The relevance of neuropsychiatric symptoms and cognitive problems in new-onset epilepsy - Current knowledge and understanding

Neurobehavioral and cognition problems are highly prevalent in epilepsy, but most research studies to date have not adequately addressed the precise nature of the relationship between these comorbidities and seizures. To address this complex issue and to facilitate collaborative, innovative research in the rising field of neurobehavioral comorbidities and cognition disturbances in new-onset epilepsy, international epilepsy experts met at the 3rd Halifax International Epilepsy Conference & Retreat at White Point, South Shore, Nova Scotia, Canada from September 18 to 20, 2014. This Conference Proceedings provides a summary of the conference proceedings. Specifically, the following topics are discussed: (i) role of comorbidities in epilepsy diagnosis and management, (ii) role of antiepileptic medications in understanding the relationship between epilepsy and neurobehavioral and cognition problems, and (iii) animal data and diagnostic approaches. Evidence to date, though limited, strongly suggests a bidirectional relationship between epilepsy and cognitive and psychiatric comorbidities. In fact, it is likely that seizures and neurobehavioral problems represent different symptoms of a common etiology or network-wide disturbance. As a reflection of this shared network, psychiatric comorbidities and/or cognition problems may actually precede the seizure occurrence and likely get often missed if not screened.

Sex differences in the medial temporal lobe during encoding and recognition of pseudowords and abstract designs

Sex differences in various cognitive abilities have been demonstrated in terms of performance differentials and, more recently, in differences in activation patterns during fMRI. Hemispheric lateralization is sometimes accentuated in sex differences; e.g., women demonstrating greater activation of the left hemisphere than men during verbal tasks. We were interested in whether this phenomenon applies to memory for words and designs (i.e., material specific memory). Using analogous verbal (pseudowords) and nonverbal (abstract designs) encoding and recognition tasks completed back-to-back in a 3T scanner, we found that women tend to show exaggerated left hippocampal activation during certain stages of encoding and recognition of verbal information, compared with men. Likewise (although to a lesser extent), men showed more right hippocampal activation than women did during the abstract design learning task. These results have important implications for the generalization of fMRI memory study results, for example to clinical populations such as patients undergoing epilepsy surgery.

Intracarotid amobarbital procedure and etomidate speech and memory test

The intracarotid amobarbital procedure (IAP) has for over 50 years been an important component of the presurgical investigation of patients with epilepsy who are candidates for surgical intervention as treatment for their seizures. Owing to increasing frequency and duration of amobarbital shortages, alternatives for this drug have been sought and implemented, but until now only the drug was changed, while the basic procedure remained essentially the same as that used with amobarbital. This paper describes the Montreal Neurological Institute experience using etomidate in place of amobarbital and introducing a significant change in the procedure: after an initial bolus injection, an infusion is used to maintain the level of hemianesthesia during critical test times. Results of 28 patients tested with this procedure are compared to results from 40 patients tested in the standard IAP.

Memory and the medial temporal lobe: hemispheric specialization reconsidered

The role of the medial temporal lobe in learning and memory has been well established in research on humans and other animals. In humans, clinical and neuroimaging studies typically suggest material-specific lateralization in which the left and right temporal lobes are associated with verbal and nonverbal memory, respectively. It is often assumed that the temporal lobes are functionally alike, differing only in terms of the content to be learned. Here we present data that challenge this notion, showing that the type of material used during a memory task can influence fMRI activation patterns beyond the expected left-verbal/right-nonverbal dichotomy. Our results also suggest some degree of functional asymmetry in the medial temporal lobe that is independent of material type, pointing to underlying processing differences between the left and right temporal lobes.

Etomidate speech and memory test (eSAM): A new drug and improved intracarotid procedure

BACKGROUND

The intracarotid amobarbital procedure (IAP) is an important part of comprehensive investigation of patients who are candidates for surgical treatment of epilepsy. Owing to repeated and lengthy shortages of amobarbital, causing delays in elective surgery, attempts have been made to find a suitable alternative anesthetic. The authors report their experience using etomidate, a widely used agent for the induction of anesthesia.

METHODS

Sixteen consecutive patients requiring IAP to evaluate memory or to lateralize speech underwent the procedure using etomidate. Prior to the procedure a catheter was placed in the internal carotid artery and an angiogram was performed. EEG was recorded and read online by an electroencephalographer. An anesthetist injected the drug, administered by bolus followed by an infusion, which was maintained until each speech measure had been sampled and new memory items had been introduced. The infusion was then stopped and testing continued as in a standard IAP.

