Record-linkage studies of the coexistence of epilepsy and bipolar disorder

Purpose

Interest is growing in a possible link between epilepsy and bipolar disorder (BPD). We used two large datasets of hospital admission data to determine whether epilepsy and BPD occur together in the same individuals more commonly than expected.

Methods

We undertook retrospective cohort studies using the Oxford Record Linkage Study (ORLS) and English national linked Hospital Episode Statistics. We constructed a cohort of people in each dataset admitted with epilepsy (without prior admission for BPD), and a control cohort (without prior admission for BPD), and compared their subsequent admission rates for BPD. Conversely, we constructed a cohort of people in each dataset admitted with BPD and a control cohort (both without prior admission for epilepsy), and compared their subsequent admission rates for epilepsy.

Results

In the epilepsy cohort, compared with the control cohort, the rate ratio (RR) for BPD was significantly high at 3.0 (95 % confidence interval 1.7–5.1) in the ORLS and 3.6 (3.3–3.9) in the all-England dataset. In the BPD cohort, the RR for epilepsy was 2.2 (1.2–3.7) in the ORLS and 4.2 (4.0–4.4) in the all-England cohort. We found no significant differences between RRs for males and females.

Conclusions

Epilepsy and BPD occur together in individuals more frequently than expected by chance.     

Comparative role of neuropsychological testing in the presurgical evaluation of children with medically intractable epilepsies

Purpose

In the present study, we evaluated the preoperative demographic, clinical, and neuropsychological variables that could predict postoperative seizure outcome in a group of pediatric epileptic patients.

Materials and methods

We studied 40 consecutive pediatric patients, ages ranging from 6 to 16 years, that underwent resective surgery for the treatment of medically intractable epilepsy at the Clinical Hospital of Ribeirão Preto School of Medicine. We performed ictal electroencephalography (EEG), interictal EEG, magnetic resonance imaging (MRI), and a preoperative neuropsychological assessment in the presurgical workup.

Results

The following factors were correlated with seizure outcome: (1) duration of epilepsy, (2) surgery localization, (3) localized Neuropsychological (NPS) Evaluation, (4) ictal EEG, (5) interictal EEG, and (6) MRI. Mental retardation, NPS tests, and the other demographic variables failed to correlate with seizure reduction.

Conclusions

The identification of predictor variables of epilepsy surgery outcome could improve the epileptic prognosis and guarantee the children's full potential development.

     

Palliative epilepsy surgery in Aicardi syndrome: a case series and review of literature

Purpose

Aicardi syndrome (AS) is a severe neurodevelopmental disorder characterized by the triad of seizures, agenesis of corpus callosum, and chorioretinal lacunae. Seizures in AS are typically frequent, of various types, and refractory to medical therapy. Optimal treatment of seizures in AS remains undetermined.

Methods

We report a series of four patients with Aicardi syndrome who underwent surgical management of their epilepsy including two with corpus callosotomy (CC) of a partial corpus callosum and three with vagus nerve stimulator implantation.

Results

Seizure outcome was variable and ranged from near complete resolution of seizures to worsening of seizure profile. The most favorable seizure outcome was seen in a patient with partial agenesis of the corpus callosum treated with CC.

Conclusions

Seizure outcome following CC or vagus nerve stimulation in patients with Aicardi syndrome is variable. Although palliative epilepsy surgery may result in improvement in the seizure profile in some patients, studies on larger patient cohorts are needed to identify the precise role that surgery may play in the multidisciplinary approach to controlling seizures in Aicardi syndrome.     

Applying a pelvic corrective force induces forced use of the paretic leg and improves paretic leg EMG activities of individuals post-stroke during treadmill walking

Objective

To determine whether applying a mediolateral corrective force to the pelvis during treadmill walking would enhance muscle activity of the paretic leg and improve gait symmetry in individuals with post-stroke hemiparesis.

Behavioral and neurophysiological mechanisms underlying motor skill learning in patients with post-stroke hemiparesis

Objective

Given the presence of execution deficits after stroke, it is difficult to determine if patients with stroke have deficits in motor skill learning with the paretic arm. Here, we controlled for execution deficits while testing practice effects of the paretic arm on motor skill learning, long-term retention, and corticospinal excitability.

The surgical management of pediatric brain tumors causing epilepsy: consideration of the epileptogenic zone

Objective

Children suffering from epilepsy with suspected low-grade tumors may benefit from a surgical approach that considers the epileptogenic zone, which can be more extensive than the tumor region. This study aimed to determine the prevalence of epilepsy in children undergoing supratentorial tumor resection and the factors predictive of postoperative seizure freedom in children with low-grade tumors.

