Post-ictal recognition memory predicts laterality of temporal lobe seizure focus: comparison with post-operative data

Memory response and neuroimaging correlates of a novel cognitive rehabilitation program for memory problems in epilepsy: A pilot study

BACKGROUND

Memory deficits are very common in epilepsy, but no standard of care exists to effectively manage them.

OBJECTIVE

We assessed effectiveness of cognitive rehabilitation (CR) on memory and neural plasticity in people with epilepsy (PWE) reporting memory impairments.

METHODS

Nine PWE completed 6 weekly sessions adapted from 2 generic CR programs enriched with information regarding epilepsy. Participants completed neuropsychological, mood, and quality of life (QOLIE-31) measures prior and after completion of CR; 5/9 participants also completed pre- and post-CR fMRI while performing a verbal paired associates learning task. FMRI data were analyzed using group spatial independent components analysis methods; paired t-tests compared spatial activations for pre-/post-CR.

RESULTS

Improvements were seen in immediate recall in Rey Auditory Verbal Learning Task, QOLIE-31, and read word recognition in paired associates task (all p's≤0.05). FMRI changes comparing pre-to-post CR were noted through increased activation in the left inferior frontal gyrus (IFG) and anterior cingulate and decreased activation in the left superior temporal gyrus; also noted were decreased activations in the default mode network (DMN), right cingulate, right middle temporal gyrus, right supramarginal gyrus, and increased DMN activation in the left cuneus.

CONCLUSIONS

This study demonstrates feasibility of conducting CR program in PWE with fMRI as a mechanistic biomarker. Improvements in cognition and cortical plasticity await confirmation in larger samples.

Memory Decline Following Epilepsy Surgery: Can We Predict Who Will Pay the Price?

Postoperative Memory Prognosis in Temporal Lobe Epilepsy Surgery: The Contribution of Postictal Memory

Sveikata L, Kavan N, Pegna AJ, et al. Epilepsia. 2019;60(8):1639-1649. doi:10.1111/epi.16281. Epub July 22, 2019. PMID: 31329286.

Objective:

The prediction of verbal memory decline after temporal lobe epilepsy (TLE) surgery remains difficult at an individual level. We evaluated the prognostic value of postictal memory testing in predicting the postoperative verbal memory function.

Methods:

Sixty-three consecutive patients were included in the analysis who underwent TLE surgery at our center with preoperative interictal/postictal and postoperative memory testing. Verbal memory was evaluated using the Rey Auditory Verbal Learning Test (RAVLT). We used reliable change indices with 90% confidence interval (90% RCIs) to evaluate a significant postoperative memory decline. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and accuracy (ACC) were calculated. The analysis was performed for all patients with TLE and for the subgroup with hippocampal sclerosis (HS).

Results:

Patients with left TLE (n = 31) had lower verbal memory scores on RAVLT than right TLE at 3 months (57% vs 78%) and 12 months (53% vs 78%) after surgery. The 90% RCI was estimated to be a loss of 4 out of 15 items. The predictive value was Sn = 42%, Sp = 84%, PPV = 39%, NPV = 86%, AUC = 0.630, and ACC = 76% to predict a verbal memory decline in the whole group (n = 63). In patients with HS (n = 41), the postictal verbal memory test had Sn = 50%, Sp = 88%, PPV = 50%, NPV = 88%, AUC = 0.689, and ACC = 81% to predict a significant postoperative decline.

Significance:

Postictal memory is a noninvasive bedside memory test that can help predict the postoperative verbal memory decline in patients with HS with an overall ACC of 81%.

Postoperative memory prognosis in temporal lobe epilepsy surgery: The contribution of postictal memory

OBJECTIVE

The prediction of verbal memory decline after temporal lobe epilepsy (TLE) surgery remains difficult at an individual level. We evaluated the prognostic value of postictal memory testing in predicting the postoperative verbal memory function.

METHODS

Sixty-three consecutive patients were included in the analysis who underwent TLE surgery at our center with preoperative interictal/postictal and postoperative memory testing. Verbal memory was evaluated using the Rey Auditory Verbal Learning Test (RAVLT). We used reliable change indices with 90% confidence interval (90% RCIs) to evaluate a significant postoperative memory decline. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and accuracy (ACC) were calculated. The analysis was performed for all TLE patients and for the subgroup with hippocampal sclerosis (HS).

