Which terms should be used to describe medications used in the treatment of seizure disorders? An ILAE position paper

A variety of terms, such as "antiepileptic," "anticonvulsant," and "antiseizure" have been historically applied to medications for the treatment of seizure disorders. Terminology is important because using terms that do not accurately reflect the action of specific treatments may result in a misunderstanding of their effects and inappropriate use. The present International League Against Epilepsy (ILAE) position paper used a Delphi approach to develop recommendations on English-language terminology applicable to pharmacological agents currently approved for treating seizure disorders. There was consensus that these medications should be collectively named "antiseizure medications". This term accurately reflects their primarily symptomatic effect against seizures and reduces the possibility of health care practitioners, patients, or caregivers having undue expectations or an incorrect understanding of the real action of these medications. The term "antiseizure" to describe these agents does not exclude the possibility of beneficial effects on the course of the disease and comorbidities that result from the downstream effects of seizures, whenever these beneficial effects can be explained solely by the suppression of seizure activity. It is acknowledged that other treatments, mostly under development, can exert direct favorable actions on the underlying disease or its progression, by having "antiepileptogenic" or "disease-modifying" effects. A more-refined terminology to describe precisely these actions needs to be developed.

Impulsiveness, personality traits and executive functioning in patients with juvenile myoclonic epilepsy

PURPOSE

To evaluate impulsiveness in adult patients with JME and its relationship with personality traits and executive functioning.

METHODS

Patients completed psychiatric evaluation (DSM IV), Barratt Impulsiveness Scale (BIS-11), Neo Revised Personality Inventory (NEO PI-R) and executive functioning evaluation comprising Controlled Oral Word Association (COWA), Digit Span, Trail Making Tests (TMT), Stroop Test (ST) and Wisconsin Card Sorting Test (WSCT). Healthy controls (63 % female, mean age 35.7 yrs. (±8.37)) were examined to allow calculation of z-scores.

RESULTS

50 patients (70 % female; mean age 32.5 yrs. (±9.2)) presented higher scores of Total (z=-0.37; p = 0.005) and Motor Impulsiveness (z=-0.79; p < 0.001) on BIS-11. Motor Impulsiveness was associated with higher rates of mild psychiatric disorders (depression and anxiety) (p = 0.035) and worse myoclonic seizure control (p = 0.007). NEO PI-R showed differences on Neuroticism (z=-0.60; p < 0.001), Openness (z = 0.38; p = 0.043), Agreeableness (z=-0.38; p = 0.033) and Conscientiousness (z=-0.53; p = 0.003). There were positive correlations between BIS-11 and Neuroticism with Total, Motor and Non-Planning Impulsiveness, on the other hand, Conscientiousness was negatively correlated with these as well as with Attentive Impulsiveness. Patients performance was worse than that of controls on COWA (z=-0.43; p = 0.009) and WCST's Total Number of Completed Categories (z=-2.08; p = 0.005), Trials Taken to Complete First Category (z=-1.56; p = 0.013), Percentage of Total Errors (z=-1.56; p < 0.001), Perseverative Errors (z=-0.73; p = 0.002), Non-Perseverative Errors (z=-1.05; p = 0.003) and Conceptual Level Responses (z=-1.52; p < 0.001). Non-Planning Impulsiveness correlated with Performance (ST and TMT).

CONCLUSION

Patients with JME present with impulsive behavior, personality features and executive dysfunction which are linked and may lead to lack of commitment in treatment and affect other aspects of life.

