Role of proton magnetic resonance spectroscopy in preoperative evaluation of patients with mesial temporal lobe epilepsy

Extra-temporal pediatric low-grade gliomas and epilepsy

Low-grade gliomas, especially glioneuronal tumors, are a common cause of epilepsy in children. Seizures associated with low-grade pediatric tumors are medically refractory and present a significant burden to patients. Often, morbidity and patients´ quality of life are determined rather by the control of seizures than the oncological process itself and the resolution of epilepsy represents an important part in the treatment of LGGs. The pathogenesis of tumor-related seizures in focal LGG tumors is multifactorial, and mechanisms differ probably among patients and tumor types. Pediatric low-grade tumors associated with epilepsy include a series of neoplasms that have a pure astrocytic or glioneuronal lineage. They are usually benign tumors with a neocortical localization typically in the temporal lobes, but also in other supratentorial locations. Gangliogliomas and dysembryoplastic neuroepithelial tumors (DNET) are the most common entities together with astrocytic gliomas (pilocytic astrocytomas and pleomorphic xanthoastrocytoma) and angiocentric gliomas, and dual pathology is found in up to 40% of glioneuronal tumors. The treatment of low-grade gliomas and associated epilepsy is based mainly on resection and the extent of surgery is the main predictor of postoperative seizure control in patients with a LGG. Long-term epilepsy-associated tumors (LEATs) tend to be well-circumscribed, and therefore, the chances for a complete resection and epilepsy control with a safe approach are very high. New treatments have emerged as alternatives to open microsurgical approaches, including laser thermal ablation or the use of BRAF inhibitors. Future advances in identifying seizure-related biomarkers and molecular tumor pathways will facilitate targeted treatment strategies that will have a deep impact both in oncologic and epilepsy outcomes.

Underutilization of advanced presurgical studies and high rates of vagus nerve stimulation for drug-resistant epilepsy: a single-center experience and recommendations

INTRODUCTION

Epilepsy surgery continues to be profoundly underutilized despite its safety and effectiveness. We sought to investigate factors that may contribute to this phenomenon, with a particular focus on the antecedent underutilization of appropriate preoperative studies.

METHODS

We reviewed patient data from a pediatric epilepsy clinic over an 18-month period. Patients with drug-resistant epilepsy (DRE) were categorized according to brain magnetic resonance imaging (MRI) findings (lesional, MRI-negative, or multifocal abnormalities) and type of epilepsy diagnosis based on semiology and electroencephalography (EEG) (focal or generalized). We then analyzed the rates of diagnostic test utilization, surgical referral, and subsequent epilepsy surgery as well as vagus nerve stimulation (VNS).

RESULTS

Of the 249 patients with a diagnosis of epilepsy, 138 (55.4%) were found to have DRE. Excluding the 10 patients with DRE who did not undergo MRI, 76 patients (59.4%) were found to be MRI-negative (non-lesional epilepsy), 37 patients (28.9%) were found to have multifocal abnormalities, and 15 patients (11.7%) were found to have a single epileptogenic lesion on MRI (lesional epilepsy). Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) were each completed in nine patients (7.0%) and magnetoencephalography (MEG) in four patients (3.1%). Despite the low utilization rate of adjunctive studies, over half (56.3%) ultimately underwent VNS alone, and 8.6% ultimately underwent definitive intracranial resection or disconnection surgery.

CONCLUSIONS

The underutilization of appropriate non-invasive, presurgical testing in patients with focal DRE may in part explain the continued underutilization of definitive, resective/disconnective surgery. For patients without access to a high-volume, multidisciplinary surgical epilepsy center, adjunctive presurgical studies [e.g., PET, SPECT, MEG, electrical source imaging (ESI), EEG-functional magnetic resonance imaging (fMRI)], even when available, are rarely ordered, and this may contribute to excessive rates of VNS in lieu of definitive intracranial surgery.

