Ictal fear in temporal lobe epilepsy: surgical outcome and focal hippocampal changes revealed by proton magnetic resonance spectroscopy imaging

Non-angry aggressive arousal and angriffsberietschaft: A narrative review of the phenomenology and physiology of proactive/offensive aggression motivation and escalation in people and other animals

Human aggression typologies largely correspond with those for other animals. While there may be no non-human equivalent of angry reactive aggression, we propose that human proactive aggression is similar to offense in other animals' dominance contests for territory or social status. Like predation/hunting, but unlike defense, offense and proactive aggression are positively reinforcing, involving dopamine release in accumbens. The drive these motivational states provide must suffice to overcome fear associated with initiating risky fights. We term the neural activity motivating proactive aggression "non-angry aggressive arousal", but use "angriffsberietschaft" for offense motivation in other animals to acknowledge possible differences. Temporal variation in angriffsberietschaft partitions fights into bouts; engendering reduced anti-predator vigilance, redirected aggression and motivational over-ride. Increased aggressive arousal drives threat-to-attack transitions, as in verbal-to-physical escalation and beyond that, into hyper-aggression. Proactive aggression and offense involve related neural activity states. Cingulate, insular and prefrontal cortices energize/modulate aggression through a subcortical core containing subnuclei for each aggression type. These proposals will deepen understanding of aggression across taxa, guiding prevention/intervention for human violence.

The localization and lateralization of fear aura and its surgical prognostic value in patients with focal epilepsy

OBJECTIVE

Fear aura has traditionally been considered relevant to epileptic discharges from mesial temporal areas, and few studies have investigated its effect on surgical outcome in drug-resistant epilepsy. We aim to assess the localizing and lateralizing value as well as prognostic significance of fear aura in patients with focal epilepsy.

METHODS

The occurrence of fear aura in relation to epileptogenic origin and its association with postoperative outcome were analyzed in 146 consecutive patients undergoing resective surgery for intractable epilepsy.

RESULTS

Ninety-four (64.4%) patients reported auras, and 31 (21.2%) reported fear aura in their seizures. One hundred ten (75.3%) patients had an Engel class I outcome until last follow-up, of whom 24 experienced fear aura preoperatively. Fear aura appeared more frequently during temporal and frontal lobe seizures, but did not lateralize the seizure onset zone. There were no significant baseline differences between patients with and without fear aura. No correlation was found between postoperative outcome and the presence of auras. Occurrence of fear aura failed to show predictive value in surgical outcome whether in pooled or subgroup analysis.

INTERPRETATION

This study advances our understanding of the origin of fear aura, and is helpful for presurgical evaluation and outcome prediction. Without lateralizing value, fear aura is more commonly seen with temporal or frontal origin. When taken as a whole, auras do not have a significant impact on seizure outcome in focal epilepsy. Patients with fear aura are no more likely to become seizure-free than those without fear aura.

Usefulness of magnetic resonance spectroscopy in mesial temporal sclerosis: a systematic review

BACKGROUND

Magnetic resonance spectroscopy (MRS) provides non-invasive information about metabolic features in different regions of the brain affected by mesial temporal sclerosis (MTS).

PURPOSE

To review articles analyzing the most common alterations in biochemical parameters in MTS and the applications of MRS in presurgical assessment.

METHODS

We undertook a systematic literature search for MRS in MTS in PubMed, SCOPUS, and Cochrane based on the MESH terms ""Magnetic Resonance Spectroscopy", "Proton Magnetic Resonance Spectroscopy", "Carbon-13 Magnetic Resonance Spectroscopy", "1H-MRS", "31P-MRS", "mesial temporal sclerosis", "hippocampal sclerosis", "mesial temporal seizure", and "mesial temporal epilepsy".

RESULTS

Of the initial 134 articles found, 30 were selected after the exclusion process. Of these, 13 detected a decrease in N-acetylaspartate (NAA), 9 showed a decreased in the ratio NAA/Cho+Cr, and 8 demonstrated a decreased in the ratio NAA/Cr, all of them in the ipsilateral hippocampus. Nine studies also found reduced NAA levels in extrahippocampal regions.

