Morphometry in temporal lobe epilepsy

Automatic Contrast Enhancement of Brain MR Images Using Hierarchical Correlation Histogram Analysis

Parkinson’s disease is a progressive neurodegenerative disorder that has a higher probability of occurrence in middle-aged and older adults than in the young. With the use of a computer-aided diagnosis (CAD) system, abnormal cell regions can be identified, and this identification can help medical personnel to evaluate the chance of disease. This study proposes a hierarchical correlation histogram analysis based on the grayscale distribution degree of pixel intensity by constructing a correlation histogram, that can improves the adaptive contrast enhancement for specific objects. The proposed method produces significant results during contrast enhancement preprocessing and facilitates subsequent CAD processes, thereby reducing recognition time and improving accuracy. The experimental results show that the proposed method is superior to existing methods by using two estimation image quantitative methods of PSNR and average gradient values. Furthermore, the edge information pertaining to specific cells can effectively increase the accuracy of the results.

Volumetric brain analysis in neurosurgery: Part 3. Volumetric CT analysis as a predictor of seizure outcome following temporal lobectomy

OBJECT

The incidence of temporal lobe epilepsy (TLE) due to mesial temporal sclerosis (MTS) can be high in developing countries. Current diagnosis of MTS relies on structural MRI, which is generally unavailable in developing world settings. Given widespread effects on temporal lobe structure beyond hippocampal atrophy in TLE, the authors propose that CT volumetric analysis can be used in patient selection to help predict outcomes following resection.

METHODS

Ten pediatric patients received preoperative CT scans and temporal resections at the CURE Children's Hospital of Uganda. Engel classification of seizure control was determined 12 months postoperatively. Temporal lobe volumes were measured from CT and from normative MR images using the Cavalieri method. Whole brain and fluid volumes were measured using particle filter segmentation. Linear discrimination analysis (LDA) was used to classify seizure outcome by temporal lobe volumes and normalized brain volume.

RESULTS

Epilepsy patients showed normal to small brain volumes and small temporal lobes bilaterally. A multivariate measure of the volume of each temporal lobe separated patients who were seizure free (Engel Class IA) from those with incomplete seizure control (Engel Class IB/IIB) with LDA (p<0.01). Temporal lobe volumes also separate normal subjects, patients with Engel Class IA outcomes, and patients with Class IB/IIB outcomes (p<0.01). Additionally, the authors demonstrated that age-normalized whole brain volume, in combination with temporal lobe volumes, may further improve outcome prediction (p<0.01).

CONCLUSIONS

This study shows strong evidence that temporal lobe and brain volume can be predictive of seizure outcome following temporal lobe resection, and that volumetric CT analysis of the temporal lobe may be feasible in lieu of structural MRI when the latter is unavailable. Furthermore, since the authors' methods are modality independent, these findings suggest that temporal lobe and normative brain volumes may further be useful in the selection of patients for temporal lobe resection when structural MRI is available.

Voxel-based morphometry of temporal lobe epilepsy: an introduction and review of the literature

We review the applications and results of voxel-based morphometry (VBM) studies that have reported brain changes associated with temporal lobe epilepsy (TLE). A PubMed search yielded 18 applications of VBM to study brain abnormalities in patients with TLE up to May 2007. Across studies, 26 brain regions were found to be significantly reduced in volume relative to healthy controls. There was a strong asymmetrical distribution of temporal lobe abnormalities preferentially observed ipsilateral to the seizure focus, particularly of the hippocampus (82.35% of all studies), parahippocampal gyrus (47.06%), and entorhinal (23.52%) cortex. The contralateral hippocampus was reported as abnormal in 17.65% of studies. There was a much more bilateral distribution of extratemporal lobe atrophy, preferentially affecting the thalamus (ipsilateral = 61.11%, contralateral = 50%) and parietal lobe (ipsilateral = 47.06%, contralateral = 52.94%). VBM generally reveals a distribution of brain abnormalities in patients with TLE consistent with the region-of-interest neuroimaging and postmortem literature. It is unlikely that VBM has any clinical utility given the lack of robustness for individual comparisons. However, VBM may help elucidate some unresolved important research questions such as how recurrent temporal lobe seizures affect hippocampal and extrahippocampal morphology using serial imaging acquisitions.

