The localizing value of ictal EEG in focal epilepsy.

OBJECTIVE: To investigate the lateralization and localization of ictal EEG in focal epilepsy. METHODS: A total of 486 ictal EEG of 72 patients with focal epilepsy arising from the mesial temporal, neocortical temporal, mesial frontal, dorsolateral frontal, parietal, and occipital regions were analyzed. RESULTS: Surface ictal EEG was adequately localized in 72% of cases, more often in temporal than extratemporal epilepsy. Localized ictal onsets were seen in 57% of seizures and were most common in mesial temporal lobe epilepsy (MTLE), lateral frontal lobe epilepsy (LFLE), and parietal lobe epilepsy, whereas lateralized onsets predominated in neocortical temporal lobe epilepsy and generalized onsets in mesial frontal lobe epilepsy (MFLE) and occipital lobe epilepsy. Approximately two-thirds of seizures were localized, 22% generalized, 4% lateralized, and 6% mislocalized/lateralized. False localization/lateralization occurred in 28% of occipital and 16% of parietal seizures. Rhythmic temporal theta at ictal onset was seen exclusively in temporal lobe seizures, whereas localized repetitive epileptiform activity was highly predictive of LFLE. Seizures arising from the lateral convexity and mesial regions were differentiated by a high incidence of repetitive epileptiform activity at ictal onset in the former and rhythmic theta activity in the latter. CONCLUSIONS: With the exception of mesial frontal lobe epilepsy, ictal recordings are very useful in the localization/lateralization of focal seizures. Some patterns are highly accurate in localizing the epileptogenic lobe. One limitation of ictal EEG is the potential for false localization/lateralization in occipital and parietal lobe epilepsies.     

Electrophysiological study of intractable epileptogenicity in human epilepsy: clinical usefulness of ictal DC shifts and cavernous sinus EEG]

In order to clarify the clinical and electrophysiological features in intractable epileptogenicity in human epilepsy, we applied the new techniques, ictal DC shifts and cavernous sinus EEG recording, for presurgical evaluation of patients with intractable partial epilepsy. (1) Ictal DC shifts were successfully recorded with subdural electrodes in 8 patients with intractable neocortical epilepsy, and an analysis of ictal DC shifts would add useful information to delineate an epileptogenic area. Scalp-recorded ictal DC shifts were also investigated in 3 patients with intractable neocortical epilepsy. It also delineated the epileptogenic area, but it was vulnerable for artifacts. (2) By using the techniques of intravascular EEG recording, we recorded EEG from the bilateral cavernous sinus (cavernous sinus EEG) in patients with intractable temporal lobe epilepsy. Cavernous sinus EEG well sensitively recorded interictal, also ictal in selected patients, epileptiform discharges which arose from the mesial temporal structure even though they were not recorded by scalp electrodes. It is concluded that the above two techniques are clinically useful for delineating an epileptogenic area in patients with neocortical epilepsy and temporal lobe epilepsy.     

The neocortico to mesio-basal limbic propagation of focal epileptic activity during the spike-wave complex.

In order to localize epileptogenic electrophysiological sources, a multichannel MEG system was used in 3 patients with partial epilepsy during presurgical evaluation. MEG and EEG (including scalp, sphenoidal and intracranial foramen ovale electrodes) were recorded simultaneously during a period of intensive video-EEG monitoring in order to observe single spontaneous spikes. In addition to MRI, SPECT and PET investigations were performed. Electrical activity subsequent to the activity of the epileptic focus could be localized by the MEG after noise reduction using a temporal correlation technique. Simultaneous registration of the magnetic field and the electrical field showed that the source of the primary focal epileptic activity (first period during the total spike wave complex where a dipolar magnetic field pattern is found) is localized in neocortical lateral regions, whereas another focal epileptic activity in a later phase of propagation occurs in temporal mesial regions. In 1 patient (case 1) the primary focal epileptic activity was localized in the surrounding neocortical tissue of an angioma and the middle and inferior temporal gyrus. The second phase of propagation is localized in temporo-basal-mesial regions, including para- and hippocampal structures. The latest center of activity occurred in posterior parts of the gyrus cinguli. In 2 other patients, the primary focal epileptogenic activity was localized at the insula and also spread into temporal basal mesial regions. A multi-modal approach to research of focal epilepsy, combining metabolic, electrical potential, magnetoencephalographic and morphological data, recorded by non-invasive techniques, offers new perspectives for the detection of involved brain regions. The 3-D and time-resolved localization of focal epileptic activity, correlated with the individual anatomy of the human brain, may improve the determination of neuronal populations involved in the individual epileptogenic process, especially in the interaction between temporal or extratemporal neocortex and limbic system.     

