Temporal relationship between awakening and seizure onset in nocturnal partial seizures

Clinical awakening can be seen just before or after seizure onsets. In this study we determined the time between onset of seizures and awakening in patients with frontal lobe epilepsy (FLE) and temporal lobe epilepsy (TLE). Sixty-eight patients who underwent video-EEG monitoring with simultaneous PSG were retrospectively examined. TLE or FLE patients having seizures during sleep were included. Seizure onset and awakening onset were marked according to clinical and electrophysiological features. The duration between awakening and seizure onset was compared in patients with TLE and FLE. Twenty-five patients who had been diagnosed with TLE (17) or FLE (8) had a total of 75 seizures during sleep. All seizures except one, occurred during NREM sleep in both TLE and FLE patients. The seizure onsets were before awakening in 49 seizures (FLE: 20, TLE: 29) and the awakening preceded the seizure onsets in 12 seizures (FLE: 3, TLE: 9). The duration between seizure onset and the awakening was shorter in FLE, either in seizures with preceding awakening or not (p=0.014, p=0.015). Awakening was mostly seen after onset of seizures rather than before, especially in TLE. But in patients with FLE the duration between seizure onset and awakening was shorter. The localization of epileptic activity may play a role for the timing of awakening mechanisms during nocturnal partial seizures.     

Hyperorality in epileptic seizures: periictal incomplete Klüver-Bucy syndrome

PURPOSE: To analyze systematically hyperorality associated with epileptic seizures and its relation to the localization of epileptic activity. METHODS: To identify patients with periictal hyperorality, we reviewed video-recordings of 269 patients (aged 6-59 years) who had consecutively undergone presurgical evaluations including ictal video-EEG recordings and high-resolution magnetic resonance imaging (MRI) and had had epilepsy surgery because of intractable frontal (FLE) or temporal lobe epilepsy (TLE). Periictal hyperorality was defined if patients put or unambiguously intended to put nonfood items into their mouths during or after at least one of the reviewed seizures. For the further analysis, we included only patients with periictal hyperorality. We reviewed their medical records and reexamined their ictal video-EEG recordings. RESULTS: We identified eight patients (six women) aged 8-59 years who had hyperorality during or after seizures. Seven patients had TLE, and one patient had frontal lobe epilepsy (FLE). Three of these patients underwent right-sided surgery, whereas five patients had surgery on the left. Three patients exhibited ictal and five showed postictal hyperorality. Interictal EEG suggested bilateral interictal epileptiform discharges (IEDs) in three patients; in two other patients, no IEDs were detected. Ictal EEG suggested bilateral involvement in six cases. Patients with unilateral epileptiform activity had left TLE. CONCLUSIONS: Periictal hyperorality is a rare phenomenon occurring in 3% of the investigated epilepsy population. We suggest that periictal hyperorality is an ictal-postictal mental disturbance, an incomplete Klüver-Bucy syndrome. In most patients, bilateral seizure activity plays an important role in the pathomechanism, but it would appear that left-sided epileptic activity without contralateral involvement also can cause periictal hyperorality.     

鉴别额叶癫痫及颞叶癫痫的临床症状学提示

目的:比较额叶癫痫(FLE)及颞叶癫痫(TLE)的临床症状学区别。方法:纳入2005年10月至2007年3月我院癫痫中心门诊临床诊断为额叶癫痫患者190名,颞叶癫痫患者257名。纳入病例满足发作间期脑电图至少一次具有局限于额叶或颞叶的放电或发作期脑电图明确提示额或颞叶起源;排除所有发作间期脑电图正常、存在多灶或定位不清的脑电异常及影像学检查具有额或颞叶以外的局灶损害者。由两位不知道患者脑电图和影像学结果的临床医生单独分析患者发作情况(先兆、复杂部分发作(CPS)、继发全面强直阵挛发作(SGTC))。用χ2检验统计数据。结果:提示颞叶癫痫最有意义的先兆是经验现象和胃气上升感(P<0.01)。情感表现在TLE中更常见(P<0.05)。口咽自动症与手部自动症是颞叶癫痫患者的典型CPS表现(P<0.01)。而躯体自动症,偏转性强直-肢体与头眼及SGTC、姿势性强直,局部阵挛发作,发作时伴随出声、植物神经症状是额叶癫痫患者的典型CPS表现(P<0.01)。发笑、震颤症状在二类中均可出现,以额叶居多(P<0.05)。言语终止,自言自语,单纯凝视发作对于二者的鉴别意义不大。额叶癫痫组具有两种以上CPS发作的病例更多(P<0.01)。结论:额叶癫痫与颞叶癫痫的症状学特征是不同的,对于临床诊断有重要价值。     

