Longitudinal distribution of hippocampal atrophy in mesial temporal lobe epilepsy

Increased Inhibition May Contribute to Maintaining Normal Network Function in the Ventral Hippocampus of a Fmr1-Targeted Transgenic Rat Model of Fragile X Syndrome

A common neurobiological mechanism in several neurodevelopmental disorders, including fragile X syndrome (FXS), is alterations in the balance between excitation and inhibition in the brain. It is thought that in the hippocampus, as in other brain regions, FXS is associated with increased excitability and reduced inhibition. However, it is still not known whether these changes apply to both the dorsal and ventral hippocampus, which appear to be differently involved in neurodegenerative disorders. Using a Fmr1 knock-out (KO) rat model of FXS, we found increased neuronal excitability in both the dorsal and ventral KO hippocampus and increased excitatory synaptic transmission in the dorsal hippocampus. Interestingly, synaptic inhibition is significantly increased in the ventral but not the dorsal KO hippocampus. Furthermore, the ventral KO hippocampus displays increased expression of the α1GABAA receptor subtype and a remarkably reduced rate of epileptiform discharges induced by magnesium-free medium. In contrast, the dorsal KO hippocampus displays an increased rate of epileptiform discharges and similar expression of α1GABAA receptors compared with the dorsal WT hippocampus. Blockade of α5GABAA receptors by L-655,708 did not affect epileptiform discharges in any genotype or hippocampal segment, and the expression of α5GABAA receptors did not differ between WT and KO hippocampus. These results suggest that the increased excitability of the dorsal KO hippocampus contributes to its heightened tendency to epileptiform discharges, while the increased phasic inhibition in the Fmr1-KO ventral hippocampus may represent a homeostatic mechanism that compensates for the increased excitability reducing its vulnerability to epileptic activity.

Scaling of Network Excitability and Inhibition may Contribute to the Septotemporal Differentiation of Sharp Waves-Ripples in Rat Hippocampus In Vitro

The functional organization of the hippocampus along its longitudinal (septotemporal or dorsoventral) axis is conspicuously heterogeneous. This functional diversification includes the activity of sharp wave and ripples (SPW-Rs), a complex intrinsic network pattern involved in memory consolidation. In this study, using transverse slices from the ventral and the dorsal rat hippocampus and recordings of CA1 field potentials we studied the development of SPW-Rs and possible changes in local network excitability and inhibition, during in vitro maintenance of the hippocampal tissue. We found that SPW-Rs develop gradually in terms of magnitude and rate of occurrence in the ventral hippocampus. On the contrary, neither the magnitude nor the rate of occurrence significantly changed in dorsal hippocampal slices during their in vitro maintenance. The development of SPW-Rs was accompanied by an increase in local network excitability more in the ventral than in the dorsal hippocampus, and an increase in local network inhibition in the ventral hippocampus only. Furthermore, the amplitude of SPWs positively correlated with the level of maximum excitation of the local neuronal network in both segments of the hippocampus, and the local network excitability and inhibition in the ventral but not the dorsal hippocampus. Blockade of α5 subunit-containing GABA_A receptor by L-655,708 significantly reduced the rate of occurrence of SPWs and enhanced the probability of their generation in the form of clusters in the ventral hippocampus without affecting activity in the dorsal hippocampus. The present evidence suggests that a dynamic upregulation of excitation and inhibition in the local neuronal network may significantly contribute to the generation of SPW-Rs, particularly in the ventral hippocampus.