RESULTS

Left-TLE patients (n = 31) had lower verbal memory scores on RAVLT than right-TLE at 3 months (57% vs 78%) and 12 months (53% vs 78%) after surgery. The 90% RCI was estimated to be a loss of 4 out of 15 items. The predictive value was Sn = 42%, Sp = 84%, PPV = 39%, NPV = 86%, AUC = 0.630, and ACC = 76% to predict a verbal memory decline in the whole group (n = 63). In HS patients (n = 41), the postictal verbal memory test had Sn = 50%, Sp = 88%, PPV = 50%, NPV = 88%, AUC = 0.689, and ACC = 81% to predict a significant postoperative decline.

SIGNIFICANCE

Postictal memory is a noninvasive bedside memory test that can help predict the postoperative verbal memory decline in patients with HS with an overall accuracy of 81%.

Interictal and postictal performances on dichotic listening test in children with focal epilepsy

Dichotic listening test (DL) is an important tool to disclose speech dominance in healthy subjects and in clinical cases. The aim of this study was to probe if focal epilepsy in children reveals a corresponding suppression of the ear reports contralateral to seizure onset site. Thus, 15 children and adolescents with clinically and electroencephalographically diagnosed focal epilepsy selected for left-hemisphere speech dominance without mental retardation were compared to matched controls according to age, gender, IQ and handedness. All children were assessed with DL for three times: Interictally (t(0)), postictally 5' (t(1)) and 1h (t(2)). At t(0), all groups revealed a right ear advantage (REA), indicating a left-hemisphere speech dominance. There was a continuous increase in right correct score (REC) over the trials for normal controls. Five minutes postictally, there was an abrupt decrease in REC with a sustained left ear correct score (LEC) for children with epilepsy, independent of which side suffered from seizures. This effect was maintained even after 1h. Thus, in children with left-hemisphere speech dominance the epileptic discharges caused a suppression of REC regardless of origin. The seizures may have a prolonged impact on attention and auditory perception for a considerable time after consciousness has been regained.

The appropriacy of fluency tests in assessing epileptic seizure lateralization in children with partial epilepsy

Fluency tests are frequently used in clinical practice to asses executive functions. The literature data are not unequivocal although in a great number of papers is pointed out the importance of the left hemisphere, specially of the left frontal lobes in the mediation of phonological fluency and the right hemisphere in the mediation of nonverbal fluency. This paper considers the suitability of fluency tests for the detection of left versus right seizure laterality. The sample consisted of thirty-two epilepsy patients divided into two groups: LHF-participants with the seizure focus in the left hemisphere (n=16), and DHF-participants with the seizure focus in the right hemisphere (n=16), and K-the control group of t age-matched healthy children (n=50) aged 7-11 years. The qualitative and quantitative comparison of the phonological and nonverbal fluency performance was carried out in consideration of the seizure laterality as well as compared to the healthy controls. The results of phonological fluency performance revealed that the performance of the LHF group was significantly reduced as compared to both DHF and K group. The analysis of nonverbal fluency performance revealed that the performance of the DHF group was significantly reduced as compared to both LHF and K group The qualitative analysis obtained valuable data, which could additionally contribute to the neuropsychological evaluation of the left versus right seizure laterality.

Postictal But Not Interictal Hemispatial Neglect in Patients with Seizures of Lateralized Onset

PURPOSE

Unilateral spatial neglect, defined as a failure to report, respond, or orient to stimuli that are presented contralaterally, has been widely documented after brain damage to right, and to a lesser degree, left frontotemporoparietal networks. Group studies involving patients with seizures with a lateralized focus have demonstrated transient dysfunctions in memory and language; however, so far, only two case reports have described transient neglect after an epileptic seizure.

METHODS

To assess the existence and consistency of this phenomenon, we evaluated 33 epilepsy patients on a line-bisection task in interictal and postictal states as compared with an age- and sex-matched control group.

RESULTS

Spatial neglect, as determined by this test, was found in the postictal but not interictal examination in patients with right parietal epileptic foci and was maximal for the left-positioned lines, whereas no neglect was found in other groups.