RESULTS

In all cases (30 hemispheres) contralateral hemiplegia followed injection. EEG slow waves were observed in every injected hemisphere, with some contralateral slowing anteriorly in 18. Global aphasia with preserved attention and cooperation followed dominant-hemisphere injections. These phenomena remained during infusion, and upon its termination returned gradually to baseline over a period of about 4 minutes.

CONCLUSIONS

Etomidate is a viable alternative to amobarbital, and its administration by bolus followed by infusion offers an improvement over the traditional intracarotid amobarbital procedure. Cognitive tests can be performed during an assured hemianesthesia of the injected hemisphere.

Gustatory agnosia

OBJECTIVE

To report the assessment of a patient exhibiting gustatory agnosia.

METHODS

Preoperative and postoperative neuropsychological, neuroimaging, and chemosensory evaluations were performed in a 39-year-old woman undergoing surgical treatment for intractable epilepsy.

RESULTS

Preoperative MRIs showed bilateral (right > left) atrophy in the medial temporal lobes and complete atrophy of the left insula. Evaluation of gustatory function revealed normal suprathreshold intensity estimation, affective evaluation, and detection thresholds but elevated recognition thresholds. A functional neuroimaging study showed activation to stimulation of aversive taste in the left amygdala. Surgical treatment entailed resection from the left medial temporal lobe that included the region of amygdala that had responded to taste. Postoperatively, detection, naming, and intensity estimation for taste remained normal, but the patient was unable to recognize different tastes (sweet, sour, salty, and bitter). A second evaluation 2.5 years after her surgery revealed no change in taste ability.

CONCLUSION

The anteromedial temporal lobe has an important role in recognizing taste quality.

Functional neuroimaging of odor imagery

We used positron emission tomography (PET) to investigate brain regions associated with odor imagery. Changes in regional cerebral blood flow (CBF) during odor imagery were compared with changes during nonspecific expectation of olfactory stimuli and with those during odor perception. Sixty-seven healthy volunteers were screened for their odor imagery (with a paradigm developed in a previous study), and 12 of them, assessed to be "good odor imagers," participated in the neuroimaging part of the study. Imagination of odors was associated with increased activation in several olfactory regions in the brain: the left primary olfactory cortical (POC) region including piriform cortex, the left secondary olfactory cortex or posterior orbitofrontal cortex (OFC), and the rostral insula bilaterally. Furthermore, blood flow in two regions within the right orbitofrontal cortex correlated significantly with the behavioral measure of odor imagery during scanning. Overall, the findings indicated that neural networks engaged during odor perception and imagery overlap partially.

Odor-induced changes in taste perception

We investigated odor-induced changes in taste perception (OICTP), by examining the influence of strawberry and soy sauce odors on perceived sweetness (Experiment 1) and saltiness (Experiment 2). We explored whether taste-smell interactions occur at the central level, by delivering odorants (strawberry, soy sauce, odorless water) and tastants (sucrose, sodium chloride) separately, and whether effects of imagined odors are comparable to those of physically presented odors. We found specific taste-smell interactions: sweetness enhancement induced by strawberry odor and saltiness enhancement induced by soy sauce odor. These interactions were elicited with separate delivery of olfactory and gustatory stimuli. Secondly, we found a similar but rather limited effect with the imagined odors: imagined strawberry enhanced perceived sweetness of water solutions, and imagined soy sauce enhanced perceived saltiness of weak sodium chloride solutions. We concluded that OICTP is a centrally mediated phenomenon, and that imagined odors can to some extent induce changes in perceived taste intensity comparable to those elicited by perceived odors.

The mind's nose: Effects of odor and visual imagery on odor detection

We examined odor imagery by looking for its effects on detection of weak odors. Seventy-two healthy subjects performed a forced-choice odor detection task in one of three conditions: after being told to imagine an odor (odor imagery), after being told to imagine an object (visual imagery), or without having received imagery instructions (no-imagery control). For the two imagery conditions, the presented and imagined stimuli were either the same (matched) or different (mismatched). There was a significant difference between detection in the matched and mismatched conditions for odor imagery, but not for visual imagery. We conclude that our paradigm does measure odor imagery and that the effect of imagery on detection is both content- and modality-specific. Further, the difference between conditions was due to lower detection with mismatched odor imagery than without imagery, indicating that interference underlies the effect.

