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.     

Occipital Lobe Developmental Malformations and Epilepsy: Clinical Spectrum, Treatment, and Outcome

Summary: Purpose : Cortical developmental malformations (CDM) are increasingly recognized in association with epilepsy. We describe 10 patients (age range 14–35 years) with symptomatic occipital lobe epilepsy and CDM.
Methods : Neurologic, neuroophthalmologic and electro-physiologic studies were performed. Patients had MRI, SPECT, and in some cases intracranial EEG investigators.
Results : Mean age of seizure onset was 8 years. We noted strong correlations between the presence of visual auras, the scalp EEG pattern, and the subtype of underlying pathology. Magnetic resonance imaging (MRI) showed CDM in all patients, with polymicrogyria and focal dysplasia being the most frequent malformations. Despite the presence of occipital lobe structural malformations in all patients, visual field deficits were present in only 2. Those who underwent cortical resections were seizure–free or showed major improvement at a mean follow–up of 3.5 years.
Conclusions : Intracranial stimulation studies and the low frequency of pre- and postoperative deficits suggest that some degree of cortical visual reorganization may occur in patients with occipital lobe malformations. Occipital lobe CDM should be sought as a cause of symptomatic occipital lobe epilepsy even though they may become symptomatic after childhood.     

Occipital Lobe Epilepsy with Scotosensitive Seizures: The Role of Central Vision

Summary: In four cases of occipital lobe epilepsy, clinical seizures and EEG discharges were evoked by darkness and/or closed eyes. In all cases the inducing factor was represented by the abolition of central vision. The importance of central vision in the excitation-inhibition process of the occipital EEG discharges is emphasized in light of the anatomophysiological organization of the visual system. Scotosensitive epilepsy and benign partial epilepsy of childhood with occipital spike-waves may represent the same clinical entity.     

Symptomatic Occipital Lobe Epilepsy

Summary: Symptomatic occipital lobe epilepsy is increasingly recognized among patients with partial-onset seizures. Although traditional clinical and electroencephalographic criteria had defined occipital lobe epilepsy in the past, new neu-roimaging techniques and the recognition of specific syndromes associated with occipital lobe epilepsy have improved the diagnosis and management of these patients. These syndromes include, among others, lesional occipital lobe epilepsy (congenital vs. acquired), MELAS, and epilepsy with bilateral occipital calcifications. The diagnosis of symptomatic occipital lobe epilepsy is improving as functional and structural neuroimaging techniques enable the detection of subtle abnormalities in such patients. This has had a direct impact on the correct classification of patients with benign occipital lobe epilepsy, basilar migraine, and symptomatic occipital lobe epilepsy. The common clinical symptoms, EEG patterns, and neuroimaging findings of these patients are discussed.     

枕叶癫痫的术前定位

目的:通过回顾分析9例枕叶癫痫患者的临床资料,讨论枕叶癫痫的临床特征和致痫灶的术前定位。方法:应用临床发作症状评估、CT/MRI扫描、SPECT/PET检查、长程视频脑电图监测、颅内电极记录以及皮层脑电监测等方法综合定位枕叶癫痫患者的致痫灶。结果:视觉先兆及头或眼向一侧偏转是最常见的发作早期改变;发作形式以复杂部分性发作为主,也可以继发全面性发作。致痫灶位于枕叶内侧面2例,背外侧面7例,其中致痫灶位于枕叶与顶叶的临界区1例,枕叶与颞叶的临界区或累及颞叶后部4例。术后随访1年以上,按照Engel's术后效果分级:Ⅰ级5例,Ⅱ级2例,Ⅲ级1例,Ⅳ级1例。结论:视觉先兆的出现常常提示致痫灶位于枕叶,MRI检查以及发作初始期头和眼向一侧偏转等症状学特点均有较高的定侧定位价值。当其他方法定位致痫灶较困难时,应用颅内电极记录有助于定位。     

Occipital Lobe Epilepsy: A Chronic Condition Related to Transient Occipital Lobe Involvement in Eclampsia

Summary: Eleven hours and 6 days, respectively, after childbirth 2 women exhibited hypertension and paroxysmal visual disturbances followed by tonic-clonic seizures and no other preeclamptic signs. Both developed partial epilepsy with occipital lobe seizures with no other neurologic defects. Neuroimaging showed no lesion during either the acute episode or 3–5 year follow-up. Selective vulnerability of the occipital lobes during eclamptic hypertensive encephalopathy was the probable pathophysiologic mechanism. Aggressive antihypertensive treatment during the acute phase may have exacerbated the risk of permanent cerebral damage.     

