Autonomic responsiveness to affective visual stimulation in temporal lobe epilepsy

Patients with temporal lobe epilepsy (TLE) have been posited by some to manifest a syndrome of interictal personality and behavioral change. Furthermore, this syndrome has been attributed to an underlying mechanism--enhanced affective responsiveness. The purpose of this investigation was to determine whether patients with TLE manifest increased emotional responsiveness relative to appropriate controls. Patients with TLE (n = 23) were compared with non-TLE (n = 7) and healthy controls (n = 16) as to their autonomic nervous system responsiveness to an emotionally stressing film. No differences were found among the groups. These results are related to the larger literature concerning epilepsy and psychopathology.     

A Psychosocial Approach to Epileptic Patients

Summary: A psychoeducational approach was taken with 174 epileptic patients. Using this approach, no family problems were recognized among patients with idiopathic generalized epilepsy (IGE) or among those with symptomatic generalized epilepsy (SGE). However, 11 patients with temporal lobe epilepsy (TLE) and 1 patient with non-temporal lobe epilepsy (non-TLE) did exhibit family problems indicating that such problems involving IGE or SGE cases can be prevented through educational programs using a psychoeducational approach. This fails, however, to prevent such problems for TLE or non-TLE cases. Furthermore, small group psychotherapy was given to 10 patients with intractable TLE. They were directed to make self-evaluations regarding therapeutic factors originally introduced by Yalom but specially modified for these particular patients. Relatively high evaluations were given on every factor when compared with the results of individual psychotherapy. These results point out the importance of providing such psychotherapeutic approaches as group psychotherapy and self-help groups in addition to educational programs in order to enhance the quality of life (QOL) of epileptic patients and their families.     

Interictal personality and behavioral traits in temporal lobe and generalized epilepsy

Fourteen patients with temporal lobe epilepsy (TLE) and 14 patients with primary generalized epilepsy (GE) were compared on a self-report questionnaire (Personal Inventory) which assesses 18 personality and behavioral traits hypothesized to characterize persons with TLE. Four traits (sense of personal destiny, dependence, paranoia, philosophical interest) were significantly elevated in the TLE group, thus lending some support to the notion of changes in behavior and thought which occur in TLE but not necessarily in other forms of epilepsy.     

Senile plaques in temporal lobe epilepsy

Senile plaques (SP) are one of the characteristic pathological lesions of Alzheimer's disease (AD). They are also seen in the brains of some non-demented individuals as an age-related change. Identification of clinical conditions associated with these incidental SP could provide insight into AD pathogenesis. We have examined the presence of SP in lobectomy specimens (n=101) removed in the surgical treatment of temporal lobe epilepsy (TLE). SP were present in 10 specimens from epileptic patients aged 36 to 61 years and the presence of SP correlated positively with patient age. No other significant AD-related pathology was identified and no patients showed any evidence of dementia on neuropsychological testing. When compared with temporal lobe tissue from non-demented, non-epileptic autopsy controls (n=406), the density and distribution of SP was the same. The age-related incidence of SP however, was significantly greater in the epileptics. This suggests that some aspects of TLE has a positive influence on the formation of SP.Generously supported by a grant from the Alzheimer Association of Ontario     

Temporal lobe epilepsy and aggression.

Research on temporal lobe epilepsy (TLE) and aggression is reviewed in order to learn why it has not contributed more to our understanding of the neural basis of aggression. The research problem can be resolved into two questions: Are temporal lobe epileptics more aggressive? What inferences can be drawn about the factors underlying aggression in TLE? Difficulties in finding suitable operational definitions for TLE and for aggression have, to date, received insufficient attention. In published studies, sample bias and lack of regard for the validity and reliability of behavioral assessments prevent our deciding whether an association exists between interictal aggressive behavior and TLE. Even if this association were demonstrated, one could not draw direct neurobehavioral inferences from it, since a variety of social and psychological, as well as neurophysiological variables could contribute to the association. These would have to be controlled. Methodological refinements could lead to more satisfactory answers to the first question, but the second is considerably more difficult. Some sources of complexity and apparent contradictions in the experimental literature on the neurology of aggression are discussed. They consist of technical problems, the complexity of the neural substrate of aggression and the influence of environmental cues and learning. The combined use of electrophysiological and interview techniques has yielded some interesting results with TLE patients.     