Effects of Perceived and Imagined Odors on Taste Detection

We assessed the influence of different odors on detection of a sweet tastant, and the ability of imagined odors to elicit the same effects as perceived odors on taste perception. The tastant used was sucrose, and the two odorants were strawberry and ham. In the first experiment, participants either smelled or imagined one of two odors during taste detection tasks (between-subject design), whereas in the second one, subjects completed both the odor imagery and perception conditions with taste detection tasks (within-subject design). The effect was odorant-specific: detection of sucrose was significantly better when subjects smelled strawberry than when they smelled ham. Furthermore, imagined odors influenced taste perception in the same way as did perceived odors. We concluded that the odor-specific effect on taste perception is an authentic perceptual phenomenon. Our results also support the notion that odor-induced changes in taste perception are mediated centrally. Finally, our findings are in agreement with reports supporting the existence of odor imagery.

Face learning and memory: the twins test

The clinical utility of current face recognition tests has been questioned. To evaluate if a new paradigm may measure this type of memory more accurately, the authors created a novel test to examine face learning (previously uninvestigated) and short- and long-term retention. For this initial investigation of test sensitivity to hemisphere of dysfunction, patients with surgical resection from a temporal lobe and healthy subjects were tested. Recognition was evaluated on 3 trials: after a single exposure, after 4 exposures (for learning), and after a 24-hr delay interval. Patients with a right resection performed significantly worse than healthy controls and patients with left resection. There was no difference between patients with a left resection and controls. Classification of individual patients to side of resection based on test results showed higher sensitivity (82%) than published for other tests and maintained good specificity (79%).

Face learning and memory: the twins test

The clinical utility of current face recognition tests has been questioned. To evaluate if a new paradigm may measure this type of memory more accurately, the authors created a novel test to examine face learning (previously uninvestigated) and short- and long-term retention. For this initial investigation of test sensitivity to hemisphere of dysfunction, patients with surgical resection from a temporal lobe and healthy subjects were tested. Recognition was evaluated on 3 trials: after a single exposure, after 4 exposures (for learning), and after a 24-hr delay interval. Patients with a right resection performed significantly worse than healthy controls and patients with left resection. There was no difference between patients with a left resection and controls. Classification of individual patients to side of resection based on test results showed higher sensitivity (82%) than published for other tests and maintained good specificity (79%).

Changes in brain activity related to eating chocolate: from pleasure to aversion

We performed successive H(2)(15)O-PET scans on volunteers as they ate chocolate to beyond satiety. Thus, the sensory stimulus and act (eating) were held constant while the reward value of the chocolate and motivation of the subject to eat were manipulated by feeding. Non-specific effects of satiety (such as feelings of fullness and autonomic changes) were also present and probably contributed to the modulation of brain activity. After eating each piece of chocolate, subjects gave ratings of how pleasant/unpleasant the chocolate was and of how much they did or did not want another piece of chocolate. Regional cerebral blood flow was then regressed against subjects' ratings. Different groups of structures were recruited selectively depending on whether subjects were eating chocolate when they were highly motivated to eat and rated the chocolate as very pleasant [subcallosal region, caudomedial orbitofrontal cortex (OFC), insula/operculum, striatum and midbrain] or whether they ate chocolate despite being satiated (parahippocampal gyrus, caudolateral OFC and prefrontal regions). As predicted, modulation was observed in cortical chemosensory areas, including the insula and caudomedial and caudolateral OFC, suggesting that the reward value of food is represented here. Of particular interest, the medial and lateral caudal OFC showed opposite patterns of activity. This pattern of activity indicates that there may be a functional segregation of the neural representation of reward and punishment within this region. The only brain region that was active during both positive and negative compared with neutral conditions was the posterior cingulate cortex. Therefore, these results support the hypothesis that there are two separate motivational systems: one orchestrating approach and another avoidance behaviours.

Working memory in another dimension: functional imaging of human olfactory working memory

The majority of working memory research has been carried out within the visual and auditory modalities, leaving it unclear how other modalities would map onto currently proposed working memory models. In this study we examined the previously uninvestigated area of olfactory working memory. Our aim was to investigate if olfactory working memory would engage prefrontal regions known to be involved in working memory for other sensory modalities. Using positron emission tomography we measured cerebral blood flow changes in 12 volunteers during an olfactory working memory task and a comparison visual working memory task. Our findings indicate that both olfactory and face working memory engaged dorsolateral and ventrolateral frontal cortex when the task requirements were matched; a conjunction analysis indicated overlap in the distribution of activity in the two tasks. Similarities and differences in activity were noted in parietal lobe regions, with both tasks engaging inferior areas of 40/7, but only visual working memory showing increased activity within left superior parietal cortex. The findings support the idea that working memory processes engage frontal cortical areas independent of the modality of input, but do not rule out the possibility of modality-specific neural populations within dorsolateral or ventrolateral cortex.