Dorsal-Ventral Differences in Modulation of Synaptic Transmission in the Hippocampus

Functional diversification along the longitudinal axis of the hippocampus is a rapidly growing concept. Modulation of synaptic transmission by neurotransmitter receptors may importantly contribute to specialization of local intrinsic network function along the hippocampus. In the present study, using transverse slices from the dorsal and the ventral hippocampus of adult rats and recordings of evoked field postsynaptic excitatory potentials (fEPSPs) from the CA1 stratum radiatum, we aimed to compare modulation of synaptic transmission between the dorsal and the ventral hippocampus. We found that transient heterosynaptic depression (tHSD, <2 s), a physiologically relevant phenomenon of regulation of excitatory synaptic transmission induced by paired stimulation of two independent inputs to stratum radiatum of CA1 field, has an increased magnitude and duration in the ventral hippocampus, presumably contributing to increased input segregation in this segment of the hippocampus. GABA_B receptors, GABA_A receptors, adenosine A1 receptors and L-type voltage-gated calcium channels appear to contribute differently to tHSD in the two hippocampal segments; GABA_BRs play a predominant role in the ventral hippocampus while both GABA_BRs and A1Rs play important roles in the dorsal hippocampus. Activation of GABA_B receptors by an exogenous agonist, baclofen, robustly and reversibly modulated both the initial fast and the late slow components of excitatory synaptic transmission, expressed by the fEPSPslope and fEPSP decay time constant (fEPSP_τ), respectively. Specifically, baclofen suppressed fEPSP slope more in the ventral than in the dorsal hippocampus and enhanced fEPSP_τ more in the dorsal than in the ventral hippocampus. Also, baclofen enhanced paired-pulse facilitation in the two hippocampal segments similarly. Blockade of GABA_B receptors did not affect basal paired-pulse facilitation in either hippocampal segment. We propose that the revealed dorsal-ventral differences in modulation of synaptic transmission may provide a means for specialization of information processing in the local neuronal circuits, thereby significantly contributing to diversifying neuronal network functioning along the dorsal-ventral axis of hippocampus.

Volumetric changes in hippocampal subregions and their relation to memory in pediatric nonlesional localization-related epilepsy

OBJECTIVE

Developmental differences in structure and function have been reported along the hippocampal subregions. The aims of this study were to determine if there were volumetric differences in hippocampal head (HH), body (HB), tail (HT), and total hippocampus (TotH)) in children with nonlesional localization-related epilepsy relative to controls, and the relation between hippocampal subregions with episodic memory and clinical parameters.

METHODS

Forty-eight children with nonlesional localization-related epilepsy, consisting of 29 left-sided and 19 right-sided epilepsy, and 27 healthy controls were recruited. All patients and controls underwent volumetric T1-weighted imaging, and verbal and nonverbal memory testing. The volume of hippocampal subregions was compared between patients and controls. The associations between left hippocampal subregions with verbal memory; right hippocampal subregions with nonverbal memory; and hippocampal subregions with age, age at seizure onset, and seizure frequency were assessed.

RESULTS

Patients with left-sided epilepsy had smaller left HH (p = 0.003) and HB (p = 0.012), right HB (p = 0.021) and HT (p = 0.015), and right TotH (p = 0.020) volumes. Those with right-sided epilepsy had smaller right HT (p = 0.018) volume. There were no statistically significant differences between verbal and nonverbal memory in left-sided and right-sided epilepsy relative to controls (all p > 0.025). In left-sided epilepsy, there was a significant association between left HH volume with verbal memory (β = 0.492, p = 0.001). There was no significant association between left and right hippocampal subregions with verbal and nonverbal memory, respectively, in right-sided epilepsy and controls (all p > 0.002). In left-sided and right-sided epilepsy, there was no significant association between hippocampal subregions with age, age at seizure onset, and seizure frequency (all p > 0.002).

SIGNIFICANCE

We have found hippocampal volume reduction, but did not identify a gradient in the severity of volume reduction along the hippocampal axis in children with localization-related epilepsy. Further study is needed to clarify if there are volumetric changes within the cornu ammonis subfields and dentate gyrus. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Variability of sclerosis along the longitudinal hippocampal axis in epilepsy: a post mortem study