Nichtinvasives Video-EEG-Monitoring in der Diagnostik fokaler Epilepsien und als Prädiktor für das postoperative Ergebnis

Video-documented seizure semiology and non-invasive EEG are mandatory elements of presurgical epilepsy diagnosis. Non-invasive interictal and ictal EEG invaluably contribute to the diagnosis and prognosis of non-tumoral mesial temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). The semiology of auras and seizures help to lateralize FLE and TLE, and add to the consistency of various methods. In posterior epilepsy, the semiology of auras and seizures provides important information on localization and prognosis as opposed to non-invasive EEG.¶???During the first two years after surgery, routine EEG helps to predict the long-term seizure outcome. Further studies about long-term seizure outcome over more than five years are necessary.¶ ???Beyond the scope of this review about non-invasive video/ EEG monitoring, a multitude of other non-invasive methods are used which would deserve seperate consideration.     

Cardiac asystole in epilepsy: clinical and neurophysiologic features

PURPOSE: Cardiac asystole provoked by epileptic seizures is a rare but important complication in epilepsy and is supposed to be relevant to the pathogenesis of sudden unexplained death in epilepsy (SUDEP). We sought to determine the frequency of this complication in a population of patients with medically intractable epilepsy and to analyze the correlation between EEG, electrocardiogram (ECG), and clinical features obtained from long-term video-EEG monitoring. METHODS: Retrospective analysis of the clinical records of hospitalized patients from May 1992 to June 2001 who underwent long-term video-/EEG monitoring. RESULTS: Of a total of 1,244 patients, five patients had cardiac asystole in the course of ictal events. In these patients, 11 asystolic events, between 4 and 60 s long in a total of 19 seizures, were registered. All seizures had a focal origin with simple partial seizures (n = 13), complex partial seizures (n = 4), and secondarily generalized seizures (n = 2). One patient showed the longest asystole ever reported (60 s) because of a seizure. Cardiac asystole occurred in two patients with left-sided temporal lobe epilepsy (TLE) and in three patients with frontal lobe epilepsy (FLE; two left-sided, one bifrontal). Two patients reported previous cardiac disease, but only one had a pathologic ECG by the time of admission. Two patients had a simultaneous central ictal apnea during the asystole. None of the patients had ongoing deficits due to the asystole. CONCLUSIONS: These findings confirm that seizure-induced asystole is a rare complication. The event appeared only in focal epilepsies (frontal and temporal) with a lateralization to the left side. A newly diagnosed or known cardiac disorder could be a risk factor for ictal asystole. Abnormally long postictal periods with altered consciousness might point to reduced cerebral perfusion during the event because of ictal asystole. Central ictal apnea could be a frequent associated phenomenon.     

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.     

Ictal head turning in frontal and temporal lobe epilepsy

Purpose: To quantitatively evaluate the difference of ictal head turning movements between patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). Methods: We investigated 38 seizures of 31 patients with unilateral TLE and 22 seizures of 14 patients with unilateral FLE where head turning occurred in the seizure evolution. The head movements were defined as ipsilateral or contralateral in reference to the lateralization of the patient’s focal epilepsy syndrome. Head movements were quantified by either referencing the head position with manually placed markers or by automatic detection of infrared marked reference points. The time of onset, duration, and angular speed of the head movements were computed, and interindividual and intraindividual analyses were performed. Key Findings: All of the TLE seizures had both contralateral and ipsilateral head turning, whereas all FLE had contralateral head turning; only 6 of 22 seizures were associated with ipsilateral head turning. Ipsilateral head turning always preceded contralateral head turning in both TLE and FLE. The head turning occurred significantly sooner after clinical seizure onset in FLE than in TLE patients (ipsilateral 0.5 vs. 16.0 s, contralateral: 4.5 vs. 21.3 s; p < 0.001). Furthermore, the duration of head turning was shorter in FLE for contralateral head turning (4.1 s) than in TLE (contralateral 6.0 s, p < 0.01); the ipsilateral head turning in the two groups did not differ (3.0 vs. 2.9 s) in duration. The angular speed of head turning did not differ for ipsilateral and for contralateral head turning in FLE and TLE. Significance: Quantitative analysis of head turning demonstrates significant differences between patients with FLE and TLE. These differences likely represent differences in spread of epileptic activity. This information may be useful in the seizure evaluation of patients considered for resective epilepsy surgery.     