The importance of semiological information based on epileptic seizure history

Semiology is the backbone of any correct categorization of seizures, as epileptic or not, focal or bilateral, and is fundamental to elucidating how they are anatomically generated in the brain. An anatomical hypothesis derived from seizure history is the precondition for optimally designed ancillary studies. Without understanding seizure semiology, no rational therapy is possible. This article describes the semiological approach using patient history based on full use of patients' self-reports as well as descriptions by witnesses. Auras represent the subjective aspects of seizures and provide important semiological clues as observable signs, sometimes including rather precise direct anatomical information. Methods of extracting, facilitating and analysing self-reports including linguistic conversation analysis are presented in detail. It is highlighted that prodromes, seizure triggers and reflex epileptic mechanisms can provide crucial information for diagnostics and therapy. Special issues considering seizure semiology in children are discussed in a separate section. Other sections are dedicated to the two most important issues of differential diagnosis: how to distinguish (1) focal from "generalized" epilepsies, particularly when focal seizure phenomena appear in a bilateral epilepsy; and (2) epileptic from a series of non-epileptic events.

Instruction manual for the ILAE 2017 operational classification of seizure types

This companion paper to the introduction of the International League Against Epilepsy (ILAE) 2017 classification of seizure types provides guidance on how to employ the classification. Illustration of the classification is enacted by tables, a glossary of relevant terms, mapping of old to new terms, suggested abbreviations, and examples. Basic and extended versions of the classification are available, depending on the desired degree of detail. Key signs and symptoms of seizures (semiology) are used as a basis for categories of seizures that are focal or generalized from onset or with unknown onset. Any focal seizure can further be optionally characterized by whether awareness is retained or impaired. Impaired awareness during any segment of the seizure renders it a focal impaired awareness seizure. Focal seizures are further optionally characterized by motor onset signs and symptoms: atonic, automatisms, clonic, epileptic spasms, or hyperkinetic, myoclonic, or tonic activity. Nonmotor-onset seizures can manifest as autonomic, behavior arrest, cognitive, emotional, or sensory dysfunction. The earliest prominent manifestation defines the seizure type, which might then progress to other signs and symptoms. Focal seizures can become bilateral tonic-clonic. Generalized seizures engage bilateral networks from onset. Generalized motor seizure characteristics comprise atonic, clonic, epileptic spasms, myoclonic, myoclonic-atonic, myoclonic-tonic-clonic, tonic, or tonic-clonic. Nonmotor (absence) seizures are typical or atypical, or seizures that present prominent myoclonic activity or eyelid myoclonia. Seizures of unknown onset may have features that can still be classified as motor, nonmotor, tonic-clonic, epileptic spasms, or behavior arrest. This "users' manual" for the ILAE 2017 seizure classification will assist the adoption of the new system.

Praxis induction. Definition, relation to epilepsy syndromes, nosological and prognostic significance. A focused review

PURPOSE

There is increasing awareness that reflex epileptic mechanisms provide unique insight into ictogenesis in human epilepsies. Several of the described triggers have in common that they imply complex visuomotor coordination and decision-making; they are today regarded as variations of one principle, i.e. praxis induction (PI). This focused review considers PI from the aspects of history and delineation, clinical and electroencephalographic presentation, syndromatic relations, prevalence, mechanisms of ictogenesis and nosological implications, treatment and prognosis.

METHODS

We reviewed a series of published articles and case reports on PI in order to clarify clinical and electroencephalographic findings, treatment and outcome.

RESULTS

Findings of both induction and inhibition by the same stimuli suggest widening the reflex epilepsy concept into a broader one of epilepsies with exogenous modification of ictogenesis. PI is closely related to juvenile myoclonic epilepsy (JME) where hyperexcitability and hyperconnectivity of the entire network of visuomotor coordination seem to provide the precondition for eliciting reflex myocloni in the musculature active in the precipitating task.

CONCLUSION

The conclusions on ictogenesis derived from PI support the concept of JME as a system disorder of the brain.