Detailed neuropathological studies of the extent of hippocampal sclerosis (HS) in epilepsy along the longitudinal axis of the hippocampus are lacking. Neuroimaging studies of patients with temporal lobe epilepsy support that sclerosis is not always localised. The extent of HS is of relevance to surgical planning and poor outcomes may relate to residual HS in the posterior remnant. In 10 post mortems from patients with long histories of drug refractory epilepsy and 3 controls we systematically sampled the left and right hippocampus at seven coronal anatomical levels along the body to the tail. We quantified neuronal densities in CA1 and CA4 subfields at each level using Cresyl Violet (CV), calretinin (CR), calbindin (CB) and Neuropeptide Y (NPY) immunohistochemistry. In the dentate gyrus we graded the extent of granule cell dispersion, patterns of CB expression, and synaptic reorganisation with CR and NPY at each level. We identified four patterns of HS based on patterns of pyramidal and interneuronal loss and dentate gyrus reorganisation between sides and levels as follows: (1) symmetrical HS with anterior-posterior (AP) gradient, (2) symmetrical HS without AP gradient, (3) asymmetrical HS with AP gradient and (4) asymmetrical cases without AP gradient. We confirmed in this series that HS can extend into the tail. The patterns of sclerosis (classical versus atypical or none) were consistent between all levels in less than a third of cases. In conclusion, this series highlights the variability of HS along the longitudinal axis. Further studies are required to identify factors that lead to focal versus diffuse HS.

Failed epilepsy surgery for mesial temporal lobe sclerosis: a review of the pathophysiology

Object

The object of the current study was to review the electrophysiology and pathological substrate of failed temporal lobe surgery in patients with mesial temporal sclerosis.

Methods

A systematic review of the literature was performed for the years 1999–2010 to assess the cause of failure and to identify potential reoperation candidates.

Results

Repeat electroencephalographic evaluation documenting ipsilateral temporal lobe onset was the most frequent cause for recurrent epileptogenesis, followed by contralateral temporal lobe seizures. Less frequently, surgical failures demonstrated an electroencephalogram that was compatible with extratemporal localization. The generation of occult or new epileptogenic zones as well as residual epileptogenic tissue could explain these findings.

Conclusions

The outcome of temporal lobe surgery for epilepsy is challenged by a somewhat consistent failure rate. Reoperation results in improved seizure control in properly selected patients. A detailed knowledge of the pathophysiology is beneficial for the reevaluation of these patients.

[Structural magnetic resonance imaging in epilepsy]

Magnetic resonance imaging is the main structural imaging in epilepsy. In patients with focal seizures, detection (and characterization) of a structural lesion consistent with electroclinical data allows therapeutic decisions without having to resort to other more expensive or invasive diagnostic procedures. The identification of some lesions may provide prognostic value, as in the case of Mesial Temporal Sclerosis (MTS) or may contribute to genetic counseling, as in the case of some Malformations of Cortical Development (MCD). The aim of this paper is to review the current state of structural MRI techniques, propose a basic protocol of epilepsy and mention the indications for structural MRI. Also, review the semiology of the main causes of epilepsy, with emphasis on MTS and MCD, by its highest frequency and by the special impact that MRI has shown in dealing with these entities.

Mesial temporal lobe epilepsy: How do we improve surgical outcome?

Surgery has become the standard of care for patients with intractable temporal lobe epilepsy, with anterior temporal lobe resection the most common operation performed for adults with hippocampal sclerosis. This procedure leads to significant improvement in the lives of the overwhelming majority of patients. Despite improved techniques in neuroimaging that have facilitated the identification of potential surgical candidates, the short-term and long-term success of epilepsy surgery has not changed substantially in recent decades. The basic surgical goal, removal of the amygdala, hippocampus, and parahippocampal gyrus, is based on the hypothesis that these structures represent a uniform and contiguous source of seizures in the mesial temporal lobe epilepsy (MTLE) syndrome. Recent observations from the histopathology of resected tissue, preoperative neuroimaging, and the basic science laboratory suggest that the syndrome is not always a uniform entity. Despite clinical similarity, not all patients become seizure-free. Improving surgical outcomes requires a re-examination of why patients fail surgery. This review examines recent findings from the clinic and laboratory. Historically, we have considered MTLE a single disorder, but it may be time to view it as a group of closely related syndromes with variable type and extent of histopathology. That recognition may lead to identifying the appropriate subgroups that will require different diagnostic and surgical approaches to improve surgical outcomes.

