Cortical and subcortical secondary epileptogenesis

Predictive Factors of Surgical Outcome in Frontal Lobe Epilepsy Explored with Stereoelectroencephalography

BACKGROUND

Resective surgery established treatment for pharmacoresistant frontal lobe epilepsy (FLE), but seizure outcome and prognostic indicators are poorly characterized and vary between studies.

OBJECTIVE

To study long-term seizure outcome and identify prognostic factors.

METHODS

We retrospectively analyzed 42 FLE patients having undergone surgical resection, mostly preceded by invasive recordings with stereoelectroencephalography (SEEG). Postsurgical outcome up to 10-yr follow-up and prognostic indicators were analyzed using Kaplan-Meier analysis and multivariate and conditional inference procedures.

RESULTS

At the time of last follow-up, 57.1% of patients were seizure-free. The estimated chance of seizure freedom was 67% (95% confidence interval [CI]: 54-83) at 6 mo, 59% (95% CI: 46-76) at 1 yr, 53% (95% CI: 40-71) at 2 yr, and 46% (95% CI: 32-66) at 5 yr. Most relapses (83%) occurred within the first 12 mo. Multivariate analysis showed that completeness of resection of the epileptogenic zone (EZ) as defined by SEEG was the main predictor of seizure outcome. According to conditional inference trees, in patients with complete resection of the EZ, focal cortical dysplasia as etiology and focal EZ were positive prognostic indicators. No difference in outcome was found in patients with positive vs negative magnetic resonance imaging.

CONCLUSION

Surgical resection in drug-resistant FLE can be a successful therapeutic approach, even in the absence of neuroradiologically visible lesions. SEEG may be highly useful in both nonlesional and lesional FLE cases, because complete resection of the EZ as defined by SEEG is associated with better prognosis.

Local and remote epileptogenicity in focal cortical dysplasias and neurodevelopmental tumours

During the pre-surgical evaluation of drug-resistant epilepsy, the assessment of the extent of the epileptogenic zone and its organization is a crucial objective. Indeed, the epileptogenic zone may be organized as a simple focal lesional site or as a more complex network (often referred to as the 'epileptogenic network') extending beyond the lesion. This distinction is particularly relevant in developmental lesions such as focal cortical dysplasias or dysembryoplastic neuroepithelial tumours and may determine both the surgical strategy and the prognosis. In this study, we have quantified the epileptogenic characteristic of brain structures explored by depth electrodes in 36 patients investigated by stereoelectroencephalography and suffering from focal drug-resistant epilepsy associated with focal cortical dysplasias or dysembryoplastic neuroepithelial tumours. This quantification was performed using the 'Epileptogenicity Index' method that accounts for both the propensity of a brain area to generate rapid discharges and the time for this area to get involved in the seizure. Epileptogenicity Index values range from 0 (no epileptogenicity) to 1 (maximal epileptogenicity). We determined Epileptogenicity Index from signals recorded in distinct brain structures including the lesional site. We studied the type of epileptogenic zone organization (focal versus network) and looked for a correlation with clinical data and post-surgical outcome. Mean Epileptogenicity Index in lesional regions was 0.87 (+/-0.25), and 0.29 (+/-0.30) in 'non-lesional' structures. The number of highly epileptogenic structures (defined by Epileptogenicity Index value >or=0.4) was 3.14 (+/-1.87) in the whole population. We found that 31% of patients had only one epileptogenic structure (N(EI>or=0.4) = 1), therefore disclosing a strictly focal epileptogenic zone organization while 25 patients had more than one epileptogenic region, disclosing a network (61%) or bilateral (8%) epileptogenic zone organization. We observed a trend for a difference in seizure outcome according to the type of epileptogenic zone organization. Indeed, 57% of patients with network organization and 87% with focal organization were seizure-free while none of those with bilateral organization became seizure-free. The determination of Epileptogenicity Index computed from electrophysiological signals recorded according to the stereoelectroencephalography technique is a novel tool. Results suggest that it can help in the delineation of the epileptogenic zone associated with brain lesions and that it could be used in the definition of the subsequent surgical resection.

Secondary epileptogenesis in humans

Secondary epileptogenesis as it applies to humans remains a controversial topic despite 40 years of investigation. Part of the controversy stems from disagreement about the definition of secondary epileptogenesis, and part of the controversy stems from the imperfect fit of animal models to the human epileptic syndromes. It may be that models of secondary epileptogenesis can be useful to describe specific epileptic syndromes such as bitemporal epilepsy and secondary bilateral synchrony, but other models may be required for remitting syndromes such as the Landau-Kleffner syndrome. The concept of secondary epileptogenesis may also provide a useful construct for evaluating patients with partial epileptic syndromes, especially those under consideration for epilepsy surgery, and for the evaluation of preventive strategies in epilepsy.