CONCLUSIONS

Our findings indicate that patients with right parietal foci can present a transient neglect phenomenon on the line-bisection task in the postictal period, even in the absence of overt clinical neglect signs. These findings might be useful in establishing the laterality and even localization of epileptic foci based on the postictal neuropsychological evaluation.

Neuropsychological differences in epileptic patients with seizures of frontal and temporal lobe origin

This investigation studied the neuropsychological differences in nonsurgical cryptogenic epileptic patients with seizures of frontal and temporal lobe origin, which were classified according to clinical criteria. Fifty-one patients with partial seizures of frontal (n = 15) or temporal (n = 36) lobe origin and 2 matched control groups were administered a battery of neuropsychological tests assessing intelligence, memory, perceptual, and frontal functions. Patients with seizures of temporal lobe onset performed worse than patients with seizures of frontal lobe origin, even in frontal functions. The findings of this study corroborate the low specificity of tasks regarded as frontal lobe tests and the difficulty in detecting frontal lobe neuropsychological focalities.

Primary hyperparathyroidism, cognition, and health-related quality of life

OBJECTIVE

To provide a rigorous and critical review of studies in which formal neuropsychological (NP) testing and measurement of health-related quality of life (HRQL) were conducted pre- and post-parathyroidectomy for primary hyperparathyroidism (PHPT). These data contribute to the discussion on the utility of surgical intervention for nonclassic PHPT.

SUMMARY BACKGROUND DATA

PHPT is a complex endocrinopathy involving calcium metabolism and a potent hormone made by the parathyroid glands. Approximately 1.5% of Americans age 65 years and older, representing more than 3.9 million people, have PHPT, and the prevalence in postmenopausal women is estimated at 3.4%. Current National Institutes of Health guidelines for curative, surgical intervention of PHPT exclude 80% of patients with hyperparathyroid disease who have subjective neurobehavioral and physical symptoms that affect the quality of their lives.

METHODS

An electronic search was conducted of prospective studies in which cognitive functioning was measured with formal NP tests and HRQL was measured with valid and reliable instruments before and following parathyroidectomy for PHPT.

RESULTS

: In studies conducted pre- and post-parathyroidectomy for PHPT, 6 small studies of cognitive functioning report inconsistent findings; however, 7 well-designed studies of HRQL report improvement across multiple domains following surgery.

CONCLUSIONS

Surgical treatment of PHPT is a viable option for patients with laboratory diagnosed, "nonclassic" PHPT. Formal NP testing and evaluation of HRQL are useful tools that may assist physicians in choosing whom to refer for parathyroidectomy. Further longitudinal study of NP functioning and HRQL in patients with laboratory diagnosed PHPT is warranted.

A controlled, prospective study of neuropsychological outcomes post parathyroidectomy in primary hyperparathyroid patients

BACKGROUND

There is an increasing number of primary hyperparathyroidism (PHPT) patients with neuropsychological or psychiatric symptoms. Many of these patients do not have osseous or renal complications to satisfy the criteria for parathyroidectomy according to the NIH guidelines.

OBJECTIVE

To assess whether there is any improvement in neuropsychological and mood symptoms following parathyroidectomy.

PATIENTS AND DESIGN

Twenty PHPT patients undergoing parathyroidectomy and 20 orthopaedic controls matched for age, gender and estimated intelligence were subjects to pre and postoperative assessment of cognition and mood with a mean surgery-retest interval of 3 months.

RESULTS

Using two tests of attentional flexibility [the Stroop test, the Digit symbol test of the Wechsler Adult Intelligence Scale-Revised (WAIS-R)], and two memory tests for prose and nonverbal material, no significant change was found between the groups when comparing scores before and after surgery. There was no improvement between pre and postoperative measures of verbal (dominant hemisphere) as opposed to visuo-spatial (nondominant hemisphere) function when compared to controls. There was no relationship between the reduction in serum calcium and the change in the neuropsychological measures postoperatively.

CONCLUSION

This controlled, prospective study demonstrates no significant improvement in neuropsychological indices using objective, validated psychometric tools in an unselected cohort of PHPT patients. No relationship was found between serum calcium level and the degree of neuropsychological deficit. More studies are needed to assess whether the effect of parathyroidectomy is beneficial and sustainable in PHPT patients with neuropsychological symptoms alone.