Ictal spitting in left temporal lobe epilepsy: report of three cases.

PURPOSE: Ictal spitting is rarely reported in patients with epilepsy. More often it is observed in patients with temporal lobe epilepsy (TLE) and is presumed to be a lateralizing sign to language nondominant hemisphere. We report three patients with left TLE who had ictal spitting registered during prolonged video-EEG monitoring. METHODS: Medical charts of all patients with medically refractory partial epilepsy submitted to prolonged video-EEG monitoring in the Epilepsy Unit at UNIFESP during a 3-year period were reviewed, in search of reports of ictal spitting. The clinical, neurophysiological and neuroimaging data of the identified patients were reviewed. RESULTS: Among 136 patients evaluated with prolonged video-EEG monitoring, three (2.2%) presented spitting automatisms during complex partial seizures. All of them were right-handed, and had clear signs of left hippocampal sclerosis on MRI. In two patients, in all seizures in which ictal spitting was observed, EEG seizure onset was seen in the left temporal lobe. In the third patient, ictal onset with scalp electrodes was observed in the right temporal lobe, but semi-invasive monitoring with foramen ovale electrodes revealed ictal onset in the left temporal lobe, confirming false lateralization in surface records. The three patients became seizure-free following left anterior temporal lobectomy. CONCLUSIONS: Ictal spitting is a rare finding in patients with epilepsy, and may be considered a localizing sign of seizure onset in the temporal lobe. It may be observed in seizures originating from the left temporal lobe, and thus should not be considered a lateralizing sign of nondominant TLE.     

Frontal lobe epilepsy

About one-quarter of patients with refractory focal epilepsies have frontal lobe epilepsy (FLE). The typical seizure semiology for FLE includes unilateral clonic, tonic asymmetric or hypermotor seizures. Interictal electroencephalograms (EEG) usually reveal interictal epileptiform discharges and rhythmical midline theta, which has localizing value. The usefulness of ictal EEG recordings is limited by frequent muscle artifacts in motor seizures and because a large portion of the frontal lobe cortex is “hidden” to scalp electrodes. Ictal single photon emission CT and positron emission tomography are able to localize FLE in about one-third of patients only. A pre-surgical evaluation should include, whenever possible, a subclassification of FLE as dorsolateral frontal, mesial frontal or basal frontal lobe epilepsy to allow a minimal cortical resection. A review of the typical findings of seizure semiology, interictal and ictal EEG regarding the different FLE subtypes is given. Etiology, medical treatment and surgery are also discussed.     

Localization of epileptogenic zone in temporal lobe epilepsy by ictal scalp EEG.

Our aim was to evaluate the ability to localize the epileptogenic zone in temporal lobe epilepsy (TLE) by ictal scalp electroencephalogram (EEG). Using simultaneous video recording, we analysed scalp EEG activity during ictal periods in 38 patients (30 patients with medial TLE (MTLE) and eight with lateral TLE (LTLE)). In 14 patients, intracranial ictal EEGs were recorded with depth electrodes, and simultaneous recordings of scalp and intracranial EEG were performed in 11 patients. Scalp EEG showed that, in all 30 patients with MTLE (71 of 72 seizures), an attenuation of background activity was observed before the appearance of ictal activity. Ictal discharges first appeared in the scalp EEG when the ictal discharges reached the lateral part of the temporal lobe on the intracranial EEG. While, in all eight patients with LTLE (25 of 25 seizures), the attenuation of background activity did not occur before the appearance of ictal activity. When the ictal discharges started in the lateral temporal lobe on intracranial EEG, ictal discharges appeared on the scalp. MTLE and LTLE could be diagnosed by the presence or absence of attenuation of background activity with clinical ictal signs before the appearance of ictal discharges.     

