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Krýsl D, Nilsson J, Rydenhag B, Edelvik Tranberg A, Hallböök T, Bjellvi J, Malmgren K, Nilsson D. [Stereoelectroencephalography - a safe and effective procedure for epilepsy surgery evaluation]. Lakartidningen 2021; 118:21106. [PMID: 34633059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In this paper, we report our experiences from the first 30 patients investigated with stereoelectroencephalography (SEEG) at Sahlgrenska University Hospital, Gothenburg, Sweden. Clinical, neurophysiological, and imaging data were reviewed. Twelve children and 18 adults with drug-resistant epilepsy underwent 33 SEEG procedures. 53% of the patients had normal brain MRI. In total, 347 SEEG electrodes were implanted (median 12 per patient). Twenty patients subsequently had resective surgery based on SEEG findings. Focal cortical dysplasia was found in all cases. In 45% of the patients, vicinity of eloquent cortex limited resections. Epilepsy surgery based on SEEG resulted in seizure freedom in 58% of the cases. Minor complications were seen in eight patients, all of which resolved without sequelae. No major complications were seen. SEEG is a safe and effective method to delineate cortical areas involved in seizure generation.
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Affiliation(s)
- David Krýsl
- med dr, överläkare, klinisk neurofysiologi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Josefin Nilsson
- docent, överläkare, klinisk neurofysiologi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Bertil Rydenhag
- professor, överläkare, neurokirurgi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Anna Edelvik Tranberg
- med dr, överläkare, neurologi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Tove Hallböök
- docent, överläkare, barnneurologi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Johan Bjellvi
- med dr, överläkare, neuro-logi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Kristina Malmgren
- senior professor, överläkare, neurologi, Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
| | - Daniel Nilsson
- docent, överläkare, neurokirurgi; samtliga Sahlgrens-ka universitetssjukhuset; Sahlgrenska akademin, Göteborgs universitet
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Bjellvi J, Cross JH, Gogou M, Leclercq M, Rheims S, Ryvlin P, Sperling MR, Rydenhag B, Malmgren K. Classification of complications of epilepsy surgery and invasive diagnostic procedures: A proposed protocol and feasibility study. Epilepsia 2021; 62:2685-2696. [PMID: 34405890 DOI: 10.1111/epi.17040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/07/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In epilepsy surgery, which aims to treat seizures and thereby to improve the lives of persons with drug-resistant epilepsy, the chances of attaining seizure relief must be carefully weighed against the risks of complications and expected adverse events. The interpretation of data regarding complications of epilepsy surgery and invasive diagnostic procedures is hampered by a lack of uniform definitions and method of data collection. METHODS Based on a review of previous definitions and classifications of complications, we developed a proposal for a new classification. This proposal was then subject to revisions after expert opinion within E-pilepsy, an EU-funded European pilot network of reference centers in refractory epilepsy and epilepsy surgery, later incorporated into the ERN (European Reference Network) EpiCARE. This version was discussed with recognized experts, and a final protocol was agreed to after further revision. The final protocol was evaluated in practical use over 1 year in three of the participating centers. One hundred seventy-four consecutive procedures were included with 35 reported complications. RESULTS This report presents a multidimensional classification of complications in epilepsy surgery and invasive diagnostic procedures, where complications are characterized in terms of their immediate effects, resulting permanent symptoms, and consequences on activities of daily living. SIGNIFICANCE We propose that the protocol will be helpful in the work to promote safety in epilepsy surgery and for future studies designed to identify risk factors for complications. Further work is needed to address the reporting of outcomes as regards neuropsychological function, activities of daily living, and quality of life.