The Study of Genetic Susceptibility and Mitochondrial Dysfunction in Mesial Temporal Lobe Epilepsy

The aim of this study is to investigate the mitochondrial dysfunction and pathogenic role of the mitochondrial genome in the progression of mesial temporal lobe epilepsy (MTLE) in vivo and in vitro. Mitochondrial DNA (mtDNA) and nuclear DNA were detected in the hippocampal samples and peripheral blood of patients with MTLE. Mitochondrial functions were detected in vivo and in vitro. In 20 patients with MTLE, mtDNA mutations involving single or multiple deletions in the hippocampus were found in 5 patients but were not detected in the peripheral blood. Two patients carried pathogenic mutations of RELN, both in the hippocampus and blood. A pathogenic mutation of DNA2 was found in the hippocampus of the 2 patients with multiple deletions but not in the blood samples. The mtDNA copy numbers showed dynamic changes in the MTLE models. In MTLE patients, low metabolism in mesial temporal lobe and hippocampus was observed by using PET-CT. Under electron microscope, the mitochondrial cristae were disordered, the density of mitochondrial matrix decreased and even vacuolated in the hippocampus neurons. In the MTLE rat models, there were dynamic changes in mitochondrial morphology; the ATP production rate decreased in the acute phase, the latent phase, and the chronic phase. Mitochondrial enzyme complex I activity decreased in both acute and chronic phases, and there was no significant difference in latent period. Decreased mitochondrial membrane potential and calcium homeostasis were detected in the epileptic cell models. We first identified somatic mutations in mtDNA in MTLE patients and comprehensively evaluated mitochondrial dysfunction in the pathogenesis of MTLE in vivo and in vitro. This evidence supports the environmental and modifying genetic interactions that contribute to the development of MTLE.

Neuroimaging methods in Epilepsy of Temporal Origin

Background:

Temporal Lobe Epilepsy (TLE) comprises the most common form of symptomatic refractory focal epilepsy in adults. Accurate lateralization and localization of the epileptogenic focus are a significant prerequisite for determining surgical candidacy once the patient has been deemed medically intractable. Structural MR imaging, clinical, electrophysiological, and neurophysiological data have an established role in the localization of the epileptogenic foci. Nevertheless, hippocampal sclerosis cannot be detected on MR images in more than 30% of patients with TLE, and the presurgical assessment remains controversial. </P><P> Discussion: In the last years, advanced MR imaging techniques, such as 1H-MRS, DWI, DTI, DSCI, and fMRI, may provide valuable additional information regarding the physiological and metabolic characterization of brain tissue. MR imaging has shifted towards functional and molecular imaging, thus, promising to improve the accuracy regarding the lateralization and the localization of the epileptogenic focus. Additionally, nuclear medicine studies, such as SPECT and PET imaging modalities, have become an asset for the decoding of brain function and activity, and can be diagnostically helpful as well, since they provide valuable data regarding the altered metabolic activity of the seizure foci.

Conclusion:

Overall, advanced MRI, SPECT, and PET imaging techniques are increasingly becoming an essential part of TLE diagnostics, when the epileptogenic area is not identified on structural MRI or when structural MRI, clinical, and electrophysiological findings are not in concordance.

ARALAR/AGC1 deficiency, a neurodevelopmental disorder with severe impairment of neuronal mitochondrial respiration, does not produce a primary increase in brain lactate

ARALAR/AGC1 (aspartate-glutamate mitochondrial carrier 1) is an important component of the NADH malate-aspartate shuttle (MAS). AGC1-deficiency is a rare disease causing global cerebral hypomyelination, developmental arrest, hypotonia, and epilepsy (OMIM ID #612949); the aralar-KO mouse recapitulates the major findings in humans. This study was aimed at understanding the impact of ARALAR-deficiency in brain lactate levels as a biomarker. We report that lactate was equally abundant in wild-type and aralar-KO mouse brain in vivo at postnatal day 17. We find that lactate production upon mitochondrial blockade depends on up-regulation of lactate formation in astrocytes rather than in neurons. However, ARALAR-deficiency decreased cell respiration in neurons, not astrocytes, which maintained unchanged respiration and lactate production. As the primary site of ARALAR-deficiency is neuronal, this explains the lack of accumulation of brain lactate in ARALAR-deficiency in humans and mice. On the other hand, we find that the cytosolic and mitochondrial components of the glycerol phosphate shuttle are present in astrocytes with similar activities. This suggests that glycerol phosphate shuttle is the main NADH shuttle in astrocytes and explains the absence of effects of ARALAR-deficiency in these cells.

The medial temporal lobe epilepsy is a bilateral disease – novel aspects

Introduction.Medial temporal lobe epilepsy (MTLE) is the most frequent form of epilepsy in adulthood. It is classified as local/regional epilepsy. However, there is increasing evidence of the involvement of both temporal lobes and this provides abundant arguments to question this view, and consider MTLE as one of the typical bilateral system epilepsies.

Aim.To provide a contemporary review of medial temporal lobe epilepsy, discussing the bilateral aspects, with reference to epilepsy surgery.