Clinical Findings in Children with Occipital Paroxysmal Discharges

Occipital paroxysmal discharges (OPDs) have been related to a variety of clinical problems. To evaluate associated symptoms and patient outcome, we studied 293 children with OPDs. Follow-up of more than 6 months was available in 141 children. Mental retardation, neurological symptoms, behavior problems, ocular symptoms, and convulsions of various types were present. Eight patients had ictal visual phenomena consistent with the diagnosis of benign epilepsy with occipital spike and wave (BEOSW). In the 141 children with at least 6 months follow-up, 58 had other types of convulsions. Clinical and EEG normalization was observed in 25 and clinical normalization only in 17. The use of antiepileptic drugs did not seem to influence the outcome although seizure control was obtained in 26 patients. In all the cases where follow-up was 9 or more years, clinical normalization was observed. Clinical symptoms in these patients were quite heterogeneous and frequently not ictal. The disappearance of OPDs with increasing age points to their being "not lesional" in origin.     

Idiopathic Photosensitive Occipital Lobe Epilepsy

Summary: We studied 10 neurologically normal patients (8 females, 2 males) aged 8–30 years (mean 17 years) who had recurrent episodes of visually induced occipital seizures. Television and computer screens were the main triggers. Seizure onset occurred between the ages of 5 and 17 years (mean 11 years). All seizures were stimulus related and began with elementary visual symptoms, followed in most patients by a slow clustering of cephalicpain, epigastric discomfort, and vomiting, with either normal or only mildly impaired responsiveness. EEG fea-tures included normal background activity, occipital spikes and waves, and a photoparoxysmal response which could be occipital, generalized, or both. Four pa-tients also showed spontaneous generalized epileptiform abnormalities, and 3 had rolandic spikes. An Oz electrode was critical in identifying epileptiform activity in some patients. Complete seizure control was achieved in most patients with monotherapy, although occasional stimulus-related seizures occurred in 3 patients who showed a wider range of photosensitivity. These patients have an idiopathic localization-related epilepsy with age-related onset and specific mode of precipitation. Although this type of epilepsy has been reported previously, it has remained underrecognized, probably because it is difficult to differentiate clinically from migraine or from nonreflex childhood idiopathic occipital epilepsy.     

Epilepsy with Bilateral Occipital Calcifications: Sturge-Weber Variant or a Different Encephalopathy?

Summary: A series of cases of epilepsy with associated bilateral occipital calcifications (EBOC) without signs of phakomatosis and without any disorders known to produce cerebral calcifications have been reported. It is unclear whether EBOC is an incomplete variant of Sturge Weber disease (SWD) or if it is a different, as yet undefined encephalopathy. We describe four new cases of EBOC that are different clinically by age of onset, type, course, severity of epilepsy, and associated cognitive deficits but that are linked by similar neuroradiologic findings. Similar to cases described in the literature, there is convincing evidence in favor of the hypothesis that these cases belong to an encephalopathy different from SWD and frequently associated with celiac disease.     

顽固性枕叶癫痫的手术治疗（附18例分析）

目的总结顽固性枕叶癫痫患者的手术治疗经验。方法自1992年6月至2004年12月我科手术治疗枕叶癫痫患者18例,其中7例行一侧枕叶皮质切除术,4例行一侧枕叶皮质切除 胼胝体切开术,3例行一侧枕叶多处软膜下横切术(MST),例行一侧枕叶切除 MST,1例行一侧枕叶切除 MST 皮层热灼术,1例行枕叶MST 胼胝体切开术。结果术后随访1年以上,1例患者疗效满意,3例效果显著,2例疗效良好,3例效果较差,手术总有效率83.3%(15/18)。结论顽固性枕叶癫痫患者的临床特点是发作时有视觉症状,伴或不伴头、眼向一侧偏转,神经电生理和神经影像学检查对术前定位有一定的帮助,且手术效果一般较好。     

Localized Pain Associated with Seizures Originating in the Parietal Lobe

PURPOSE: Ictal pain is a rare symptom of seizures. Epileptic pain may be experienced unilaterally (lateral/ peripheral), cephalically, or in the abdomen. Painful seizures have been associated with seizure origin in both the parietal and the temporal lobes. We report on the different types of epileptic pain and discuss its etiology and possible localizing value. METHODS: We reviewed the records of patients referred to our epilepsy program over the last 6 years. Eight (1.4%) of 573 patients had pain as an early prominent symptom of their seizures. RESULTS: Pain was predominantly unilateral in three patients, cephalic in two, and abdominal in three patients. Seizure onset was in or involving the parietal lobe in all patients, and when the painful symptoms were lateralized, they were contralateral to the side of seizure origin. Parietal lobe seizure origin was determined by both intracranial EEG recording and neuroimaging [magnetic resonance imaging (MRI), ictal single photon emission computed tomography (SPECT)] in five patients, and by both scalp EEG and neuroimaging in three patients. CONCLUSIONS: We conclude that ictal pain is a rare symptom of parietal lobe seizure origin with lateralizing potential.     