Transient epileptic amnesia: regional brain atrophy and its relationship to memory deficits

Transient epileptic amnesia (TEA) is a recently recognised form of epilepsy of which the principle manifestation is recurrent, transient episodes of isolated memory loss. In addition to the amnesic episodes, many patients describe significant interictal memory difficulties. Performance on standard neuropsychological tests is often normal. However, two unusual forms of memory deficit have recently been demonstrated in TEA: (i) accelerated long-term forgetting (ALF): the excessively rapid loss of newly acquired memories over a period of days or weeks and (ii) remote autobiographical memory loss: a loss of memories for salient, personally experienced events of the past few decades. The neuroanatomical bases of TEA and its associated memory deficits are unknown. In this study, we first assessed the relationship between subjective and objective memory performance in 41 patients with TEA. We then analysed MRI data from these patients and 20 matched healthy controls, using manual volumetry and voxel-based morphometry (VBM) to correlate regional brain volumes with clinical and neuropsychological data. Subjective memory estimates were unrelated to performance on standard neuropsychological tests but were partially predicted by mood, ALF and remote autobiographical memory. Manual volumetry identified subtle hippocampal volume loss in the patient group. Both manual volumetry and VBM revealed correlations between medial temporal lobe atrophy and standard anterograde memory scores, but no relation between atrophy and ALF or remote autobiographical memory. These results add weight to the hypothesis that TEA is a syndrome of mesial temporal lobe epilepsy. Furthermore, they suggest that although standard anterograde memory test performance is related to the degree of mesial temporal lobe damage, this is not true for ALF and autobiographical amnesia. It is possible that these unusual memory deficits have a more diffuse physiological basis rather than being a consequence of discrete structural damage.

Relationship between post-operative depression/anxiety and hippocampal/amygdala volumes in temporal lobectomy for epilepsy

PURPOSE

Patients with temporal lobe epilepsy (TLE) often present mood disturbances, which may either exacerbate or remit following surgery. The objective of the study was to investigate the relationship between post-operative depressive/anxiety symptoms and hippocampal/amygdala volumes following anterior temporal lobectomy.

METHODS

Thirty-five patients operated for TLE were assessed for mood disturbances by the Beck depression inventory (BDI) and Beck anxiety inventory (BAI). Post-operative MRI data were collected and volumetric analysis of the hippocampi (HV) and amygdala (AV) was performed. Correlations between volumetric data, measures of mood, and demographic and clinical data were calculated.

RESULTS

BDI scores significantly correlated with the intact HV (p=0.029) as well as the absolute difference between the intact and remnant HV (p=0.021). This was evident in left-side resections (p=0.049); in right-side resections the correlation was marginally non- significant (p=0.057). Depressed patients also had smaller remnant AV (p=0.002). Furthermore, BAI was negatively correlated with the HV remnant in left-side resections (p=0.038). No other significant associations between post-operative mood disturbances and various demographic and clinical variables were observed.

CONCLUSION

The severity of depressive symptomatology in operated epilepsy patients correlates with the extent of hippocampal and amygdala resection; this association appears to be more evident in left-side resections.