CONCLUSIONS

The main findings were a decrease in NAA in the ipsilateral hippocampus. In addition, NAA levels were low outside the hippocampus so MTS could be a more extensive disease. Patients without MTS also presented a decrease in NAA in the ipsilateral hippocampus although NAA was even lower in the MTS patients. Thus, MRS could be useful in the presurgical evaluation to locate the epileptogenic focus, but not specific for the diagnosis of MTS.

Peri-Ictal and Para-Ictal Psychiatric Phenomena: A Relatively Common Yet Unrecognized Disorder

Patients with epilepsy can experience different neuropsychiatric symptoms related (peri-ictal) or not (interictal) with seizures. Peri-ictal symptoms can precede (pre-ictal) or follow (post-ictal) the seizure, or even be the expression of the seizure activity (ictal). Neuropsychiatric symptoms, such as irritability and apathy, are among the most frequent pre-ictal manifestations. Ictal fear is reported by around 10% of patients with focal seizures, and sometimes can be difficult to differentiate from panic attacks. Post-ictal anxiety, mood and psychotic symptoms are also frequently reported by patients. Peri-ictal phenomena can occur as isolated symptom or as a cluster of symptoms, sometimes resembling a full-blown psychiatric syndrome. Actually, peri-ictal and interictal neuropsychiatric manifestations seem to be closely associated.

Amygdala levels of the GluA1 subunit of glutamate receptors and its phosphorylation state at serine 845 in the anterior hippocampus are biomarkers of ictal fear but not anxiety

Fear is a conscious state caused by exposure to real or imagined threats that trigger stress responses that affect the body and brain, particularly limbic structures. A sub-group of patients with mesial temporal lobe epilepsy related to hippocampus sclerosis (MTLE-HS) have seizures with fear, which is called ictal fear (IF), due to epileptic activity within the brain defensive survival circuit structures. Synaptic transmission efficacy can be bi-directionally modified through potentiation (long-term potentiation (LTP)) or depression (long-term depression (LTD)) as well as the phosphorylation state of Ser831 and Ser845 sites at the GluA1 subunit of the glutamate AMPA receptors, which has been characterized as a critical event for this synaptic plasticity. In this study, GluA1 levels and the phosphorylation at Ser845 and Ser831 in the amygdala (AMY), anterior hippocampus (aHIP) and middle gyrus of temporal neocortex (CX) were determined with western blots and compared between MTLE-HS patients who were showing (n = 06) or not showing (n = 25) IF. Patients with IF had an 11% decrease of AMY levels of the GluA1 subunit (p = 0.05) and a 21.5% decrease of aHIP levels of P-GluA1-Ser845 (p = 0.009) compared to patients not showing IF. The observed associations were not related to imbalances in the distribution of other concomitant types of aura, demographic, clinical or neurosurgical variables. The lower levels of P-GluA1-Ser845 in the aHIP of patients with IF were not related to changes in the levels of the serine/threonine-protein phosphatase PP1-alpha catalytic subunit or protein kinase A activation. Taken together, the GluA1 subunit levels in AMY and P-GluA1-Ser845 levels in the aHIP show an overall accuracy of 89.3% (specificity 95.5% and sensitivity 66.7%) to predict the presence of IF. AMY levels of the GluA1 subunit and aHIP levels of P-GluA1-Ser845 were not associated with the psychiatric diagnosis and symptoms of patients. Taken together with previous findings in MTLE-HS patients with IF who were evaluated by stereotactic implanted depth electrodes, we speculate our findings are consistent with the hypothesis that AMY is not a centre of fear but together with other sub-cortical and cortical structures integrates the defensive circuit that detect and respond to threats. This is the first report to address neuroplasticity features in human limbic structures connected to the defensive survival circuits, which has implications for the comprehension of highly prevalent psychiatric disorders and symptoms.

Panic and epilepsy in adults: A systematic review

The purpose of the current paper was to review the empirical literature on the cooccurrence of panic and epilepsy, in order to determine whether there is an increased risk of panic attacks and panic disorder among adults with epilepsy and an increased risk of epilepsy among adults with panic disorder. Given the overlap between panic and ictal fear, a preliminary aim of the current review was to critically evaluate the methodology used to differentiate between diagnoses of panic disorder and epilepsy in existing research. A literature search was conducted in relevant electronic databases, and articles that directly focused on panic and epilepsy among adults were selected for the current review (n = 17). Overall, results suggest that rates of epilepsy are elevated among individuals with panic disorder and that panic attacks are elevated among individuals with epilepsy, but rates of panic disorder among people with epilepsy are inconsistent. However, most studies did not use sufficiently rigorous methods to differentiate between panic disorder and epilepsy. Therefore, a critical next step in this area of research is to develop a standard procedure for differentiating ictal fear from panic attacks and panic disorder.