Methods

Subjects 3 months to 21 years undergoing supratentorial brain tumor resection between 2007 and 2011 were included in this retrospective study. Children with supratentorial, cortically based tumors and a preoperative diagnosis of epilepsy were considered epilepsy surgery candidates. Pre- and postoperative MRI were reviewed and scored for extent of resection, adjacent dysplasia, and remaining abnormal cortex postoperatively.

Results

The prevalence of seizures in all cases of supratentorial tumors was 46/87 (53 %). Eighteen were epilepsy surgery candidates. Eight of 18 (44 %) were seizure-free postoperatively with a mean follow-up of 39 months. Children who were seizure free postoperatively had tried fewer anticonvulsants than those with continued seizures (1.7 v. 2.9, p?=?0.01). Presurgical evaluation was nonstandardized, and a more extensive workup and resection were performed in children who continued to have seizures postoperatively.

Conclusions

All epilepsy surgery candidates had low-grade tumors on histological evaluation, indicating that a surgical approach that takes into consideration the epileptogenic zone is reasonable in this population. Gross total resection should be the goal, with additional attention to resection of the epileptogenic zone when located in the noneloquent cortex.     

Acute Resective Surgery for the Treatment of Refractory Status Epilepticus

Background

To identify the role of acute surgical intervention in the treatment of refractory status epilepticus (RSE).

Methods

Retrospective review of consecutive patients who underwent epilepsy surgery from 2006 to 2015 was done to identify cases where acute surgical intervention was employed for the treatment of RSE. In addition, the adult and pediatric RSE literature was reviewed for reports of surgical treatment of RSE.

Results

Nine patients, aged 20–68 years, with various etiologies were identified to have undergone acute surgical resection for the treatment of RSE, aided by electrocorticography. Patients required aggressive medical therapy with antiepileptic drugs and intravenous anesthetic drugs for 10–54 days and underwent extensive neurodiagnostic testing prior to resective surgery. Eight out of nine patients survived and five patients were seizure-free at the last follow-up. The literature revealed 13 adult and 48 pediatric cases where adequate historical detail was available for review and comparison.

Conclusions

We present the largest cohort of consecutive adult patients who underwent resective surgery in the setting of RSE. We also reveal that surgery can be efficacious in aborting status and in some can lead to long-term seizure freedom. Acute surgical intervention is a viable option in prolonged RSE and proper evaluation for such intervention should be conducted, although the timing and type of surgical intervention remain poorly defined.

     

Transkutane Vagusnervstimulation

Background

Approximately 20-40?% of epilepsy patients show drug resistance and a large number of patients under antiepileptic therapy suffer from side effects including cognitive disorders and depression. Transcutaneous vagus nerve stimulation (t-VNS) can be used for these patients as a supplementary treatment to resection epilepsy surgery.

Aim

The main aims of this investigation were to test the safety, tolerability and practicality of t-VNS in epilepsy patients.

Material and methods

For the proof of concept trial ten patients with pharmacoresistant epilepsy (eight with focal and two with generalized epilepsy) were recruited. For admission to the study a minimum frequency of four seizures per month was necessary. The medication dosage was kept constant in the baseline and in the total treatment phase. The auricular branch of the vagus nerve (ABVN) of the left ear was stimulated. The stimulation pulses were biphasic with a frequency of 10/s and a pulse width of 300 µs. After an initial training period the stimulation was carried out in the morning, midday and evening for 1 h each over a period of 9 months. The subjectively experienced frequency of seizures, continuous video EEG (electroencephalogram) long-term conduction carried out 4 times for 1 week each and cognitive and functional alterations were considered to be end point parameters.

Results

The total treatment period of 9 months was completed by seven patients. Of these seven patients five showed a reduction in the frequency of seizures during the 9-month treatment period and two reported an increase in seizures. In two patients the seizure frequency was reduced by 45 % and 48 % in a comparison between baseline and end of treatment. In two further patients contradictions arose between the subjective report on seizure frequency and the objectively quantified frequency in the video EEG. For one patient the interictal epileptic EEG activity was continually reduced during the course of the 9-month period.

Conclusion

The t-VNS procedure represents a procedure which is well tolerated and practical for long-term treatment.     