Greater contribution of N-methyl-D-aspartic acid receptors in ventral compared to dorsal hippocampal slices in the expression and long-term maintenance of epileptiform activity

Functional segregation along the dorso-ventral axis of the hippocampus is a developing concept. The higher susceptibility of the ventral hippocampus to epileptic activity compared with dorsal hippocampus is one of the main features, which still has obscure mechanisms. Using the model of magnesium-free medium and field recordings, single epileptiform discharges displayed higher incidence (77% vs 57%), rate (41.7+/-3.1 vs 13.5+/-0.7 events/min), duration (173.9+/-17.7 vs 116.8+/-13.6 ms) and intensity (coastline, 25.4+/-2.5 vs 9.5+/-1.8) in ventral compared with dorsal rat hippocampal slices. In addition, the decay phase of the evoked synaptic potentials was 110% slower in ventral slices. The N-methyl-D-aspartate (NMDA) receptor antagonist d-(-)-2-amino-5-phosphonopentanoic acid (50-100 microM) decreased the discharge rate and coastline similarly in ventral and dorsal slices, but it shortened the discharges in ventral slices (by 40%) only. The NMDA receptor antagonist 3-((R)-2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid (10 microM) decreased the rate in both groups and additionally shortened discharges in both kinds of slices, an effect which was greater in ventral ones (31% vs 13%). Furthermore, both drugs shortened the evoked potentials more in ventral (77%) than in dorsal slices (52%). On the other hand, 1 microM of 3-((R)-2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid shortened the discharges and evoked synaptic potentials only in ventral slices, and slowed down the discharge rate only in dorsal slices. Addition of NMDA, in the magnesium-free medium, enhanced activity in both kinds of slices. At 5 and 10 microM of NMDA 51% of the ventral but only 9% of the dorsal slices displayed persistent epileptiform discharges, which were recorded for at least one hour after reintroduction of magnesium in the medium. At 10-20 microM the enhancement of activity was transient, followed by suppression of discharges in 40% and 76% of the ventral and dorsal slices, respectively. Most of the slices having experienced suppression did not develop persistent activity. We propose that the NMDA receptors contribute to the higher susceptibility of the ventral hippocampus to expression and long-term maintenance of epileptiform discharges. This diversification may be related to other aspects of hippocampal dorso-ventral functional segregation.

Entorhinal Cortex Involvement in Human Mesial Temporal Lobe Epilepsy: An Electrophysiologic and Volumetric Study

PURPOSE

Several studies have demonstrated diminution in the volume of entorhinal cortex (EC) ipsilateral to the pathologic side in patients with temporal lobe epilepsy (TLE). The relation between the degree of EC atrophy and the epileptogenicity of this structure has never been directly studied. The purpose of the study was to determine whether atrophy of the EC evaluated by the quantitative magnetic resonance imaging (MRI) method is correlated with the epileptogenicity of this structure in TLE.

METHODS

Intracerebral recordings (SEEG method) of seizures from 11 patients with mesial TLE were analyzed. Seizures were classified according to patterns of onset: pattern 1 was the emergence of a low-frequency, high-amplitude rhythmic spiking followed by a tonic discharge, and pattern 2 was the emergence of a tonic discharge in the mesial structures. A nonlinear measure of SEEG signal interdependencies was used to evaluate the functional couplings occurring between hippocampus (Hip) and EC at seizure onset. MRI volumetric analysis was performed by using a T(1)-weighted three-dimensional gradient-echo sequence in TLE patients and 12 healthy subjects.

RESULTS

Significant interactions between Hip and Ec were quantified at seizure onset. The EC was found to be the leader structure in most of the pattern 2 seizures. Volumetric measurements of EC demonstrated an atrophy in 63% of patients ipsilateral to the epileptic side. A significant correlation between the strength of EC-Hip coupling and the degree of atrophy was found. In addition, in those patients that had a normal EC volume, the EC was never the leader structure in Ec-Hip coupling.

CONCLUSIONS

These results validate the potential role of volumetry to predict the epileptogenesis of the EC in patients with hippocampal sclerosis and MTLE.