Correlation between extreme fear and focal cortical dysplasia in anterior cingulate gyrus: Evidence from a surgical case of refractory epilepsy

Localizing the semiology of ictal fear and seizure onset in epilepsy patients is commonly challenging due to limited value of routine electroencephalography (EEG) and very few surgical attempts. Here we reported a case of refractory epilepsy characterized by aura of extreme fear and hypermotor seizures, in which the left (dominant hemisphere) anterior cingulate gyrus (ACG) was determined to be the epileptogenic zone (EZ) through multiple modalities of presurgical evaluation including analysis of high frequency oscillation on intracranial EEG. Tailored resection of EZ was thus performed and pathological examination revealed focal cortical dysplasia (FCD) type IIb. The patient has been seizure free during an 18-month follow-up. The report has provided novel anatomical, electrophysiological and surgical evidences suggesting the critical role of ACG in ictal fear and possibility of surgical management of fear-manifesting refractory epilepsy.

Anxiety disorders in people with epilepsy

Anxiety disorders are frequent, though probably underdiagnosed, comorbidities in epilepsy. Epilepsy and anxiety may share common neurobiological correlates as shown in animal models and suggested by studies demonstrating anxiety disorders before the manifestation of epilepsy. Comorbid anxiety disorders have a major impact on the affected patients' quality of life and may increase the risk for suicidality. Successful treatment of the epilepsy may alleviate anxiety symptoms. Treatment of anxiety is based on selective serotonin reuptake inhibitors, benzodiazepines (although only as second-line choices), and psychotherapy. Specific AEDs (especially pregabalin) have been shown to have anxiolytic properties. This paper is aimed at reviewing anxiety disorders in patients with epilepsy discussing current scientific evidence about pathophysiology, clinical aspects, and treatment strategies.

Epilepsy-induced behavioral changes during the ictal phase

In epilepsy, experiential phenomena and behavioral manifestations may pose a number of problems in terms of differential diagnosis. From a clinical point of view, ictal psychiatric symptoms represent partial seizures, mainly partial ones. In the majority of cases, they are very brief (lasting from a few seconds to a few minutes), stereotyped, out of context, and frequently associated with subtle or overt automatisms and postictal confusion of variable duration. In some cases, such symptoms are followed by alteration of consciousness as the ictus evolves to a complex partial seizure or a generalized tonic-clonic seizure. This paper reviews clinically relevant behavioral patterns during seizures discussing clinical phenomenology and relevance in terms of lateralizing value.

Temperament and character traits in patients with epilepsy: epileptic personality

Personality and behavioral changes in epilepsy are well documented. However, neither the quantitative characteristics nor the etiology of these changes is clear yet. Cloninger has developed a psychobiological personality model that provides a way to evaluate personality in a dimensional way. This study examined the relationship between epilepsy and Cloninger's dimensional psychobiological personality model. A total of 73 epilepsy outpatients and 79 healthy controls were examined using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders, the Turkish version of the Temperament and Character Inventory, and an epilepsy questionnaire. Epilepsy patients had higher harm avoidance (HA) and lower persistence, self-directedness (SD), and cooperativeness scores than healthy controls did. In epileptic subjects, there was no correlation between age and duration of epilepsy. Subjects with partial seizures had higher HA scores and lower SD scores than generalized ones. Comorbid depression was represented with lower SD scores. In multiple linear regression models, only major depressive disorder predicted lower scores of SD. This study confirms specific personality changes among epileptics according to Cloninger's dimensional personality model and indicates a relationship between the characteristics of epilepsy and psychiatric comorbidity.