Methods.A literature review and a resume of the author’s own experiences with MTLE patients.

Results.Recent electrophysiological and neuroimaging data provide convincing data supporting that MTLE is a bilateral disease. The uni-and bilateral features form a continuum and the participation rate of the two temporal lobes determine course and surgical perspective of the individual patient.

Conclusions.The contradictory data of invasive presurgical evaluations of MTLE patients suggest that there need to identify further indicatory markers of bilaterality and thus change the presurgical evaluation from the non-invasive towards the invasive ways. The mechanisms of the interrelationship between the two temporal lobes in MTLE warrants further research.

The Use of Magnetic Resonance Spectroscopy in the Evaluation of Pediatric Patients With Seizures

BACKGROUND

The objective was to determine if it is useful to routinely add magnetic resonance spectroscopy (MRS) to magnetic resonance imaging (MRI) in the evaluation of seizure in the pediatric patient. Specifically, how often does MRS contribute information to conventional MRI?

METHODS

A retrospective search, over a period of 3 years, of patients <18 years of age who underwent both MRI and MRS as part of the evaluation of seizures yielded a total of 233 cases in 216 patients. The medical records were reviewed to determine how many patients carried a diagnosis relevant to seizures. The MRIs and MRSs were reviewed by two neuroradiologists and an MR physicist/spectroscopist who determined by consensus in how many cases MRS contributed information regarding management, diagnosis, or prognosis, in addition to the findings on MRI alone.

RESULTS

In 100 of 233 cases (43%), MRS contributed information additional to MRI. In 40 cases, MRS contributed information relevant to patient management by prompting an evaluation for an underlying inborn error of metabolism. MRS contributed information relevant to diagnosis in 24 of 100 cases (e.g., neoplasm versus dysplasia). MRS contributed information relevant to prognosis in 36 cases (e.g., hypoxic-ischemic injury). MRS added more information in cases where the patients had a diagnosis relevant to seizure before imaging. Interestingly, in 25 cases where the MRI was normal, MRS was found to be abnormal, which prompted evaluation for an inborn error of metabolism.

CONCLUSIONS

These results suggest that MRS is a useful evaluation tool in addition to MRI for children undergoing imaging for the evaluation of seizures.

The use of magnetic resonance spectroscopy in the evaluation of epilepsy

Magnetic resonance spectroscopy (MRS) is indicated in the imaging protocol of the patient with epilepsy to screen for metabolic derangements such as inborn errors of metabolism and to characterize masses that may be equivocal on conventional magnetic resonance imaging for dysplasia versus neoplasia. Single-voxel MRS with echo time of 35 milliseconds may be used for this purpose as a quick screening tool in the epilepsy imaging protocol. MRS is useful in the evaluation of both focal and generalized epilepsy.

Identifying the affected hemisphere with a multimodal approach in MRI-positive or negative, unilateral or bilateral temporal lobe epilepsy

Patients with non-lesional or bilateral temporal-lobe epilepsy (TLE) are often excluded from surgical treatment. This study investigated focus lateralization in TLE to understand identification of the affected hemisphere with regard to non-lesional or bilateral affection and postsurgical outcome. A total of 24 TLE patients underwent presurgical evaluation with magnetic resonance imaging (MRI), proton magnetic resonance spectroscopy ((1)H-MRS), video-electroencephalogram (video-EEG), and/or intracranial EEG (icEEG), and they were classified as MRI-positive or negative, unilateral or bilateral TLE cases. In patients with positive-MRI, MRI and (1)H-MRS indicated high (100%) concordant lateralization to EEG findings in unilateral TLE, and moderate (75%) concordance to icEEG findings in bilateral TLE; whereas in patients with negative-MRI, (1)H-MRS indicated moderate (60%-75%) concordance to EEG and/or icEEG in unilateral TLE, and relatively low (50%) concordance to icEEG in bilateral TLE. Ninety point nine percent of patients with unilateral TLE and 41.7% of patients with bilateral TLE (including 50% of MRI-negative bilateral TLE) became seizure-free. The MRS findings were not correlated with seizure outcome, while non-seizure-free patients had an insignificantly higher percentage of contralateral N-acetyl aspartate (NAA) reduction compared with seizure-free patients, indicating the relatively low predictive value of (1)H-MRS for surgical outcome. Further, EEG and icEEG findings were significantly correlated with seizure outcome, and for patients with positive MRI, MRI findings were also correlated with seizure outcome, indicating the predictive value of these modalities. The results suggested that a multimodal approach including neuroimaging, EEG, and/or icEEG could identify seizure focus in most cases, and provide surgical options for non-lesional or bilateral TLE patients with a possible good outcome.