MR-based in vivo hippocampal volumetrics: 2. Findings in neuropsychiatric disorders

Magnetic resonance imaging (MRI) has opened a new window to the brain. Measuring hippocampal volume with MRI has provided important information about several neuropsychiatric disorders. We reviewed the literature and selected all English-language, human subject, data-driven papers on hippocampal volumetry, yielding a database of 423 records. Smaller hippocampal volumes have been reported in epilepsy, Alzheimer's disease, dementia, mild cognitive impairment, the aged, traumatic brain injury, cardiac arrest, Parkinson's disease, Huntington's disease, Cushing's disease, herpes simplex encephalitis, Turner's syndrome, Down's syndrome, survivors of low birth weight, schizophrenia, major depression, posttraumatic stress disorder, chronic alcoholism, borderline personality disorder, obsessive-compulsive disorder, and antisocial personality disorder. Significantly larger hippocampal volumes have been correlated with autism and children with fragile X syndrome. Preservation of hippocampal volume has been reported in congenital hyperplasia, children with fetal alcohol syndrome, anorexia nervosa, attention-deficit and hyperactivity disorder, bipolar disorder, and panic disorder. Possible mechanisms of hippocampal volume loss in neuropsychiatric disorders are discussed.

Bilateral mesial temporal lobe epilepsy: comparison of scalp EEG and hippocampal MRI-T2 relaxometry

OBJECTIVE

Bilateral hippocampal abnormality is frequent in mesial temporal lobe sclerosis and might affect outcome in epilepsy surgery. The objective of this study was to compare the lateralization of interictal and ictal scalp EEG with MRI T2 relaxometry.

MATERIAL AND METHODS

Forty-nine consecutive patients with intractable mesial temporal lobe epilepsy (MTLE) were studied with scalp EEG/video monitoring and MRI T2 relaxometry.

RESULTS

Bilateral prolongation of hippocampal T2 time was significantly associated with following bitemporal scalp EEG changes: (i) in ictal EEG left and right temporal EEG seizure onsets in different seizures, or, after regionalized EEG onset, evolution of an independent ictal EEG over the contralateral temporal lobe (left and right temporal asynchronous frequencies or lateralization switch; P = 0.002); (ii) in interictal EEG both left and right temporal interictal slowing (P = 0.007). Bitemporal T2 changes were not, however, associated with bitemporal interictal epileptiform discharges (IED). Lateralization of bilateral asymmetric or unilateral abnormal T2 findings were associated with initial regionalization of the ictal EEG in all but one patient (P < 0.005), with lateralization of IED in all patients (P < 0.005), and with scalp EEG slowing in 28 (82,4%) of 34 patients (P = 0.007).

CONCLUSION

Our data suggest that EEG seizure propagation is more closely related to hippocampal T2 abnormalities than IED. Interictal and ictal scalp EEG, including the recognition of ictal propagation patterns, and MRI T2 relaxometry can help to identify patients with bitemporal damage in MTLE. Further studies are needed to estimate the impact of bilateral EEG and MRI abnormal findings on the surgical outcome.

Qualitative and quantitative imaging of the hippocampus in mesial temporal lobe epilepsy with hippocampal sclerosis

MR imaging allows the in vivo detection of hippocampal sclerosis (HS) and has been instrumental in the delineation of the syndrome of mesial temporal lobe epilepsy with HS (mTLE-HS). MR features of HS include hippocampal atrophy with an increased T2 signal. Quantitative MR imaging accurately reflects the degree of hippocampal damage.Ictal single photon emission computed tomography (SPECT) in mTLE-HS shows typical perfusion patterns of ipsilateral temporal lobe hyperperfusion, and ipsilateral frontoparietal and contralateral cerebellar hypoperfusion. Interictal 18fluoro-2-deoxyglucose positron emission tomography (PET) shows multiregional hypometabolism, involving predominantly the ipsilateral temporal lobe. 11C-flumazenil PET shows hippocampal decreases in central benzodiazepine receptor density. Future strategies to study the etiology and pathogenesis of HS should include longitudinal MR imaging studies,MR studies in families with epilepsy and febrile seizures, stratification for genetic background, coregistration with SPECT and PET, partial volume correction and statistical parametric mapping analysis of SPECT and PET images.