Ictal fear auras after selective amygdalohippocampectomy: the use of ictal SPECT and scalp EEG in the presurgical reevaluation

The perception of fear aura in complex partial seizures is linked to epileptic discharges within mesial temporal lobe structures. Although selective amygdalohippocampectomy often leads to favorable seizure control, persistence of fear auras after surgery can hamper quality of life significantly. We describe two patients with persistent fear auras after selective amygdalohippocampectomy who had to be reevaluated for a second operative procedure. In one patient, ictal SPECT revealed focal hyperperfusion within the left temporal pole. In the other patient, localization of the focus was possible with ictal scalp EEG, which revealed closely time-related focal theta activity in the right frontotemporal electrodes. Both patients underwent a second surgery leading to complete remission. The persistence of fear auras after selective amygdalohippocampectomy provides an example of involvement of a complex neuronal network in the generation of this emotional state during mesiotemporal lobe seizures. Ictal SPECT or ictal scalp EEG may be valuable in identifying the involved areas and in guiding the surgeon to render these patients seizure free.

Temporal lobe epilepsy in children

The temporal lobe is a common focus for epilepsy. Temporal lobe epilepsy in infants and children differs from the relatively homogeneous syndrome seen in adults in several important clinical and pathological ways. Seizure semiology varies by age, and the ictal EEG pattern may be less clear cut than what is seen in adults. Additionally, the occurrence of intractable seizures in the developing brain may impact neurocognitive function remote from the temporal area. While many children will respond favorably to medical therapy, those with focal imaging abnormalities including cortical dysplasia, hippocampal sclerosis, or low-grade tumors are likely to be intractable. Expedient workup and surgical intervention in these medically intractable cases are needed to maximize long-term developmental outcome.

Hyperventilation-induced ictal fear in nonlesional temporal lobe epilepsy

Hyperventilation is a traditional seizure-provoking procedure used mainly in idiopathic generalized epilepsy and with a relatively limited role in partial epilepsy. Ictal fear is a rare seizure semiology seen in temporal lobe epilepsy. It has been suggested that the amygdala and anterior hippocampus are involved in generating ictal fear. We describe a rare patient with nonlesional temporal epilepsy who, while hyperventilating during an electroencephalography recording, developed complex partial seizures presenting as ictal fear. The particular sensitivity of the anterior hippocampus (probably the amygdala) to hypocapnia might be an important factor contributing to seizures. To avoid misdiagnosing this unusual condition as a pseudo-seizure, a detailed history and seizure semiology, as well as a concurrent electroencephalography recording, are mandatory.

Mimetic automatisms expressing a negative affect in two patients with temporal lobe epilepsy

Ictal automatisms of fear or sadness, of which the patient is unaware and which are not preceded by a corresponding emotion, have not been well characterized. Of 557 patients admitted for video/EEG monitoring, 2 (0.36%) were identified who had automatisms of fear and sadness. One patient was found to have a sudden ictal expression of sadness of which he was not aware. The second patient showed a sudden fearful expression, followed by oral automatisms, staring, and amnesia for the event. Both patients had left mesial temporal lobe epilepsy. The patient with ictal fear underwent further invasive monitoring and became seizure free after a limited mesial temporal resection. The mesial temporal structures not only mediate emotional experiences, but can also activate stereotyped expressions of fear or sadness without the patient's awareness, arguing for an efferent pathway for expressing negative affects within the mesial temporal lobe.

Impaired extinction of fear and maintained amygdala-hippocampal theta synchrony in a mouse model of temporal lobe epilepsy

PURPOSE

The relationship between epilepsy and fear has received much attention. However, seizure-modulated fear and physiologic or structural correlates have not been examined systematically, and the underlying basics of network levels remain unclear to date. Therefore, this project was set up to characterize the neurophysiologic basis of seizure-related fear and the contribution of the amygdala-hippocampus system.

METHODS

The experimental strategy was composed of the following steps: (1) use of the mouse pilocarpine model of temporal lobe epilepsy (TLE); (2) behavioral analyses of anxiety states in the elevated plus maze test, light-dark avoidance test, and Pavlovian fear conditioning; and (3) probing neurophysiologic activity patterns in amygdala-hippocampal circuits in freely behaving mice.

RESULTS

Our results displayed no significant differences in basic anxiety levels comparing mice that developed spontaneous recurrent seizures (SRS) and controls. Furthermore, conditioned fear memory retrieval was not influenced in SRS mice. However, during fear memory extinction, SRS mice showed an extended freezing behavior and a maintained amygdala-hippocampal theta frequency synchronization compared to controls.

