less likely to be working full-time (23% vs 42%, p < 0.001). A large majority of patients (92%) considered epilepsy surgery worthwhile regardless of the resection site, and this was associated with favorable outcomes (favorable = 98% vs unfavorable = 74%, p < 0.001). The findings suggest that resective epilepsy surgery yields favorable long-term postoperative seizure and psychosocial outcomes.     

Reliable change indices and standardized regression-based change score norms for evaluating neuropsychological change in children with epilepsy

Reliable change indices (RCIs) and standardized regression-based (SRB) change score norms permit evaluation of meaningful changes in test scores following treatment interventions, like epilepsy surgery, while accounting for test–retest reliability, practice effects, score fluctuations due to error, and relevant clinical and demographic factors. Although these methods are frequently used to assess cognitive change after epilepsy surgery in adults, they have not been widely applied to examine cognitive change in children with epilepsy. The goal of the current study was to develop RCIs and SRB change score norms for use in children with epilepsy. Sixty-three children with epilepsy (age range: 6–16; M = 10.19, SD = 2.58) underwent comprehensive neuropsychological evaluations at two time points an average of 12 months apart. Practice effect-adjusted RCIs and SRB change score norms were calculated for all cognitive measures in the battery. Practice effects were quite variable across the neuropsychological measures, with the greatest differences observed among older children, particularly on the Children's Memory Scale and Wisconsin Card Sorting Test. There was also notable variability in test–retest reliabilities across measures in the battery, with coefficients ranging from 0.14 to 0.92. Reliable change indices and SRB change score norms for use in assessing meaningful cognitive change in children following epilepsy surgery are provided for measures with reliability coefficients above 0.50. This is the first study to provide RCIs and SRB change score norms for a comprehensive neuropsychological battery based on a large sample of children with epilepsy. Tables to aid in evaluating cognitive changes in children who have undergone epilepsy surgery are provided for clinical use. An Excel sheet to perform all relevant calculations is also available to interested clinicians or researchers.     

Memory outcome following left anterior temporal lobectomy in patients with a failed Wada test

PurposeThis study aimed to compare the memory outcome following left anterior temporal lobectomy (ATL) between patients with a failed Wada test and patients who passed the Wada test.MethodsFrom 1996 to 2002, we performed the Wada test on all patients with unilateral left mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and concordant electroclinical data before ATL. We used a 12-item recognition paradigm for memory testing and awarded a score of + 1 for each correct response and − 0.5 for each incorrect response. No patient was denied surgery on the basis of Wada scores. We assessed cognitive and memory functions using the Wechsler Adult Intelligence Scale and the Wechsler Memory Scale preoperatively and at one year after ATL. We compared the number of patients who showed decline in memory scores, as per the published reliable change indices, between the patients with a failed Wada test and the patients who passed the Wada test.ResultsOut of the 116 eligible patients with left MTLE-HS, 88 underwent bilateral Wada test, while 28 underwent ipsilateral Wada test. None of them developed postoperative amnesia. Approximately, one-third of patients with a failed Wada memory test when the failure was defined as a contralateral score of < 4, as an ipsilateral score of > 8, and as an asymmetry score of < 0. The patients with Wada memory failure had a longer pre-ATL duration of epilepsy (p < 0.003). The memory and quality-of-life outcomes did not differ between the group with a failed Wada memory test and the group who passed the Wada memory test. The results remained the same when analyses were repeated at various other cutoff points.ConclusionThe patients with left MTLE-HS with concordant electroclinical, MRI, and neuropsychological data should not be denied ATL solely on the basis of Wada memory test results.     

Objective evaluation of personality and psychopathology in temporal lobe versus extratemporal lobe epilepsy

Previous research has been equivocal on personality trait and psychopathology differences between temporal lobe and other types of epilepsy, as well as between patients with right and left temporal lobe seizure foci. In this study, personality differences between patients with right temporal (n = 23), left temporal (n = 21), and extratemporal (n = 24) epilepsy were investigated using the NEO Personality Inventory—Revised (NEO-PI-R). No statistically significant differences were found on any of the NEO-PI-R domains or facet trait scales. There were also no significant differences between groups on the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), a measure of psychopathology. However, mild elevations were seen in all groups on clinical scales related to physical symptoms, health concern, and depression. These data suggest there are no consistent personality or psychopathology differences, as measured by the NEO-PI-R and the MMPI-2, between patients with left temporal, right temporal, and extratemporal epilepsy whose seizures are localized using video/EEG monitoring.     