Benign epileptiform discharges in Rolandic region with mesial temporal lobe epilepsy: MEG, scalp and intracranial EEG features

AIM OF THE STUDY: To report benign epileptiform discharges (BEDs) in the Rolandic region, coexisting in a pediatric patient with intractable localization-related epilepsy, secondary to hippocampal sclerosis. METHODS: We describe the clinical features, MRI, scalp video EEG, magnetoencephalography (MEG) and intracranial video EEG findings, and surgical outcome in a 9-year-old boy with BEDs and intractable complex partial seizures. RESULTS: MRI showed left hippocampal sclerosis. Scalp video EEG interictally demonstrated left temporal spike and sharply contoured slow waves, and right fronto-centro-temporal spike and waves. Ictal scalp video EEG showed left temporal rhythmic sharp waves after the clinical onset of epigastric aura, followed by staring. MEG showed interictal dipoles in the bilateral Rolandic regions with a uniform orientation and right hemispheric predominance. Intracranial video EEG, with bilateral mesial temporal depth and fronto-temporo-parietal strip electrodes, interictally showed polyspikes and slow waves with superimposed low-amplitude fast waves in the left mesial and posterior lateral temporal regions, and spike and waves in the bilateral fronto-parietal regions. Ictal onset was marked by low-amplitude fast waves in the left mesial and posterior lateral temporal regions. He underwent left anterior temporal lobectomy with hippocampectomy. Pathology was hippocampal sclerosis. Predominant right fronto-centro-temporal spike and waves and MEG right Rolandic dipoles persisted after surgery. He was seizure-free 14 months after surgery. CONCLUSION: This is the first report on MEG and intracranial video EEG features of BEDs in the Rolandic region, coexisting with hippocampal sclerosis. Persistence of contralateral benign MEG Rolandic dipoles after surgery indicates that BEDs are coincidental in mesial temporal lobe epilepsy. MEG identified Rolandic dipoles, although was unable to localize the deep and focal epileptogenic dipoles from the hippocampal sclerosis.     

Ictal and Interictal Activity in Partial Epilepsy Recorded with Multichannel Magnetoelectroencephalography: Correlation of Electroencephalography/Electrocorticography, Magnetic Resonance Imaging, Single Photon Emission Computed Tomography, and Positron Emission Tomography Findings

Ictal and interictal epileptic activity was recorded for the first time by multichannel magnetoencephalography (MEG) in three patients with partial epilepsy. Pre- and intra-operative localization of the epileptogenic region was compared. The interictal epileptic activity was localized at the same region of the temporal or frontal lobe as the ictal activity. Main zones of ictal activity were shown to evolve from the tissue at the centers of interictal activity. Pre- and intra-operative electrocorticography (ECoG) as well as postoperative outcome confirmed localization in the temporal and frontal lobe. Results also correlated with findings from scalp EEG, interictal and ictal single photon emission computed tomography (SPECT), positron emission tomography (PET), and magnetic resonance imaging (MRI). Combined multichannel MEG/EEG recording permitted dipole localization of interictal and ictal activity.     

Ictal magnetoencephalography in temporal and extratemporal lobe epilepsy

PURPOSE: We evaluated visual patterns and source localization of ictal magnetoencephalography (MEG) in patients with intractable temporal lobe epilepsy (TLE) and extratemporal epilepsy (ETE). METHODS: We performed spike and seizure recording simultaneously with EEG and MEG on two patients with TLE and five patients with ETE. Scalp EEG was recorded from 21 channels (10-20 international system), whereas MEG was recorded from two 37-channel sensors. We compared ictal EEG and MEG onset, frequency, and evolution and performed MEG dipole source localization of interictal spikes and early ictal discharges and co-registered dipoles to brain magnetic resonance imaging (MRI). We correlated dipole characteristics with intracranial EEG, surgical resection, and outcome. RESULTS: Ictal MEG lateralized seizure onset in both TLE patients and demonstrated ictal onset, frequency, and evolution in accordance with EEG. Ictal MEG source analysis revealed tangential vertical dipoles in the anterolateral angle in one patient, and anterior dipoles with anteroposterior orientation in the other. Intracranial EEG revealed regional entorhinal seizure onset in the first patient. Both patients became seizure free after temporal lobectomy. In ETE, ictal MEG demonstrated visual patterns similar to ictal EEG and had concordant localization with interictal MEG in all five patients. Two patients underwent surgery. Ictal MEG localization was concordant with intracranial EEG in both cases. One patient had successful outcome after surgery. The second patient did not improve after limited resection and multiple subpial transections. CONCLUSIONS: Ictal MEG can demonstrate ictal onset frequency and evolution and provide useful localizing information before epilepsy surgery.     