DISCUSSION

These results indicate specific alterations in conditioned fear behavior and related neurophysiologic activities in the amygdala-hippocampal network contributing to impaired fear memory extinction in mice with TLE. Clinically, the nonextinguished fear memories may well contribute to the experience of fear in patients with TLE.

Phenomenology of hallucinations, illusions, and delusions as part of seizure semiology

In partial epilepsy, a localized hypersynchronous neuronal discharge evolving into a partial seizure affecting a particular cortical region or cerebral subsystem can give rise to subjective symptoms, which are perceived by the affected person only, that is, ictal hallucinations, illusions, or delusions. When forming the beginning of a symptom sequence leading to impairment of consciousness and/or a classic generalized seizure, these phenomena are referred to as an epileptic aura, but they also occur in isolation. They often manifest in the fully awake state, as part of simple partial seizures, but they also can be associated to different degrees of disturbed consciousness. Initial ictal symptoms often are closely related to the physiological functions of the cortical circuit involved and, therefore, can provide localizing information. When brain regions related to sensory integration are involved, the seizure discharge can cause specific kinds of hallucinations, for example, visual, auditory, gustatory, olfactory, and cutaneous sensory sensations. In addition to these elementary sensory perceptions, quite complex hallucinations related to a partial seizure can arise, for example, perception of visual scenes or hearing music. By involving psychic and emotional spheres of human perception, many seizures also give rise to hallucinatory emotional states (e.g., fear or happiness) or even more complex hallucinations (e.g., visuospatial phenomena), illusions (e.g., déjà vu, out-of-body experience), or delusional beliefs (e.g., identity change) that often are not easily recognized as epileptic. Here we suggest a classification into elementary sensory, complex sensory, and complex integratory seizure symptoms. Epileptic hallucinations, illusions, and delusions shine interesting light on the physiology and functional anatomy of brain regions involved and their functions in the human being. This article, in which 10 cases are described, introduces the fascinating phenomenology of subjective seizure symptoms.

Ictal EEG remains the prominent predictor of seizure-free outcome after temporal lobectomy in epileptic patients with normal brain MRI

PURPOSE

While an abnormal pre-operative high-resolution brain MRI portends a favorable outcome in patients undergoing resective epilepsy surgery for medically intractable localization-related epilepsy (LRE), a normal MRI is less favorable. Ascertaining desirable pre-operative predictors for successful anterior temporal lobectomy (ATL) in LRE patients with a normal brain MRI is essential to better anticipate surgical outcome.

METHODS

Patients with LRE and normal temporal structures on MRI underwent ATL at two epilepsy centers in the southeastern US (FL and NC). Outcome was separated into those patients that were seizure free (SF), and those that were not seizure free (NSF), and those NSF were stratified in accordance with the Engel classification system. Those with a pre-operative history of clinical risk factors, unilateral anterior temporal interictal epileptiform discharges (IEDs), well localized scalp ictal EEG with rhythmic temporal theta at onset, localized PET/ictal SPECT, and Wada asymmetry with >2.5/8, were evaluated for the purpose of predicting outcome. Where appropriate, data is presented as a median (mean +/- S.D.).

RESULTS

Thirty-nine patients, median age 33 years, were followed up 2 years (3+/-1.2) after ATL. Overall, 22/39 (56.4%) patients were identified as SF, and 17/39 (43.6%) patients were NSF. Ictal EEG with rhythmic temporal theta at onset was the only predictive measure of seizure-free outcome (p=0.001, Fisher's exact test), and also favorably correlated with seizure reduction (p=0.0001, r(2)=0.34, multiple regression analysis). None of the other predictors examined added greater predictive value.

CONCLUSIONS

ATL is a favorable option for patients with LRE even when high-resolution brain MRI reveals normal temporal structures. Normal brain MRI patients with localizing pre-operative scalp ictal EEG, have better outcomes following ATL.

Gustav Flaubert's "nervous disease": an autobiographic and epileptological approach

More than 20 years ago, complex partial epilepsy of occipital-temporal origin was suggested as having been the "nervous disease" of Gustave Flaubert, one of the most famous French novelists. The aim of the present work, therefore, was to reevaluate the diagnosis of Flaubert's "nervous disease" in the light of reemerged biographic information and letters, as well as the numerous scientific advances in epilepsy and its psychopathology in recent years. If the semiology of the reported attacks is considered, epilepsy ranks among the most probable diagnoses. In our opinion, psychopathological considerations suggest primary involvement of mesial temporal lobe structures with typical findings of ictal and interictal mood behavior.