Increased intensity perception of aversive taste following right anteromedial temporal lobe removal in humans

We used a modified version of the Spatial Taste Test to assess taste intensity perception in patients with either left or right temporal resection from the anteromedial temporal lobe (AMTL), and a group of control subjects. Sweet, sour, salty and bitter solutions were applied onto discrete locations of the tongue to stimulate either left or right fungiform, or left or right foliate papillae. Intensity ratings were assessed with the Labeled Magnitude Scale. Subjects also sipped 5 ml of each solution for whole mouth stimulation. Genetically based determinants of taste sensitivity were assessed with ratings of 6-n-propylthiouracil, and covaried from all analyses. As in previous studies, analysis of covariance indicated that the subjects in the right temporal group rated an aversive bitter taste as more intense than did subjects in the control group. In contrast, there were no group differences for sucrose ratings, suggesting that the AMTL may be involved preferentially in processing aversive compared with hedonic tastes. No group x side, or group x location effects were present. These results confirm that removal of the right AMTL in humans results in increased taste intensity/aversiveness perception. This finding complements existing literature indicating that the AMTL is important for processing aversive taste, and suggests that inhibitory mechanisms may play an important role in such processing.

Changes in Taste Intensity Perception Following Anterior Temporal Lobe Removal in Humans

To investigate the role of the anterior temporal lobe in taste perception, we compared taste intensity estimations made by patients who had removal from either the left or the right anterior temporal lobe for the treatment of intractable epilepsy with a group of healthy control subjects. Estimations were made for five concentrations of each of four different tastes, as well as for five cards of varying saturations of gray, which served as a control task. A cross-modal magnitude estimation procedure was employed in which subjects used distance on a measuring tape to reflect intensity estimation. Distances were then transformed into logs, and the slope and the correlation with stimulus concentration or saturation was calculated. Correlation was taken as a measure of accuracy of estimation and slope was taken as a measure of perceived intensity. As predicted, repeated measures analysis of variance (ANOVA) revealed a significant difference between the control group and both patient groups in taste intensity estimations, but not for grayness, reflecting the importance of the anterior temporal lobe in low-level gustatory but not visual perception. Additionally, repeated measures ANOVA for slopes indicated that subjects in the right temporal group rated the bitter taste as more intense than did subjects in other groups, possibly reflecting increased intensity perception of the unpleasant bitter taste.

Neural mechanisms involved in odor pleasantness and intensity judgments

Olfactory processing in the human brain was examined using positron emission tomography. Twelve normal volunteers were scanned while smelling pairs of odors: they were asked to judge which odor was more pleasant in one condition, and which was more intense in a second condition; they also were scanned while sniffing an odorless stimulus. As in prior studies, greater cerebral blood flow was found in the right orbitofrontal cortex during both pleasantness and intensity judgments as compared to baseline. Cerebellar activity was also seen, but contrary to expectations no activity was detected in the primary olfactory (piriform) cortex. Only the pleasantness judgment elicited additional activity within the hypothalamus, suggesting that this structure may be involved in affective processing that requires access to information about internal state.

Neuropsychological assessment for temporal lobe epilepsy surgery

Neuropsychological assessment consists of a comprehensive evaluation of cognitive functioning and most often some evaluation of motor skills and sensory status also. Cognitive functions sampled typically include "intelligence" (IQ tests), attention, language skills, visuospatial abilities, "executive skills" and other abilities associated with frontal-lobe function, and learning and memory. Thus, the assessment samples vary widely among a variety of functions, providing a comprehensive picture of an individual's strengths and weaknesses. The resulting pattern points to the probable site of epileptic focus. Neuropsychological findings also serve to predict the risk for postsurgical cognitive decline and, when performance before and after operation is compared, they provide data on the impact of surgery upon cognitive functioning. Comprehensive evaluation of learning and memory is particularly important in this context, because of the frequency of temporal lobe epilepsy and the prominence of memory dysfunction associated with it. In addition, patients slated for elective surgery may also undergo an intracarotid amobarbital procedure (IAP), which is performed to determine the side of cerebral dominance for language and to test the memory capabilities of each hemisphere alone. All of these specialized neuropsychological tools are discussed in this paper.