Early development destructive brain lesions and their relationship to epilepsy and hippocampal damage

Fifty-one consecutive adult patients with epilepsy and early development destructive brain lesions were divided into three main groups according to the topographic distribution of the lesion on magnetic resonance imaging: hemispheric (H) (n=9); main arterial territory (AT) (n=25) and arterial borderzone (Bdz) (n=17). Eight (89%) patients from group H presented status epilepticus in the first 5 years of life, five of them associated with fever. Seventeen of the 25 patients from group AT (76%) had an obvious hemiparesis observed early in life. In addition, major prenatal events were significantly more common in the group AT compared with the other two groups. Among patients from group Bdz, prenatal or postnatal events were not identified, except for one patient. Conversely, nine patients from group Bdz (60%) showed a history of perinatal complications. Hippocampal atrophy (HA) was determined by visual analysis in 74.5% of all patients and by volumetry in 92%. The frequency of HA was comparable among groups, but patients from group H presented the most severe atrophy and more frequent hyperintense T2 hippocampal signal. In conclusion, these three groups of patients with early destructive lesions and epilepsy (H, AT and Bdz), appear to have distinct pathogenic mechanisms. Our data show that there is a striking association of HA with different patterns of neocortical destructive lesions of early development. This association seems to be related to a common and synchronic pathogenic mechanism. The recognition of the pattern and degree of HA among these patients with intractable seizures may influence the surgical rationale.

Do recurrent seizures cause neuronal damage? A series of studies with MRI volumetry in adults with partial epilepsy

Despite optimal treatment, 30% of epilepsy patients develop intractable epilepsy and continue to have recurrent seizures or other symptoms of epileptic syndrome restricting their ability to lead a full life. Hippocampal sclerosis is found in 60-70% of patients with intractable temporal lobe epilepsy (TLE). However, it is not known whether the damage in the hippocampus is the cause or the consequence of TLE. The purpose of the present series of studies was to investigate with magnetic resonance imaging (MRI) the appearance of medial temporal lobe damage during the course of partial epilepsy, and, particularly, to determine whether recurrent or prolonged seizures contribute to the damage. Altogether 259 partial epilepsy patients were investigated with quantitative MRI. High lifetime seizure number, complex febrile convulsions in the medical history, and early age at the onset of spontaneous seizures contributed to hippocampal damage in patients with TLE. The risk factors that predicted amygdaloid volume reduction were intracranial infection and complex febrile convulsions. Damage in the hippocampus or in the amygdala was rare at the time of first spontaneous seizures in TLE. In contrast, hippocampal damage was apparent in chronic TLE patients with years of frequent seizures. Chronic cryptogenic drug-resistant TLE patients had smaller mean hippocampal volumes ipsilateral to the seizure focus than controls. In all TLE patients, ipsilateral hippocampal volume correlated negatively with the lifetime seizure number. The mean amygdaloid volumes in chronic TLE patients did not differ from those in controls. However, about 20% of chronic patients had > or = 20% volume reduction in the amygdala. The mean volumes of the entorhinal cortex ipsilateral to the epileptic focus in cryptogenic TLE patients did not differ from those in controls. However, the entorhinal cortex was damaged in a subpopulation of TLE patients with associated hippocampal damage TLE. The findings of the present series of studies support the hypothesis that damage in the medial temporal lobe structures may be both the cause and consequence of TLE. The data provide evidence that in some patients hippocampal damage may progress as a function of repeated seizures, and argue for efficient drug therapy or early surgery to reach complete seizure control. Future research should address strategies for disease-modifying therapies and ultimately remission of the epileptic process.

Decreased ability of rat temporal hippocampal CA1 region to produce long-term potentiation

Tetanic stimulation of Schaffer collaterals in the CA1 region of transverse slices, taken from the septal (dorsal) part of young rat hippocampus, produced N-Methyl-D-aspartate-dependent long-term potentiation (LTP) of the rising slope of excitatory postsynaptic potential (mean 38%). Under identical conditions of stimulation (100 Hz, 1 s) slices taken from the temporal (ventral) third of hippocampus presented a substantially reduced ability for LTP (mean 5%). The defect appeared to lie with the induction rather than the maintenance phase of LTP. These results suggest that a significant functional differentiation at the local synaptic plasticity level occurs between the two poles of hippocampus, which together with the substantial differences in their extrinsic connections, may help explain the reported differential participation of neurons in these parts of hippocampus during animal memory tests.