Temperament and character factors in Korean children with seizure disorders

Although the organic and psychosocial consequences of seizure disorders are thought to affect temperament and character patterns, these patterns in children with seizure disorders have not yet been investigated. We therefore investigated temperament and character patterns in Korean children with seizure disorders and their associations with seizure-related variables. The Korean version of the Junior Temperament and Character Inventory was used to assess temperament and character factors of 65 children with seizure disorders (32 boys, 33 girls; mean age, 10.6 +/- 1.8 years) and 65 healthy controls matched for age and sex. Children with seizure disorders showed higher harm avoidance, and lower persistence, self-directedness, and cooperativeness than controls. In children with seizure disorders, character factors such as self-directedness, cooperativeness, and self-transcendence were significantly associated with seizure type, and cooperativeness was correlated with seizure severity. Novelty seeking and self-directedness were correlated with paternal educational level and parental economic status, respectively. These findings suggest that children with seizure disorders have distinctive temperament and character patterns, with seizure type being the most influential factor modulating character patterns.

Ictal fear: semiologic characteristics and differential diagnosis with interictal anxiety disorders

INTRODUCTION: Ictal fear (IF) is one of the most frequent emotional auras. It is the sole or predominant manifestation of simple partial seizures or initial expression of a complex partial seizure. It is more often experienced in patients with mesial temporal lobe epilepsy (TLE), probably associated with mesial temporal structures, like the amygdala. Anxiety disorders are very common psychiatric disorders associated with epilepsy, with a prevalence of 15 to 25%. OBJECTIVES: To describe three patients with IF with refractory mesial TLE, also presenting the results of EEG, imaging exams, neuropsychological, quality of life and psychiatric evaluations. METHODS AND RESULTS: Three case reports of patients with refractory mesial TLE and IF followed up in the outpatient's clinic at the Epilepsy Section, Universidade Federal de São Paulo, Brazil, were submitted to presurgical evaluation and corticoamygdalohippocampectomy. Two patients presented ictal scalp-sphenoidal EEG onset on left side. Two patients had major depressive disorder in psychiatric evaluation. CONCLUSION: Although IF is the most frequent ictal psychological symptom, anxiety and mood disorders are very common psychiatric comorbidity in patients with epilepsy. It was concluded that differential diagnosis of interictal anxiety disorders, panic attacks and IF can be difficult, and requires careful management.

Investigation of social and emotion information processing in temporal lobe epilepsy with ictal fear

This study examined whether patients with temporal lobe epilepsy (TLE) and ictal fear (IF) show emotion recognition deficits similar to those associated with amygdala damage. Three groups of patients (13 with TLE and IF, 14 with TLE and nonfear auras (non-IF), and 10 with idiopathic generalized epilepsy (IGE)) completed tests of visual and face processing, face emotion recognition and social judgment, together with measures of psychological adjustment (Hospital Anxiety and Depression Scale; SCL-90-R) and Quality of Life (QOLIE-31). All three epilepsy groups had fear recognition deficits, with relatively greater impairments in the IF group. Fear recognition deficits were associated with impaired social judgment of trustworthiness, duration of epilepsy, and a measure of quality of life. Social cognition impairments previously associated with amygdala dysfunction are also a feature of the neuropsychology of TLE, and extend the hypothesis in that they may additionally play a role in IGE.

Consciousness, epilepsy, and emotional qualia

The last decade has seen a renaissance of consciousness studies, witnessed by the growing number of scientific investigations on this topic. The concept of consciousness is central in epileptology, despite the methodological difficulties concerning its application to the multifaced ictal phenomenology. The authors provide an up-to-date review of the neurological literature on the relationship between epilepsy and consciousness and propose a bidimensional model (level vs contents of consciousness) for the description of seizure-induced alterations of conscious states, according to the findings of recent neuroimaging studies. The neurophysiological correlates of ictal loss and impairment of consciousness are also reviewed. Special attention is paid to the subjective experiential states associated with medial temporal lobe epilepsy. Such ictal phenomenal experiences are suggested as a paradigm for a neuroscientific approach to the apparently elusive philosophical concept of qualia. Epilepsy is confirmed to represent a privileged window over basic neurobiological mechanisms of consciousness.