The dos and don'ts of neuropsychological assessment in epilepsy

Neuropsychologists have a significant role in the assessment, treatment, and rehabilitation of people with epilepsy. This includes providing an assessment of an individual's cognitive strengths and weaknesses with respect to being a candidate for the surgery program, detailing intellectual and memory impairments as part of a rehabilitation service, and documenting specific antiepileptic drug effects as part of routine clinical management. Each of these specific roles requires careful consideration with respect to the potential pitfalls they can present to the neuropsychologist. In this article, we have attempted to identify the most obvious "dos and don'ts" in the neuropsychological assessment of people with epilepsy. These range from issues relating to the reliance of measures, to the failure to document patients' backgrounds, to the importance of considering the psychometric tests that we use. We have attempted to emphasize the importance or value of a well-conducted neuropsychological assessment to the management of the person with epilepsy.

Short- and long-delay intracranial ERP repetition effects dissociate memory systems in the human brain

Prior exposure to a stimulus can facilitate the performance to subsequent presentations of that stimulus. ERP studies have shown that this facilitation is associated with the modulation of two components (N400 and P600). Investigation of the time course of both behavioral and ERP repetition effects have led to the assumption that it is subserved by the combination of at least two mechanisms operating at different time-points: a short-delay semantic activation and a long-lasting episodic mechanism. The present experiment recorded intracranial ERPs from various structures during a continuous recognition memory task to investigate the respective contribution of the different brain regions to short- and long-delay ERP repetition effects. The results are in good agreement with both the classical neuropsychological literature and the more recent data obtained with functional imagery techniques. They provide electrophysiological evidence of multiple anatomo-functional memory systems in the human brain: a short-term semantic activation system and a long-term episodic memory system, with interface structures that coordinate the functioning of these two systems.

Comprehensive postictal neuropsychology improves focus localization in epilepsy

In recent years, new techniques such as single photon emission computed tomography (SPECT), positron emission tomography (PET) and magnetic resonance imaging (MRI) have been used to improve the localization of epileptic foci during the noninvasive evaluation procedure for epilepsy surgery. Since ictal/or immediate postictal SPECT studies were shown to localize epileptic foci better than interictal SPECT, we addressed the question of whether immediate postictal neuropsychological examination would show the same effect. Neuropsychological examinations were carried out postictally and interictally using a broad range of tests. Postictal results were analyzed with regard to lateralizing and localizing information about the epileptogenic region. Seventeen patients suffering from temporal and extratemporal pharmacoresistant epilepsy were investigated postictally with a subset of tests used for the interictal neuropsychological examination. A significant improvement in focus localization was seen in comparison with interictal neuropsychology (p = 0.014). We conclude that neuropsychology can yield lateralizing and sometimes localizing information, even for extratemporal foci, if carried out during the postictal period and based on a global analysis of the clinical neuropsychological picture.

Location of the epileptic zone and its physiopathological effects on memory-related activity of the temporal lobe structures: a study with intracranial event-related potentials

PURPOSE

Neuropsychological research with epileptic patients has suggested that the location of seizure focus may be an important variable determining the nature and severity of memory impairments. According to this assumption, this study was designed to investigate the effects of the location of the epileptic zone on the memory-related activity recorded directly from different temporal lobe structures.

METHODS

Intracranial event-related potentials (ERPs) were recorded during a continuous recognition memory task, which is known to elicit the modulation of N400 and P600 components (i.e., the ERP old/new effect). The patients were separated into three groups according to the location of their epileptic zone: unilateral temporal (UTE), temporal plus extratemporal (TEE), and bitemporal (BTE). Recordings were obtained from three temporal lobe structures: hippocampus, amygdala, and lateral temporal cortex.

RESULTS

The results showed that in the hippocampus, the ERP old/new effect was abolished in the TEE group only. In the amygdala, although largely unaffected, the ERP modulation appeared to be more impaired in UTE patients. Contrasting with these data is the observation that the magnitude and reliability of the ERP old/new effect recorded at the neocortical level increases as the epileptic zone extends to the temporal lobes (i.e., BTE>TEE>UTE).