A Comparison of Magnetoencephalography, MRI, and V-EEG in Patients Evaluated for Epilepsy Surgery

PURPOSE: To determine the efficacy and relative contribution of several diagnostic methods [ictal and interictal scalp and intracranial EEG, magnetic resonance imaging (MRI), and magnetoencephalography (MEG)] in identifying the epileptogenic zone for resection. METHODS: This was a prospective study using a masked comparison-to-criterion standard. Fifty-eight consecutive patients with refractory partial epilepsy from two university comprehensive epilepsy programs were studied. Patients who were evaluated for and underwent epilepsy surgery were recruited. The main outcome measure was the efficacy of each diagnostic method to identify the resected epileptogenic zone, when referenced to surgical outcome. RESULTS: MEG (52%) was second only to ictal intracranial V-EEG in predicting the epileptogenic zone for the entire group of patients who had an excellent surgical outcome (seizure free or rare seizure). In a subanalysis, for patients who had temporal lobe surgery, this same relation was seen (MEG, 57%, ictal intracranial V-EEG, 62%). With extratemporal resection, ictal (81%) and interictal (75%) intracranial EEG were superior to MEG (44%) in predicting the surgery site in those patients with an excellent outcome. Finally, for all patients who had a good surgical outcome, MEG (52%) was better than ictal (33%) or interictal (45%) scalp VEEG in predicting the site of surgery. CONCLUSIONS: These results indicate that MEG is a very promising diagnostic method and raise the possibility that it may obviate the need for invasive EEG in some cases or reduce the length of scalp EEG evaluation in others.     

Surgical implications of neuromagnetic spike localization in temporal lobe epilepsy

PURPOSE: To investigate the clinical usefulness of magnetoencephalography (MEG) as a guide to the surgical treatment of temporal lobe epilepsy (TLE). METHODS: Preoperative spike localization by MEG was compared with seizure outcome and postoperative spike localization at 12 months after resective surgery in 16 patients with TLE. Spike localization was classified into anterior temporal (AT) and non-AT localization in 11 patients without neocortical lesion treated with anterior temporal lobectomy (ATL); and lesion and lobar localization in five patients with neocortical lesion treated with lesionectomy (n = 3) or lesionectomy with medial temporal resection (n = 2). RESULTS: All five patients with AT localization became seizure free and spike free after surgery. Among the six patients with non-AT localization, two became seizure free and spike free, two became seizure free with residual spikes, one had residual seizures but no spikes, and one had both residual seizures and spikes. All three patients with lesion localization and two with lobar localization had favorable seizure outcome and became spike free after surgery. CONCLUSIONS: MEG spike localization can identify neocortical sources remote from the presumed epileptogenic area. Favorable seizure outcome can be expected in patients with AT localization after ATL and patients with lesion localization after lesionectomy. In contrast, non-AT localization indicates either nonmedial TLE or spike propagation to the posterior and extratemporal neocortex. Similarly, lobar localization indicates spike propagation from an epileptogenic lesion or extensive epileptogenicity. Patients with non-AT localization or lobar localization should undergo intensive evaluations, such as intracranial EEG, for improved seizure outcome.     

Pre-surgical evaluation and surgical outcome of 41 patients with non-lesional neocortical epilepsy.

Pre-surgical evaluation and the surgical treatment of non-lesional neocortical epilepsy is one of the most challenging areas in epilepsy surgery. The aim of this study was to evaluate the surgical outcome and the diagnostic role of ictal scalp electroencephalography (EEG), interictal (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET), and ictal technetium-99m hexamethylpropyleneamine oxime single photon emission tomography ( (99m)Tc-HMPAO SPECT). In 41 non-lesional neocortical epilepsy patients (16 frontal lobe epilepsy, 11 neocortical temporal lobe epilepsy, seven occipital lobe epilepsy, four parietal lobe epilepsy, and three with multifocal onset) who underwent surgical treatment between December 1994 and July 1998, we evaluated the surgical outcome with a follow-up of at least 1 year. The localizing and lateralizing values of ictal scalp EEG, interictal FDG-PET, and ictal SPECT were evaluated in those patients with good surgical outcome. Ictal scalp EEG had the highest diagnostic sensitivity in the localization of epileptogenic foci (69.7% vs. 42.9% for FDG-PET and 33.3% for ictal SPECT; P= 0.027). However, no significant difference was found in the lateralization of the epileptogenic hemisphere among the three modalities (78.8% for ictal scalp EEG, 57.2% for FDG-PET, and 55.5% for ictal SPECT; P= 0.102). During a mean follow-up of 2.77 +/- 1.12 years, 33 (80.5%) showed good surgical outcome (seizure free or seizure reduction >90%), including 16 (39.0%) seizure free patients. Ictal scalp EEG was the most useful diagnostic tool in the localization of epileptogenic foci. Interictal FDG-PET and ictal SPECT were found to be useful as complementary and, sometimes, independent modalities. Many patients with non-lesional neocortical epilepsy would benefit from surgical treatment.     

