Characteristics of medial temporal lobe epilepsy: II. Interictal and ictal scalp electroencephalography,neuropsychological testing,neuroimaging, surgical results,and pathology

Sixty-seven patients with temporal lobe epilepsy without circumscribed, potentially epileptogenic lesions, who were studied with intracranial electrodes and who became seizure free following temporal lobectomy were retrospectively evaluated with regard to preoperative scalp electroencephalographic (EEG) findings, neuropsychological test results, neuroimaging findings, results of surgery, and pathology of resected tissue. Interictal scalp EEG showed paroxysmal abnormalities during prolonged monitoring in 64 patients (96%). These were localized in the anterior temporal region in 60 (94%) of these 64 patients. Bilateral independent paroxysmal activity occurred in 42% of the patients and was preponderant over the side of seizure origin in half. Ictal EEG changes were rarely detected at the time of clinical seizure onset, but lateralized buildup of rhythmic seizure activity during the seizure occurred in 80% of patients. In 13%, the scalp EEG seizure buildup was, however, contralateral to the side of seizure origin as subsequently determined by depth EEG and curative surgery. Lateralized postictal showing, when present, was a very reliable lateralizing finding. Neuropsychological testing provided lateralizing findings concordant with the side of seizure origin in 73% of patients. When neuropsychological testing produced discordant results or nonlateralizing findings, those patients were usually found to have right temporal seizure origin. Intracarotid amobarbital (Amytal) testing demonstrated absent or marginal memory functions on the side of seizure onset in 63% of patients, but 26 patients (37%) had bilaterally intact memory. In those patients who had magnetic resonance imaging, it was very sensitive in detecting subtle medial temporal abnormalities. These abnormalities were present in 23 of 28 magnetic resonance images, and corresponded with mesial temporal sclerosis on pathological examination in all but 2 patients. Eighty-one percent of the 51 patients who had adequate pathological examination of tissue had mesial temporal sclerosis. Forty-one patients with adequate pathological examination had histories of febrile seizures and of these 38 (93%) had mesial temporal sclerosis.     

Parietal lobe epilepsy: diagnostic considerations and results of surgery.

Eleven patients, evaluated between 1983 and 1988, with parietal lobe seizure origin as determined by circumscribed lesion detection in all and successful surgery in 10, were retrospectively evaluated in terms of clinical seizure characteristics and electroencephalographic (EEG) findings. Seven of 11 patients reported auras prior to seizures. In 4 patients, auras were lateralized somatosensory sensations, but in 1 they were ipsilateral to the side of seizure origin, and in 2 they had only occurred many years previously when seizures began. Other auras were either nonspecific or suggested seizure origin outside of the parietal lobe. Observed seizures were of two types: asymmetrical tonic seizures with or without clonic activity and complex partial seizures with loss of contact and automatisms. Four patients had only the first type of seizure and an equal number had only the second type. Three patients had both types of seizures during different episodes. Scalp EEGs correctly localized the side and region of seizure onset in only 1 patient. Three additional patients with congruent parietal localization on scalp EEG had additional misleading EEG findings. All patients had lesions detected with neuroimaging, but in 5 this detection occurred after they had been initially evaluated. These 5 patients had intracranial EEG studies designed to localize the region of seizure origin, and correct seizure onset localization was achieved in 2. Of the other 3 patients, false localization occurred in 1, and 2 could not be localized. Four patients with known lesions and 2 of the patients in whom lesions were detected after initial intracranial evaluations were studied with subdural grid electrodes placed over the lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

False lateralization by surface EEG of seizure onset in patients with temporal lobe epilepsy and gross focal cerebral lesions

Medically intractable temporal lobe seizures developed in 3 patients with radiological and clinical evidence of a gross focal cerebral lesion acquired early in life. All had bilateral independent epileptogenic discharges from the lateral and inferomesial regions of both hemispheres. Scalp and sphenoidal electroencephalographic (EEG) recordings suggested that the seizures originated from the side contralateral to the known cerebral lesion. Because the lateralizing evidence presented by the ictal EEG conflicted with the clinical data, depth electrodes were implanted stereotaxically to determine the side of onset of the seizures. These studies showed that the seizures originated from the limbic structures of the damaged hemisphere in all 3 patients. At operation the mesial temporal lobe structures showed gliotic changes in all. The patients have remained seizure-free for 3 to 13 years postoperatively. These findings suggest that depth electrode recordings may be required to clarify the lateralization of seizure onset in such cases. Extracranial EEG findings must be interpreted with caution in epileptic patients who have gross focal lesions.     