Significance of Simple Partial Seizures in Temporal Lobe Epilepsy

Summary: We determined how localization of simple partial seizures (SPS) correlated with localization of complex partial seizure (CPS) in scalp/sphenoidal EEG and assessed prognosis after temporal lobe resective surgery in patients with an ictal correlate of SPS in scalp/sphenoidal EEG recordings. EEGs were recorded with the 10–20 system of electrode placement and supplemented with sphenoidal electrodes. Between 1985 and 1992, 183 patients with temporal lobe epilepsy (TLE) reported an aura (SPS) during inpatient monitoring; all were eligible for inclusion in our study. The EEGs during SPS showed ictal changes in 51 patients (28%, 117 SPS). Forty-four patients had unilateral temporal interictal spikes (IIS), and SPS and CPS always arose from the same region. Seven patients had bitemporal interictal spikes; SPS colocalized with CPS in 4 patients (57%), SPS were contralateral to CPS in 2 patients, and 1 patient had bilateral independent CPS but unilateral SPS. SPS accompanied by EEG ictal changes conveyed a favorable prognosis in patients who underwent epilepsy surgery. Scalp/sphenoidal recorded IIS but were less reliable in identifying the location of CPS onset in patients with bitemporal spikes.     

Benign Occipital Epilepsy: A Family Study

Benign occipital epilepsy is a newly recognized form of partial epilepsy in children. It is characterized by motor seizures preceded in some cases by visual symptoms and a relatively benign course. We present three siblings with this condition and a fourth with the EEG abnormalities. A family study including 25 relatives demonstrated a typical EEG abnormality in 26% of relatives. These EEG changes were more evident in younger members. These findings suggest an autosomal dominant pattern for the EEG abnormalities with age-dependent expression and variable penetrance of the seizure disorder.     

颞-枕叶交界区癫痫的致痫区定位研究

目的 探讨颞-枕叶交界区癫痫的脑电图、电临床症状学特点及其在致痫区定位诊断中的意义.方法 7例怀疑颞-枕叶交界区癫痫的患者,进行了长程视频脑电图监测,根据电生理及头颅MRI结果,进行术前评估及颞-枕叶交界区病灶切除,随访1年.结果 (1)发作起始的症状和体征:所有患者无论病史和监测中均无初级视幻觉,7例中2例有视错觉或复杂视幻觉;快速眨眼(有或无发作先兆)做为发作起始的体征见于6例患者中;(2)头皮脑电图间歇期癫痫样放电位于双侧4例,同侧颞-枕区2例,同侧颞区1例;头皮脑电图发作期7例中5例发作起始表现为弥漫性放电,无侧向性,1例位于同侧后头部,1例为同侧颞区;(3)手术及预后:7例患者中5例行颞-枕交界区病灶切除术,2例术后完全无发作,1例术后有偶发先兆,2例患者术后发作未减少;另外2例未接受外科治疗.结论 发作起始期先兆症状学可为颞-枕叶交界区癫痫致痫区定位诊断提供重要线索,而头皮脑电图间歇期和发作期癫痫放电对颞-枕叶交界区癫痫致痫区定位只能提供参考线索.正确和充分的颅内电极(特别是深部电极)置入并记录发作期颅内电极脑电图改变,对发作起始区的定位诊断可能提供更重要的资料.     

Visual Abnormalities and Occipital EEG Discharges: Risk Factors for West Syndrome

Summary: Seventeen infants (7 boys and 10 girls) with visual abnormalities (such as poor tracking and following and nystagmoid eye movement) and occipital slow activities with irregular polyspikes on EEG were studied. Two thirds of the children showed development of West syndrome with hypsarrhythmia on follow-up EEG. In 1 child, hypsarrhythmia was evident on the follow-up EEG, but no clinical seizures occurred. Because most of the children in our series developed West syndrome, patients with visual abnormalities associated with occipital EEG discharges in early infancy may be at high risk for West syndrome. Occipital abnormalities in early infancy may relate to the occurrence of West syndrome.     