Dissociation in temporal lobe epilepsy and pseudo-epileptic seizure patients

Patients with epileptic seizures (ES) and especially those with temporal lobe epilepsy (TLE) share many symptoms with patients with pseudo-epileptic seizures (PES), and the differentiation between them is often difficult There is growing evidence that a subgroup of PES patients suffer from a dissociative disorder. It is recognized that dissociative symptoms pertain to both psychological and somatoform components of experience. Questionnaires assessing dissociation might provide positive criteria for the diagnosis of PES. In this study, the Dissociation Questionnaire (DIS-Q) and the Somatoform Dissociation Questionnaire (SDQ-20) were administered to patients with ES (TLE, non-TLE) and PES. To control for the influence of general psychoneurotic complaints, the SCL-90 was administered. Apart from this, answers on a trauma questionnaire were related to the diagnosis. Results showed that PES patients scored significantly higher on the SDQ-20, also after correction with the SCL-90, and no difference was found on the DIS-Q. Also, PES patients significantly more often reported sexual traumatic experiences. A logistic regression revealed that results on the SDQ-20 have no independent value in addition to the contribution of gender, age, age at seizure onset, and the presence of sexual abuse in the prediction of the diagnosis. In conclusion, somatoform and not psychological dissociative symptoms are characteristic for PES patients in comparison to ES patients. Other measures are needed within the framework of the differential diagnosis between PES and ES.     

Personality and Neuropsychological Aspects of Temporal Lobe Epileptics and Schizophrenics

Abstract: The present study was designed to ascertain and explore whether distinct personality profiles and neuropsychological features characterized temporal lobe epilepsy (TLE) vs. schizophrenic patients (Sc). The subjects were 20 epileptics and 19 schizophrenics matched with an overall IQ. They underwent various personality and neuropsychological tests. These results showed that the personality of the left-TLE patients tended to be more sensitive, aggressive, hostile and emotionally labile than the right-TLE and Sc patients. Finally, the Sc patients showed poor performances in verbal and nonverbal delayed tasks, especially on the right visual hemifield ones. These results suggested that they have the frontal lobe dysfunction, especially of the left hemisphere.     

Personality and neuropsychological aspects of temporal lobe epileptics and schizophrenics

The present study was designed to ascertain and explore whether distinct personality profiles and neuropsychological features characterized temporal lobe epilepsy (TLE) vs. schizophrenic patients (Sc). The subjects were 20 epileptics and 19 schizophrenics matched with an overall IQ. They underwent various personality and neuropsychological tests. These results showed that the personality of the left-TLE patients tended to be more sensitive, aggressive, hostile and emotionally labile than the right-TLE and Sc patients. Finally, the Sc patients showed poor performance in verbal and nonverbal delayed tasks, especially on the right visual hemifield ones. These results suggested that they have the frontal lobe dysfunction, especially of the left hemisphere.     

Amygdala volumetry in "imaging-negative" temporal lobe epilepsy

OBJECTIVE: Although amygdala abnormalities are sometimes suspected in "imaging-negative" patients with video EEG confirmed unilateral focal epilepsy suggestive of temporal lobe epilepsy (TLE), amygdala asymmetry is difficult to assess visually. This study examined a group of "imaging-negative" TLE patients, estimating amygdala volumes, to determine whether cryptic amygdala lesions might be detected. METHODS: Review of video EEG monitoring data yielded 11 patients with EEG lateralised TLE and normal structural imaging. Amygdala volumes were estimated in this group, in 77 patients with pathologically verified hippocampal sclerosis (HS), and in 77 controls. RESULTS: Seven of 11 "imaging-negative" cases had both significant amygdala asymmetry and amygdala enlargement, concordant with seizure lateralisation. Although significant amygdala asymmetry occurred in 35 of 77 HS patients, it was never attributable to an abnormally large ipsilateral amygdala. Compared with patients with HS, patients with amygdala enlargement were less likely to have suffered secondarily generalised seizures (p<0.05), and had an older age of seizure onset (p<0.01). CONCLUSION: Abnormal amygdala enlargement is reported in seven cases of "imaging-negative" TLE. Such abnormalities are not observed in patients with HS. It is postulated that amygdala enlargement may be attributable to a developmental abnormality or low grade tumour. It is suggested that amygdala volumetry is indicated in the investigation and diagnosis of "imaging-negative" TLE.     