Epilepsy surgery in Belgium, the experience in Gent

Between January 1992 and July 1998, 320 patients were presurgically evaluated for medically refractory epilepsy at the University Hospital of Gent. All patients underwent a comprehensive presurgical evaluation, including extensive neurological history and examination, video-EEG monitoring of interictal EEG and habitual seizures, and optimum magnetic resonance (MR). In a large subgroup of these patients, a comprehensive neuropsychological examination and interictal 18FDG-PET were performed. Subsequently, a bilateral carotid angiography and intracarotid amytal procedure (Wada-test) were planned in 49 patients to establish hemispheric language dominance and bilateral memory function. After proper selection, 23 patients underwent invasive video-EEG monitoring with intracranial implantation of parenchymal and/or subdural electrodes to further document the area of seizure onset. From the initial group of 320 potential surgical candidates, 75 patients (42 males, 33 females) with mean age of 29 years (range: 2 months-55 years) and mean duration of uncontrolled seizures of 15 years (range: 2 weeks-38 years) eventually underwent a surgical procedure. Sixty of 75 patients were on high dose antiepileptic polytherapy. Optimum MR detected structural abnormalities, confined to a limited brain area, in 71 patients. These abnormalities were of space-occupying nature in 31 cases; an atrophic lesion was suspected in 39 patients; a combination of space-occupying and atrophic lesion was seen in 1 case. Structural abnormalities were most frequently located in the temporal lobe (n = 53) and the frontal lobe (n = 10). Video-EEG monitoring documented complex partial seizures in 67 patients with occasional secondary generalisation in 32. Most patients had complex partial seizures of temporal lobe as defined by clinical and EEG criteria. Two patients had only simple partial seizures. Ultimately, an area of seizure onset could be determined in all patients. Temporal lobectomy with hippocampectomy was the most commonly performed procedure (n = 42). In 13 patients, complete lesionectomies were performed for epileptogenic structural lesions in and outside the temporal lobe. In 2 patients, only partial lesionectomies were possible; in 5 patients, only biopsies in combination with partial lesionectomies could be performed. Anterior 2/3 callosotomy was performed in 4 patients and hemispherectomy was performed in 2 patients. Postsurgical seizure control, after average follow-up of 50 months (range: 12-98 months), was excellent in 49 patients who became seizure-free. In these patients, antiepileptic therapy was tapered 2 years after surgery. Patients in whom only biopsies or partial lesionectomies were performed have poor seizure control. Epilepsy surgery is a rewarding therapeutic alternative for patients with medically refractory epilepsy. Comprehensive presurgical evaluation and epilepsy surgery provide excellent neurological, neurophysiological, neuropsychological and imaging research opportunities.     

Extratemporal surface EEG features do not preclude successful surgical outcomes in drug-resistant epilepsy patients with unitemporal MRI lesions

Of 47 patients with onset of intractable partial seizures and temporal lobe MRI lesions, subjected to presurgical evaluation and temporal lobe surgery, we identified eight (mean age: 24 years; range: 7-52 years) demonstrating surface interictal and/or ictal EEG features suggestive of an extratemporal localisation. All eight patients underwent surgery aiming to predominantly resect the lesion, without extending to the extratemporal region. The patients were prospectively followed (mean follow-up duration: 38 months; range: 12-66 months) and all achieved excellent postoperative seizure control. Extratemporal surface interictal/ictal EEG features were more often encountered in tumoural and focal cortical dysplasia cases, compared with medial temporal sclerosis cases, and were most frequently localised over frontopolar and suprasylvian-pericentral locations. We postulate that propagation of interictal/ictal activity from the epileptogenic region of the temporal lobe to extratemporal neocortical areas, perhaps utilising the temporal pole and insula as intermediary nodes of a common epileptogenic network, accounts for the presence of our cohort's discordant lesion and EEG features.     