[11C]Flumazenil PET in patients with epilepsy with dual pathology

PURPOSE

Coexistence of hippocampal sclerosis and a potentially epileptogenic cortical lesion is referred to as dual pathology and can be responsible for poor surgical outcome in patients with medically intractable partial epilepsy. [11C]Flumazenil (FMZ) positron emission tomography (PET) is a sensitive method for visualizing epileptogenic foci. In this study of 12 patients with dual pathology, we addressed the sensitivity of FMZ PET to detect hippocampal abnormalities and compared magnetic resonance imaging (MRI) with visual as well as quantitative FMZ PET findings.

METHODS

All patients underwent volumetric MRI, prolonged video-EEG monitoring, and glucose metabolism PET before the FMZ PET. MRI-coregistered partial volume-corrected PET images were used to measure FMZ-binding asymmetries by using asymmetry indices (AIs) in the whole hippocampus and in three (anterior, middle, and posterior) hippocampal subregions. Cortical sites of decreased FMZ binding also were evaluated by using AIs for regions with MRI-verified cortical lesions as well as for non-lesional areas with visually detected asymmetry.

RESULTS

Abnormally decreased FMZ binding could be detected by quantitative analysis in the atrophic hippocampus of all 12 patients, including three patients with discordant or inconclusive EEG findings. Decreased FMZ binding was restricted to only one subregion of the hippocampus in three patients. Areas of decreased cortical FMZ binding were obvious visually in all patients. Decreased FMZ binding was detected visually in nonlesional cortical areas in four patients. The AIs for these nonlesional regions with visual asymmetry were significantly lower than those for regions showing MRI lesions (paired t test, p = 0.0075).

CONCLUSIONS

Visual as well as quantitative analyses of FMZ-binding asymmetry are sensitive methods to detect decreased benzodiazepine-receptor binding in the hippocampus and neocortex of patients with dual pathology. MRI-defined hippocampal atrophy is always associated with decreased FMZ binding, although the latter may be localized to only one sub-region within the hippocampus. FMZ PET abnormalities can occur in areas with normal appearance on MRI, but FMZ-binding asymmetry of these regions is lower when compared with that of lesional areas. FMZ PET can be especially helpful when MRI and EEG findings of patients with intractable epilepsy are discordant.

Normative volumetric data of the developing hippocampus in children based on magnetic resonance imaging

PURPOSE

To acquire normative data of the hippocampus and its postnatal growth in 50 children (age, 1 month to 15 years) without epilepsy.

METHODS

Morphometry of the hippocampus was carried out by using a spoiled FLASH 3D sequence (sagittal orientation), whereas the volume of the brain was assessed with a T2-weighted spin-echo sequence (transverse orientation). The volume of the hippocampus and the brain was determined by following Cavalieri's principle. Growth curves of the brain and hippocampus were fitted to a nonlinear Boltzmann sigmoidal equation.

RESULTS

Intra-/interobserver coefficient of variation was 2.0/4.9% for hippocampal volume measurements and 2.0/2.1% for brain volumetry. A significant difference in volume was noted between the right and left hippocampus (p < 0.001), with the right side being larger on average by 0.10 cc. Correlation coefficients of growth curves ranged between 0.71 and 0.94. Growth curves demonstrated a faster development of the hippocampus in girls. A steeper slope of hippocampal growth as compared with brain growth was found in girls, whereas in boys, the slope of brain growth was steeper.

CONCLUSIONS

Our findings will be of help in evaluating vulnerable phases of the hippocampal formation with accelerated growth, thereby leading to a better understanding of the development of hippocampal sclerosis in early childhood.

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.