Crossed aphasia in a patient with complex partial seizures: evidence from intracarotid amobarbital testing, functional cortical mapping, and neuropsychological assessment.

We report a right-handed patient who became transiently aphasic following a right temporal lobectomy for control of intractable complex partial seizures. Preoperative intracarotid amobarbital testing revealed right-hemisphere language dominance, although bilateral language representation was present. Memory testing during unilateral electrical hippocampal simulation with depth electrodes indicated reliance on left-hemisphere mesial temporal lobe structures for verbal memory. Functional mapping for language during surgery established several right perisylvian regions that, when stimulated, produced speech arrest and/or paraphasic substitution. One-year follow-up neuropsychological assessment demonstrated an increase in verbal learning and decrease in visual memory, a pattern associated with patients who have undergone right temporal lobectomy. These data demonstrate that (1) right cerebral language dominance can be observed when ipsilateral seizure onset is present (2) verbal memory and language dominance are not necessarily linked, and (3) some reported cases of crossed aphasia may in fact have bilateral language representation.     

Memory for objects presented soon after intracarotid amobarbital sodium injections in patients with medically intractable complex partial seizures

We evaluated the abilities of 36 patients with intractable temporal lobe epilepsy and left hemisphere dominance for language to later recognize objects presented in the confusional phase after left intracarotid amobarbital injection. Eighteen of 24 patients with left, but only 4/12 with right, temporal lobe epilepsy recognized at least two-thirds of objects during a post-test. These results demonstrate that the initial muteness and apparent confusion after amobarbital injection do not prohibit the formation of new memories; this gives further support to the idea that consciousness can be retained despite transient disruption of function of the language-dominant hemisphere.     

Usefulness of language and memory testing during intracarotid amobarbital testing: observations from an fMRI study

BACKGROUND: Several procedures for testing language lateralization and memory function exist during the intracarotid amobarbital test (IAT). The use of functional magnetic resonance imaging (fMRI) gives the opportunity to assess the validity of some of these procedures, or at least to inspect the neuronal correlates. A comprehensive fMRI protocol was tested, aimed at addressing aspects of lateralization of language, as well as testing memory in relation to activation of mesiotemporal regions. Here we report observations with possible consequences for the current IAT procedures. MATERIALS AND METHODS: The protocol consisted of three language tasks (overt naming, semantic decision and silent word generation) and two memory tasks (encoding and retrieving visual scenes). The paradigms used a block-related procedure in nine right-handed normal volunteers. During the procedure dynamic weighted full brain images were acquired which are sensitive to the blood oxygenation activation effect. RESULTS : Encoding showed symmetrical bilateral activation in the mesiotemporal regions, specifically the hippocampus, parahippocampal gyrus and fusiform gyrus. With a retrieval task activation of the mesiotemporal areas was restricted to the posterior hippocampal area. Overt object naming showed results, similar to encoding tasks with bilateral activation of hippocampal areas. Silent word generation showed much stronger ability to lateralize than the other two language-related tasks and especially object naming. CONCLUSION: Activation revealed by fMRI activation shows that IAT procedures, using active semantic language processing or comprehensive procedures with multiple language tasks have the highest guarantee for individual activation lateralization. Simple object naming does not guarantee a lateralized language fMRI activation pattern. Of the different memory procedures during IAT, the procedures (Interview and the Montreal) demanding encoding processing will be related to larger areas of bilateral hippocampal activation than procedures (Seattle) exclusively requiring retrieval. Moreover, tasks using recognition of previously presented language items (naming objects) are equally effective for assessing hippocampal activation compared with presenting separate memory items.     

Memory performance during the intracarotid amobarbital procedure and neuropsychological assessment in medial temporal lobe epilepsy: the limits of material specificity

We investigated the relationship between material-specific memory performance elicited during the Wada test, or intracarotid amobarbital procedure (IAP), and classic neuropsychological assessment in 89 surgical candidates with refractory medial temporal lobe epilepsy (MTLE). The neuropsychological battery included measures of simple and complex verbal and visual memory, whereas the IAP material consisted of verbal and dually encodable stimuli. Neuropsychological testing revealed that reduced verbal memory performance was associated with left-sided MTLE, whereas visual memory tasks revealed no differences between patients with left-sided and right-sided MTLE. During IAP, memory performance was worse with the ipsilesional hemisphere, regardless of lesion side. Most importantly, performance on verbal memory tests was significantly, but moderately, correlated with left hemispheric IAP performance, indicating that memory tasks using verbal material are a valid marker of left hemispheric integrity in left language-dominant MTLE patients and significantly predict left hemispheric memory performance during IAP. In contrast, performance on classic visual memory tests is unrelated to right hemispheric IAP performance, suggesting that the currently used visual memory stimuli do not reflect right hemispheric sensitivity.     