Intracranial EEG findings in patients with lesional lateral temporal lobe epilepsy

PURPOSE: Intracranial EEG in patients with lesional lateral temporal lobe epilepsy is rarely reported. Therefore, the number of patients with seizures arising independently from ipsilateral mesial structures or contralateral hemisphere has not been clarified. We analyzed the intracranial EEG of cases with localized lesion in the lateral temporal cortex. METHODS: We studied 15 patients who satisfied the following criteria: (1) MRI depicted a lesion less than 4cm in diameter located lateral to the collateral sulcus and at least 3cm posterior to the temporal pole; (2) intracranial EEG with electrodes placed on bilateral temporal lobes captured at least one complex partial seizure; and (3) postoperative follow-up period of 2 years or longer. The mean age of seizure onset was 16.6 years (range, 11-25) and that at surgery was 26.7 years (range, 16-36). RESULTS: A total of 147 complex partial seizures, 51 simple partial seizures, 16 secondarily generalized seizures, and over 80 subclinical seizures were recorded. On the lesional side, many clinical seizures were recorded from the lateral cortex. Independent of the lateral temporal onset seizures, ictal discharges originating from the mesial temporal structures were recorded in 7 of 15 patients (47%). Moreover, onset of ictal discharges from the contralateral temporal lobe was recorded in 7 of 15 patients (47%). Interictal spikes from ipsilateral mesial structures were recorded in all patients. The presence of ipsilateral mesial onset seizures was not associated with hippocampal neuron losses. CONCLUSION: Intracranial EEG analysis revealed that approximately one-half of the patients with structural lesions in the lateral cortex showed independent epileptogenic areas in ipsilateral mesial structures. Although ictal discharges originating from the contralateral temporal lobe were recorded in a half of these patients, this finding does not constitute a contraindication of resective surgery. Interictal spike is not an indicator of whether mesial structures should be resected.     

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.     

Clinical Profile of Partial Seizures Beginning at Less Than Four Years of Age

Clinical features of all our 46 patients whose recurrent partial seizures began at age less than or equal to 47 months were studied. Thirty-seven (80%) had motor seizures which were exclusively unilateral in 14 patients, bilaterally synchronous in 8, and both unilateral and bilaterally synchronous in 15. Thirty-three patients (72%) had complex partial seizures (CPS), and 11 patients (24%) had simple partial somatosensory seizures. Clinical seizures were recorded by EEG in 18 patients (39%), and a subclinical (larval) seizure was recorded in 1; those in 10 patients arose from a temporal lobe, 4 were from a frontal lobe, and in 5 they involved two adjacent lobes from onset. Several extra-ictal features reliably indicated lobe or hemisphere of seizure onset. The lobe of principal interictal EEG spikes corresponded to seizure origin in 33 of 34 patients (97%), and regional delta activity corresponded to lobe of seizure origin in 22 of 24 patients (92%). The seizures of all 13 patients with unilateral neurologic signs corresponded to the hemisphere implicated by the deficit. Computed tomography (CT) scan showed lesions in 30 patients (65%) and corresponded to the lobe of seizure onset in 27 of the 30 (90%). Seizures arose primarily from a frontal lobe in 22 of 46 patients (48%), from a temporal lobe in 14 patients (30%), and from an occipital-parietal-posterotemporal region in 6 patients (13%); only the hemisphere of origin could be determined in 4 patients. Cortical developmental abnormalities were the most common known cause (12 patients, 26%); febrile seizures and primary brain tumors occurred in 10 and 8 patients, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hypermotor seizures in patients with temporal pole lesions