Interictal regional delta slowing is an EEG marker of epileptic network in temporal lobe epilepsy

Purpose: Several studies have suggested that interictal regional delta slowing (IRDS) carries a lateralizing and localizing value similar to interictal spikes and is associated with favorable surgical outcomes in patients with temporal lobe epilepsy (TLE). However, whether IRDS reflects structural dysfunction or underlying epileptic activity remains controversial. The objective of this study is to determine the cortical electroencephalography (EEG) correlates of scalp‐recorded IRDS, in so doing, to further understand its clinical and biologic significances. Methods: We examined the cortical EEG substrates of IRDS with electrocorticography (ECoG‐IRDS) and delineated the spatiotemporal relationship between ECoG‐IRDS and both interictal and ictal discharges by recording simultaneously scalp and intracranial EEG in 18 presurgical candidates with TLE. Key Findings: Our results demonstrated that ECoG‐IRDS is typically a mixture of delta/theta slowing and spike‐wave potentials. ECoG‐IRDS was predominantly recorded from basal and anterolateral temporal cortex, occasionally in mesial, posterior temporal, and extratemporal regions. Abundant IRDS was most commonly observed in patients with neocortical temporal lobe epilepsy (NTLE), whereas infrequent to moderate IRDS was usually observed in patients with mesial temporal lobe epilepsy (MTLE). The anatomic distribution of ECoG‐IRDS was highly correlated with the irritative and seizure‐onset zones in 10 patients with NTLE. However, it was poorly correlated with the irritative and seizure‐onset zones in the 8 patients with MTLE. Significance: These findings demonstrate that IRDS is an EEG marker of epileptic network in patients with TLE. Although IRDS and interictal/ictal discharges likely arise from the same neocortical generator in patients with NTLE, IRDS in patients with MTLE may reflect a network disease that involves temporal neocortex.     

Abstracts of the 5th joint meeting of the German, Austrian, and Swiss Sections of the International League Against Epilepsy, Basle, May 16-19, 2007

