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

Anterior Cingulate Epilepsy: A Review

SUMMARY

In this review, the semiology, and characteristics of noninvasive investigations suggestive of anterior cingulate and anterior midcingulate epilepsy are detailed by the authors. The clinical presentation is representative of a recently recognized rostrocaudal gradient of functional connectivity with seizures of the anterior cingulate cortex manifesting emotional and interoceptive aura followed by a hyperkinetic or complex motor seizures. The few reports of anterior midcingulate epilepsy show a trend toward a higher proportion of sensory auras and premotor semiology. Ictal pouting, vocalizations, and, in particular, laughter are strong indicators of epilepsy arising or spreading to this region. Although scalp EEG was traditionally thought to provide little information, the data provided in this review demonstrate that most patients will have abnormalities over the frontal or frontotemporal regions. Frontotemporal abnormalities at least interictally provide valuable information regarding lateralization. The etiology of epilepsy arising from the anterior cingulate region seems to be most frequently secondary to focal cortical dysplasia (FCD), followed by neoplasms and vascular lesions, particularly cavernomas, although one cannot rule out a publication bias. Findings of nuclear medicine imaging is seldomly reported but both positron emission tomography and ictal single-photon computed tomography can identify the generator or the network often showing abnormalities extending to the frontal regions. The few available magnetoencephalography (MEG) studies reveal mixed results, sometimes providing false lateralization of the focus. Anterior cingulate epilepsy is difficult to recognize, but the features summarized in this review should prompt suspicion in clinical practice.

Outcomes of cingulate epilepsy surgery: insights from an institutional and patient-level systematic review and meta-analysis

OBJECTIVE

Due to their deep and medial location, range of seizure semiologies, and poor localization on ictal electroencephalography (EEG), cingulate gyrus seizures can be difficult to diagnose and treat. The aim of this study was to review the available evidence on postoperative outcomes after cingulate epilepsy surgery.

METHODS

A comprehensive literature search of the PubMed/MEDLINE, Ovid Embase, Ovid Scopus, and Cochrane Library databases was conducted to identify studies that investigated postoperative outcomes of patients with cingulate epilepsy. Seizure freedom at the last follow-up (at least 12 months) was the primary endpoint. The literature search was supplemented by the authors' institutional series (4 patients).

RESULTS

Twenty-one studies were identified, yielding a total of 105 patients (68 with lesional epilepsy [65%]). Median age at surgery was 23 years, and 56% of patients were male. Median epilepsy duration was 7.5 years. Invasive EEG recording was performed on 69% of patients (53% of patients with lesional epilepsy and 97% of those with nonlesional epilepsy, p < 0.001). The most commonly resected region was the anterior cingulate (55%), followed by the posterior (17%) and middle (14%) cingulate. Lesionectomy alone was performed in 9% of patients. Additional extracingulate treatment was performed in 54% of patients (53% of patients with lesional epilepsy vs 57% of those with nonlesional epilepsy, p = 0.87). The most common pathology was cortical dysplasia (54%), followed by low-grade neoplasm (29%) and gliosis (8%). Seizure freedom was noted in 72% of patients (median follow-up 24 months). A neurological deficit was noted in 27% of patients (24% had temporary deficit), with the most common deficit being motor weakness (13%) followed by supplementary motor area syndrome (9.5%). Univariate survival analysis revealed significantly greater probability of seizure freedom in patients with lesional epilepsy (p = 0.015, log-rank test).

CONCLUSIONS

Surgical treatment of drug-resistant focal epilepsy originating from the cingulate gyrus is safe, leads to low rates of permanent adverse effects, and leads to high rates of long-term seizure freedom in carefully selected patients. These data may serve as a benchmark for surgical counseling of patients with cingulate epilepsy.

Association Between Semiology and Anatomo-Functional Localization in Patients With Cingulate Epilepsy: A Cohort Study

BACKGROUND AND OBJECTIVES

Cingulate epilepsy (CE) is a rare and challenging type of focal epilepsy, due to the polymorphic semiology of the seizures, mimicking other types of epilepsy, and the limited utility of scalp-EEG.

METHODS

We selected consecutive drug-resistant subjects with CE who were seizure-free after surgery, with seizure onset zone (SOZ) confirmed in the CC (cingulate cortex) by histology and/or SEEG. We analysed subjective and objective ictal manifestations using video recordings and correlated semeiology with anatomical CC subregions (anterior, anterior middle, posterior middle and posterior) localization of SOZ.

RESULTS

We analysed 122 seizures in 57 patients. Seizures were globally characterized by complex behaviors, typically natural seeming and often accompanied by emotional components.All objective ictal variables considered (pronation of the body or getting up from a lying/sitting position, tonic/dystonic posturing, hand movements, asymmetry, vocalizations, fluidity and repetitiveness of motor manifestations, awareness and emotional and autonomic components) were differently distributed among CC subregions (p<.05) Along the rostro-caudal axis fluidity and repetitiveness of movement, vocalizations, body pronation and emotional components decrease anterior-posteriorly, while tonic/dystonic postures, signs of lateralization and awareness increase.Vestibular and asymmetric somatosensory, somatosensory and epigastric and enteroceptive/autonomic symptoms were distributed differently among CC subregions (p<.05). Along the rostro-caudal axis vestibular, somatosensory and somatosensory asymmetric symptoms increase anterior-posterior.

DISCUSSION

CE is characterized by a spectrum of semeiological manifestations with a topographic distribution. CE semiology could indicate which cingulate sector is mainly involved.

Anxiety as the only manifestation of focal non-convulsive status epilepticus: case report and review of the literature

Psychiatric disorders represent common comorbidities in epileptic patients. Sometimes anxiety is part of the ictal semiology, especially during seizures arising from/involving frontal or temporal lobes. We describe a patient with focal epilepsy and recurrent hyperkinetic seizures who also presented prolonged episodes characterized by massive anxiety, alarm and fear. A Video-Electroencephalographic monitoring performed during one of these attacks revealed a continuous epileptiform activity over the right frontal regions, consistent with a focal non-convulsive status epilepticus accounting for the patient's psychiatric symptoms. Our case confirms the complex relationship between epilepsy and anxiety. A review of the literature is also included.