Hypermotor seizures are considered to be characteristic of frontal lobe epilepsy, with only rare occurrence in temporal lobe epilepsy. After noting hypermotor seizures in several patients with lesions involving the pole of the temporal lobe, we investigated whether temporal pole lesions were associated with hypermotor seizures. We systematically reviewed medical records, MRI images and pathological findings in consecutive patients who underwent epilepsy surgery over the preceding 10 years in our institution and identified eight patients with temporal pole lesions and intractable complex partial seizures. We analyzed all recorded seizures for semiology, classifying seizures as hypermotor or typical "psychomotor." Four patients exhibited hypermotor seizure semiology and four patients manifested typical psychomotor seizure characteristics. In patients with hypermotor seizures, scalp EEG tended to demonstrate lateral anterior temporal ictal onset, with lesser involvement of the sphenoidal electrode, while the patients with psychomotor seizures had initial inferomesial temporal rhythmic theta activity. Two patients with hypermotor seizures had implanted frontal and temporal subdural grids demonstrating orbitofrontal spread before hypermotor behavior. Patients underwent either anterior temporal lobectomy or lesionectomy. All improved considerably, with six patients seizure-free since surgery. We conclude that hypermotor seizures occur frequently in patients with temporal pole lesions. A search for temporal pole pathology is recommended for patients with hypermotor seizures and temporal epileptiform discharges. Modification of the surgical approach to include this region should be considered in patients who exhibit hypermotor seizures.     

Surgical Treatment of Complex Partial Seizures: Results, Lessons, and Problems

Summary: The underlying seizure tendency of complex partial seizures often involves the temporal region of the brain, but the frontal lobe can also produce similar complex partial seizures. By the end of 1980, 1,210 patients with medically refractory temporal lobe epilepsy had been operated on at the Montreal Neurological Institute. Nontumoral epileptogenic lesions were present in 1,034 patients, 169 had tumors, and 7 had major vascular malformations. Thirty-seven percent of the 894 evaluable patients with nontumoral epileptogenic lesions have become and remained seizure-free. Two hundred thirty-six (26%) patients had a marked reduction of seizure tendency. Within the seizure-free group, 63% had a complete or nearly complete reduction of their medically refractory tendency following temporal lobectomy. Of the patients with temporal lobe epilepsy due to tumoral lesions, 46% of the evaluable patients have become and remained seizure-free, and 76% have had a complete or nearly complete reduction of seizure tendency.     

Long-Term Follow-Up of Stereotactic Lesionectomy in Partial Epilepsy: Predictive Factors and Electroencephalographic Results

We performed an extended follow-up study assessing the efficacy of stereotactic lesionectomy in 23 patients with foreign-tissue lesions and intractable partial epilepsy. Sixteen lesions involved functional or eloquent cortex as determined by anatomic localization. By definition, the surgical objective in these patients was excision of the lesion, and not the surrounding cerebral cortex. The mean duration of follow-up was 48.5 months (range 26-69 months). Seventeen patients (74%) had a significant reduction in seizures (greater than or equal to 90%) after lesionectomy. Thirteen patients (56%) had a class I operative outcome (seizure-free, single seizure episode, or auras only). Five of these patients were successfully discontinued from antiepileptic drug (AED) therapy. Patients with temporal lobe lesions were statistically less likely to be rendered seizure-free (p less than 0.05). Age at operation, duration of epilepsy, and underlying pathology were not significant predictors of seizure outcome. The anatomic distribution of extracranial EEG recorded epileptiform activity did not appear to be an important determinant of outcome. The absence of interictal epileptiform activity in the 3-month postoperative EEG correlated with a significant reduction in seizures. Long-term follow-up indicates that lesionectomy may be effective in select patients with medically refractory partial seizure disorders.     