Presidential Symposium ¹ E. Pataraia
¹ University Hospital of Neurology (Vienna, A) Goals, methodology: Epilepsy surgery is defined as any neurosurgical intervention with the primary goal to relieve intractable epilepsy. On the other hand essential brain regions like primary motor and sensory cortex as well as brain areas supporting language and memory functions have to be spared to avoid neurological deficits caused by the operation. Thus, the exact localization of the epileptogenic zone and of essential brain regions is crucial for the successful surgical treatment of seizures that can only be accomplished during a thorough presurgical work‐up. A new noninvasive brain mapping procedure magnetoencephalography (MEG) was employed during the presurgical evaluation for localization of the epileptogenic zones and for the determination of hemispheric dominance and intrahemispheric localization of linguistic functions in patients with drug‐resistant focal epilepsies. Results: The role of MEG for the localization of the epileptogenic zone in the noninvasive evaluation of patients with focal drug‐resistant epilepsies: We evaluated the sensitivity and selectivity of interictal MEG versus prolonged ictal and interictal scalp video‐ EEG in order to identify patient groups that would benefit from preoperative MEG testing. One hundred thirteen consecutive patients with medically refractory epilepsy who underwent surgery were included. The epileptogenic region predicted by interictal and ictal Video‐EEG (V‐EEG) and MEG was defined in relation to the resected area as perfectly overlapping with the resected area, partially overlapping, or nonoverlapping. Using MEG, we were able to localize the resected region in a greater proportion of patients (72.3%) than with noninvasive V‐EEG (40%). MEG contributed to the localization of the resected region in 58.8% of the patients with a non‐localizing V‐EEG study and 72.8% of the patients for whom V‐EEG only partially identified the resected zone. Overall, MEG and V‐EEG results were equivalent in 32.3% of the cases, and additional localization information was obtained using MEG in 40% of the patients. MEG was most useful for presurgical planning in patients who had either partially or nonlocalizing V‐EEG results. Functional organization of interictal spike complex in medial temporal lobe epilepsies: Thirty patients with mesial temporal lobe epilepsy (MTLE) using combined MEG and EEG recordings were icluded. Spikes could be recorded in 14 patients (47%) during the 2‐ to 3‐h MEG/EEG recording session. The MEG and EEG spikes were subjected to separate dipole analyses and the spike dipole localizations were superimposed on MRI scans. All spike dipoles could be localized to the temporal lobe with a clear preponderance in the medial region. Based on dipole orientations in MEG, patients could be classified into two groups: patients with anterior medial vertical (AMV) dipoles, suggesting epileptic activity in the mediobasal temporal lobe and patients with anterior medial horizontal (AMH) dipoles, indicating involvement of the temporal pole and the anterior parts of the lateral temporal lobe. Whereas patients with AMV dipoles had strictly unitemporal interictal and ictal EEG changes during prolonged video‐EEG monitoring, 50% of patients with AMH dipoles showed evidence of bitemporal affection on interictal and ictal EEG. Nine patients underwent epilepsy surgery so far: all five patients with AMV dipoles became completely seizure‐free postoperatively (Class Ia) and two out of four patients with AMH dipoles experienced persistent auras (Class Ib). Plasticity of the brain mechanisms for receptive language in patients with mesial temporal lobe epilepsy and structural lesions: We examined brain activation profiles for receptive language function in patients with left hemisphere space occupying lesions and patients with left temporal lobe epilepsy due to mesial temporal sclerosis (MTS) to assess whether cross‐ and intrahemispheric plasticity for language varied as a function of lesion type or location. We evaluated 44 patients: 21 patients with MTS and 23 lesional patients. All patients underwent preoperative language mapping while performing a word recognition task. The location of the activity sources was subsequently determined by co‐registering them with MRIs. The number of clustered, contiguous activity sources located in temporal and inferior parietal regions (excluding sources in somatosensory cortices) was then assessed. Hemispheric lateralization of language‐specific magnetic activity was determined as left hemispheric, right hemispheric and bilateral according to relation of the acceptable late activity sources in left and right hemispheres. Patients were classified into two groups based on the location of the cluster(s) of language‐specific activity sources within the dominant hemisphere: typical localization of receptive language‐specific cortex (if the cluster of activity sources fell within the cortical region that is commonly identified as Wernicke's area) and atypical localization of receptive language‐specific cortex (if the cluster of activity sources did not overlap with Wernicke's area). A higher incidence of atypical language lateralization was noted among patients with MTS compared with lesional patients (43% vs. 13%). The majority of MTS patients with early seizure onset (before 5 years of age) showed atypical language lateralization. In contrast, the precise location of receptive language‐specific cortex within the dominant hemisphere was found to be outside of Wernicke's area in 30% of lesional patients and only 14% of MTS patients. There is an increased probability of a partial or total displacement of key components of the brain mechanisms responsible for receptive language function to the nondominant hemisphere in MTS patients. Early onset of seizures was strongly associated with atypical language lateralization. Lesions in the dominant hemisphere tend to result in an intrahemispheric reorganization of linguistic function. Organization of receptive language‐specific cortex before and after left temporal lobectomy: In the present study we documented the reorganization of brain areas mediating receptive language function in patients with left temporal lobe epilepsy after a standard anterior temporal lobe resection. We evaluated which patients were most likely to show a change in the lateralization and localization of the mechanisms supporting receptive language and if such changes were associated with neuropsychological function. The results of preoperative Wada‐testing and pre‐ and post‐operative neuropsychological testing and MEG language mapping were compared. Patients with atypical (bilateral) hemispheric dominance pre‐operatively were significantly more likely than patients with (typical) left‐hemisphere dominance to show evidence of increased right hemisphere participation in language functions after surgery. Patients with left hemispheric dominance preoperatively were more likely to show intra‐hemispheric changes involving a slight inferior shift of the putative location of Wernicke's area. Patients with bilateral representation tended to perform worse on neuropsychological test measures obtained both pre‐ and postoperatively. Interhemispheric functional reorganization of language‐specific areas may occur in patients undergoing left anterior temporal lobectomy. Intrahemispheric reorganization may take place even when the resection does not directly impinge upon Wernicke's area. Conclusions: Combined MEG/EEG dipole modeling can identify subcompartments of the temporal lobe involved in epileptic activity and may be helpful to differentiate between subtypes of mesial temporal lobe epilepsy noninvasively. MEG is most useful for presurgical planning in patients who have either partially or nonlocalizing V‐EEG results in the noninvasive evaluation phase. We predict the replacement of the more invasive procedure with MEG in the near future for temporal lobe epilepsies, subsequent to the optimization of the conditions under which preoperative MEG is performed. MEG can be especially helpful in the localization of language‐critical cortex in sites other than those expected within the dominant hemisphere. Our findings also suggest that not only structural elements, but also functional factors have an effect on receptive language organization in the brain. Factors influencing atypical language lateralization have theoretical importance for understanding the organization and reorganization of higher cognitive functions, as well as practical implications, especially in brain surgery and neurological rehabilitation. MEG is a useful method in clinical practice, as it has the capacity to provide reliable images of the working brain of individual subjects, and it is capable of capturing relevant aspects of brain activation by reflecting the actual participation of a particular area in the function under investigation. Finally, it is capable of capturing both the spatial as well as the temporal features of that activation.     