Electrophysiology of Bimanual-Bipedal Automatisms

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

Continuous Source Imaging of Scalp Ictal Rhythms in Temporal Lobe Epilepsy

Summary: Purpose: We wished to determine whether continuous EEG source imaging can predict the location of seizure onset with sublobar accuracy in temporal lobe epilepsy (TLE).
Methods : We retrospectively analyzed the earliest scalp ictal rhythms, recorded with 23- to 27-channel EEG, in 40 patients with intractable TLE. A continuous source analysis technique with multiple fixed dipoles (Focus 1.1) decomposed the EEG into source components representing the activity of major cortical sublobar surfaces. For the temporal lobe, these were basal, anterior tip, anterolateral, and posterolateral cortex. Ictal EEG onset was categorized according to its most prominent and leading source component. All patients underwent intracranial EEG studies before epilepsy surgery, and all had a successful surgical outcome (follow-up >1 year).
Results : Most patients with ictal rhythms having a predominant basal source component had hippocampal-onset seizures, whereas those with seizures with prominent lateral source activity had predominantly temporal neocortical seizure origins. Seizures with a prominent anterior temporal tip source component mostly had onset in entorhinal cortex. Seizures in some patients had several equally large and nearly synchronous source components. These seizures, which could be modeled equally well by a single oblique dipole, had onset predominantly in either entorhinal or lateral temporal cortex.
Conclusions : Multiple fixed dipole analysis of scalp EEG can provide information about the origin of temporal lobe seizures that is useful in presurgical planning. In particular, it can reliably distinguish seizures of mesial temporal origin from those of lateral temporal origin.     

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.     

Clinical implications of scalp ictal EEG pattern in patients with temporal lobe epilepsy

ObjectiveTo determine the clinical implications of scalp ictal EEG pattern in patients with temporal lobe epilepsy (TLE).MethodsScalp EEG ictal patterns were retrospectively determined in 27 consecutive patients with medically refractory temporal lobe epilepsy who underwent phase-1 scalp video-EEG and phase-2 simultaneous scalp and intracranial video-EEG recordings for pre-surgical evaluation.ResultsOf the 192 temporal lobe seizures recorded during phase-1 and phase-2 scalp video-EEG studies, 124 (65%) seizures were associated with theta/alpha (5–9 Hz) ictal onset pattern, and 68 (35%) seizures were associated with delta (2–5 Hz) ictal onset pattern. Fourteen (52%) patients had exclusively theta/alpha ictal onset, 3 (11%) patients had exclusively delta ictal onset, and 10 (37%) patients had mixed theta/alpha and delta ictal onsets. MTLE was observed in 26 patients who had 124 seizures with theta/alpha ictal onset and 59 seizures with delta ictal onset. LTLE was observed in one patient who had 9 seizures with delta ictal onset. Scalp ictal EEG pattern was not significantly correlated with postsurgical seizure outcomes.ConclusionsBoth scalp delta and theta/alpha ictal onset patterns can be commonly found in patients with MTLE.SignificanceScalp delta ictal onset is not a unique EEG pattern for LTLE as commonly believed.     