Lateralization of temporal lobe epilepsy (TLE) and discrimination of TLE from extra-TLE using pattern analysis of magnetic resonance spectroscopic and volumetric data

PURPOSE: To examine whether or not pattern analysis of magnetic resonance volumetric (MRVol) and proton magnetic resonance spectroscopic imaging (1H-MRSI) data would enable (a) the accurate lateralization of temporal lobe epilepsy (TLE) and (b) the discrimination of TLE from extratemporal epilepsy (E-TLE). METHODS: For lateralization analysis, we used data from 150 nonforeign tissue lesional TLE patients [88 left-sided (L-TLE), 46 right-sided (R-TLE), and 16 bilateral (Bi-TLE)]. For the discrimination of TLE from E-TLE, we used data from 174 patients (145 with unilateral TLE, 14 with unilateral E-TLE, and 15 with widespread epileptogenic zones involving both the TL and extra-TL regions-multilobar epilepsy). A series of "leave-one-out" cross-validated linear discriminant analyses were performed using the MRVol and 1H-MRSI data sets to lateralize TLE and discriminate it from E-TLE. RESULTS: Lateralization: The leave-one-out linear discriminant analyses were able to correctly lateralize (with a posterior probability >0.50) 120 (90%) of the 134 L-TLE and R-TLE patients. Imposing higher posterior probability (>0.95) increased accuracy of lateralization to 98%, with only two discordant cases who underwent surgery on the side of electroencephalogram, and both had bad outcome. Discrimination: the leave-one-out linear discriminant analyses were able to correctly classify (with a posterior probability >0.50) 142 (89%) of the 159 TLE and E-TLE patients. Accuracy increased slightly as higher posterior probability cutoffs were imposed, with fewer patients being classified. CONCLUSIONS: Pattern analysis of 1H-MRSI and MRVol data can accurately lateralize TLE. Discriminating TLE from E-TLE was less accurate, probably due to the presence of temporal lobe damage in some patients with E-TLE reflecting dual pathology.     

Alzheimer's disease and epilepsy: insight from animal models

Alzheimer's disease (AD) and epilepsy are separated in the medical community, but seizures occur in some patients with AD, and AD is a risk factor for epilepsy. Furthermore, memory impairment is common in patients with epilepsy. The relationship between AD and epilepsy remains an important question because ideas for therapeutic approaches could be shared between AD and epilepsy research laboratories if AD and epilepsy were related. Here we focus on one of the many types of epilepsy, temporal lobe epilepsy (TLE), because patients with TLE often exhibit memory impairment, depression and other comorbidities that occur in AD. Moreover, the seizures that occur in patients with AD may be nonconvulsive, which occur in patients with TLE. Here we first compare neuropathology in TLE and AD with an emphasis on the hippocampus, which is central to both AD and TLE research. Then we compare animal models of AD pathology with animal models of TLE. Although many aspects of the comparisons are still controversial, there is one conclusion that we suggest is clear: some animal models of TLE could be used to help address questions in AD research, and some animal models of AD pathology are bona fide animal models of epilepsy.     