Localizing significance of temporal intermittent rhythmic delta activity (TIRDA) in drug-resistant focal epilepsy.

OBJECTIVE: Temporal intermittent rhythmic delta activity (TIRDA) is an EEG pattern characterized by sinusoidal trains of activity, ranging from 1 to 3.5 Hz, and well localized over the temporal regions. It is considered to be an indicator of temporal lobe epilepsy (TLE), but full agreement between different authors has still not been reached. The aim of this study was therefore to assess the role of TIRDA in localizing the epileptogenic zone, which was estimated using anatomo-electro-clinical correlations obtained from non-invasive pre-surgical investigations, in a large group of patients affected by drug-resistant partial epilepsy. METHODS: The occurrence of TIRDA was investigated using a prolonged Video-EEG recording of 129 patients affected by drug-resistant partial epilepsy that underwent a non-invasive pre-surgical protocol. Patients were divided into 3 groups: TLE only, extratemporal epilepsy, and multilobar epilepsy including temporal lobe. According to the epileptogenic zone identified using anatomo-clinical-radiological correlations, 3 different subgroups of TLE were identified: mesial, lateral, and mesio-lateral. Statistical analysis was performed in order to evaluate the relationship between TIRDA and the epileptogenic zone, and neuroradiological, neuropathological, EEG interictal and ictal findings. RESULTS: The pattern of TIRDA was observed in 52 out of the 129 (40.3%) patients studied. Significant correlations were found between TIRDA and: (i) mesial and mesio-lateral TLE; (ii) mesial temporal sclerosis; (iii) interictal epileptiform discharge localized over the anterior temporal regions; and (iv) 5-9 Hz temporal ictal discharge. CONCLUSIONS: Our research shows that TIRDA plays a role in localizing the epileptogenic zone, suggesting that this pattern might be considered as an EEG marker of an epileptogenesis that involves the mesial structures of the temporal lobe. However, further studies investigating the relationship between intracranial EEG monitoring and simultaneous scalp EEG recording are needed in order to confirm our findings and improve our understanding of the significance of TIRDA.     

无创性定位手段在颞叶内侧癫(癎)患者癫(癎)灶定位中的价值

目的 评价多种无创性定位手段在颞叶内侧癫(癎)患者术前癫(癎)灶定位中的可靠性.方法 选择2002年5月至2005年5月间在我院行前颞叶内侧切除,随访1年以上,预后为Engle I级的40例患者,回顾性地总结这组病例发作间期和发作期脑电图、发作症状、头颅MRI、发作问期SPECT所提供的定侧定位信息,分析其在癫疴灶定位中的价值.结果 (1)发作间期颞前尖波:出现单侧独立尖波者37例(92.5%),其中35例(94.6%)与癫(癎)灶侧别相符;(2)发作期脑电图:32例获取了发作期脑电图,26例(81.2%)的发作期脑电图可提供定侧信息,其中25例(96.2%)与癫(癎)灶的侧别相符;(3)发作症状:23例(57.5%)患者的发作症状可以提供癫(癎)灶侧别信息,其中19例(82.6%)提供的侧别信息与癫(癎)灶侧别一致;(4)头颅MRI:38例(95.0%)头颅MRI提示一侧海马及颞叶的信号或结构异常,其中37例(97.4%)与癫(癎)灶侧别相符;(5)发作间期SPECT:23例患者行同位素检查,22例(95.7%)可提供癫(癎)灶侧别信息,其中18例(81.8%)与癫(癎)灶侧别相符.结论 颞叶内侧癫(癎)术前无创性定位定侧方法中,提供定侧信息比较敏感的方法依次为SPECT、MRI、发作问期脑电图、发作期脑电图和发作症状,而定侧信息可靠性的高低依次为头颅MRI、发作期脑电图、发作间期脑电图、发作症状和SPECT.     