Ipsilateral corticospinal pathways in congenital hemiparesis on routine magnetic resonance imaging

Several transcranial magnetic stimulation studies have demonstrated that patients with congenital hemiparesis can possess ipsilateral corticospinal pathways projecting from the contralesional hemisphere to the paretic hand. This study reports on signal abnormalities in the pons (focal areas of hyperintensity on T(2)-weighted magnetic resonance imaging), which were observed in the course of the corticospinal tract of the contralesional hemisphere in 6 of 10 patients with evidence for ipsilateral corticospinal projections on transcranial magnetic stimulation, but in none of 13 patients without such projections. Thus this magnetic resonance imaging abnormality seems to be related to the presence of ipsilateral corticospinal projections from the contralesional hemisphere in congenital hemiparesis.     

Visual cognitive function in infants with intractable epilepsy before and after surgery

Purpose

One purpose of pediatric epilepsy surgery is to improve psychomotor development. However, few methods are available for evaluating cognitive function in infants with severe developmental delays. We used the following battery of tests to evaluate visual cognitive function of infants following surgery for intractable epilepsy.

Methods

The following battery of tests were used to evaluate eight patients before and 1 month after surgery: (1) Erhardt Developmental Vision Assessment (EDVA); (2) evaluation of ocular pursuit for a flashing LED toy; (3) three visual acuity tests preferential looking procedure, optokinetic nystagmus, and Sheridan’s Test for Young Children and Retarded balls vision test; and (4) existing developmental test.

Results

EDVA scores and ocular pursuit score with a flashing LED toy showed the same trends with developmental age as the existing developmental tests. However, in some patients, the EDVA score and ocular pursuit score improved greatly, whereas the developmental age changed very little.

Conclusions

These tests are suitable for patients with intractable epilepsy and severe developmental delay. By performing these tests before and after surgery, small cognitive changes occurring soon after the surgery may be detected.     

Endoscopic treatment of convexity arachnoid cysts

Objective

The aim of this study was to investigate the endoscopic treatment of cerebral hemisphere convexity arachnoid cyst.

Methods

Eight cases of hemisphere convexity arachnoid cyst treated with cyst–ventricular or cisternal endoscopic approach in September 2007 to March 2011 were retrospectively recruited. The clinical symptoms, radiological findings, surgical indications, surgical approach, complications, and follow-up studies were analyzed.

Results

All patients showed convexity arachnoid cysts adjacent to the ventricles or cisternal. After treatment, all patients showed decrease in size of the cysts (100 %), with preoperative symptoms disappeared in six patients and improved in two cases. In one case, postoperative subdural effusion was found without symptoms reported.

Conclusion

Endoscopic surgery is ideal for treatment of arachnoid cysts adjacent to the ventricles or cisternal.     

Predicting hand function after hemispherotomy: TMS versus fMRI in hemispheric polymicrogyria

Patients with hemispheric malformations of cortical development (such as polymicrogyria) often develop medically intractable epilepsies for which hemispherotomy can be an excellent treatment option. Transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) are noninvasive methods used to evaluate the sensorimotor system in adults and children before surgery. Preoperative results of both methods and their predictive values regarding hand function after hemispherotomy are described in four boys with hemispheric polymicrogyria, pharmacoresistent epilepsy, and hemiparesis with preserved grasp function of the paretic hand. TMS showing ipsilateral projections from the contralesional hemisphere but no evidence of crossed corticospinal projections from the lesioned hemisphere correctly predicted preserved postoperative grasp function in all four patients. In contrast, the interpretation of sensorimotor fMRI in patients with congenital hemiparesis is more difficult, as ipsilesional activation can occur as it was the case in three of four patients in the current study. This activation might represent contralaterally preserved primary somatosensory (S1) and not primary motor (M1) representation and is apparently not necessary for the paretic hand to still perform grasp movements.     

Surgery for extratemporal nonlesional epilepsy in children: a meta-analysis

Purpose

Previous small studies have demonstrated that seizure outcomes following surgery for extratemporal lobe epilepsy (ETLE) in children are worse than those for temporal lobe epilepsy. We have conducted a meta-analysis of the available literature to better understand ETLE surgical outcomes in children.

Methods

We searched PubMed (1990–2009) for appropriate studies using the following terms: ETLE, ETLE surgery, ETLE surgery outcome, frontal lobe epilepsy, occipital lobe epilepsy, and parietal lobe epilepsy. Our collected data included patient age at seizure onset and surgery, the cerebral lobe involved with epileptogenesis, MRI findings, predominant seizure semiology, intracranial monitoring use (electrode implantation), epileptic region histopathology, and postoperative seizure outcome. Statistical analysis was performed to determine associations among these variables and postoperative outcome.