Autoradiography reveals selective changes in serotonin binding in neocortex of patients with temporal lobe epilepsy

The main goal of the present study was to evaluate binding to serotonin in the neocortex surrounding the epileptic focus of patients with mesial temporal lobe epilepsy (MTLE). Binding to 5-HT, 5-HT(1A), 5-HT(4), 5-HT(7) receptors and serotonin transporter (5-HTT) in T1-T2 gyri of 15 patients with MTLE and their correlations with clinical data, neuronal count and volume were determined. Autopsy material acquired from subjects without epilepsy (n=6) was used as control. The neocortex from MTLE patients demonstrated decreased cell count in layers III-IV (21%). No significant changes were detected on the neuronal volume. Autoradiography experiments showed the following results: reduced 5-HT and 5-HT(1A) binding in layers I-II (24% and 92%, respectively); enhanced 5-HT(4) binding in layers V-VI (32%); no significant changes in 5-HT(7) binding; reduced 5-HTT binding in all layers (I-II, 90.3%; III-IV, 90.3%, V-VI, 86.9%). Significant correlations were found between binding to 5-HT(4) and 5-HT(7) receptors and age of seizure onset, duration of epilepsy and duration of antiepileptic treatment. The present results support an impaired serotoninergic transmission in the neocortex surrounding the epileptic focus of patients with MTLE, a situation that could be involved in the initiation and propagation of seizure activity.

Structural abnormalities are similar in familial and nonfamilial mesial temporal lobe epilepsy

BACKGROUND/OBJECTIVE

Diffuse temporal lobe abnormalities can be observed on MRI of patients with mesial temporal lobe epilepsy (MTLE). Our objective was to perform qualitative and quantitative analyses of temporal lobe structures in patients with familial MTLE (FMTLE) and nonfamilial MTLE.

METHODS

Two groups of patients were ascertained: 67 FMTLE patients (14 with refractory seizures) and 30 patients with nonfamilial refractory MTLE. We performed qualitative analyses of MRI (with multiplanar reconstruction) and volumes of hippocampi and anterior temporal lobes in all patients, and in a normal control group of 23 individuals. We used the Chi-square test and ANOVA for statistical analyses.

RESULTS

We identified anterior temporal lobe abnormalities by visual analysis in only 4% of FMTLE patients and atrophy of the anterior temporal lobe by volumetric analysis in 19%. In the group of nonfamilial MTLE patients we found anterior temporal lobe abnormalities by visual analysis in 17% of patients and anterior temporal lobe atrophy in 13%. Hippocampal atrophy was present in 90% of FMTLE and in 83% of nonfamilial MTLE. No signs of cortical dysplasia were observed.

CONCLUSION

Anterior temporal lobe atrophy and other abnormalities outside the mesial portion of temporal lobes were infrequent in both familial and nonfamilial MTLE patients. Despite the genetic basis, hippocampal atrophy in FMTLE is not associated with other abnormalities outside the mesial temporal regions.

Linguistic deficits following left selective amygdalohippocampectomy: a prospective study

Language deficits in 10 patients with medically intractable left-sided temporal lobe epilepsy prior to and following selective amygdalohippocampectomy are described. Preoperatively, a pattern of minor linguistic deficits was observed in three patients; isolated minor naming deficits were detectable in one additional patient. Three months after surgery, six patients' linguistic functions were unchanged, whereas in four patients, a significant decline in linguistic functions could be observed. All four patients revealed a very similar language syndrome characterized by reduced language comprehension and fluency, well-articulated speech, frequent word-finding difficulties, circumlocutions, and semantic paraphasias in the absence of any phonological disorder. These deficits remained stable during the 12-month follow-up period. However, magnetic resonance imaging did not show any neocortical lesions outside the resection area. Possible explanations for these findings include neuronal cell loss and deafferentiation in cortical areas, disruption of the basal temporal language area pathways, reorganization of the language network in chronic temporal lobe epilepsy, and neocortical lesions due to the surgical intervention. Furthermore, correlations between linguistic and demographic data for our patients suggest that patients older at epilepsy onset are at greater risk for developing postoperative language deficits.