CONCLUSIONS

It is concluded that the memory-related activity modulation of memory ERPs recorded from different temporal lobe structures is affected differently by the presence of an epileptic zone as a function of its location. The possible clinical implications of these findings in surgery planning are also discussed.

Memory, simple and complex language, and the temporal lobe

Nineteen patients with intractable temporal lobe epilepsy who underwent anterior temporal lobectomy were given a highly specific memory battery (23 tests) pre- and post- (1 week; 1, 2, and 6 months; 1 and 2 years) resection. Sixteen of 23 tests revealed that memory performance of temporal lobe epilepsy patients was worse than normal controls prior to surgery (p < .001), while the most profound differences were seen in the remembering and generation of inferences from connected discourse. Almost no differences were observed in delayed nonmatching to sample tasks (recognition without language task). MRI results revealed that anterior, middle, and posterior hippocampal abnormality was extensive in 12 of 19 patients, and 12 also showed medial temporal lobe abnormalities and volume loss. Hippocampal damage was negatively correlated with extended delay memory performance for connected discourse: worse performance was associated with greater damage. Few differences in less complex memory performance were observed pre-postsurgery. While ordinary recognition functions were preserved, results demonstrated that dominant medial temporal lobe structures appeared heavily involved in language-generated memory, and hippocampus is heavily implicated in both simple and complex language.

The role of the temporal lobes in recognizing visuospatial materials: remembering versus knowing

Recognition memory for abstract visuospatial designs was assessed in unilateral temporal lobe epilepsy (TLE) patients and normal controls using a remember/know recognition paradigm. Subjects assigned "remember" judgments to recognized items for which they could recall the study presentation, and "know" judgments to items recognized on the basis of familiarity without conscious recollection of the study episode. In Experiment 1 normal controls and left TLE patients gave more "know" than "remember" recognition judgments for visuospatial materials. Right TLE subjects, however, showed the opposite response pattern. Experiment 1a demonstrated that this dissociation between left and right temporal patients occurred in both presurgery and postsurgery patients. In Experiment 2 recognition was assessed following encoding conditions in which subjects answered questions about either the number of lines in the designs or the appropriateness of verbal labels for presented stimuli. The previous pattern of "know" and "remember" responses was replicated for all groups in the line count condition, but was reversed for normal controls in the label condition. These results are interpreted within a theoretical framework in which "remember" responses are based on the contribution of distinctiveness of individual items to recognition whereas "know" judgements reflect perceptual fluency.

Differential involvement of the human temporal lobe structures in short- and long-term memory processes assessed by intracranial ERPs

Intracranial event-related potentials (ERPs) elicited during a recognition memory task were recorded in 25 epileptic patients by using depth electrodes sampling four different regions within the temporal lobe (amygdala, hippocampus, anterior and posterior temporal cortices). The task was a continuous recognition memory task in which repeated items were presented after 6 or 19 intervening items following their first presentation. This study was performed to investigate the respective role of the different temporal lobe structures in short-term memory (STM) and long-term memory (LTM) processing. Subregions of the temporal lobe were differently involved in these two memory systems. The posterior temporal cortex is specifically involved in STM processing, whereas the amygdala, hippocampus, and anterior temporal cortex contribute to both STM and LTM. Moreover, it appeared that the latter structures play their own role in LTM. The anterior temporal cortex and amygdala may contribute to recency discrimination, and the hippocampus seems rather to be involved in maintaining memory traces. These findings suggest that the temporal lobe structures may function in a complementary way by subserving different aspects of information processing.

Functional heterogeneity of the frontal lobe: evidence from intracranial memory ERPs

Intracranial event-related potentials (ERPs) elicited during a recognition memory task were recorded in 17 epileptic patients by using depth electrodes sampling different regions within the frontal lobe. The task was a continuous recognition memory task in which repeated items were presented after six or 19 intervening items following their first presentation. Such a paradigm is one of the experimental tasks requiring both short-term memory and interference control processes which are thought to be subserved by the frontal lobe. The results provide electrophysiological support for the classical view that the frontal lobe is heterogeneous region encompassing a number of functional systems subserving different aspects of memory processing. The anterior dorsolateral and cingulate cortices were found to contribute to short-term memory and recency judgment. The orbital region is more likely to be involved in interference control. The posterior part of the frontal cortex plays a role in some processes related to the control of the motor response.