Are adverse effects of antiepileptic drugs different in symptomatic partial and idiopathic generalized epilepsies? The Portuguese-Brazilian validation of the Liverpool Adverse Events Profile

We report the results of administration of the Portuguese-Brazilian translation of the Liverpool Adverse Events Profile (LAEP) to 100 patients (mean age=34.5, SD=12.12; 56 females), 61 with symptomatic partial epilepsy (SPE) and 39 with idiopathic generalized epilepsy (IGE) (ILAE, 1989) who were on a stable antiepileptic drug (AED) regimen and being treated in a Brazilian tertiary epilepsy center. Carbamazepine was the most commonly used AED (43.0%), followed by valproic acid (32.0%). Two or more AEDs were used by 69.0% of patients. The mean LAEP score (19 questions) was 37.6 (SD=13.35). The most common adverse effects were sleepiness (35.0%), memory problems (35.0%), and difficulty in concentrating (25.0%). Higher LAEP scores were associated with polytherapy with three or more AEDs (P=0.005), female gender (P<0.001), older age (P<0.001), and uncontrolled seizures (P=0.045). The intraclass coefficient (test-retest reliability) for LAEP overall score was 0.848 (95% CI=0.782-0.895), with a range from 0.370 (unsteadiness) to 0.750 (memory problems). Cronbach's α coefficient (internal consistency) was 0.903. The LAEP was highly correlated with Quality of Life in Epilepsy-31 inventory (r=-0.804, P>0.001) and Hospital Anxiety and Depression Scale (Depression: r=0.637, P<0.001; Anxiety: r=0.621, P<0.001) dimensions. LAEP overall scores were similar in people with SPE and IGE and were not helpful in differentiating adverse effects in these two groups. Clinical variables that influenced global LAEP were seizure frequency (P=0.050) and generalized tonic-clonic seizures in the last month (P=0.031) in the IGE group, and polytherapy with three or more AEDs (P=0.003 and P=0.003) in both IGE and SPE groups.

Kallikrein 1 is overexpressed by astrocytes in the hippocampus of patients with refractory temporal lobe epilepsy, associated with hippocampal sclerosis

Kallikrein 1 (hK1) is a tissue enzyme responsible for kinin release in inflammatory cascade. This study was delineated to study the distribution and the co-localization of hK1 and kinin B1 and B2 receptors with glial and/or neuronal proteins markers, in the hippocampus of patients with refractory temporal lobe epilepsy, associated with hippocampal sclerosis (TLE-HS), comparing with control tissues. Hippocampal levels of KLK1 mRNA were also measured. hK1, kinin B1 and B2 receptors, NeuN and GFAP were analyzed using immunohistochemistry and confocal microscopy and KLK1 mRNA was quantified with real time PCR. Increased expression of hK1 by astrocytes co-localized with GFAP was found, contrasting with kinin B1 and B2 receptors, which were co-localized with NeuN in the sclerotic hippocampus. In addition, KLK1 mRNA was also up-regulated in same tissues. These data suggest an overexpression of kallikrein-kinin system and a neuron-glia interaction in the inflammatory process present in refractory TLE-HS.

The renin-angiotensin system is upregulated in the cortex and hippocampus of patients with temporal lobe epilepsy related to mesial temporal sclerosis

PURPOSE

As reported by several authors, angiotensin II (AngII) is a proinflammatory molecule that stimulates the release of inflammatory cytokines and activates nuclear factor kappaB (NFkappaB), being also associated with the increase of cellular oxidative stress. Its production depends on the activity of the angiotensin converting enzyme (ACE) that hydrolyzes the inactive precursor angiotensin I (AngI) into AngII. It has been suggested that AngII underlies the physiopathological mechanisms of several brain disorders such as stroke, bipolar disorder, schizophrenia, and disease. The aim of the present work was to localize and quantify AngII AT1 and AT2 receptors in the cortex and hippocampus of patients with temporal lobe epilepsy related to mesial temporal sclerosis (MTS) submitted to corticoamygdalohippocampectomy for seizure control.

METHOD

Immunohistochemistry, Western blot, and real-time PCR techniques were employed to analyze the expression of these receptors.

RESULTS

The results showed an upregulation of AngII AT1 receptor as well as its messenger ribonucleic acid (mRNA) expression in the cortex and hippocampus of patients with MTS. In addition, an increased immunoexpression of AngII AT2 receptors was found only in the hippocampus of these patients with no changes in its mRNA levels.

DISCUSSION

These data show, for the first time, changes in components of renin-angiotensin system (RAS) that could be implicated in the physiopathology of MTS.