Mesial Temporal Lobe Epilepsy: Clinical Features and Seizure Mechanism

Summary: To study the clinical features of mesial temporal lobe epilepsy, 24 cases were selected based on two criteria: (a) the origin of seizure was localized to the mesiotemporal region on phase 2 monitoring, and (b) a class 1 or 2 postoperative result was obtained after selective mesiotemporal resection. A history of febrile convulsion, particularly in the form of status epilepticus, seems to be a prognostic factor. As for presurgical evaluation, electroencephalography (EEG), magnetic resonance imaging (MRI), magnetoencephalography (MEG), and ictal single-photon emission-computed tomography (SPECT) are important tests. Recording of spontaneous seizures by means of intracranial electrodes is the most reliable for diagnosis. Ammon's horn sclerosis and mesial temporal sclerosis are the most frequent pathologic findings. The seizure mechanism was studied by means of depth EEG recordings and ictal SPECT. The hippocampal formation is more responsible than the amygdala for the origin of seizures. Preferential pathways for seizure spread may be the fornix and stria terminalis, amygdalofugal fibers, and uncinate fasciculus. The concept of mesial temporal lobe epilepsy is valid for selecting medically refractory but surgically remediable patients for surgical treatment.     

Temporal Lobe Epilepsy in Early Childhood

To explore the electroclinical features of temporal lobe epilepsy (TLE) in early childhood, we studied results of video-EEG and other tests of 14 children aged 16 months to 12 years selected by seizure-free outcome after temporal lobectomy. Four children had mesiotemporal sclerosis, 1 had cortical dysplasia, and 9 had low-grade temporal neoplasms. The children had complex partial seizures (CPS) with symptomatology similar to that of adults with TLE, including decreased responsiveness and automatisms. Automatisms tended to be simpler in the younger children, typically limited to lip smacking and fumbling hand gestures. Scalp/sphenoidal EEC showed anterior/inferior temporal interictal sharp waves and unilateral temporal seizure onset in the 4 children with mesiotemporal sclerosis and in the child with cortical dysplasia, but EEG findings in 9 children with low-grade temporal tumors were complex, including multifo-cal interictal sharp waves or poorly localized or falsely lateralized EEG seizure onset. In children without tumors, video-EEG was critical to localization of the epi-leptogenic zone for resection, but in patients with tumors video-EEG was less localizing and its main value was to confirm that the reported behaviors were epileptic seizures with semiology typical of temporal lobe onset.     

Occipital Lobe Seizures Related to Clinically Asymptomatic Celiac Disease in Adulthood

We report the electroclinical ictal findings of four epileptic patients with clinically asymptomatic celiac disease (CD). Celiac disease diagnosis was suspected by past history and/or computed tomography (CT) findings in all patients and confirmed by laboratory tests and jejunal biopsy. All patients had paroxysmal visual manifestations and ictal EEG discharges arising from the occipital lobe. Epilepsy evolution was favorable in two patients and severe in 2, regardless of CT evidence of occipital corticosubcortical calcifications in 2 patients. Occipital lobe seizures may be characteristic of the epilepsy related to CD, and epileptic patients with these seizures of unknown etiology should be carefully investigated for malabsorption. If past history and/or laboratory tests suggest gastrointestinal (GI) dysfunction they should also undergo small intestinal biopsy even if they do not have GI tract symptoms.     

Occipital Paroxysmal Discharges Suppressed By Eye Opening: Variability in Clinical and Seizure Manifestations in Childhood

Summary: The EEG in childhood epilepsy with occipital paroxysms (CEOP) was termed "distinctive" by Gastaut (1985) and Talwar et al. (1992) and "characteristic" by Herranz Tanarro et al. (1984), which suggests that the EEG is specific and diagnostic for CEOP. However, this hypothesis has been challenged (Newton and Aicardi, 1983; Beaumanoir and Grandjean, 1987). To test this, we reviewed 5,291 EEG reports made in 51/2 years in the only tertiary pediatric center in Newfoundland and Labrador. We identified 31 children who had one or more EEGs with occipital spike/sharp waves showing suppression of discharges with eye opening and normal background activity. Six had CEOP, 17 had benign nocturnal childhood occipital epilepsy, 5 had symptomatic epilepsy, 3 had unusual complex partial seizures (CPS), 4 had only provoked seizures, and 2 had no definite seizures. Overlap between seizure types was common. The EEG criteria for CEOP are not very specific.     

Dreams and Epilepsy

The relationship between dreams and epilepsy is illustrated by two patients whose awake epileptic seizures and recurrent dreams during night sleep had similar content. In both of our cases the EEG showed right anterior temporal spike discharge, suggesting a role for the temporal lobe in the association between dreams and seizures.