Intracranial topography of event-related potentials (N400/P600) elicited during a continuous recognition memory task

To isolate the anatomical locus of the neural activity most important for generating or modulating the scalp-recorded N400 and P600 components elicited during continuous recognition memory tasks, intracranial event-related potentials (ERPs) were recorded from medial and lateral aspects of the temporal, frontal, parietal, and occipital lobes in 25 patients undergoing stereoelectroencephalography for seizure localization. Large-amplitude and polarity-inverted ERPs were recorded from various temporal, frontal, and parietal structures, whereas the memory-related ERP modulation assessed by the ERP repetition effect was present only in those brain areas that play the most important role in memory processing. These data suggest that the scalp-recorded N400 and P600 components may represent the most readily observable aspect of synchronous activity occurring across widely distributed brain structures and neural systems underlying different cognitive mechanisms, which all contribute to some aspect of information processing during recognition memory.

Postictal courses of cognitive deficits in focal epilepsies

Patients with epileptic seizures frequently complain of long-lasting cognitive impairment after a seizure. We evaluated this issue in 31 patients with epileptic seizures of a frontal (n = 8) or temporal lobe origin [right temporal lobe (RTL) n = 8/left temporal lobe (LTL) n = 15]. Seizures were secondarily generalized in 18 patients. Computerized testing of verbal and nonverbal recognition memory was performed before the seizure, directly after postictal reorientation, and 30 min and 1 h later. Repeated testing of 14 healthy persons served as control. The following results were obtained: Depending on seizure generalization, postictal reorientation times were 1-45 min. Frontal lobe seizures showed no effect on postictal memory performances, but verbal and visual recognition memory was significantly decreased after temporal lobe seizures. Decrease in either verbal or visual memory and time of recovery were related to lateralization of seizure onset. Functional recovery after reorientation lasted 30 min to 1 h. The decrease in performance was more severe after generalized seizures. Decision times during memory performance were not significantly affected by the seizures. Temporal lobe seizures lead to circumscribed and long-lasting memory deficits, which can be assumed to affect patients' capabilities seriously. Pre- and postictal testing is a useful tool for determining postictal cognitive impairment and in determining the site of seizure onset.

Visual half-field testing of memory functions in patients considered for surgical treatment of intractable complex partial epilepsy

The present research employed the visual half-field (VHF) technique to assess memory functions in normal subjects and in patients with unilateral temporal lobe epilepsy prior to surgery. Two studies were conducted. In Study 1, concrete and abstract words were presented to the left (LVF) or the right visual half field (RVF), and measures were made of response latencies, naming, free recall, and recognition. In Study 2, pictures depicting random shapes with low verbal association values were presented, and measures were made of latencies for identification and recognition of the shapes. Overall, the results showed a RVF advantage for words, but no lateralization for shapes. A selective hemisphere memory deficit was obtained for abstract words in patients with left temporal lobe lesions. Otherwise, no obvious lesion-related differences were found in the preoperative analyses. It is concluded that VHF testing of verbal information, but not abstract visuo-spatial information, is discriminative in assessing hemispheric functions in normal subjects and patients with temporal-lobe epileptic lesions.

Dissociations among memory measures in memory-impaired subjects: evidence for a processing account of memory

Deficits in conceptual transfer on both implicit and explicit memory tests were obtained for memory-impaired temporal lobe epileptic (TLE) subjects in three studies. In Experiment 1, in which a generate-read paradigm was employed, memory-impaired TLEs failed to show normal generation effects on conceptually driven tests of semantic cued recall and general knowledge questions, although their data-driven memory as measured by word-fragment completion and graphemic cued recall tasks was normal. In Experiment 2, memory-impaired patients having left temporal lobe seizure foci were tested on these four tasks and compared with nonimpaired TLEs having right temporal foci. The left TLEs showed deficits on conceptually driven tasks and normal memory for data-driven tests. These findings were extended in Experiment 3, in which left TLE patients failed to show any benefit from blocked study, as compared with random study, on category production and semantic cued-recall tests, although right TLEs and normal controls showed blocking effects on both tasks. These findings may be accommodated by a processing framework of memory in which memory-impaired patients are characterized as having deficits in conceptual, but not in data-driven, processing capabilities.