Immunohistochemical study of six cases of Taylor's type focal cortical dysplasia: correlation with electroclinical data

PURPOSE

Cortical specimens from six patients operated on for drug-resistant epilepsy diagnosed as Taylor's type focal cortical dysplasia were submitted to neuropathological and immunohistochemical studies.

METHODS

All patients were submitted to presurgical investigations including clinical and neuropsychological evaluations, EEG/video telemetry of ictal and interictal events, magnetic resonance imaging, and ictal and interictal single-photon emission computed tomography (SPECT). Recordings from electrocorticography (ECoG) were obtained in four cases and from subdural electrode implantation in two. Postsurgical follow-up was assessed according to Engel's score. Immunohistochemistry (IHC) was processed for parvalbumin (PV), calbindin D28-K (CB), nonphosphorylated neurofilaments (SMI-311), glial fibrillary acidic protein (GFAP) in all cases.

RESULTS

We found continuous/quasi-continuous spikes and sharp-wave patterns in three cases and frequent repetitive bursting of polyspikes and ECoG seizures in two cases. Every patient showed cortical dyslamination, abnormal and giant neurons, and balloon cells. GFAP immunoreactivity was found in astrocytes and some balloon cells that were less intensely stained. Nonphosphorylated neurofilaments SMI-311 immunoreactivity was found in normal and giant neurons and in some balloon cells, making visible thin neuropils. PV immunoreactivity was present in normal interneurons and in fibers in layers IV-V. PV-negative balloon cells were surrounded by abundant PV-positive fibers. CB immunoreactivity was found mostly in interneurons in layers II-III.

CONCLUSIONS

Our research is inconclusive. More cases should be investigated, and we must draw more accurate anatomic correlations between the ECoG recordings and surgical specimens studied with IHC.

Rasmussen encephalitis associated with segmental vitiligo of the scalp: clinicopathologic report

A 3-year-old boy with segmental vitiligo, poliosis, and alopecia over the right side of the scalp developed epilepsia partialis continua involving the left side of the body and progressive atrophy of the right cerebral hemisphere. There was a right ear dysacusia and a perilimbal vitiligo associated with an area of iris depigmentation in the right eye. Pleocytosis and hypergammaglobulin were detected in cerebrospinal fluid. Because medical treatment that included phenobarbital, phenytoin, carbamazepine, oxcarbazepine, benzodiazepines, corticosteroids, gamma-globulin, and a ketogenic diet was ineffective, he underwent a right hemispherectomy. Neuropathologic examination showed a widespread scattered inflammatory process with numerous microglial nodules and perivascular lymphocytic cuffing associated with degenerative changes with severe neuronal loss, loosening of the neuropil, and microcystic changes with tissue collapse. The coexistence of vitiligo and possibly Vogt-Koyanagi-Harada syndrome in this child reinforces the autoimmune theory as the pathogenesis of Rasmussen syndrome.

Clinical characteristics and surgical outcome of patients with temporal lobe tumors and epilepsy

This is a retrospective study of 21 surgically treated patients with temporal lobe tumors and epilepsy. Evaluation included clinical data, EEG findings, structural scans, pathological diagnosis and post-surgical follow-up. There were 9 cases of ganglioglioma, 5 pilocytic astrocytoma, 3 ganglioneuroma, 2 dysembryoplastic neuroepithelial tumor, 1 pleomorphic xantoastrocytoma, and 1 meningioangiomatosis. Mean follow-up time was 22 months and outcome was evaluated according to Engel's classification; 76.2% were classified in class I and 23.8% in II and III. All patients classes II and III had been submitted to mesial and neocortical resections. There were no differences related to clinical characteristics, pathological diagnosis or duration of follow-up in patients seizure-free or not. All patients had abnormal MRI and ten of these had normal CT; the MRI characteristics were compared to pathological diagnosis and specific histological characteristics of the tumors were not discernible by MRI. We concluded that MRI was essential for the diagnosis and precise location of TL tumors. Ganglioglioma was the most frequent tumor and lesionectomy associated to mesial resection doesn't guarantee a better prognosis.