Intracranial EEG in predicting surgical outcome in frontal lobe epilepsy

Purpose: Surgery in frontal lobe epilepsy (FLE) has a worse prognosis regarding seizure freedom than anterior lobectomy in temporal lobe epilepsy. The current study aimed to assess whether intracranial interictal and ictal EEG findings in addition to clinical and scalp EEG data help to predict outcome in a series of patients who needed invasive recording for FLE surgery. Methods: Patients with FLE who had resective surgery after chronic intracranial EEG recording were included. Outcome predictors were compared in patients with seizure freedom (group 1) and those with recurrent seizures (group 2) at 19–24 months after surgery. Key Findings: Twenty‐five patients (16 female) were included in this study. Mean age of patients at epilepsy surgery was 32.3 ± 15.6 years (range 12–70); mean duration of epilepsy was 16.9 ± 13.4 years (range 1–48). In each outcome group, magnetic resonance imaging revealed frontal lobe lesions in three patients. Fifteen patients (60%) were seizure‐free (Engel class 1), 10 patients (40%) continued to have seizures (two were class II, three were class III, and five were class IV). Lack of seizure freedom was seen more often in patients with epilepsy surgery on the left frontal lobe (group 1, 13%; group 2, 70%; p = 0.009) and on the dominant (27%; 70%; p = 0.049) hemisphere as well as in patients without aura (29%; 80%; p = 0.036), whereas sex, age at surgery, duration of epilepsy, and presence of an MRI lesion in the frontal lobe or extrafrontal structures were not different between groups. Electroencephalographic characteristics associated with lack of seizure freedom included presence of interictal epileptiform discharges in scalp recordings (31%; 90%; p = 0.01). Detailed analysis of intracranial EEG revealed widespread (>2 cm) (13%; 70%; p = 0.01) in contrast to focal seizure onset as well as shorter latency to onset of seizure spread (5.8 ± 6.1 s; 1.5 ± 2.3 s; p = 0.016) and to ictal involvement of brain structures beyond the frontal lobe (23.5 ± 22.4 s; 5.8 ± 5.4 s; p = 0.025) in patients without seizure freedom. The distribution of ictal onset patterns was similar in both groups, and fast rhythmic activity in the beta to gamma range was found in 57% of seizure‐free patients compared to 70% of patients with recurrent seizures. Analysis of the temporal relation between first clinical alterations and EEG seizure onset did not reveal significant differences between both groups of patients. In multivariate analysis, resection in the left hemisphere (odds ratio [OR] 12.197 95% confidence interval [95% CI] 1.33–111.832; p = 0.027) and onset of seizure spread (odds ratio [OR] 0.733, 95% CI 0.549–0.978, p = 0.035) were independent predictors of ongoing seizures. Significance: Widespread epileptogenicity as indicated by rapid onset of spread of ictal activity likely explains lack of seizure freedom following frontal resective surgery. The negative prognostic effect of surgery on the left hemisphere is less clear. Future study is needed to determine if neuronal network properties in this hemisphere point to intrinsic interhemispheric differences or if neurosurgeons are restrained by proximity to eloquent cortex.     

Frontal lobe epilepsy: Clinical characteristics, surgical outcomes and diagnostic modalities.

OBJECTIVE: To identify surgical prognostic factors and to characterize clinical features according to the location of the intracranial ictal onset zone of frontal lobe epilepsy (FLE) in order to assess the role of various diagnostic modalities, including concordances with presurgical evaluations. METHODS: We studied 71 FLE patients who underwent epilepsy surgery and whose outcomes were followed for more than 2 years. Diagnoses were established by standard presurgical evaluation. RESULTS: Clinical manifestations could be categorized into six types: initial focal motor (9 patients), initial versive seizure (15), frontal lobe complex partial seizure (14), complex partial seizure mimicking temporal lobe epilepsy (18), initial tonic elevation of arms (11), and sudden secondary generalized tonic-clonic seizure (4). Thirty-seven patients became seizure-free after surgery. Five patients were deleted in the analysis because of incomplete resection of ictal onset zones. The positive predictive value of interictal EEG, ictal EEG, MRI, PET, and ictal SPECT, respectively were 62.5%, 56.4%, 73.9%, 63.2%, and 63.6%, and the negative predictive value were 46.0%, 44.4%, 53.5%, 44.7%, and 51.7%. No significant relationship was found between the diagnostic accuracy of these modalities and surgical outcome, with the exception of MRI (p=0.029). Significant concordance of two or more modalities was observed in patients who became seizure-free (p=0.011). We could not find any clinical characteristic related to surgical outcome besides seizure frequency. No definite relationship was found between the location of intracranial ictal onset zone and clinical semiology. CONCLUSION: Although various diagnostic methods can be useful in the diagnosis of FLE, only MRI can predict surgical outcome. Concordance between presurgical evaluations indicates a better surgical outcome.     