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Affiliation(s)
- Johan Bjellvi
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - J Helen Cross
- UCL-NIHR BRC Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK.,Young Epilepsy, Lingfield, UK
| | - Maria Gogou
- Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK
| | - Mathilde Leclercq
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Lyon 1 University, Member of the ERN EpiCARE, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Lyon 1 University, Member of the ERN EpiCARE, Lyon, France
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
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Bjellvi J, Edelvik Tranberg A, Rydenhag B, Malmgren K. In Reply: Risk Factors for Seizure Worsening After Epilepsy Surgery in Children and Adults: A Population-Based Register Study. Neurosurgery 2021; 88:E366. [PMID: 33372220 DOI: 10.1093/neuros/nyaa560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Johan Bjellvi
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden.,Department of Neurology Sahlgrenska University Hospital Gothenburg, Sweden
| | - Anna Edelvik Tranberg
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden.,Department of Neurology Sahlgrenska University Hospital Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden.,Department of Neurosurgery Sahlgrenska University Hospital Gothenburg, Sweden
| | - Kristina Malmgren
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden.,Department of Neurology Sahlgrenska University Hospital Gothenburg, Sweden
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Bjellvi J, Edelvik Tranberg A, Rydenhag B, Malmgren K. Risk Factors for Seizure Worsening After Epilepsy Surgery in Children and Adults: A Population-Based Register Study. Neurosurgery 2021; 87:704-711. [PMID: 31792497 PMCID: PMC7490157 DOI: 10.1093/neuros/nyz488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/02/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Increased seizure frequency and new-onset tonic-clonic seizures (TCS) have been reported after epilepsy surgery. OBJECTIVE To analyze potential risk factors for these outcomes in a large cohort. METHODS We studied prospectively collected data in the Swedish National Epilepsy Surgery Register on increased seizure frequency and new-onset TCS after epilepsy surgery 1990-2015. RESULTS Two-year seizure outcome was available for 1407 procedures, and data on seizure types for 1372. Increased seizure frequency at follow-up compared to baseline occurred in 56 cases (4.0%) and new-onset TCS in 53 (3.9%; 6.6% of the patients without preoperative TCS). Increased frequency was more common in reoperations compared to first surgeries (7.9% vs 3.1%; P = .001) and so too for new-onset TCS (6.7% vs 3.2%; P = .017). For first surgeries, binary logistic regression was used to analyze predictors for each outcome. In univariable analysis, significant predictors for increased seizure frequency were lower age of onset, lower age at surgery, shorter epilepsy duration, preoperative neurological deficit, intellectual disability, high preoperative seizure frequency, and extratemporal procedures. For new-onset TCS, significant predictors were preoperative deficit, intellectual disability, and nonresective procedures. In multivariable analysis, independent predictors for increased seizure frequency were lower age at surgery (odds ratio (OR) 0.70 per increasing 10-yr interval, 95% CI 0.53-0.93), type of surgery (OR 0.42 for temporal lobe resections compared to other procedures, 95% CI 0.19-0.92), and for new-onset TCS preoperative neurological deficit (OR 2.57, 95% CI 1.32-5.01). CONCLUSION Seizure worsening is rare but should be discussed when counseling patients. The identified risk factors may assist informed decision-making before surgery.
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Affiliation(s)
- Johan Bjellvi
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Edelvik Tranberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Bjellvi J, Olsson I, Malmgren K, Wilbe Ramsay K. Epilepsy duration and seizure outcome in epilepsy surgery: A systematic review and meta-analysis. Neurology 2019; 93:e159-e166. [PMID: 31182508 PMCID: PMC6656653 DOI: 10.1212/wnl.0000000000007753] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/21/2019] [Indexed: 11/15/2022] Open
Abstract
Objective To conduct a systematic review and meta-analysis on the effect of earlier or later resective epilepsy surgery on seizure outcome. Methods We searched the electronic databases PubMed, EMBASE, and Cochrane Library for studies investigating the association of epilepsy duration and seizure freedom after resective surgery. Two reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias. We combined data in meta-analyses using a random effects model. We assessed the certainty of evidence according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results Twenty-five studies were included, 12 of which had data suitable for meta-analyses. Comparing seizure outcome if epilepsy surgery was performed before vs after 2, 5, 10, and 20 years of epilepsy duration, and comparing epilepsy duration <5 years to >10 years, we found significant effects favoring shorter duration with risk differences ranging from 0.15 to 0.21 and risk ratios ranging from 1.20 to 1.33 (p < 0.01 for all comparisons). According to GRADE, we found low certainty of evidence favoring shorter epilepsy duration before surgery. Conclusion People with shorter epilepsy duration are more likely to be seizure-free at follow-up. Furthermore, there is a positive association between shorter duration and seizure freedom also for very long epilepsy durations. Patients who might benefit from epilepsy surgery should therefore be referred for presurgical assessments without further delay, regardless of epilepsy duration. The low certainty of evidence acknowledges concerns regarding study heterogeneity and possible residual confounding.