[Bradycardia as an epileptic manifestation in temporal epilepsy: report of a case]

We describe a patient who had cardiac arrhythmia as epileptic manifestation. In a 34-year-old woman who had many episodes of loss of consciousness, the simultaneous ECG and video-EEG monitoring recorded bradycardia with a short episode of asystole (4 seconds) and left temporal rhythmic theta activity on EEG. MRI showed a small mass lesion in the left parahippocampal gyrus. Alterations in cardiac rhythm have been reported in epileptic seizures and tachycardia is the most common finding associated with them; bradyarrhythmia during seizures was uncommon. Many interconnections among insular cortex, limbic system and hypothalamus, may be responsible for vegetative manifestations in temporal lobe epilepsy.

[Sexual disorders in epilepsy. Results of a multidisciplinary evaluation]

Eleven epileptic men who complained of epilepsy and sexual dysfunction were submitted to a multidisciplinary evaluation. Mean age was 27 years (20-34), mean epilepsy duration was 19 years (0.5-32) and the mean seizure frequency was two by week (0-7). Ten patients had partial seizures and one other had myoclonic epilepsy. Ten patients were treated with antiepileptic drugs (phenytoin--1, carbamazepine--8, clonazepam--3, clobazam--2, valproic acid--3, vigabatrin--1). As defined in the DSM III-R, the complaints were: erectile disorder (9), hypoactive sexual desire disorder (4), frotteurism (4), inhibited orgasm (3), premature ejaculation (3), fetishism (2), voyeurism (2), exhibitionism (2), pedophilia (1) and sexual aversion disorder (1). Two patients showed hypogonadotropic hypogonadism on endocrinologic screening. Urological evaluation disclosed organic erectile dysfunction in other two. One patient had a diagnosis of psychogenic sexual disorder. In six patients a conclusive etiologic diagnosis was not reached. This report shows the multifactorial nature of sexual disorder in epilepsy and underlies the need of a multidisciplinar evaluation.

Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases

OBJECTIVE AND IMPORTANCE

We report three cases of cerebellar hemorrhage complicating supratentorial craniotomies for the treatment of epilepsy. In a literature review, we identified only four similar cases of cerebellar hemorrhage after temporal lobectomy for the treatment of epilepsy.

CLINICAL PRESENTATION AND RESULTS

Three young and otherwise healthy patients underwent frontal, occipital, and temporal resections for the treatment of refractory epilepsy. The hemorrhage manifested as peduncular tremor, ataxia, and decerebrate posturing presenting early in the postoperative period. The diagnosis was established by computed tomography and/or magnetic resonance imaging. Benign outcomes were observed for all patients.

CONCLUSION

Based on the available data, it is our opinion that brain dislocation resulting from excessive intraoperative cerebrospinal fluid drainage is a possible mechanism for this rare complication of supratentorial craniotomy. The overdrainage seems to be less hazardous when the procedure is performed for the removal of space-occupying mass lesions. In contrast, the resection of nonexpanding tissues, such as in lobectomies for the treatment of epilepsy, may be an additional risk factor, because the incidence of this complication seems to be higher in these situations.

Clinical and EEG analysis of mesial and lateral temporal lobe seizures

The analysis of the temporal lobe seizures through video-EEG systems shows that they often consist of a sequence of clinical and EEG features which may suggest the localization and the lateralization of the epileptogenic lobe. We analyzed clinical and EEG features of 50 temporal lobe seizures which were separated in group 1 with 25 patients (related to mesial temporal sclerosis) and group 2 with 25 patients (other neocortical temporal lesions). Among the auras, the epigastric type was the most frequent and predominated in group 1. There were differences between the two groups, considering dystonic and tonic posturing and versive head and eye movements. Dystonic posturing was always contralateral to the ictal onset and was considered the most useful lateralizing clinical feature. Ictal speech, spitting and blinking automatisms, prolonged disorientation for place and a greatest percentage of postictal language preservation occurred in right temporal seizures. Postictal aphasia and global disorientation predominated in left temporal seizures. EEG was important for lateralizing the epileptogenic lobe, specially considering rhythmic ictal activity and postictal findings.