Multimodal neuroimaging in presurgical evaluation of drug-resistant epilepsy

Intracranial EEG (icEEG) monitoring is critical in epilepsy surgical planning, but it has limitations. The advances of neuroimaging have made it possible to reveal epileptic abnormalities that could not be identified previously and improve the localization of the seizure focus and the vital cortex. A frequently asked question in the field is whether non-invasive neuroimaging could replace invasive icEEG or reduce the need for icEEG in presurgical evaluation. This review considers promising neuroimaging techniques in epilepsy presurgical assessment in order to address this question. In addition, due to large variations in the accuracies of neuroimaging across epilepsy centers, multicenter neuroimaging studies are reviewed, and there is much need for randomized controlled trials (RCTs) to better reveal the utility of presurgical neuroimaging. The results of multiple studies indicate that non-invasive neuroimaging could not replace invasive icEEG in surgical planning especially in non-lesional or extratemporal lobe epilepsies, but it could reduce the need for icEEG in certain cases. With technical advances, multimodal neuroimaging may play a greater role in presurgical evaluation to reduce the costs and risks of epilepsy surgery, and provide surgical options for more patients with drug-resistant epilepsy.

Double inversion recovery magnetic resonance imaging (MRI) in the preoperative evaluation of hippocampal sclerosis: correlation with volumetric measurement and proton magnetic resonance spectroscopy (¹H MRS)

OBJECTIVE

To determine whether the finding of hyperintense hippocampal signal intensity on double inversion recovery (DIR) magnetic resonance imaging is correlated with hippocampal volume loss and metabolic abnormalities in patients with mesial temporal lobe epilepsy (MTLE).

METHODS

This retrospective study had institutional review board approval, and informed consent was obtained. Thirteen patients with unilateral hippocampal sclerosis and 13 age-matched healthy control subjects were included. Quantitative assessment for hippocampus of the patients and the control subjects was determined, including DIR, 3-dimensional T1-weighted imaging and proton magnetic resonance spectroscopy. Hippocampal relative signal intensity on DIR images (RSIDIR), volumes, and N-acetylaspartate-to-choline and creatine/phosphocreatine ratios were measured during one magnetic resonance imaging session, and asymmetry indexes (AI) of bilateral hippocampi were calculated. Hippocampal RSIDIR and AIDIR were compared between the patients and the control subjects. The RSIDIR and AIDIR were further correlated with the quantitative MR measures and with the age at onset and duration of MTLE. Statistical analyses were performed with Student t test, 1-way analysis of variance, and Pearson correlation.

RESULTS

On DIR images, the hippocampi ipsilateral to the seizure focus demonstrated relatively extreme hyperintensity. The ipsilateral hippocampi showed significantly increased RSIDIR compared with contralateral hippocampi and the healthy subjects (F = 197.956, P < 0.001). The hippocampal AIDIR in the patients was also significantly higher than that in the control group (t = 24.896, P < 0.001). Significant Pearson correlations (2-tailed) were obtained between the RSIDIR and the volume of the ipsilateral hippocampi (r = -0.762, P < 0.01) and between the RSIDIR and duration of epilepsy (r = 0.557, P < 0.05). Moreover, there were significant correlations between the AIDIR and the AIvolume (r = 0.609, P < 0.05) and between the AIDIR and the duration of epilepsy (r = 0.610, P < 0.05). However, no significant correlations of hippocampal DIR measures with proton magnetic resonance spectroscopy were obtained.

CONCLUSIONS

Double inversion recovery imaging of the brain can yield complementary information about hippocampal pathology and efficiently lateralize the hippocampal sclerosis in patients with MTLE.

Neuroimaging biomarkers of epileptogenesis

Much progress has been made in the field studying the process of epileptogenesis via neuroimaging techniques. Conventional imaging methods include magnetic resonance imaging with morphometric analysis, magnetic resonance spectroscopy and positron emission tomography. Newer network-based methods such as diffusion tensor imaging and functional magnetic resonance imaging with resting functional connectivity are being developed and applied to clinical use. This review provides a brief summary of the major human and animal studies in both partial and generalized epilepsies that demonstrate the potential of these imaging modalities to serve as biomarkers of epileptogenesis.