Nontumoral occipitotemporal epilepsy: localizing findings and surgical outcome

We describe a syndrome of medically intractable occipitotemporal epilepsy of nontumoral developmental origin and its treatment by surgery. From our epilepsy surgery database of 1988 to 1996, we selected all patients without neoplasm who had at least two characteristics localizing to the occipital lobe (clinical symptoms, interictal focus, ictal onset, or a lesion on magnetic resonance imaging scanning) and one to the temporal lobe (interictal spikes or seizure onset). We discuss seizure characteristics, electroencephalographic (EEG), magnetic resonance imaging, positron emission tomographic, and single-photon emission computed tomographic findings, pathological findings, surgical approach, outcome from resective surgery, and implications for pathophysiology. Sixty-nine percent of our 16 patients with occipitotemporal syndrome had neuronal migration disorder, suggesting a developmental etiology of this entity. Initial signs or symptoms suggested occipital lobe seizure onset in 13 of 16 patients. On scalp EEG, interictal spikes were localized to the temporal lobe in 9 and to the occipital lobe in 1; seizure onset was poorly localized. Intracranial EEG localized seizure onset to the area of temporo-occipital junction in 77% of patients. Positron emission tomography and single-photon emission computed tomography showed occipital and temporal or widespread deficits, and neuropsychological performance was diffusely abnormal. Surgical results were best with occipital and temporal resections, but sometimes satisfactory after occipital resection even with temporal (ipsilateral) EEG findings. Temporal resection with hippocampectomy uniformly failed to control seizures. An often refractory, probably developmental epileptic syndrome with regional occipitotemporal distribution can be diagnosed by a specific constellation of findings, which has implications for treatment and pathophysiology.     

Parietal Lobe Lesional Epilepsy: Electroclinical Correlation and Operative Outcome

Summary: We retrospectively studied ictal behavior, extracranial EEG, and operative outcome in 10 consecutive patients with intractable partial epilepsy of presumed parietal lobe origin who received a lesionectomy, i.e., resection of the neuroimaging-identified abnormality, at the Mayo Clinic. Nine patients had a pathologically verified foreign-tissue lesion, e.g., tumor or vascular malformation, and 1 patient had gliosis. All patients with foreign-tissue lesions were rendered seizure-free. The patient with gliosis experienced a reduction in seizure tendency. There were no operative complications. The most common seizure type was a simple partial seizure with visual, motor, or sensory symptoms (n = 8). Complex partial seizures (n = 5) and secondarily generalized tonic-clonic seizures (GTC, n = 2) were also observed. The ictal behavior was often nonspecific although useful in identifying lateralization of the epileptogenic zone. Extracranial interictal and ictal EEG changes were unreliable markers of the parietal lobe origin of seizure activity. Lesionectomy without chronic intracranial monitoring or functional mapping may be an effective and safe alternative surgical procedure in patients with partial epilepsy related to parietal lobe lesions.     

Hyperkinetic seizures in patients with temporal lobe epilepsy: clinical features and outcome after temporal lobe resection

Purpose: Temporal lobe epilepsy (TLE) is usually associated with automatisms. Hyperkinetic seizures are supposed to be unusual. Because we witnessed several patients with TLE and ictal hyperkinetic symptoms, we retrospectively assessed the number, clinical findings, and seizure outcome in such patients who had undergone temporal lobe resection. Methods: We reviewed medical history, video–electroencephalography (EEG) recording and neuroimaging of adult patients who underwent epilepsy surgery for TLE at the Kork Epilepsy Center over the last 20 years with a minimum postoperative follow‐up of 12 months. Key Findings: Among 294 patients who were resected exclusively in the temporal region, we identified 17 (6%) who presented with hyperkinetic semiology such as violent vocalization, complex movements of the proximal segments of the limbs, rotation of the trunk, pelvic thrusting, or early tonic or dystonic posturing. Most of the patients had a preceding aura. Ictal EEG activity was located in the corresponding temporal region, usually with a wide distribution over temporal electrodes with fast spread to unilateral frontal electrodes and to the contralateral side. Neuroimaging revealed extended lesions in the temporal lobe involving mesial and neocortical structures. Most of the patients underwent classical anterior temporal lobe resection including amygdalo‐hippocampectomy. Fourteen patients (82%) became completely seizure‐free (Engel class Ia). Histopathology showed mainly focal cortical dysplasia plus hippocampal sclerosis. Significance: Hyperkinetic seizure semiology may occasionally occur in patients with TLE and is, therefore, no contradiction to the hypothesis of TLE if scalp EEG patterns and neuroimaging findings correspond. The postoperative seizure outcome is favorable in such patients and not different from outcome data in classical TLE.     