Neuroimaging findings in Rasmussen's syndrome

Rasmussen's syndrome is a progressive childhood disease of unknown cause characterized by severe epilepsy, hemiparesis, mental deterioration, inflammation of one cerebral hemisphere, and brain atrophy. Computed tomography, single-photon emission computed tomography (SPECT), and magnetic resonance (MR) neuroimaging findings of 8 patients with pathologically confirmed Rasmussen's syndrome were evaluated retrospectively. All patients showed a predominance of the atrophy in the temporoinsular region and cerebral hemispheric alterations on MR images in a similar extension as seen on SPECT studies. Focal increase in regional cerebral blood flow was observed in the 4 patients presenting with epilepsia partialis continua at the time of hexamethylpropyleneamineoxime injection. Extensive cortical hypoperfusion was noted in the other 4 patients who received the injection during the interictal state. Cerebellar functional abnormalities were present in 6 patients, 2 of them with structural damage.

Surgical treatment of refractory epilepsy associated with space occupying lesions. Experience and review

Surgery for space occupying lesions of the brain associated with intractable epilepsy represents a special problem because relief of the epilepsy in as much an operative goal as excision of the space occupying lesion itself. This study concerns 32 patients with space occupying lesions and intractable epilepsy who underwent excision of the lesion with acute intraoperative electrocorticography guided resection of the epileptogenic focus. Of the 32 patients, 16 formed a subgroup of gangliogliomas alone. The remaining were mixed lesions, predominantly benign. The duration of seizures in these patients ranged from 2 to 30 years, and the seizure frequency varied from 1 to 300 convulsions per month. The operative procedures included temporal corticectomy, amygdalo-hippocampectomy, and extratemporal corticectomies. Twenty nine patients were in Engel class I postoperatively, and three patients were in Engel class II. The findings with gangliogliomas were also considered in a separate group. This study strongly suggests that the operative procedure under electrocorticography guidance improves seizure outcome in space occupying lesions related intractable epilepsy.

Double pathology in Rasmussen's encephalitis: etiologic considerations

In a 7-year-old girl with epilepsia partialis continua (EPC) involving the left face, arm, and leg for 1 year, serial neuroimaging studies showed progressive, brain atrophy. Because medical treatment was ineffective, she underwent a large fronto-temporal surgical resection. Neuropathological examination showed loss of lamination and dysplastic neurons, gliosis, microglial nodules, and perivascular cuffing. Such "double pathology" (dysgenesia and a chronic inflammatory process) may have implications for the pathophysiology of Rasmussen's syndrome.

[Single photon emission tomography in temporal epilepsy: interictal and ictal studies with visual and semi quantitative analysis]

Single photon emission tomography (SPECT) was performed in 27 patients with refractory complex partial seizures from the temporal lobes due to mesial temporal sclerosis. Independent blinded observers assessed the 28 interictal studies and 9 ictal/postictal studies. Visual analysis of interictal studies detected hypoperfusion in 22, ipsilateral to the epileptogenic zone in 19 (67%) and contralateral in 3 (10.7%). Quantified temporal lobe asymmetry, greater than a previously derived normal range, correctly identified the epileptogenic zone in 16 (61.5%) with false lateralization in 4 (15.3%). In all 9 cases in which they were performed, ictal/postictal studies showed hyperperfusion at the region of epileptic focus. In 3 patients with complex partial seizures followed by symmetric generalized tonic-clonic seizures, hyperperfusion restricted to the temporal lobe was demonstrated. In 5 of these patients the interical studies were unable to demonstrate localized changes. There were no significant correlations between SPECT findings and clinical parameters or EEG slowing in the temporal lobes.