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Affiliation(s)
- Johan Bjellvi
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.B., K.M.), and Institute of Clinical Sciences, Department of Paediatrics (I.O.), Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg; and Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) (K.W.R.), Stockholm, Sweden.
| | - Ingrid Olsson
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.B., K.M.), and Institute of Clinical Sciences, Department of Paediatrics (I.O.), Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg; and Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) (K.W.R.), Stockholm, Sweden
| | - Kristina Malmgren
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.B., K.M.), and Institute of Clinical Sciences, Department of Paediatrics (I.O.), Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg; and Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) (K.W.R.), Stockholm, Sweden
| | - Karin Wilbe Ramsay
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.B., K.M.), and Institute of Clinical Sciences, Department of Paediatrics (I.O.), Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg; and Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) (K.W.R.), Stockholm, Sweden
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Bjellvi J, Timby N, Flink R. [Status epilepticus in children and adults]. Lakartidningen 2018; 115:E4XY. [PMID: 29786808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Status epilepticus, a condition with prolonged or repeated seizures, is a common neurological emergency with significant morbidity and mortality. This text outlines the treatment and initial work-up for convulsive and non-convulsive status epilepticus in adults and children. The most serious form is convulsive (tonic-clonic) status epilepticus, which requires rapid treatment and work-up. Bensodiazepines are the preferred initial treatment, while antiepileptic drugs and anesthetics are added if seizures continue. For other forms of status epilepticus, the treatment depends on the type of seizures and the patient's general condition. Etiological work-up is essential in any case of status epilepticus. Effective treatment and work-up in status epilepticus requires a defined treatment protocol and multidisciplinary cooperation.
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Affiliation(s)
- Johan Bjellvi
- Sahlgrenska universitetssjukhuset - Goteborg, Sweden - Neurosjukvården, Sahlgrenska Universitetssjukhuset Göteborg, Sweden
| | - Niklas Timby
- Norrlands universitetssjukhus - Umea, Sweden Norrlands universitetssjukhus - Umea, Sweden
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Bjellvi J, Flink R, Rydenhag B, Malmgren K. Complications of epilepsy surgery in Sweden 1996–2010: a prospective, population-based study. J Neurosurg 2015; 122:519-25. [DOI: 10.3171/2014.9.jns132679] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Detailed risk information is essential for presurgical patient counseling and surgical quality assessments in epilepsy surgery. This study was conducted to investigate major and minor complications related to epilepsy surgery in a large, prospective series.
METHODS
The Swedish National Epilepsy Surgery Register provides extensive population-based data on all patients who were surgically treated in Sweden since 1990. The authors have analyzed complication data for therapeutic epilepsy surgery procedures performed between 1996 and 2010. Complications are classified as major (affecting daily life and lasting longer than 3 months) or minor (resolving within 3 months).
RESULTS
A total of 865 therapeutic epilepsy surgery procedures were performed between 1996 and 2010, of which 158 were reoperations. There were no postoperative deaths. Major complications occurred in 26 procedures (3%), and minor complications in 65 (7.5%). In temporal lobe resections (n = 523), there were 15 major (2.9%) and 41 minor complications (7.8%); in extratemporal resections (n = 275) there were 9 major (3.3%) and 22 minor complications (8%); and in nonresective procedures (n = 67) there were 2 major (3%) and 2 minor complications (3%). The risk for any complication increased significantly with age (OR 1.26 per 10-year interval, 95% CI 1.09–1.45). Compared with previously published results from the same register, there is a trend toward lower complication rates, especially in patients older than 50 years.