Progressive aphasia in a patient with Pick's disease: a neuropsychological, radiologic, and anatomic study

Although Pick's disease is generally considered as a dementia characterized by signs of frontal lobe dysfunction, it can present with selective language defects rather than with cognitive decline. In this study, we report prospective and serial clinical, neuropsychological, and neuroradiologic observations in a 59-year-old man whose prominent disturbance was in the retrieval and learning of names denoting concrete entities and actions. Postmortem study confirmed the diagnosis of Pick's disease and revealed that neuronal loss and gliosis were most prominent in left anterior temporal cortices. The findings are in keeping with evidence that the left anterior temporal cortices and interconnected hippocampal system are critically involved in the learning and retrieval of verbal lexical items. The evidence from this patient, along with similar evidence from the literature we reviewed, suggests that when patients present with a progressive aphasia characterized by anomia, Pick's disease should be considered as the probable diagnosis.     

Intracranial and spinal metastases from a ganglioglioma with unusual cytogenetic abnormalities in a patient with complex partial seizures

We describe an unusual clinical presentation of a ganglioglioma in a patient with complex partial seizures. The patient underwent a right temporal lobectomy with subtotal tumor resection at age 15 years, followed by a complete resection 1 year later. Follow-up MRI scan a year later documented recurrence and leptomeningeal dissemination. Another biopsy was performed. Pathological examination revealed similar histology in all three resections, with a ganglioglioma showing no evidence of anaplasia. The tumor exhibited a number of karyotypic abnormalities, notably, a paracentric inversion of chromosome 7. In summary, despite lacking anaplastic features by conventional histological criteria, this ganglioglioma showed an unsusual karyotype and demonstrated radiological evidence of widespread dissemination. Received: 14 May 1996     

Crossed aphasia in a patient with congenital lesion in the right hemisphere

Abstract

A phonologically based treatment was implemented to train oral picture naming in four aphasic subjects with severe word-retrieval deficits. An initial assessment based on current cognitive neuropsychological models of naming indicated different levels of phonological and/or semantic deficits underlying naming failure across the subjects. Using a single-subject multiple baseline design across behaviours and subjects, the effects of treatment were evaluated by daily probing of both trained and untrained items across lexical tasks: oral naming, oral reading, and written naming. Results indicated successful acquisition of trained naming targets for the four subjects, and varied patterns of response generalization to naming of untrained phonologically and semantically related pictures, and to oral reading and written naming for the same words. Baseline levels of oral reading performance were noted to predict success in oral naming treatment. Differences in generalization patterns across tasks are discussed with regard to the varying functional levels of breakdown noted across subjects. This investigation demonstrates the utility of cognitive models in guiding the development of appropriate treatment strategies and generalization measures, and the importance of incorporating single-subject experimental designs in documenting changes associated with treatment.     

Isolated unilateral cortical oedema and complex partial seizures in association with coxsackievirus B infection

A unilateral cortical oedema in association with coxsackievirus B infection is reported. A 10-year-old girl presented with right hemiparesis and complex partial seizures. The cerebral MRI showed a unique pattern of isolated unilateral cortical oedema sparing the white matter with intravascular gadolinium enhancement of the left hemispheric sulcal veins. With anticonvulsant medication, the patient recovered within two weeks and MRI abnormalities were completely resolved after four weeks, whereas the EEG left hemispheric slowing showed delayed normalisation over the following five months.     

Apparent complex partial seizures in a bipolar patient after withdrawal of carbamazepine

A 64-year-old woman with long-standing bipolar illness was treated with carbamazepine and clonazepam with minimal success. Discontinuation of carbamazepine and clonazepam was followed by episodic amnesia, purposeless behavior, déjà vu, and confusion. Although her EEG was normal, the episodes were compatible with complex partial seizures and ceased after carbamazepine and clonazepam were reinstituted. This case raises the question of whether discontinuing carbamazepine and clonazepam can induce complex partial seizures in bipolar patients.     