Temporal lobe magnetic resonance spectroscopic imaging following selective amygdalohippocampectomy for treatment-resistant epilepsy

OBJECTIVES

Magnetic resonance spectroscopic imaging (MRSI) may show circumscribed or extensive decreased brain N-acetyl aspartate (NAA)/creatine and phosphocreatine (Cr) in epilepsy patients. We compared temporal lobe MRSI in patients seizure-free (SzF) or with persistent seizures (PSz) following selective amygdalohippocampectomy (SAH) for medically intractable mesial temporal lobe epilepsy (mTLE). We hypothesized that PSz patients had more extensive temporal lobe metabolite abnormalities than SzF patients.

MATERIALS AND METHODS

MRSI was used to study six regions of interest (ROI) in the bilateral medial and lateral temporal lobes in 14 mTLE patients following SAH and 11 controls.

RESULTS

PSz patients had more temporal lobe ROI with abnormally low NAA/Cr than SzF patients, including the unoperated hippocampus and ipsilateral lateral temporal lobe.

CONCLUSION

Postoperative temporal lobe MRSI abnormalities are more extensive if surgical outcome following SAH is poor. MRSI may be a useful tool to improve selection of appropriate candidates for SAH by identifying patients requiring more intensive investigation prior to epilepsy surgery. Future prospective studies are needed to evaluate the utility of MRSI, a predictor of successful outcome following SAH.

Emotion recognition from facial expressions in a temporal lobe epileptic patient with ictal fear

Ictal fear (IF) is an affective aura observed in patients with temporal lobe epilepsy. It has been suggested that the amygdala, a region implicated in emotion processing, is involved in generating IF. Several studies have reported that the patients with IF have disturbances in emotional experience, but there has been no testing of the emotional recognition in those patients. In this report, emotion recognition from facial expressions was investigated in a patient with IF. The patient suffered from IF due to temporal lobe epilepsy, and underwent hippocampectomy surgery which completely suppressed IF. We examined the patient before and after surgery. Before surgery, the patient tended to attach enhanced fear, sadness, and anger to various facial expressions. After surgery, such biases disappeared. As an underlying mechanism of the pre-surgical skewed perception of emotional stimuli, the abnormal epileptogenic circuits involving a hypersensitive amygdala possibly due to the kindling mechanism were suggested.

Medical comorbidities in the treatment of epilepsy

The treatment of epilepsy extends far beyond seizure control. Many comorbidities have a significant impact on the medical management and quality of life of patients with epilepsy. In this review, we examine interactions between epilepsy and some common medical conditions. Psychiatric disorders with a high prevalence in epilepsy include mood disorders, anxiety disorders, and psychosis. Depression is common, psychosis occurs both in direct relation to seizures and interictally, and suicide rates are increased. Changes in sexual function and reduced fertility and marriage rates are described, including a discussion of polycystic ovary syndrome, which is increased in women with epilepsy. The effects of other chronic medical comorbid conditions are reviewed, including the effects of antiepileptic medications on bone health and the impact of renal insufficiency on pharmacological therapy of epilepsy.

Future aspects of the presurgical evaluation in epilepsy

Epilepsy surgery is a successful therapeutic approach in patients with medically intractable epilepsy. The presurgical evaluation aims to detect the epileptogenic brain area by use of different diagnostic techniques. In this review article the current diagnostic procedures applied for this purpose are described. The diagnostic armamentarium can be divided conceptually into three different groups: assessment of function/dysfunction, structural/morphologic imaging methods and functional neuroimaging techniques. Properties, diagnostic power and limits of all diagnostic tools used in the diagnostic evaluation are discussed. In addition, future perspectives and the diagnostic value of new technologies are mentioned. Some are increasingly gaining acceptance in the routine preoperative diagnostic procedure like MR volumetry or MR spectroscopy of the hippocampus in patients with temporal lobe epilepsy. Some, on the other hand, like MEG and 11C-flumazenil PET, still remain experimental diagnostic tools as they are technically demanding and cost intensive. Besides the refinement of established techniques, co-registration of different modalities like spike-triggered functional MRI will play an important role in the non-invasive detection of the epileptic seizure focus and may change the regimen of the preoperative diagnostic work up of epilepsy patients in the future.