Spirituality and religion in epilepsy

Revered in some cultures but persecuted by most others, epilepsy patients have, throughout history, been linked with the divine, demonic, and supernatural. Clinical observations during the past 150 years support an association between religious experiences during (ictal), after (postictal), and in between (interictal) seizures. In addition, epileptic seizures may increase, alter, or decrease religious experience especially in a small group of patients with temporal lobe epilepsy (TLE). Literature surveys have revealed that between .4% and 3.1% of partial epilepsy patients had ictal religious experiences; higher frequencies are found in systematic questionnaires versus spontaneous patient reports. Religious premonitory symptoms or auras were reported by 3.9% of epilepsy patients. Among patients with ictal religious experiences, there is a predominance of patients with right TLE. Postictal and interictal religious experiences occur most often in TLE patients with bilateral seizure foci. Postictal religious experiences occurred in 1.3% of all epilepsy patients and 2.2% of TLE patients. Many of the epilepsy-related religious conversion experiences occurred postictally. Interictal religiosity is more controversial with less consensus among studies. Patients with postictal psychosis may also experience interictal hyper-religiosity, supporting a "pathological" increase in interictal religiosity in some patients. Although psychologic and social factors such as stigma may contribute to religious experiences with epilepsy, a neurologic mechanism most likely plays a large role. The limbic system is also often suggested as the critical site of religious experience due to the association with temporal lobe epilepsy and the emotional nature of the experiences. Neocortical areas also may be involved, suggested by the presence of visual and auditory hallucinations, complex ideation during many religious experiences, and the large expanse of temporal neocortex. In contrast to the role of the temporal lobe in evoking religious experiences, alterations in frontal functions may contribute to increased religious interests as a personality trait. The two main forms of religious experience, the ongoing belief pattern and set of convictions (the religion of the everyday man) versus the ecstatic religious experience, may be predominantly localized to the frontal and temporal regions, respectively, of the right hemisphere.     

Temporal lobe epilepsy surgery: different surgical strategies after a non-invasive diagnostic protocol

AIM: To test a non-invasive presurgical protocol for temporal lobe epilepsy (TLE) based on "anatomo-electro-clinical correlations". METHODS: All consecutive patients with suspected TLE and seizure history <2 years were entered into the protocol, which included video-electroencephalographic (EEG) monitoring and magnetic resonance imaging (MRI). Three different TLE subsyndromes (mesial, lateral, mesiolateral) were identified by combined anatomical, electrical, and clinical criteria. "Tailored" surgery for each subsyndrome was offered. Patients with seizure history <2 years, MRI evidence of temporal mass lesion, and concordant interictal EEG and clinical data bypassed video-EEG monitoring and were directly scheduled for surgery. RESULTS: Lesionectomy was performed without video-EEG recording in 11 patients with tumorous TLE. Of 146 patients studied with video-EEG, 133 received a TLE diagnosis. Four were excluded for neuropsychological risks, eight refused surgery, and 121 underwent surgery. Of 132 consecutive patients who underwent surgery, 101 had at least one year of follow up. They were divided into a "hippocampal sclerosis/cryptogenic" group (n = 57) and a "tumours/cortical organisation disorders" group (n = 44). In the first group, extensive temporal lobectomy (ETL) was performed in 40 patients, anteromesial temporal lobectomy (AMTL) in 17 patients. At follow up, 47 patients were seizure free. In the second group, lesionectomy plus ETL was performed in 23 patients, lesionectomy plus AMTL in six patients, and lesionectomy alone in 15 patients. Thirty nine patients were seizure free. CONCLUSIONS: These findings suggest that different TLE subsyndromes can be identified accurately using non-invasive anatomo-electro-clinical data and can be treated effectively and safely with tailored surgery.     

Depression in epilepsy. Significance and phenomenology

Depression is common in epileptics, but few studies of this relationship exist. We investigated the prevalence of depression in comparably disabled outpatients and its phenomenology in psychiatrically hospitalized inpatients. Fifty-five percent of 175 outpatient epileptics and 30% of 70 matched controls reported depression; 30% of epileptics vs 7% of controls reported prior suicide attempts. Epileptics were four times more likely to have been hospitalized for depression than nonepileptics. Twenty depressed epileptic inpatients were characterized by "endogenous" rather than "neurotic" features with more psychotic traits, paranoia, and underlying chronic dysthymia. Sixteen patients had complex partial seizures, and ten of 11 patients had a lateralized electroencephalographic focus lateralized to the left hemisphere. These results suggest a specific epileptic psychosyndrome due to limbic dysfunction.     