Clinical patterns of patients with temporal lobe epilepsy and pure amygdalar atrophy

PURPOSE

MRI volumetric measurements (MRIvol) have been proven reliable in determining mesial temporal atrophy in patients with TLE. We attempted to correlate the clinical features with different patterns of hippocampal formation (HF) and amygdala (AM) atrophy in patients with TLE without foreign tissue lesion.

METHODS

We studied 65 patients with refractory TLE. They were divided into five groups according to MRIvol results: pure AM atrophy (n = 11, 10 unilateral and one bilateral), unilateral HF atrophy (n = 16), bilateral HF atrophy (n = 12), unilateral AM + HF atrophy (n = 13), and patients with normal volumes of AM and HF (n = 13). MRIvol of AM and HF were performed by using a protocol previously described by Watson et al. (Neurology 1992;42:1743-50).

RESULTS

Patients with AM atrophy had later onset of seizures compared with those with unilateral HF atrophy (p < 0.01). History of febrile convulsions (p < 0.0001) and frequent secondarily generalized tonic-clonic seizures (GTCSs) were more often found in patients with HF atrophy compared with those with pure AM atrophy and those with normal volumes (p = 0.04). Prolonged postictal confusion was more often found with AM atrophy (p = 0.05). Memory impairment was more severe in patients with HF atrophy than in those with AM atrophy only or in those with normal volumes (p = 0.03). There were no significant differences among the five groups in the following parameters: age, duration of epilepsy, seizure frequency, and presence and type of aura.

CONCLUSIONS

Prolonged postictal confusion appeared to be related to AM atrophy, in keeping with previous clinical observations. These patients also had a lower incidence of early febrile convulsions, older age at epilepsy onset, lower frequency of secondary GTCS, and lesser memory dysfunction compared with patients with hippocampal atrophy.

Human cortical gustatory areas: a review of functional neuroimaging data

In an effort to define human cortical gustatory areas we reviewed functional neuroimaging data for which coordinates standardized in Talairach proportional space were available. We observed a wide distribution of peaks within the insula and parietal and frontal opercula, suggesting multiple gustatory regions within this cortical area. Multiple peaks also emerged in the orbitofrontal cortex. However, only two peaks, both in the right hemisphere, were observed in the caudolateral orbitofrontal cortex, the region likely homologous to the secondary taste area described in monkeys. Overall significantly more peaks originated from the right hemisphere suggesting asymmetrical cortical representation of taste favoring the right hemisphere.

Human brain function during odor encoding and recognition. A PET activation study

In previous positron emission tomography (PET) studies we have shown significant regional cerebral blood flow (rCBF) increases during olfactory stimulation: unilaterally in the right orbitofrontal cortex, and bilaterally in the inferior frontal and temporal lobes (piriform cortex). In the present study we investigated brain function during different stages of olfactory memory processing. Subjects were scanned during four tasks: odor encoding, long-term odor recognition, short-term odor recognition and a no-odor sensorimotor control task. Subjects were 12 right-handed healthy volunteers (6 men, 6 women). Each subject underwent a training session four days prior to their PET scan to learn the six odors required for the long-term memory scan. PET scans were obtained with a Siemens Exact ECAT HR+ 3D system using H2(15)O methodology and 60-sec scanning intervals. PET images were coregistered with each subject's magnetic resonance imaging scan, averaged, and transformed into standard stereotaxic space. Paired image subtractions were analyzed for rCBF changes. Preliminary analyses have revealed significant activation of the right orbitofrontal region and bilateral piriform cortices during the long-term odor recognition task compared with the control task. Activation of the right piriform cortex was present during the short-term recognition task. Brain activity during encoding and retrieval tasks also involved prefrontal cortices. PET activation studies of memory in other modalities have led to hypotheses of a hemispheric encoding/retrieval asymmetry in frontal cortex; the generalizability of this theory to olfactory memory will be discussed.