EEG morphology of partial epileptic seizures

We studied the EEG features of partial seizures in 66 patients. An EEG evolution (morphology and/or frequency change) characterised 79% of attacks: 92% of 48 events with clinical features, but only 44% of 18 subclinical seizures. Aside from attenuation which initiated 7 seizures (11%), 31 (47%) began with sinusoidal waves, 25 (39%) with repetitive epileptiform potentials, and 10 (15%) with both phenomena. Metamorphosis between these forms occurred in about 1/3 of seizures beginning with either form alone. A wave form change occurred in 44% of clinical attacks but only 7% of subclinical seizures. Spikes and sharp waves were the most common repetitive epileptiform potentials encountered. Repetition rate of phenomena at onset usually lay in the theta or delta range except for a few with high frequency sinusoidal waves. Further ictal EEG progression was more likely to occur if a mixed frequency change or frequency increase characterised early evolution.

The early involvement of subcortical structures during the development of a cortical seizure focus

Cortical surface electrodes and bipolar depth electrodes were implanted stereotaxically in the ventral posterolateral and paracentral thalamic nuclei, amygdala, hippocampus, and putamen in adult cats to determine the progressive involvement of these structures in the generalization of an experimentally induced seizure disorder. Prior to (45-65 days) and following (50-70 days) subpial injection of 0.04 ml of aluminum hydroxide in the sensorimotor cortex, 30 min EEG records were obtained regularly in each animal. At the time of aluminum hydroxide injection, there was no persistent abnormal EEG activity resulting from electrode implantation. In all animals, intermittent slow waves and epileptiform activity appeared in subcortical or extrafocal structures prior to the development of epileptiform activity in the primary focus. These abnormalities were frequently associated with brief clinical seizures and were clearly independent of abnormal activity in the primary focus. Only later in the development of the seizure disorder was activity in the secondary foci observed to be dependent on frequent epileptiform activity in the primary focus. These results demonstrate that multiple, independent foci develop in subcortical structures before the occurrence of a well developed, fully "mature" cortical primary focus.

Propagation of focal motor seizures in the pubescent monkey

The rate of local cerebral glucose utilization was determined for quantification of energy metabolism in macrostructures of the sensorimotor system during propagation of focal motor seizures in 24-month-old monkeys. The rate was measured in 4 control animals and in 4 monkeys each with seizures limited to the contralateral face, seizures of the contralateral face and upper extremity, and bilateral expression of seizures. Glucose utilization increased significantly, primarily unilaterally, with propagation. The increase was greatest in the sensory and motor cerebral cortices, putamen, and globus pallidus, was somewhat less in sensory and motor thalamic relay nuclei, and was least in the cerebellar cortex.

The generalized convulsive seizure state induced by daily electrical stimulation of the amygdala in split brain cats

Daily unilateral electrical stimulation of amygdala in forebrain bisected cats provoked the development of the final stage of the kindled convulsion with remarkable rapidity regardless of presence or absence of anterior commissure. The chronological and spatial pattern of propagation of afterdischarge, interictal spike discharge, and clinical manifestations strongly suggest the significant role played by the midbrain reticular formation and possibly other brainstem structures in the progressive electroclinical seizure development. This assumption was supported by the results of a lesion study in which placement of a destructive lesion in the ipsilateral midbrain reticular formation markedly increased the generalized seizure triggering threshold, lateralized the afterdischarge to the stimulated hemisphere when induced with increased intensity stimulation, fragmented clinical seizure manifestations, and failed to produce progression of clinical and electrographic events with prolonged daily stimulation. This is in contrast to the insignificant effect produced by a peduncular lesion. Our findings suggest that vertical (limbic-brainstem), but not horizontal (transhemispheric interlimbic) connection is critically involved in the amygdaloid seizure development while the forebrain commissures may play a role in the development of bisynchronous and bisymmetrical ictal and interictal electrographic and clinical manifestations. Finally, possible differential effect of forebrain bisection depending on developing in contrast with a established (cerebral) hemispheric epileptogenic process is postulated to explain the "facilitatory" effect observed in our series in contrast to the beneficial effects reported on some intractable seizure patients.

Gelastic epilepsy

A case of retinitis pigmentosa with laughing epilepsy is described. Stereotyped repetitive episodes of limb movement, rigidity, and cackling laughter responding to diazepam are recorded. One episode is presented as gelastic status epilepticus and the clinical and EEG features are reported. Features of gelastic epilepsy are discussed and briefly compared with other laughing disorders. A short history of the condition is accompanied by a relevant review of the literature. The possible importance of hypothalamic lesions in laughing epilepsy is discussed and the absence of consistent EEG findings is noted.