Group‐specific regional white matter abnormality revealed in diffusion tensor imaging of medial temporal lobe epilepsy without hippocampal sclerosis

Purpose: In comparison to temporal lobe epilepsy (TLE) patients with hippocampal sclerosis (TLE‐HS), TLE patients without HS (TLE‐NH) have a similar clinical course but may result in worse surgical outcome. We investigated whether the clinical features related to the lack of HS in TLE patients (TLE‐NH) can be explained by water diffusion abnormalities throughout diffusion tensor imaging (DTI) by voxel‐based analysis. Methods: Nineteen patients with TLE‐HS (left/right TLE 12:7), 18 patients with TLE‐NH (left/right TLE 10:8), and 20 controls were included in the study. By statistical parametric mapping (SPM2), the diffusion properties specific to disease characteristics (TLE‐HS vs. TLE‐NH) were analyzed. Results: In TLE‐HS, we found the areas of increased mean diffusivity (MD) in their ipsilateral temporal and extratemporal areas including the hippocampus, parahippocampal, and frontoparietal regions. Left TLE‐HS showed a characteristic MD increase in the ipsilateral posterior cingulum, isthmus of corpus callosum, and contralateral occipital and temporal regions, which was not observed in right TLE‐HS group. In left TLE‐NH, two regions of increased MD were observed in the ipsilateral posterior fornix (within fusiform gyrus) and posterior cingulum. Right TLE‐NH did not show any increased MD. Discussion: In left TLE‐NH, we could find the water diffusion change along the posterior cingulum, which was quite different from the extensive abnormality from TLE‐HS. In addition, there was a lesion‐side–specific distribution (left predominant) of pathology in mesial TLE. This provides a possibility that TLE‐NH is a heterogenous or entity different from TLE‐HS.     

Folate and monoamine metabolism in epilepsy.

In 27 drug-treated epileptics there was a significant fall in serum, red cell and CSF folate levels compared with 15 untreated epileptics and 22 neurological controls. The 3 folate parameters were positively correlated with each other and negatively correlated with serum phenobarbitone, diphenylhydantoin and primidone. There was also a significant elevation of CSF 5-hydroxyindoleacetic acid (5HIAA) in the drug-treated epileptics; but this was not seen until "therapeutic" serum levels of phenobarbitone and diphenylhydantoin had been achieved and was most marked in clinically intoxicated patients. Similar trends were observed in CSF homovanillic acid (HVA). CSF 5HIAA and HVA were positively correlated with each other, especially in the drug-treated patients, in whom both amine metabolites were also negatively correlated with CSF folate. A possible relationship between folate and monoamine metabolism is discussed with particular reference to the antiepileptic and toxic effects of phenobarbitone, diphenylhydantoin and primidone.     

Day/night patterns of focal seizures

PURPOSE: In many patients with epilepsy seizures occur with a day/night pattern. Our aims were to compare day/night patterns in seizure frequency among patients with different epileptogenic regions. METHODS: We analyzed video-EEG recordings in 15 patients with temporal lobe (TLE) and 11 with extratemporal lobe epilepsy (XTLE). Each seizure was classified according to subject group (TLE vs XTLE), sleep/wake state, and time of day of seizure occurrence (grouped into 6 x 4-hour "bins"). RESULTS: Of 90 seizures, 41 occurred in TLE and 49 in XTLE patients. There were day/night patterns of seizure occurrence in each group, with differences in the patterns between groups. In TLE, 50% of seizures occurred between the hours of 15:00 and 19:00 (17% would be expected by chance in each 4-hour "bin": F=3.59, P<0.006). In XTLE, there was a peak between 19:00 and 23:00 (47%: F=4.72, P<0.0018). The effect of time on seizures was least pronounced in the XTLE patients who had more than one epileptogenic region. The proportion of seizures occurring from sleep was significantly less in TLE (19%) than in XTLE patients (41%) [P<0.04, Fisher's exact test]. CONCLUSIONS: There are clear day/night patterns of seizure occurrence in epilepsy, with differences in the patterns between TLE and XTLE. There is an additional interaction with sleep/wake state, with relatively few seizures occurring from sleep in TLE compared with XTLE. Thus, it appears that both sleep/wake state and day/night or circadian rhythms may affect seizure proclivity, with different effects depending on the location of the epileptogenic region.     