Frontal lobe epileptic seizures are accompanied by elevated pitch during verbal communication

The objective of our study was to assess alterations in speech as a possible localizing sign in frontal lobe epilepsy. Ictal speech was analyzed in 18 patients with frontal lobe epilepsy (FLE) during seizures and in the interictal period. Matched identical words were analyzed regarding alterations in fundamental frequency (?o) as an approximation of pitch. In patients with FLE, ?o of ictal utterances was significantly higher than ?o in interictal recordings (p = 0.016). Ictal ?o increases occurred in both FLE of right and left seizure origin. In contrast, a matched temporal lobe epilepsy (TLE) group showed less pronounced increases in ?o, and only in patients with right‐sided seizure foci. This study for the first time shows significant voice alterations in ictal speech in a cohort of patients with FLE. This may contribute to the localization of the epileptic focus. Increases in ?o were interestingly found in frontal lobe seizures with origin in either hemisphere, suggesting a bilateral involvement to the planning of speech production, in contrast to a more right‐sided lateralization of pitch perception in prosodic processing.     

Hyperreligiosity in temporal lobe epilepsy: redefining the relationship

Seventy-six subjects with the primary diagnosis of complex partial seizures with a unilateral temporal lobe focus were examined for the presence of hyperreligiosity. Fifty-one subjects had a left temporal lobe seizure focus and 25 had a right temporal lobe seizure focus. In addition to the temporal lobe epilepsy (TLE) groups, two reference groups were also examined. The first consisted of 31 subjects with primary generalized seizures. The second control group consisted of 27 subjects with documented pseudoseizures and no objective evidence of recurrent epileptic seizures. In all cases, the documentation of seizures or pseudoseizures as well as the localization of the seizure focus was accomplished through simultaneous videotaped recording of the 16-channel scalp EEG tracing and the concurrent overt behavior during the ictal phase. The results of this study fail to support the hypothesis that individuals with TLE are characteristically hyperreligious during the interictal state. There were no significant group differences between the left vs. the right TLE groups, nor were there any significant group differences between the two TLE groups vs. the two comparison groups.     

Speech preservation during language-dominant, left temporal lobe seizures: report of a rare, potentially misleading finding

PURPOSE: To evaluate the prevalence and mechanism of ictal speech in patients with language-dominant, left temporal lobe seizures. METHODS: We retrospectively reviewed the video-EEG telemetry records for the presence of ictal speech in 96 patients with surgically proven left temporal lobe epilepsy and studied the seizure-propagation patterns in three patients who required intracranial EEG recordings for seizure localization. RESULTS: Ictal speech preservation was observed in five patients. One patient's seizures demonstrated rapid propagation of the ictal discharges to the contralateral temporal area where the seizure evolved, resembling a nondominant temporal lobe seizure. The other two patients had ictal discharges that remained confined to the inferomesial temporal areas, sparing language cortex. CONCLUSIONS: Preservation of speech in complex partial seizures of language-dominant, left temporal lobe origin is rare. Based on intracranial EEG recordings, the likely mechanism underlying this potentially misleading clinical finding is the preservation of language areas due to limited seizure-propagation patterns.     

Hypersalivation in temporal lobe epilepsy

PURPOSE: We sought to determine whether hypersalivation helps lateralize seizure onset during complex partial seizures of temporal lobe origin. Several clinical signs, which help lateralize seizure onset, have been reported in temporal lobe epilepsy (TLE). Increased salivation only occasionally has been reported as a manifestation of partial epilepsy. METHODS: Of 590 consecutive patients admitted for video-EEG monitoring, either as a part of a presurgical evaluation of medically intractable epilepsy or for diagnosis and clarification of their paroxysmal symptoms, we identified 10 patients with ictal hypersalivation as a prominent manifestation of complex partial seizures. We reviewed the clinical features, scalp-sphenoidal video-EEG monitoring, intracarotid amytal (Wada) testing, hippocampal volumetric magnetic resonance imaging (MRI), and fluorodeoxyglucose-positron emission tomography (FDG-PET) scans of these patients. RESULTS: Of the 10 patients with ictal hypersalivation, seven patients had nondominant/right TLE, and three patients had dominant/left TLE. All patients had hippocampal atrophy on volumetric MRI. Eight of the 10 patients underwent standard temporal lobectomy with amygdalohippocampectomy (six right, two left). All of the operated-on patients had a seizure-free (Engel class I) outcome, and their increased salivation resolved. Two patients, who did not undergo surgical treatment, continue to have complex partial seizures with increased salivation. CONCLUSIONS: We conclude that increased salivation as a prominent ictal finding in complex partial seizures of temporal lobe origin is more likely to be of nondominant temporal lobe origin. Further studies with larger numbers of patients are needed to replicate this finding.