White matter disruption is associated with persistent seizures in tuberous sclerosis complex

Background and aimsWhite matter is diffusely altered in tuberous sclerosis complex (TSC), and these alterations appear to be more evident in subjects with a more severe neurologic phenotype. However, little is known on the correlation between white matter alterations and epilepsy in TSC. The aims of this study were to evaluate the effects of early onset and refractory seizures on white matter by using diffusion tensor imaging (DTI).MethodsWe enrolled 20 children with TSC and epilepsy onset in the first 3 years of life and grouped them according to seizure persistence or freedom. All patients underwent brain MRI with DTI. Specific ROIs have were placed to generate tracks to calculate fractional anisotropy (FA) and apparent diffusion coefficient (ADC). Statistical analysis was performed by ANOVA.ResultsChildren with persistent seizures presented an overall reduced FA, with statistically significant differences on the cingulum (right p = 0.003, left p = 0.016), the left cerebral peduncle (p = 0.020), the superior cerebellar peduncles (right p = 0.008, left p = 0.002), the posterior limbs of internal capsule (right p = 0.037, left p = 0.015), the external capsule (right p = 0.018, left p = 0.031), the inferior frontooccipital fasciculus (right p = 0.010, left p = 0.026), and the temporal trunk (right p = 0.017, left p = 0.001).ConclusionsOur study demonstrated that children with persistent seizures present more significant alterations of brain connectivity in areas crucial for global cognitive maturation, executive functions, and verbal abilities, implying a higher risk of cognitive impairment, attention-deficit hyperactivity disorder, and autism.     

Do sphenoidal electrodes aid in surgical decision making in drug resistant temporal lobe epilepsy?

ObjectiveThe utility of sphenoidal electrodes (SPh) in analyzing interictal epileptiform discharges (IEDs) and ictal electrography remains controversial, despite its widespread use.MethodsOne hundred and twenty-two consecutive patients with presumed temporal lobe epilepsy (TLE) who underwent presurgical evaluation were prospectively studied. SPh and Silverman’s electrodes were placed, in addition to routine electrodes in 10–20 international system. IEDs and ictal electroencephalography (EEG) were analyzed separately in bipolar and referential montages. The proportion of patients selected for surgery after adjusting for SPh placement based on the earlier ictal onset and IEDs were analyzed.ResultsOf the 8701 IEDs in SPh, only 65% were seen over the scalp bipolar montage; 1392 (16%) IEDs were confined to SPh electrodes, and were not seen at scalp bipolar montage (p < 0.001). Spike amplitudes were highest at SPh (p < 0.001). Of the 592 seizures analyzed, 62 (61%) had simultaneous SPh and scalp onset, while in 26 (25%) SPh onset preceded the scalp.ConclusionsOut of the 35 patients with unilateral mesial temporal sclerosis (MTS) with additional neocortical changes and/or non-lateralized bitemporal IEDs and/or diffuse ictal onset (group 1), 27 were selected for surgery (77%). About 7% was selected for surgery in this group by SPh placement. Also, in patients with bilateral MTS (group 2), 25% (5/20) were chosen for anterior temporal lobectomy, SPh provided an additional benefit in 11% (p < 0.001). Patients with normal magnetic resonance imaging (group 3) and temporal plus epilepsy (group 4) had a lower surgical yield, only 12% and 9.5% could undergo surgery. They were denied surgical candidacy with SPh (p < 0.001).SignificanceOne-third of patients after SPh placement were selected for resective surgery obviating the need for invasive monitoring. The maximum yield was noted in unilateral MTS (associated with additional neocortical features or non-lateralized bilateral temporal interictal IEDs or diffuse ictal onset in scalp EEG) and in bilateral MTS. Those with normal MRI/temporal plus epilepsy could be excluded from direct resective surgery.     

Gender and age influence in daytime and nighttime seizure occurrence in epilepsy associated with mesial temporal sclerosis

ObjectivesThe aim of this study was to analyze the daytime and nighttime seizure distribution during video-EEG monitoring in patients with epilepsy associated with unilateral mesial temporal sclerosis (MTS) and the role of gender, age, and lesion side on 24-hour seizure distribution.MethodsWe studied 167 consecutive adult (age ≥ 16 years) patients with epilepsy associated with unilateral mesial temporal sclerosis that had three or more recorded seizures during continuous video-EEG monitoring with a minimum recording time period of 24 h. Seizure onset time was classified according to occurrence in six 4-hour periods.ResultsSeven hundred thirty-five seizures were evaluated. We observed two higher seizure occurrence periods: 08:01–12:00 (p = 0.001) and 16:01–20:00 (p = 0.03). Significantly fewer seizures were observed between 0:01 and 4:00 (p = 0.01). Nonuniform seizure distribution was noted in women (p < 0.0001), in young patients (less than 45 years of age) (p < 0.0001), and in both patients with left (p = 0.03) and patients with right mesial temporal sclerosis (p = 0.008). Men presented uniform seizure occurrence distribution (p = 0.15). Women had fewer seizures than expected and fewer seizures than men between 0:01–04:00 (p < 0.0001 and p = 0.0015, respectively) and 04:01–08:00 (p = 0.01 and p = 0.03, respectively). Young patients (age < 45 years) had two seizure occurrence peaks, 08:01–12:00 (p = 0.016) and 16:01–20:00 (p = 0.004). Middle-aged/old patients (≥ 45 years) had only one seizure occurrence peak, 08:01–12:00 (p = 0.012). Young patients had more seizures than middle-aged/old patients between 16:01–20:00 (p = 0.04). No differences were noted between left and right MTS.SignificanceWe observed two seizure occurrence peaks: morning and late afternoon/evening. We encountered variations in daytime and nighttime seizure distribution according to gender and age, but not according to side of MTS. Future studies are needed to confirm these findings and to unravel the neurobiological substrate underlying daytime and nighttime variations of seizure occurrence in different age groups and between genders.