Electroencephalographic, volumetric, and neuropsychological indicators of seizure focus lateralization in temporal lobe epilepsy

CONTEXT: Anterior temporal lobectomy is an effective treatment for medically intractable temporal lobe seizures. Identification of seizure focus is essential to surgical success. OBJECTIVE: To examine the usefulness of presurgical electroencephalography (EEG), magnetic resonance imaging (MRI), and neuropsychological data in the lateralization of seizure focus. DESIGN: Presurgical EEG, MRI, and neuropsychological data were entered, independently and in combination, as indicators of seizure focus lateralization in discriminant function analyses, yielding correct seizure lateralization rates for each set of indicators. SETTING: Comprehensive Epilepsy Program, Shands Teaching Hospital, University of Florida, Gainesville. PATIENTS: Forty-four right-handed adult patients who ultimately underwent successful anterior temporal lobectomy. Left-handed patients, those with less-than-optimal surgical outcome, and any patients with a history of neurological insult unrelated to seizure disorder were excluded from this study. MAIN OUTCOME MEASURES: For each patient presurgical EEG was represented as a seizure lateralization index reflecting the numbers of seizures originating in the left hemisphere, right hemisphere, and those unable to be lateralized. Magnetic resonance imaging data were represented as left-right difference in hippocampal volume. Neuropsychological data consisted of mean scores in each of 5 cognitive domains. RESULTS: The EEG was a better indicator of lateralization (89% correct) than MRI (86%), although not significantly. The EEG and MRI were significantly superior to neuropsychological data (66%) (P=.02 and .04, respectively). Combining EEG and MRI yielded a significantly higher lateralization rate (93%) than EEG alone (P<.01). Adding neuropsychological data improved this slightly (95%). CONCLUSIONS: The EEG and MRI were of high lateralization value, while neuropsychological data were of limited use in this regard. Combining EEG, MRI, and neuropsychological improved focus lateralization relative to using these data independently.     

Celiac Disease, Bilateral Occipital Calcifications and Intractable Epilepsy: Mechanisms of Seizure Origin

Summary: Purpose: To elucidate the mechanisms of seizure origin in patients with celiac disease and bilateral occipital calcifications (CEBOC). Individuals with CEBOC frequently present with occipital lobe seizures, but additional lesions and additional attack patterns may occur.
Methods: We studied two men and one woman who had CEBOC. Villous atrophy was revealed in the two patients who underwent duodenal biopsy. All had a comprehensive presurgical evaluation, including prolonged video-EEG recordings. Two had magnetic resonance imaging (MRI) with volumetric study of mesial temporal structures (MRIV). One patient had undergone stereotactic intracranial depth electrode studies (SEEG).
Results: All patients presented with intractable complex partial seizures. Two had partial simple seizures with visual aura. Neurologic examination was normal; one was of normal intelligence, and two were mildly retarded. Neuroimaging studies showed that each had bilateral occipital calcifications as well as epileptiform abnormalities over temporal lobes. In one, MRI showed an additional right frontal lesion, but SEEG demonstrated right occipital lobe seizure origin with anterior spread; this male patient later underwent a right occipital lobe resection. Another with a history of prolonged febrile convulsions had bilateral hippocampal and amygdalar atrophy demonstrated by MRIV.
Conclusions: In one patient, SEEG confirmed that seizures originated in the occipital lobe. The presence of dual pathology was demonstrated in another, raising the possibility of both occipital and temporal seizure onset. The presence of extraoccipital lesions or of mesial temporal atrophy requires SEEG for clarification of seizure onset. In the absence of confounding factors and when laterality can be demonstrated, surgical treatment may be considered.     