CONCLUSIONS
This is the largest reported prospective series of complication data in epilepsy surgery. The complication rates comply well with published results from larger single centers, confirming that epilepsy surgery performed in the 6 Swedish centers is safe. Patient age should be taken into account when counseling patients before surgery.
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Affiliation(s)
- Johan Bjellvi
- 1Epilepsy Research Group, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden; and
| | - Roland Flink
- 2Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
| | - Bertil Rydenhag
- 1Epilepsy Research Group, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden; and
| | - Kristina Malmgren
- 1Epilepsy Research Group, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden; and
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Hedegärd E, Bjellvi J, Edelvik A, Rydenhag B, Flink R, Malmgren K. Complications to invasive epilepsy surgery workup with subdural and depth electrodes: a prospective population-based observational study. J Neurol Neurosurg Psychiatry 2014; 85:716-20. [PMID: 24293000 PMCID: PMC4078707 DOI: 10.1136/jnnp-2013-306465] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In some patients who undergo presurgical workup for drug-resistant epilepsy invasive seizure monitoring is needed to define the seizure onset zone and delineate eloquent cortex. Such procedures carry risks for complications causing permanent morbidity and even mortality. In this study, prospective data on complications in a national population-based sample were analysed. DESIGN Complication data from the prospective Swedish National Epilepsy Surgery Register were analysed for 271 patients in whom therapeutic surgery was preceded by invasive monitoring 1996-2010. RESULTS Complications occurred in 13/271 patients (4.8%). Subdural grids carried the highest risk of complications (7.4%). There was no surgical mortality or permanent morbidity. Subdural haematomas were most common (n=7) followed by epidural haematomas (n=3). Valproate treatment and having a haematoma was associated with an OR of 1.53 (CI 0.38 to 6.12) compared to having a haematoma without valproate treatment. Having a complication during invasive monitoring was associated with a significant OR of 6.27 (CI 1.32 to 29.9) of also having a complication at therapeutic surgery compared to the risk of having a complication only at surgery. CONCLUSIONS In this prospective population-based epilepsy surgery series, the most common complications were haematomas, and subdural grids carried the highest risk. Close supervision and rapid interventions led to avoidance of permanent morbidity. The clinical implications of the slightly increased risk of haematomas with valproate treatment needs further investigation as does the finding of an increased risk for complications at epilepsy surgery for patients who had a complication during invasive monitoring.
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Affiliation(s)
- Emelie Hedegärd
- Epilepsy Research Group, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
| | - Johan Bjellvi
- Epilepsy Research Group, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
| | - Anna Edelvik
- Epilepsy Research Group, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
| | - Bertil Rydenhag
- Epilepsy Research Group, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
| | - Roland Flink
- Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
| | - Kristina Malmgren
- Epilepsy Research Group, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden
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Anckarsäter H, Piechnik S, Tullberg M, Ziegelitz D, Sörman M, Bjellvi J, Karlsson E, Fernandez NV, Wikkelso C, Forsman A. Persistent regional frontotemporal hypoactivity in violent offenders at follow-up. Psychiatry Res 2007; 156:87-90. [PMID: 17689934 DOI: 10.1016/j.pscychresns.2006.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 11/29/2006] [Accepted: 12/26/2006] [Indexed: 11/17/2022]
Abstract
Since cross-sectional brain-imaging studies demonstrating frontotemporal cerebral hypoactivity in violent offenders have generally been carried out around the time of trial and sentencing, the findings might be influenced by the stressful situation of the subjects. It seems that no group of offenders with this finding has yet been followed longitudinally. We have re-examined nine offenders convicted of lethal or near-lethal violence in whom single photon emission tomography (SPECT) previously had demonstrated frontotemporal hypoperfusion. The mean interval between the initial and the follow-up examination was 4 years. The initially observed hypoactivity was found to have remained virtually unchanged at follow-up: no mean change in the group exceeded 5% in 12 assessed regions of interest. Although preliminary due to the small sample size, this study suggests that frontotemporal brain hypoactivity is a trait rather than a state in perpetrators of severe violent crimes.
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Affiliation(s)
- Henrik Anckarsäter
- Forensic Psychiatric Clinic, Malmö University Hospital, Lund University, Sweden
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