Results

Ninety-five patients from 17 studies satisfied the inclusion criteria. Pathological findings (p?=?0.039) and seizure type (p?=?0.025) were significantly associated with outcome: A larger proportion of patients with cortical dysplasia and complex partial seizures experienced better outcomes. Age at surgery (p?=?0.073) and the cerebral resection site (p?=?0.059) were marginally associated with seizure outcome.

Conclusions

This study confirms previous reports: Surgical outcomes for ETLE epilepsy are significantly worse than those for temporal lobe epilepsy. The reasons for this difference may include the diffuse nature of the pathology involved in ETLE, difficulty in localizing the seizure focus in young children, and involvement of “eloquent” nonresectable cortex in epileptogenesis. Because of the reporting variability among different epilepsy centers, more uniform protocols are necessary for fair evaluation and comparison of outcomes among the different centers.     

Do patients with congenital hemiparesis and ipsilateral corticospinal projections respond differently to constraint‐induced movement therapy?

This study investigates whether the type of corticospinal reorganization (identified by transcranial magnetic stimulation) influences the efficacy of constraint-induced movement therapy (CIMT). Nine patients (five males, four females; mean age 16y [SD 6y 5mo], range 11-30y) controlling their paretic hand via ipsilateral corticospinal projections from the contralesional hemisphere and seven patients (three males, four females; mean age 17y [SD 7y], range 10-30y) with preserved crossed corticospinal projections from the affected hemisphere to the paretic hand underwent 12 consecutive days of CIMT. A Wolf motor function test applied before and after CIMT revealed a significant improvement in the quality of upper extremity movements in both groups. Only in patients with preserved crossed projections, however, was this amelioration accompanied by a significant gain in speed, whereas patients with ipsilateral projections tended to show speed reduction. These data, although preliminary, suggest that patients with congenital hemiparesis and ipsilateral corticospinal projections respond differently to CIMT.     

Urodynamic outcomes of detethering in children: experience with 46 pediatric patients

Aim

Tethered cord syndrome (TCS) manifests with neurological and urological complaints. Surgical detethering is the main treatment for TCS. Children with urological symptoms are required objective pre- and postoperative evaluations in order to predict urological outcome. The aims of this study are to investigate the effects of detethering procedure on the urodynamic tests and to determine the relationship between the changes of urodynamic tests and the patients’ age and gender.

Material and methods

The data of urodynamic tests in 46 pediatric patients, who underwent surgery for TCS, were retrospectively evaluated. Bladder capacity, post-voiding residual urine volume, maximum intravesical pressure, and bladder compliance of each patient were measured in preoperative period and at the third month after surgery. These parameters were statistically compared, and the correlations of these parameters with age, gender, and etiology of the TCS were also investigated.

Results

Bladder capacity and post-voiding residual urine volume were decreased and maximum intravesical pressure and bladder compliance were increased after surgery for TCS. The decrease in bladder capacity was significant in patients older than 10 years (p < 0.05). The increase in maximum intravesical pressure was also positively correlated with age (p < 0.05). But the increase in bladder compliance was negatively correlated with age (p < 0.05).

Conclusion

Bladder capacity, post-voiding residual urine volume, and bladder compliance are mainly affected by surgery in patients with TCS. From the urological viewpoint, children older than 10 years are most likely to benefit from surgery for TCS.

     

Effectiveness of total corpus callosotomy for diffuse bilateral polymicrogyria: Report of three pediatric cases

Purpose

Polymicrogyria, a malformation of the cerebral cortex, frequently causes epilepsy. Diffuse bilateral polymicrogyria (DBP) is related to poor epilepsy prognosis, but most patients with DBP are not good candidates for resective epilepsy surgery and effectiveness of corpus callosotomy (CC), a palliative surgery, for patients without resective epileptogenic cortices, has not been established in DBP. Because CC might be effective against DBP-related epilepsy, we conducted total CC in three pediatric DBP cases.

Surgery for perirolandic epilepsy: Epileptogenic cortex resection guided by chronic intracranial electroencephalography and electric cortical stimulation mapping

Subject

The objective of this study was to assess outcome with regard to seizure status and neurological function in patients undergoing resective surgery involving the perirolandic area.

Method

All 15 patients who underwent perirolandic cortical resection between October 2006 and September 2007 at the Comprehensive Epilepsy Centre of Beijing Xuanwu Hospital were included in the study. The locations of functional cortical areas, ictal onset zones and epileptogenic lesions were mapped by chronic intracranial EEG recordings and electric cortical stimulation. Seizure outcome was determined using the modified classification of Engel and colleagues. Motor and sensory deficits were monitored.