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

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

The clinical usefulness of ictal surface EEG in neocortical epilepsy

PURPOSE: Localizable scalp EEGs, during ictal episodes, appear to be rare in neocortical epileptic syndromes. However, studies based on large numbers of patients are also rare. This study aims to identify the characteristic patterns of variable neocortical epilepsies and to evaluate their clinical usefulness in the localization of epileptogenic focuses. METHODS: We retrospectively assessed 394 noninvasive ictal recordings from 86 patients who subsequently underwent invasive study and resective surgery. Ictal EEGs were recorded using a video-EEG monitoring system with electrodes placed according to the International 10-20 system, with additional anterior temporal electrodes. The ictal recordings were analyzed according to localizing accuracy and frequency characteristics. The durations of discrete or regional ictal rhythms were also measured. RESULTS: The percentage of discrete or regional EEGs was 23% in frontal lobe epilepsy, 52% in lateral temporal lobe epilepsy, 70% in occipital lobe epilepsy, and 10% in parietal lobe epilepsy. In order of frequency, the localizable ictal rhythms were theta, beta, alpha, delta, and rhythmic spike-and-wave. The duration of discrete or regional ictal rhythms was significantly shorter in frontal lobe epilepsy and parietal lobe epilepsy than in other epilepsies. Ictal beta activity was the most common rhythm in discrete-patterned EEGs. Structural lesions found on MRI did not significantly affect the localization of epileptogenic focuses in the patients. The type of seizure was not related to the degree of localization, with the exception of simple partial seizure. CONCLUSIONS: Ictal surface EEG was clinically helpful in the localization of epileptogenic focuses in at least some neocortical epileptic syndromes.     

Ictal onset localization of epileptic seizures by magnetoencephalography

OBJECTIVES: The aim of this study was to localize the ictal onset zone of focal epileptic seizures by magnetoencephalography (MEG) and to compare the results with interictal MEG localizations, ictal and interictal electroencephalography (EEG) results and magnetic resonance imaging (MRI) in epilepsy surgery candidates. MATERIALS AND METHODS: Data of 13 patients with partial seizures during MEG recording were analysed. Measurements were performed with a Magnes II dual unit system. RESULTS: In six of 13 cases, the ictal onset zone could be localized by MEG, with all interictal MEG findings being confirmed by ictal MEG results. In four cases, the ictal MEG localization results were corresponding to the ictal EEG localization results. In two cases, EEG yielded no comparable information. CONCLUSION: Ictal onset localization is feasible with MEG. Both interical and ictal MEG contribute valuable information to the presurgical assessment of epilepsy patients.     

Is 11C-flumazenil PET superior to 18FDG PET and 123I-iomazenil SPECT in presurgical evaluation of temporal lobe epilepsy?

OBJECTIVE: To determine the contribution of 18FDG PET, 11C-flumazenil PET, and 123I-iomazenil SPECT to the presurgical evaluation of patients with medically intractable complex partial seizures. METHODS: Presurgical evaluation was performed in 23 patients, who were considered candidates for temporal lobe resective surgery (14 females and nine males with a median age of 34 (range 13 to 50) years). The presurgical diagnosis was based on seizure semiology as demonstrated with ictal video recording, ictal and interictal scalp EEG recordings, and MRI. RESULTS: Eighteen patients had convergent findings in clinical semiology, interictal and ictal EEG with scalp and sphenoidal electrodes, and MRI that warranted surgery without depth EEG (DEEG). In five patients with insufficient precision of localisation, DEEG with intracerebral and subdural electrodes was performed. MRI showed abnormalities in 22 out of 23 patients. Of these 22, 18 had mesial temporal sclerosis. This was limited to the mesial temporal lobe in four and more widespread in the temporal lobe in 14 patients. In one patient only enlargement of the temporal horn was found and in three others only white matter lesions were detected. 18FDG PET showed a large area of glucose hypometabolism in the epileptogenic temporal lobe, with an extension outside the temporal lobe in 10 of 23 patients. Only in one of these patients DEEG showed extratemporal abnormalities that were concordant with a significant extratemporal extension of hypometabolism in 18FDG PET. 18FDG PET was compared with the results of scalp EEG: in none of the patients was an anterior temporal ictal onset in scalp EEG related to a maximum hypometabolism in the mesial temporal area. By contrast, the region of abnormality indicated by 11C-flumazenil PET was much more restricted, also when compared with DEEG findings. Extension of abnormality outside the lobe of surgery was seen in only two patients with 11C-flumazenil and was less pronounced compared with the intratemporal abnormality. Both 18FDG PET and 11C-flumazenil PET reliably indicated the epileptogenic temporal lobe. Thus these techniques provide valuable support for the presurgical diagnosis, especially in patients with non-lesional MRI or non-lateralising or localising scalp EEG recordings. In those patients in whom phase 1 presurgical evaluation on the basis of classic methods does not allow a localisation of the epileptogenic area, PET studies may provide valuable information for the strategy of the implantation of intracranial electrodes for DEEG. Previous studies have suggested that 11C-flumazenil binding has a closer spatial relationship with the zone of ictal onset than the area of glucose hypometabolism, but this study suggests rather that the decrease in the 11C-flumazenil binding simply reflects a loss of neurons expressing the benzodiazepine-GABA receptor. 11C-flumazenil PET did not prove to be superior to 18FDG PET. CONCLUSION: In 21 patients sufficient material was obtained at surgery for a pathological examination. In 17 mesial temporal sclerosis, in one an oligodendroglioma grade B, in another a vascular malformation and in two patients no abnormalities were found. Although all 21 patients with pathological abnormality showed hypometabolic zones with 18FDG PET and a decreased uptake in 11C-flumazenil binding, there was no strong correlation between pathological diagnosis and functional abnormal areas in PET. Grading of medial temporal sclerosis according to the Wyler criteria showed no correlation with the degree of hypometabolism in either 18FDG or 11C-flumazenil PET. The interictal 123I-iomazenil SPECT technique was highly inaccurate in localising the lobe of surgery.     