The safety and efficacy of propofol as a replacement for amobarbital in intracarotid Wada testing of presurgical patients with epilepsy

ObjectiveThe intracarotid sodium amytal procedure (the “Wada test”) has for many years been the gold standard for language and memory lateralization and remains an important part of presurgical analysis for patients with medically intractable seizures. Due to shortages in the key sedative (amobarbital), neuropsychologists have turned to alternatives such as propofol. Our aim was to investigate the safety and efficacy of propofol relative to amobarbital in the Wada test.MethodsWe performed a retrospective review of the 97 Wada procedures performed at University of Iowa Hospitals and Clinics from 2007 through mid-2015.ResultsPropofol produced similar lateralization rates as amobarbital for both language and memory. Similar rates of patients in each group went on to have the resection surgery. With regard to safety, there were no differences found in average rate or severity of adverse effects. None of the demographic characteristics reviewed were predictive of increased risk for either drug.SignificanceThese findings support previous studies indicating that propofol is as safe and efficacious as amobarbital, and can continue to be used in Wada procedures with confidence.     

Processing proper nouns in aphasia: Evidence from assessment and therapy

Background: Dissociations between proper and common names following brain damage have frequently been reported (see Yasuda, Nakamura, & Beckman, 2000, for review) and suggest that these different word classes are processed by distinct mechanisms. The dissociations are often observed in people with relatively pure impairments, but might also be expected more generally in aphasia. There is the further possibility that the different vocabulary groups require different therapy approaches. Yet, to our knowledge, no study has explored whether treatments that are known to be successful with common nouns are also successful with proper nouns. Aims: This study had two main aims: to compare the comprehension and production of common and proper nouns in 20 people with aphasia; and to investigate whether semantic naming therapy is equally effective for common and proper nouns. Methods & Procedures: A total of 20 people with aphasia were tested in their ability to comprehend and produce matched sets of proper and common nouns. The stimuli comprised: 20 famous people, 20 famous places, 20 high‐familiarity common nouns, and 20 low‐familiarity common nouns. Participants were also tested with personally relevant proper names, such as the names of family members. In the second phase of the study 10 of the original participants were given semantic therapy for both common and proper nouns. Experimental measures explored effects on treated and untreated words. Outcomes & Results: Initial testing found that comprehension scores were generally high, with no word class effect. In production, proper nouns were significantly more difficult to name than the matched common nouns. However, this finding excluded personally relevant proper nouns, which were the most successfully named items. Results from the second phase showed that semantic therapy was equally effective in improving naming of both common and proper nouns. As in many previous studies, effects were almost entirely confined to treated items. Conclusions: Our findings suggest that proper nouns induce more naming failures in aphasia than common nouns. However, despite this, they seem equally amenable to therapy. Clinical and theoretical implications are discussed.     

Possible induction of West syndrome by oxcarbazepine therapy in a patient with complex partial seizures

Oxcarbazepine has been reported to precipitate myoclonic, generalised tonic-clonic, absence, and complex partial seizures, and carbamazepine to precipitate absences, myoclonic seizures and spasms. Here, we report a one-year, six-month-old girl with complex partial seizures who developed infantile spasms, developmental regression, and hypsarrhythmia during the two weeks directly following initiation of oxcarbazepine (14?mg/kg/day). All of these resolved within a few days after discontinuation of this medication. Although we cannot rule out that the above association may have been coincidental, or that the improvement may have been due to concurrent therapy, this case raises the possibility that oxcarbazepine, like carbamazepine, may precipitate infantile spasms and West syndrome.     

Crossed aphasia following cerebral infarction in a right-handed patient with atypical cerebral language dominance

Journal of Neurology - Crossed aphasia (CA), usually referred to as an acquired language disturbance, is caused by a lesion in the cerebral hemisphere ipsilateral to the dominant hand, and the...     