Results

At last follow-up 5 patients (33%) were in Engel class I, 4 (27%) were in class II, 3 (20%) were in class III, and 3 (20%) were in class IV. Nine patients suffered immediate functional deficits; 8 of these recovered completely within 2 weeks to 3 months of surgery. One had mild persistent loss of finger motor control.

Conclusion

After accurate presurgical evaluation using invasive recordings and functional brain mapping, epileptogenic cortical resection can give excellent results and few deficits in patients with perirolandic epilepsy.     

The use of MRI-guided laser-induced thermal ablation for epilepsy

Purpose

Epilepsy surgery is constantly researching for new options for patients with refractory epilepsy. MRI-guided laser-induced thermal ablation for epilepsy is an exciting new minimally invasive technology with an emerging use for lesionectomy of a variety of epileptogenic focuses (hypothalamic hamartomas, cortical dysplasias, cortical malformations, tubers) or as a disconnection tool allowing a new option of treatment without the hassles of an open surgery.

Methods

MRI-guided laser interstitial thermal therapy (MRgLITT) is a procedure for destroying tissue-using heat. To deliver this energy in a minimally invasive fashion, a small diameter fiber optic applicator is inserted into the lesion through a keyhole stereotactic procedure. The thermal energy induces damage to intracellular DNA and DNA-binding structures, ultimately leading to cell death. The ablation procedure is supervised by real-time MRI thermal mapping and confirmed by immediate post-ablation T1 or FLAIR MRI images.

Results

The present report includes an overview of the development and practice of an MR-guided laser ablation therapy known as MRI-guided laser interstitial thermal therapy (MRgLITT). The role of modern image-guided trajectory planning in MRgLITT will also be discussed, with particular emphasis on the treatment of refractory epilepsy using this novel, minimally invasive technique.

Conclusion

MRI-guided laser-induced thermal ablation for epilepsy is an exciting new minimally invasive technology that finds potential new applications every day in the neurosurgical field. It certainly brings a new perspective on the way we practice epilepsy surgery even though long-term results should be properly collected and analyzed.     

Seizure and developmental outcomes after hemispherectomy in children and adolescents with intractable epilepsy

Purpose

The aim of this study is to describe a series of pediatric hemispherectomies, reviewing pathologic substrate, epilepsy characteristics and seizure outcome as well as developmental profiles, before and after surgery, in different domains.

Methods

Seventeen patients with full pre-surgical work-up, minimum follow-up of 12 months, and at least one post-surgical neuropsychological evaluation were selected. Three had Rasmussen encephalitis (RE), five hemispheric malformations of cortical development (MCD), and nine hemispheric vascular lesions.

Results

At latest follow-up, all patients with RE and 66.7 % of those with vascular lesions are in Engel’s class I; in the latter group, pre-surgical independent contralateral EEG discharges statistically correlated with a worse seizure outcome. Patients with MCD showed the worst seizure outcome. Pre-surgical language transfer to the right hemisphere was confirmed in a boy with left RE, operated on at 6 years of age. Patients with MCD and vascular lesions already showed severe global developmental delay before surgery, which persists afterwards. A linear correlation was found between earlier age at surgery and better outcome in personal–social, gross motor, and adaptive domains, in the vascular lesions group. The case with highest cognitive improvement had continuous spike and wave during sleep on pre-surgical EEG.

Conclusions

Pathologic substrate was the main factor related with seizure outcome. In children with MCD and vascular lesions, although developmental progression is apparent, significant post-surgical improvements are restricted by the severity of pre-surgical neuropsychological disturbances and a slow maturation. Early surgery assessment is recommended to enhance the possibilities for a better quality of life in terms of seizure control, as well as better autonomy and socialization.     

Primary Ewing's sarcoma of the skull: radical resection and immediate cranioplasty after chemotherapy. A technical note

Purpose

The current standard treatment of Ewing's sarcoma is chemotherapy followed by surgery, making an immediate cranial reconstruction in a one-step surgical procedure possible.

Methods

We describe the technique used to repair a cranial defect after the resection of a primary Ewing's sarcoma of the skull in a one-step surgical procedure.

Results

Bone repair with a custom-made cranioplasty immediately after resection of a primary Ewing's sarcoma of the skull avoids deformities and late complications associated with reconstructive surgery after radiotherapy and not interfere with radiotherapy and neither with follow-up.

Conclusion

A one-step surgical procedure after chemotherapy for primary Ewing's sarcoma of the skull could be safer, less aggressive and more radical; avoiding deformities and late complications.