Cesare Lombroso, cortical dysplasia, and epilepsy: Keen findings and odd theories

Malformations of cortical development

Structural abnormalities of the brain are increasingly recognized in patients that suffer from pharmacoresistant focal epilepsies by applying high-resolution imaging techniques. In many of these patients, epilepsy surgery results in control of seizures. Neuropathologically, a broad spectrum of malformations of cortical development (MCD) is observed in respective surgical brain samples. These samples provide a unique basis to further understand underlying pathomechanisms by molecular approaches and develop improved diagnostics and entirely new therapeutic perspectives. Here we provide a comprehensive description of neuropathological findings, available classification systems as well as molecular mechanisms of MCDs. We emphasize the recently published ILEA classification system for focal cortical dysplasias (FCDs), which are now histopathologically distinguished as types I to III. However, this revised classification system represents a major challenge for molecular neuropathologists, as the underlying pathomechanisms in virtually all FCD entities will need to be specified in detail. The fact that only recently, the mammalian target of rapamycin (mTOR)-antagonist Everolimus has been introduced as a treatment of epilepsies in the context of tuberous sclerosis-associated brain lesions is a striking example of a successful translational "bedside to bench and back" approach. Hopefully, the exciting clinico-pathological developments in the field of MCDs will in short term foster further therapeutic breakthroughs for the frequently associated medically refractory epilepsies.

The Lombrosian prejudice in medicine. The case of epilepsy. Epileptic psychosis. Epilepsy and aggressiveness

In the nineteenth century, epilepsy became subject of experimental research. Lombroso established a relationship between epilepsy and criminality believing in the existence of epileptoid traits and atavism. He tried to demonstrate the common origin of epilepsy, criminality, and genius; factors deteriorating the CNS would act upon centers, which control behavior and ethics. This impairment would cause a lack of control on the lower nervous centers, reducing restraints of instincts and criminal behavior. He described developmental frontal cortex lesions in epileptic patients (today Taylor's dysplasia) and these observations supported the erroneous conviction of a relationship between criminality and epilepsy. Neurological, behavioral, and criminological sciences analyzed Lombroso's doctrine, whereas it was controversial that epileptic patients should be prone to violent actions and aggressive behavior. Today, there is an international panel of experts on epilepsy, which suggests five relevant criteria to determine if a crime committed with aggressiveness could result from epileptic seizures.

Epilepsy and stigma: an approach to understanding through the life and works of the Brazilian writer Machado de Assis (1839-1908)

Machado de Assis (1839-1908)-novelist, short story writer, essayist, and poet-is a fascinating personality. Had he written in French, English, German, or Italian, he would have achieved universal fame and would be in the same company as Balzac, Tolstoy, Dickens, and Dostoevsky. This article discusses stigma in epilepsy through Machado de Assis' life, literary work, and letters to other Brazilian writers. Founder of the Brazilian Academy of Letters, Machado offers an insoluble enigma to psychologists and essayists. Born in stark poverty, feeble, and ugly, he had to fight the taint of epilepsy. The documentation of epilepsy in Machado de Assis' texts and letters and the testimony of his contemporaries is unique, allowing the comprehension of scientific concepts and stigma related to epilepsy in the 19th century, when the positivist ideas of the Italian neuropsychiatrist Cesare Lombroso (1835-1909) permeated nascent Brazilian neuropsychiatry. Much of the stigma associated with epilepsy we witness today emerged from these concepts. Even today in Brazil, when barbaric crimes are committed, headlines in newspapers produced by forensic psychiatrists often attribute the conduct of the criminal to epileptic behavior.

Neuropathology of epilepsy and psychosis: the contributions of J.A.N. Corsellis

Professor J.A.N. Corsellis, whose life and work is recalled here, gained great insight into the meaning of morphological cerebral aberrations found in neuropsychiatric disease through exact neuropathological investigations of tissue specimens obtained from patients with distinct syndromes. He was a leading authority in the field. We have searched and compiled resources relating to J.A.N. Corsellis' life and work, including personal memories from colleagues and data from scientific publications. J.A.N. Corsellis made seminal contributions to the understanding of neuropsychiatric disease; his works substantially added to the understanding of the dementias, schizophrenia and the psychoses, and morphological sequelae of boxing. In seizure disorders, his name is linked to the first description of focal cortical dysplasia and limbic encephalitis, the pathology of status epilepticus and Ammon's horn sclerosis, and the systematic investigation of epilepsy surgery specimens in general. Both his life and work are closely linked to Runwell Hospital, Wickford, Essex and the Maudsley Hospital. During his professional life he established a large brain bank, now known as the Corsellis Collection. J.A.N. Corsellis had significant impact on neuroscience; many of his observations were groundbreaking and are still valid.

Focal Cortical Dysplasias: clinical implication of neuropathological classification systems

Focal Cortical Dysplasias (FCDs) are highly epileptogenic brain lesions and are a frequent cause for drug-resistant focal epilepsies in humans. FCDs present with variable histopathological patterns, including architectural, cytoarchitectural or white matter abnormalities. Pathomechanisms compromising neuroblast proliferation, migration, or differentiation are likely to play a role in the etiology of FCD variants. FCDs were subsumed, therefore, into the broad spectrum of malformations of cortical development. The most frequent subtype comprises FCD Type II, which in general occurs as isolated lesion in extratemporal location and is histopathologically characterized by dysmorphic neurons (Type IIA) and balloon cells (Type IIB). Neuroimaging hallmarks include hyperintense T2-signaling and a "transmantle sign". Electrophysiological recordings show peculiar interictal spike patterns and complete surgical resection results in favorable seizure control. In contrast, FCD Type I can be identified in young children with severe epilepsy and psychomotor retardation. Parietal, temporal, and occipital lobes may be involved in seizure generation, although neuroimaging often reveals normal contrast intensities. Surgical resection strategies ameliorate seizure frequencies in many children, whereas complete seizure relief can be achieved only in rare cases. According to the currently used FCD classification system, the same histopathological FCD Type I variant can be diagnosed as associated lesion in the large cohort of epilepsy patients with hippocampal sclerosis, low-grade glio-neuronal tumors, vascular malformations, or glial scarring. MRI is often not helpful to detect the dysplastic cortical areas. In addition, there is no specific electrophysiological pattern for an associated dysplastic lesion. Surgical resection of the epileptogenic area results, however, in favorable seizure control. These findings argue for a revised neuropathological classification system that distinguishes isolated versus associated FCD variants to obtain a better correlation with electro-clinical findings and prediction of postsurgical seizure control.

Is a picture worth a thousand words? Neuroimaging in the courtroom

Neuroimaging has advanced our understanding of how the living brain operates, providing structural and functional images of both healthy and diseased brains. This technology pervades today's society, particularly affecting the legal arena. Some judges argue that scientific evidence, which offers insight into the offender's mental state, is crucial because it is the only means of determining whether an offender's punishment is proportional to his crime. Other judges argue that “objective” evidence does not “wholly determine the controversy,” and focus instead on their duty as gatekeepers to independently evaluate scientific evidence. If courts use brain images to make their culpability determinations more objective and sound, these images must meet pertinent legal standards and shed light on medical conditions. For neuroimaging to meet these legal and medical standards with scientific integrity, scientists must convincingly correlate the dynamic images in a person's brain with the way the person is thinking or acting at that moment.