Intractable complex partial seizures associated with posterior cerebral artery giant aneurysm: a case report

Giant aneurysms have rarely been reported in association with intractable complex partial seizures (CPS). We report a 30-year-old man with intractable CPS since age 18 years. Seizure onset was electrically localized to right temporal lobe. Preoperative neuroimaging studies showed a partially thrombosed giant aneurysm of the right posterior cerebral artery. Selective amygdalohippocampectomy and occlusion of the posterior cerebral artery did not cause deficits. The patient has been seizure-free for 15 months after operation. We review the relevant literature on aneurysms as a cause of epilepsy.

Functional significance of MRI defined mesial temporal sclerosis in temporal lobe epilepsy

The functional significance of MRI-defined mesial temporal sclerosis in temporal lobe epilepsy (TLE) is not completely established. In order to study the possible relationship between signals of mesial temporal sclerosis on MRI and interictal SPECT findings we selected 18 patients with complex partial seizures, unilateral temporal EEG focus and normal CT. The EEG focus was defined by the presence of interictal sharp waves and slow background on several scalp EEG obtained during many years of follow up in all patients and by ictal recordings with sphenoidal electrodes in 12 patients. Group I comprised patients (n = 11) in whom MRI showed mesial temporal sclerosis; group II patients (n = 7) had normal MRIs. All patients were submitted to interictal 99m-Tc HMPAO injections with concomitant EEG monitoring. Lateralized hypoperfusion ipsilateral to the EEG was found in 13 patients (72%). In all Group II and in 6 Group I patients a temporal hypoperfusion was found. This SPECT study showed a higher positivity rate in patients with normal MRI than previously reported. On the other hand, in all these group II patients a neocortical origin of epileptic focus was suspected on clinical or electroencephalographic basis. Positive SPECT findings may be at least as prevalent in neocortical as in mesiolimbic epilepsy.

[Clinical manifestations in complex partial crisis of the temporal lobe: a video-electroencephalographic study]

We analysed 27 complex partial seizures arising from the temporal lobes recorded on videotape simultaneously with the EEG emphasizing the motor manifestations specially dystonic posturing, ictal paresis and head and eye forced deviation (version). The temporal lobe origin of the seizures was based on the agreement of many scalp-sphenoidal or zygomatic interictal and ictal EEG recordings, CT and MRI findings, interictal and, in some patients, ictal SPECT studies. 8 patients had surgery. In 5 from 7 patients who had temporal lobectomy, mesial temporal sclerosis was the anatomopathological finding and in one patient who had selective amigdalohippocampectomy, hemosiderosis and gliosis probably due to bleeding of a posterior cerebral artery giant aneurysm was found. All patients have been seizure free after surgery. While dystonic posturing and ictal paresis, present in 18 seizures (66.6%), were excellent as lateralizing seizure signs, since they were always contralateral to the ictal onset, contralateral and ipsilateral versive head and eye movements were observed.

MRI and brain spect findings in patients with unilateral temporal lobe epilepsy and normal CT scan

26 patients with temporal lobe epilepsy clinically documented by several abnormal interictal surface EEGs with typical unitemporal epileptiform activity and a normal CT scan were studied. Interictal 99mTC HMPAO brain SPECT and MRI were performed in all subjects. Abnormalities were shown in 61.5% of MRI (n = 16) and 65.4% of SPECT (n = 17). Hippocampal atrophy associated to a high signal on T2-weighted MRI slices suggesting mesial temporal sclerosis was the main finding (n = 12; 75% of abnormal MRI). MRI correlated well to surface EEG in 50% (n = 13). There was also a good correlation between MRI and SPECT in 30.7% (n = 8). SPECT and EEG were in agreement in 57.7% (n = 15). MRI, SPECT and EEG were congruent in 26.9% (n = 7). These results support the usefulness of interictal brain SPECT and MRI in detecting lateralized abnormalities in temporal lobe epilepsy. On the other hand, in two cases, interictal SPECT correlated poorly with surface EEG. This functional method should not be used isolately in the detection of temporal lobe foci. MRI is more useful than CT as a neuroimaging technique in temporal lobe epilepsy. It may detect small structural lesions and mesial temporal lobe sclerosis which are not easily seen with traditional CT scanning.