Rapid stereological quantitation of temporal neocortex in TLE

To determine the extent of neocortical atrophy in the temporal lobe using rapid stereological analysis of magnetic resonance slices in patients with temporal lobe epilepsy and to compare the findings to those obtained by visual analysis of high-resolution magnetic resonance images. 25 patients with temporal lobe epilepsy, along with 25 age-matched controls were scanned using a 1.5 Tesla magnetic resonance imaging machine (GE signa systems Paris). Visual analysis was performed on standard high-resolution images. Volumetric analysis of hippocampus and temporal neocortex was performed using computer-aided stereology (MEASURE program, Patrick Barta, Johns Hopkins, Baltimore, USA). Stereological volumetric analysis demonstrated isolated hippocampal atrophy in only nine (36%) cases including three (12%) with bilateral disease. However, eight (32%) cases had combined hippocampal and neocortical atrophy and three (12%) had isolated neocortical atrophy. All volumetric measurements took less than 10 min. On the other hand, visual analysis suggested that 17 (68%) had hippocampal atrophy alone with only two (8%) having combined neocortical atrophy and a further two (8%) having isolated neocortical atrophy. Nearly half of the patients had temporal neocortical atrophy with or without hippocampal atrophy. This rapid, accurate and non-biased quantitative technique has wide clinical utility and is significantly more valuable in detecting neocortical atrophy than visual analysis alone. The results support the notion that abnormalities may be overlooked by current standards of routine magnetic resonance imaging.

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.

Progressive neocortical damage in epilepsy

Our objective was to determine the pattern and extent of generalized and focal neocortical atrophy that develops in patients with epilepsy and the factors associated with such changes. As part of a prospective, longitudinal follow-up study of 122 patients with chronic epilepsy, 68 newly diagnosed patients, and 90 controls, serial magnetic resonance imaging scans were obtained 3.5 years apart. Image subtraction was used to identify diffuse and focal neocortical change that was quantified with a regional brain atlas and a fully automated segmentation algorithm. New focal or generalized neocortical volume losses were identified in 54% of patients with chronic epilepsy, 39% of newly diagnosed patients and 24% of controls. Patients with chronic epilepsy were significantly more likely to develop neocortical atrophy than control subjects. The increased risk of cerebral atrophy in epilepsy was not related to a history of documented seizures. Risk factors for neocortical atrophy were age and multiple antiepileptic drug exposure. Focal and generalized neocortical atrophy commonly develops in chronic epilepsy. Neocortical changes seen in a quarter of our control group over 3.5 years were likely to reflect physiological changes. Our results show that ongoing cerebral atrophy may be widespread and remote from the putative epileptic focus, possibly reflecting extensive networks and interconnections between cortical regions.

Reduced extrahippocampal NAA in mesial temporal lobe epilepsy

PURPOSE

Structural and metabolic abnormalities in the hippocampal region in medial temporal lobe epilepsy (mTLE) are well described; less is known about extrahippocampal changes. This study was designed to characterize extrahippocampal metabolic abnormalities in mTLE with magnetic resonance spectroscopy in combination with tissue segmentation and volumetry of gray and white matter.

METHODS

Multislice magnetic resonance spectroscopic imaging (1H-MRSI) in combination with tissue segmentation was performed on 16 patients with mTLE and 12 age-matched healthy volunteers. The data were analyzed by using a regression-analysis model that estimated the metabolite concentrations in 100% cortical gray and 100% white matter in the frontal lobe and nonfrontal brain. The segmented image was used to calculate the fraction of gray and white matter in these regions.

RESULTS

mTLE had significantly lower N-acetyl aspartate (NAA) in ipsi- and contralateral frontal gray (p = 0.03) and in ipsi- and contralateral nonfrontal white matter (p = 0.008) compared with controls. Although there were no associated volumetric deficits in frontal gray and white matter, ipsilateral nonfrontal gray matter (p = 0.003) was significantly smaller than that in controls.

CONCLUSIONS

mTLE is associated with extrahippocampal metabolic abnormalities and volumetric deficits, but these do not necessarily affect the same regions.

Individual variations in the sulcal anatomy of the basal temporal lobe and its relevance for epilepsy surgery: an anatomical study performed using magnetic resonance imaging

OBJECT

The concept of selective amygdalohippocampectomy is based on pathophysiological insights into the epileptogenicity of the hippocampal region and the definition of the clinical syndrome of mesial temporal lobe epilepsy (TLE). High-resolution magnetic resonance (MR) imaging allows correlation of the site of histologically conspicuous tissue with anatomical structure. The highly variable sulcal pattern of the basal temporal lobe, however, definitely complicates the morphometric analysis of histomorphologically defined subdivisions of the hippocampal region. The goal of this study was to define individual variations in the sulcal anatomy on the basis of preoperative MR images obtained in patients suffering from TLE.