脑磁图联合颅内电极脑电图在癫痫外科治疗中的应用

目的研究脑磁图(MEG)与颅内电极脑电图(i EEG)联合在癫痫外科治疗中的应用价值。方法应用MEG参与到将行颅内电极埋置患者的术前评估中:根据电-临床症状学、影像学、脑电图、MEG等结果设计出颅内电极埋置方案,进而行颅内电极置入并监测i EEG,捕捉发作期,最终根据定位结果行手术治疗。结果最终成功定位癫痫发作起始区并手术治疗者38例。其中证实为颞叶癫痫(TLE)的16例中,MEG与i EEG定位一致者仅6例,而颞叶以外癫痫(NTLE)22例中两者一致者达16例,两组结果有统计学差异。所有患者术后随访:EngelⅠ级28例,Ⅱ级5例,Ⅲ级3例,Ⅳ级2例。结论 MEG运用于NTLE时较TLE有着更高的与i EEG的一致率。区别于视频脑电图、MRI等其它的无创检查,MEG能够对有创的i EEG电极埋置起到额外指导作用。MEG与i EEG联合,能使电极埋置更合理精确、有针对性,能获得较高的癫痫手术疗效。     

Diagnostic Reliability and Significance of Irregular Beta Patterns

Abstract: We designated EEGs with marked and irregular beta waves in basic patterns as "irregular beta patterns" on the basis that these patterns are related with particular symptoms such as dysphoria, irritability and autonomic symptoms and they implicate choice of therapeutic agents. Because of good response to antiepileptic agents in patients with "irregular beta patterns" along with EEG characteristics, we hypothesized that the prevalence of "irregular beta patterns" is higher in epileptics than in other psychiatric patients. In the present study, we tested this hypothesis, investigating actual frequencies of these patterns among different diagnostic categories for all patients whose EEG were recorded in all the first-visit patients to the Outpatient Clinic, Deparmtent of Neuropsychiatry of the Tokyo University Hospital during one year period of 1986. Before starting this investigation, we checked the interrater reliability for these patterns. Therefore, two studies are reported here. In Study 1, five raters judged 98 EEG recordings blindly (43 epileptics and 55 healthy subjects). As a result, the generalized Kappa of 0.473 was obtained, indicating our agreement level was moderate or fair. This result lends support to our contention that irregular beta patterns are reliably judged. In Study 2, we judged the EEG recordings (137 schizophrenics, 62 affective disorders, 43 epileptics and 55 healthy controls) and calculated the prevalence rate of "irregular beta patterns" among the diagnostic categories. The results show that the prevalence rates of "irregular beta patterns" among psychiatric disorders and normal controls were 13% (18/137) in schizophrenics, 11% (7/62) in affective disorders, 14% (6/43) in epileptics and 4% (2/55) in healthy controls. These rates did not differ significantly among the three disorders. Thus, our hypothesis was not supported. The clinical significance of these patterns is discussed.     

Neural correlates of verbal semantic memory in patients with temporal lobe epilepsy

Functional imaging data suggest that the core network engaged in verbal semantic memory (SM) processing encompasses frontal and temporal lobe structures, with a strong left lateralization in normal right handers. The impact of long term temporal lobe epilepsy (TLE) on this network has only partly been elucidated. We studied verbal SM in 50 patients with chronic, intractable TLE (left TLE=26, right TLE=24) and 35 right handed normal controls using a verbal fMRI semantic decision paradigm. All patients had language lateralized to the left hemisphere, as verified by the intracarotid amobarbital procedure. Within and between group analyses showed remarkable, group-specific activation profiles. The control group activated frontal and temporal areas bilaterally, with a strong left predominance. Left TLE patients showed a shift of activations of left frontal and medial temporal areas to homologous regions in the right hemisphere. Furthermore, left TLE subjects utilized subcortical structures such as the thalamus and putamen to accomplish the verbal SM task. Contrastively, the activation pattern of right TLE patients resembled that of normal controls, but exhibited "hypofrontality" with a shift from frontal to posterior regions in the temporal, parietal and occipital lobe. Our results show that chronic epileptic activity originating from temporal seizure foci is associated with an alteration of neural circuits which support semantic language processing and that side of seizure focus has a specific impact on the resulting activation network. These findings presumably result from morphological changes and from functional reorganization which are both inherent to chronic TLE.