Postictal behavior. A clinical and subdural electroencephalographic study

OBJECTIVE

To examine postictal behaviors after temporal lobe complex partial seizures (CPSs) and to correlate these behavioral phenomena with side of origin and ictal spread pattern.

DESIGN

Review language and other behavioral phenomena after seizures defined by subdural electroencephalography.

SETTINGS

A surgical epilepsy center.

PATIENTS

We studied postictal behavior following 65 CPSs in 18 patients with left hemisphere language dominance using subdural electrode recordings.

INTERVENTION

Subdural electrodes.

MAIN OUTCOME MEASURES

Language function, affect, orientation, and postictal automatisms.

RESULTS

Following the CPS ictal discharge, the mean interval for initial nonreflexive response to an environmental stimulus was 43 seconds (left foci, 57 seconds; right foci, 29 seconds; not significantly) and for first correct verbal response was 219 seconds (left foci, 275 seconds; right foci, 167 seconds; not significant). Impaired comprehension with fluent but unintelligible speech, as well as anomia, occurred after seizures arising from either temporal lobe. All nine seizures followed by global or nonfluent aphasia originated on the left side. Paraphasic errors were significantly more common after left temporal CPSs. Prolonged disorientation for place and flat affect were significantly more common after right temporal CPS. Postictal automatisms were frequent and included rubbing of the face, fumbling and picking hand movements, and repetitive oral movements.

CONCLUSIONS

Postictal paraphasias, disorientation for place, and flat affect most likely reflect the functions of the area from which seizures arise but not the areas involved by spread.

[Primary reading epilepsy: therapeutic efficacy of clonazepam in one case]

Primary reading epilepsy is a rare form of reflex epilepsy, in which reading is the specific stimulus evoking attacks. The authors report a case of an 18-year-old man who since the age of 17 presented myoclonic jaw jerking provoked exclusively by reading. In one episode, in which reading was not interrupted, jerks were followed by a generalized convulsive seizure. EEG with routine activating procedures was normal, while EEG recorded during reading showed bilaterally synchronous paroxysmal small-voltage spikes, more prominent in frontocentral regions, coinciding with jaw myoclonus. Complete clinical seizures control and EEG normalization were achieved with clonazepam 2 mg daily in a 24-month follow-up.

[Nemaline myopathy: report of a case with a histochemical and electron microscopy study]

Report of a case of a male child, with hypotonia since birth, along with severe feeding difficulties due to lack of swallowing, that resulted in a permanent gastrostomy. Despite the delayed motor development, he had a normal intelligence. An electromyography was suggestive of primary muscle involvement. A fresh-frozen muscle biopsy stained by the modified Gomori trichrome and processed by histochemistry and electron microscopy presented the typical nemaline rods and deficiency of type II muscle fibers. It is made a brief revision about the clinical symptoms, origin and pathogenesis of nemaline bodies. The case reported probably represents a nemaline myopathy, of the congenital type.

[Tuberous sclerosis: a multidisciplinary study of 15 cases]

Report of a multidisciplinary study of patients affected with tuberous sclerosis, 8 of them males and 7 females, with ages ranging from 19 months to 23 years; 11 of these cases were sporadic, while the remaining 4 cases lacked information regarding family data. The following skin signs were observed: Pringle's adenoma in 9 cases; achromatic spots in 9 cases; periungueal fibroma in 3 cases. One of the patients had a heart tumor. Two patients had borderline intelligence, while the other 13 were mentally retarded of varying degrees. Epileptic seizures were present in 13 patients, atypical absence and tonus crises were frequent. Three of the patients had had infantile spasms in the first year of life as the first neurological symptom of the disease. Computer assisted axial tomography was performed in 7 cases and was positive in all of them, by revealing intracranial calcifications even in 4 cases in which the standard X-ray pictures had been silent about this eventuality.