METHODS

The authors analyzed coronal MR images obtained in 50 patients for the presence of and intrinsic relationships among the rhinal, collateral, and occipitotemporal sulci. The surface relief of consecutive sections of 100 temporal lobes was graphically outlined and the resulting maps were used for visual analysis. The sulci were characterized by measurement of their depth, distance to the temporal horn, and laterality. The anatomical measurements and frequencies of sulcal patterns were assessed for statistical correlation with patients' histories and the lateralization of the seizure focus.

CONCLUSIONS

Statistical assessment shows that patient sex is a significant factor in sulcal patterns. Anatomical measurements are significantly decreased on the side of the seizure origin, which relates to loss of white matter, a known morphological abnormality associated with TLE. Magnetic resonance imaging allows for accurate preoperative knowledge of individual sulcal patterns and facilitates intraoperative orientation to anatomical landmarks.

Structural brain abnormalities in patients with schizophrenia, epilepsy, and epilepsy with chronic interictal psychosis

Chronic interictal psychotic syndromes, often resembling schizophrenia, develop in some patients with epilepsy. Although widespread brain abnormalities are recognized as characteristic of schizophrenia, prevailing but controversial hypotheses on the co-occurrence of epilepsy and psychosis implicate left temporal lobe pathology. In this study, quantitative MRI methods were used to address the regional specificity of structural brain abnormalities in patients with epilepsy plus chronic interictal psychosis (E+PSY, n=9) relative to three comparison groups: unilateral temporal lobe epilepsy without chronic psychosis (TLE, n=18), schizophrenia (SCZ, n=46), and healthy control subjects (HC, n=57). Brain measures, derived from a coronal spin-echo MRI sequence, were adjusted for age and cerebral volume. Relative to HC, all patient groups had ventricular enlargement and smaller temporal lobe, frontoparietal, and superior temporal gyrus gray matter volumes, with the extent of these abnormalities greatest in E+PSY. Only TLE had temporal lobe white matter deficits, as well as smaller hippocampi, which were ipsilateral to the seizure focus. Structural brain abnormalities in E+PSY are not restricted to the left temporal lobe. The confluence of cortical gray matter deficits in E+PSY and SCZ suggests salience to chronic psychosis.

Statistical analysis of hippocampal asymmetry in schizophrenia

The asymmetry of brain structures has been studied in schizophrenia to better understand its underlying neurobiology. Brain regions of interest have previously been characterized by volumes, cross-sectional and surface areas, and lengths. Using high-dimensional brain mapping, we have developed a statistical method for analyzing patterns of left-right asymmetry of the human hippocampus taken from high-resolution MR scans. We introduce asymmetry measures that capture differences in the patterns of high-dimensional vector fields between the left and right hippocampus surfaces. In 15 pairs of subjects previously studied (J. G. Csernansky et al., 1998, Proc. Natl. Acad. Sci. USA 95, 11406-11411). we define the difference in hippocampal asymmetry patterns between the groups. Volume analysis indicated a large normative asymmetry between left and right hippocampus (R > L), and shape analysis allowed us to visualize the normative asymmetry pattern of the hippocampal surfaces. We observed that the right hippocampus was wider along its lateral side in both schizophrenia and control subjects. Also, while patterns of hippocampal asymmetry were generally similar in the schizophrenia and control groups, a principal component analysis based on left-right asymmetry vector fields detected a statistically significant difference between the two groups, specifically related to the subiculum.