Temporal lobectomy in patients with bitemporal epilepsy defined by depth electroencephalography

Patient selection for temporal lobectomy was reviewed for 23 patients with seizures that arose independently from each temporal lobe as detected by depth electroencephalography (EEG). Although neuropsychological testing, interictal EEG findings, imaging studies, and subclinical seizures were also considered, all patients offered temporal lobectomy had (1) at least 50% of the clinical seizures originating from the lobe to be resected, (2) adequate contralateral memory on testing with amobarbital, and (3) no clear evidence of an extratemporal focus. Eleven patients underwent temporal lobectomy. Pathological findings were considered positive in all nine specimens reviewed. Nine patients had no seizures, one had greater than 75% reduction in seizure frequency, and 1 had 50 to 75% reduction. Pathological features and clinical outcome were similar in the 6 patients with fewer than 80% and the 5 patients with at least 80% of seizures originating from the resected lobe. Thus, having fewer than 80% of seizures originate from one temporal lobe should not be an absolute contraindication for temporal lobectomy.     

Unidirectional whole body turning: a new lateralising sign in complex partial seizures

BACKGROUND: The lateralising significance of unidirectional whole body turning in patients with complex partial seizures (CPS) arising from the temporal lobe was evaluated. METHODS: A total of 330 patients undergoing long term video-EEG study were included. "Unidirectional whole body turning" was defined as rotation of the trunk, head, and limbs by >90 degrees and lasting >10 s. EEG correlates, MRI, and SPECT findings were compared and outcome after surgery was noted for patients with follow up data for >1 year. RESULTS: Unidirectional whole body turning was observed in 13 patients with a mean age of 18+/-8 years. Concordance of the side of whole body turning with the EEG focus and MRI findings was observed in 11 of the 13 patients (84.7%) and in 26 of 28 seizures (92.8%). The six patients who underwent temporal lobectomy or resection of lesion, opposite to the direction of body turning, had good seizure outcome. CONCLUSION: Unidirectional whole body turning is a new lateralising sign in temporal lobe CPS with good predictive value for epileptogenic focus contralateral to the direction of turning.     

Asymmetric seizure termination in primary and secondary generalized tonic–clonic seizures

Purpose:   In temporal lobe epilepsies an asymmetric termination (AST) of the clonic phase of secondary generalized tonic–clonic seizures (sGTCS) reliably lateralizes the side of seizure onset. The last clonic activity occurs ipsilateral to the side of the seizure onset zone. We compared the prevalence and lateralizing value of AST in sGTCS of frontal and temporal lobe origin as well as in primary generalized tonic–clonic seizures (pGTCS).
Methods:   We analyzed 177 seizures in 84 consecutive patients. Forty-one patients had temporal lobe epilepsy (TLE), 24 frontal lobe epilepsy (FLE), and 19 had nonfocal (primary) generalized epilepsies (GE). All patients underwent intensive video-EEG (electroencephalography) monitoring, high-resolution magnetic resonance imaging (MRI), neuropsychological testing, and single photon emission computed tomography/positron emission tomography (SPECT/PET) when feasible. Two investigators blinded for diagnosis, EEG, and imaging data assessed frequency and side of the last clonic jerk.
Results:   AST occurred in 63% of patients with TLE (47% of seizures), in 71% with FLE (60% of seizures), and in 42% with GE (21% of seizures). These results were not significant for patients, but significant for seizures in TLE versus GE and in FLE versus GE (p < 0.001). The positive predictive value (PPV) for the side of seizure onset was 74% (p = 0.003) in TLE and 75% (p = 0.008) in FLE.
Discussion:   AST in sGTCS lateralizes the side of seizure onset in TLE and in FLE to the ipsilateral hemisphere with a high PPV. However, AST was also observed in GE. Therefore, asymmetric clinical signs should not inevitably lead to the assumption of focal epilepsy syndromes.     

Sexual automatisms in complex partial seizures

Ictal sexual automatisms such as masturbatory activity, pelvic thrusting, or similar automatisms for which the patient is amnesic have been attributed to temporal lobe disease. Of 61 patients with medically refractory complex partial seizures, 14 had frontal lobe seizure foci. Four of these patients manifested sexual automatisms in some or all of their seizures. Frontal lobe seizure origin was documented by depth EEG in three patients. In the fourth, a calcified lesion was demonstrated radiologically. In three patients, frontal lobectomy revealed abnormal frontal lobe pathology and was followed by 75 to 100% reduction in seizure frequency. Sexual automatisms did not occur in patients with seizures originating in any area other than the frontal lobe.