Vigabatrin in complex partial seizures: a long-term study

The efficacy and safety of oral vigabatrin (VGB) as add-on therapy in the long-term treatment of poorly controlled epilepsy were evaluated in 19 patients with complex partial seizures, either with or without secondary generalization. The study was run with a single-blind, placebo-controlled, crossover design, and included 2 months of placebo and 13-15 months of treatment with VGB, at doses ranging from 1 to 4 g/day. Of the 14 patients who completed the trial, 2 were seizure free, in 5 seizure frequency dropped by more than 75% and in another 5 by more than 50% with respect to baseline. The decrease in seizure frequency in the group as a whole was significant at all observation points of the trial. Three patients were not entered into the long-term phase due to lack of improvement (an increase in seizure frequency was observed in one of them), and 2 were excluded later because improvement disappeared leading to unauthorized changes in comedication. Side effects were mild and never caused discontinuation of treatment. In conclusion, VGB showed a remarkable efficacy and safety in the long-term treatment of complex partial seizures.     

After-discharges and seizures during pediatric extra-operative electrical cortical stimulation functional brain mapping: Incidence,thresholds, and determinants

Objective

This study examined the incidence, thresholds, and determinants of electrical cortical stimulation (ECS)-induced after-discharges (ADs) and seizures.

Impairment of executive functions in a patient with a focal lesion in the anterior cingulate cortex. Evidence from neuropsychological assessment

Patients with naturally occurring lesions involving the anterior cingulate cortex are rare and there thus exist very few reports of focal lesions in this area. We report a longitudinal study of a new case of selective anterior cingulate damage due to the presence of an angiocavernoma at the junction of the anterior third with the middle third of the right gyrus cinguli. Before surgery, the results of several, different tests suggested a significant impairment of executive functions, including deficits in planning, monitoring of ongoing behavior, and strategy shifting, as well as an exaggerated susceptibility to retroactive interference. Most of these symptoms disappeared completely or almost completely after the surgical removal of the angiocavernoma, although exaggerated susceptibility to interference was found to persist four months after surgery.     

Lorazepam: a controlled trial in patients with intractable partial complex seizures

Lorazepam was studied in a double-blind, placebo-controlled, crossover trial in eight patients with frequent partial complex seizures refractory to therapy with a combination of standard anticonvulsant drugs. Concomitant antiepileptic drugs were maintained at therapeutic serum levels throughout the study, and concentrations of lorazepam were monitored. Following an 8-week baseline observation, patients were randomly assigned to placebo or lorazepam (1 mg BID). The dose was increased biweekly until seizures stopped or unacceptable side effects occurred. Eight weeks later, patients were crossed over, and the same escalating dose paradigm was followed. When seizure frequency during the last 2 weeks of each treatment was compared, seven of eight patients had fewer seizures on lorazepam, and the eighth had decreased seizure duration (a significant difference: p less than 0.01, two-tailed sign test). Blood level data suggest a narrow therapeutic window, with seizure improvement occurring at concentrations of 20-30 ng/ml and side effects at greater than 33 ng/ml. Lorazepam appears to be a useful adjunct in refractory partial complex seizure therapy. It should not be stopped abruptly, as an increase in seizure frequency may result.     

Cognitive fMRI and neuropsychological assessment in patients with secondarily generalized seizures

OBJECTIVES: Cognitive dysfunction is a frequent comorbid disorder in epilepsy which has been associated with high seizure frequency. We examined the effect of secondarily generalized tonic-clonic seizures (SGTCS) on cognitive dysfunction using neuropsychological assessment and fMRI. PATIENTS AND METHODS: Sixteen patients with localization-related epilepsy of varying etiologies and SGTCS underwent extensive neuropsychological assessment. Functional MRI was performed probing the frontal and temporal lobes with two paradigms aimed at investigating speed of mental processing and working memory. RESULTS: A high number of total lifetime SGTCS was associated with lower intelligence scores. Moreover, a trend towards cognitive decline related to the number of SGTCS was observed. A relatively increased prefrontal activation related to the number of SGTCS was demonstrated, plus a trend towards a decreased activation in the frontotemporal areas. CONCLUSION: High numbers of SGTCS are associated with a drop in intelligence scores and altered prefrontal brain activation. A shift from frontotemporal to prefrontal activation seems to have occurred, suggesting that a functional reorganization of working memory is induced by a high number of SGTCS. It remains uncertain if this reorganization reflects a compensation mechanism, or the underlying pathological processes of cognitive dysfunction.