Neuronal hypertrophy in the neocortex of patients with temporal lobe epilepsy

The underlying cause of neocortical involvement in temporal lobe epilepsy (TLE) remains a fundamental and unanswered question. Magnetic resonance imaging has shown a significant loss in temporal lobe volume, and it has been proposed that neocortical circuits are disturbed functionally because neurons are lost. The present study used design-based stereology to estimate the volume and cell number of Brodmann's area 38, a region commonly resected in anterior temporal lobectomy. Studies were conducted on the neocortex of patients with or without hippocampal sclerosis (HS). Results provide the surprising finding that TLE patients have significant atrophy of neocortical gray matter but no loss of neurons. Neurons are also significantly larger, dendritic trees appear sparser, and spine density is noticeably reduced in TLE specimens compared with controls. The increase in neuronal density we found in TLE patients is therefore attributable to large neurons occupying a much smaller volume than in normal brain. Neurons in the underlying white matter are also increased in size but, in contrast to other reports, are not significantly elevated in number or density. Neuronal hypertrophy affects HS and non-HS brains similarly. The reduction in neuropil and its associated elements therefore appears to be a primary feature of TLE, which is not secondary to cell loss. In both gray and white matter, neuronal hypertrophy means more perikaryal surface area is exposed for synaptic contacts and emerges as a hallmark of this disease.

Hemicranial volume deficits in patients with temporal lobe epilepsy with and without hippocampal sclerosis

PURPOSE

In patients with refractory temporal lobe epilepsy, studies have suggested volume deficits measured by MRI of brain structures outside the epileptogenic hippocampus. Hippocampal sclerosis (HS) is a frequent, but not obligate, finding in such patients. The present study examines the influence of the presence of HS on quantitative magnetic resonance imaging (MRI) measurements.

METHODS

We analyzed 47 patients and 30 controls by quantitative MRI, including intracranial volume (ICV), hemicranial volume, hippocampal volume (HCV), and T2 relaxometry. MRI results were compared with histological findings in the resected temporal lobe.

RESULTS

Histology documented HS in 35 patients (HS group) and other findings in 12 patients (no-HS group). In both groups, the hemicranial volume ipsilateral to the epileptogenic focus was significantly smaller than on the contralateral side (p < 0.004). The HCV on both sides was smaller in the HS group compared with patients without HS (p < or = 0.004). Unilateral hippocampal atrophy and increased T2 value were found in 71% of patients with HS, and bilaterally normal HCV and T2 value were found in 67% of patients without HS.

CONCLUSIONS

The smaller hemicranial volume on the focus side, irrespective of the presence or absence of HS suggests a different pathogenic mechanism for the additional hemicranial volume deficit, compared to HS itself. The contralateral HCV deficit depends on the presence of HS, indicating a pathogenic connection between damage to both hippocampi.

Neuroimaging in epilepsy

Neuroimaging techniques have improved the understanding, diagnosis, and management of epilepsy. By providing excellent structural information, MRI is the technique of choice in evaluating patients with epilepsy. Functional imaging techniques, including MR spectroscopy, functional MRI, positron emission tomography, and single photon emission CT, permit noninvasive assessment of the epileptic substrate, its functional status, and neuroreceptors. The MRI-based techniques will potentially assume a greater role in the cost-effective workup of the patient. Currently, newer techniques such as magnetoencephalography, magnetic source imaging, and optical imaging are research tools.

Cortical and hippocampal volume deficits in temporal lobe epilepsy

PURPOSE

To use quantitative magnetic resonance imaging (MRI) methods to examine the extent of volume abnormalities in the hippocampus and in extrahippocampal brain regions in localization-related epilepsy of temporal lobe origin (TLE).

METHODS

Hippocampal, temporal lobe, and extratemporal lobe volumes were examined with 3-mm spin-echo coronal MRI scans in patients with unilateral TLE who were candidates for temporal lobe resection. Measures were adjusted for normal variation due to intracranial volume and age based on 72 healthy male controls. Group differences between 14 male TLE [7 left TLE (LTLE), 7 right TLE (RTLE)] patients and a subset of 49 age range-matched controls were examined with analysis of variance (ANOVA).

RESULTS

As compared with controls, patients with TLE had smaller temporal lobe and frontoparietal region gray matter volumes, bilaterally, smaller temporal lobe white matter volumes bilaterally, and larger ventricular volumes. In contrast to these bilateral tissue volume deficits, hippocampal volume deficits in TLE were ipsilateral to the epileptogenic temporal lobe.

CONCLUSIONS

Extrahippocampal volume abnormalities were bilateral and occurred in both temporal and extra-temporal cortical regions in TLE, whereas hippocampal deficits were related to the side of the epileptogenic focus. These data suggest that brain abnormalities in TLE are not limited to the epileptogenic region.