颅内电极监测对顽固性颞叶癫痫致痫灶的定位价值

目的:探讨发作期及发作间期颅内电极监测对癫痫灶的定位作用。方法:20例难治性颞叶癫痫,经临床、影像学及头皮脑电图不能确定致痫灶部位,应用立体定向技术,在患者双侧颞叶植入硬膜下条状电极,进行长时间视频脑电图监测,记录发作期和发作间期的脑电图变化,并与头皮脑电图、MRI进行比较,分析癫痫灶部位,进行手术治疗,术后跟踪随访,评估致痫灶定位的准确性。结果:20例癫痫病人颅内电极埋藏时间1～5天,每个患者至少监测到2次临床发作,每一病例均记录发作间期和发作期的异常放电活动。15例发作间期与发作期定侧一致,2例发作间期为双侧棘波病灶,3例发作间期定位与发作期不一致。按Engel术后效果分级:手术效果满意(癫痫发作消失)13例(65%),显著改善3例(15%),良好3例(15%),无效1例(5%)。所有病例均未出现因颅内电极埋藏而致的并发症。结论:对于致痫灶不能定位的难治性癫痫,应用颅内电极记录方法,尤其是发作期起始时脑电图变化,可以确定致痫灶位置,为癫痫手术治疗提供可靠的依据。     

Presurgical evaluation for partial epilepsy: relative contributions of chronic depth-electrode recordings versus FDG-PET and scalp-sphenoidal ictal EEG

One hundred fifty-three patients with medically refractory partial epilepsy underwent chronic stereotactic depth-electrode EEG (SEEG) evaluations after being studied by positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) and scalp-sphenoidal EEG telemetry. We carried out retrospective standardized reviews of local cerebral metabolism and scalp-sphenoidal ictal onsets to determine when SEEG recordings revealed additional useful information. FDG-PET localization was misleading in only 3 patients with temporal lobe SEEG ictal onsets for whom extratemporal or contralateral hypometabolism could be attributed to obvious nonepileptic structural defects. Two patients with predominantly temporal hypometabolism may have had frontal epileptogenic regions, but ultimate localization remains uncertain. Scalp-sphenoidal ictal onsets were misleading in 5 patients. For 37 patients with congruent focal scalp-sphenoidal ictal onsets and temporal hypometabolic zones, SEEG recordings never demonstrated extratemporal or contralateral epileptogenic regions; however, 3 of these patients had nondiagnostic SEEG evaluations. The results of subsequent subdural grid recordings indicated that at least 1 of these patients may have been denied beneficial surgery as a result of an equivocal SEEG evaluation. Weighing risks and benefits, it is concluded that anterior temporal lobectomy is justified without chronic intracranial recording when specific criteria for focal scalp-sphenoidal ictal EEG onsets are met, localized hypometabolism predominantly involves the same temporal lobe, and no other conflicting information has been obtained from additional tests of focal functional deficit, structural imaging, or seizure semiology.     

Controversies in clinical neurophysiology. MEG is superior to EEG in the localization of interictal epileptiform activity: Con.

OBJECTIVE: To assess whether MEG is superior to scalp-EEG in the localization of interictal epileptiform activity and to stress the 'con' part in this controversy. METHODS: Advantages and disadvantages of the two techniques were systematically reviewed. RESULTS: While MEG and EEG complement each other for the detection of interictal epileptiform discharges, EEG offers the advantage of long-term recording significantly increasing its diagnostic yield which is not feasible with MEG. Localization accuracies of EEG and MEG are comparable once inaccuracies for the solution of the forward problem are eliminated. MEG may be more sensitive for the detection of neocortical spike sources. EEG and MEG source localizations show comparable agreement with invasive electrical recordings, can clarify the spatial relationship between the irritative zone and structural lesions, guide the placement of invasive electrodes and attribute epileptic activity to lobar subcompartments in temporal lobe epilepsy and to a lesser extent in extratemporal epilepsy. CONCLUSIONS: A clear superiority of MEG over EEG for the localization of interictal epileptiform activity cannot be derived from the studies presently available. SIGNIFICANCE: The combination of EEG and MEG provides information for the localization of interictal epileptiform activity which cannot be obtained with either technique alone.