Regional cerebral blood flow and language dominance: SPECT during intracarotid amobarbital testing

We examined the relation between language dominance and regional cerebral blood flow (rCBF) during the intracarotid amobarbital procedure (IAP). A previous report limited to three patients suggested that dominant rather than nondominant hemisphere IAP may have a differential effect on rCBF. Behavioral assessment during the IAP also suggests that dominant hemisphere injection results in a differential effect on memory and affective symptoms rather than nondominant injection. Thirteen patients were assessed using single-photon emission CT (SPECT) brain imaging during both left and right IAP. The SPECTs were coregistered with the individual's MRI. Changes in rCBF during each IAP were compared with the patient's baseline SPECT. Nine patients had left hemisphere dominance, two were right dominant, and two had bilateral speech representation. In the left dominant subjects, left-hemisphere injection had a consistently greater effect on rCBF than right-hemisphere injection in the anterior (p < 0.005) and posterior (p < 0.01) temporal neocortex. There was also a trend for greater hypoperfusion in the frontal lobe of the left hemisphere. rCBF in the ipsilateral hippocampus was not significantly different after each injection (p > 0.05). In the two patients with right hemisphere speech, the reverse pattern was seen, with greater hypoperfusion after right (dominant) hemisphere injection. There was no consistent asymmetry in the two patients with bilateral speech. Dominant hemisphere IAP results in significantly greater hypoperfusion than does nondominant injection. These data provide a physiologic basis for behavioral differences noted after dominant versus nondominant IAP.

Children who can't smell the coffee: isolated congenital anosmia

Two children with isolated congenital anosmia, a rare syndrome of deficient restricted neuronal migration, are presented with early diagnosis confirmed by standardized smell testing and detailed neuroimaging studies. Recognition of this disorder and its spectrum of presentations provides important insights into the molecular mechanisms underlying the development of the olfactory system.

Flavor processing: more than the sum of its parts

We used positron emission tomography to evaluate differential processing of olfactory, gustatory and combined olfactory and gustatory (flavor) stimuli as indicated by comparison of evoked cerebral blood flow (CBF) changes during these conditions. We found significant CBF decreases in primary gustatory and secondary gustatory and olfactory cortices during simultaneous presentation compared with independent presentations of identical stimuli, suggesting that flavor processing is not represented by a simple convergence of its component senses. Additionally, CBF increases in the amygdala and basal forebrain were observed in a mismatched flavor condition versus a matched flavor condition, suggesting a role for these structures in processing novel or unpleasant stimuli.

Contribution of medial versus lateral temporal-lobe structures to human odour identification

To investigate possible distinct contributions of different temporal-lobe structures to odour identification, the University of Pennsylvania Smell Identification Test was administered monorhinally to seizure-free patients who had undergone one of three types of temporal-lobe resection practised in three different institutions for surgical treatment of epilepsy. The resections were neocorticectomy (Dublin), selective amygdalohippocampectomy (Zurich), or anterior temporal-lobe resection with encroachment on amygdala and hippocampus (Montreal). Resections, analysed from MRI scans, showed unexpected encroachment on medial structures in most patients of the neocorticectomy groups, and largest amygdala and hippocampal resections in the amygdalohippocampectomy groups. Impaired odour identification was observed in all patient groups, irrespective of surgical approach, with greatest impairment in the nostril ipsilateral to the resection. The finding of deficits in all three surgical groups suggests that damage in the anterior temporal area, perhaps in piriform cortex, is sufficient to disrupt performance on this task; it may be that function is disrupted in the medial temporal-lobe region by disconnection when the periamygdaloid area is damaged, even when amygdala and hippocampus are left intact. An alternative explanation for our results is that damage in any one of these areas disrupts a complex network involving several distinct temporal-lobe structures.

A role for the right anterior temporal lobe in taste quality recognition

We conducted two experiments to examine central processing of the taste of citric acid. In the first experiment, elevated citric acid recognition thresholds, but normal detection thresholds, were observed in a group of patients who had undergone a right anterior temporal lobectomy for the treatment of epilepsy, compared with a control group and a group of patients who had undergone the same operation in the left hemisphere. In the second study, using positron emission tomography, we compared regional cerebral blood flow (rCBF) in a condition in which citric acid was presented with one in which water was presented (with similar somatosensory stimulation across both conditions). We observed increased rCBF bilaterally in the caudolateral orbitofrontal cortex, in the right anteromedial temporal lobe, and in the right caudomedial orbitofrontal cortex. The elevated recognition thresholds exhibited in patients with resection of the right anteromedial temporal lobe may be accounted for by damage in an area corresponding to that of the rCBF increase. These results suggest that although taste sensation may be computed in the primary taste cortex, recognition requires further processing by structures located in the anteromedial temporal lobe. Furthermore, they point to preferential processing of this higher-order gustatory function by the right cerebral hemisphere.

Learning and retention of words and designs following excision from medial or lateral temporal-lobe structures

We sought to elucidate the contributions of the amygdala, hippocampus and temporal neocortex to learning and memory for verbal and visuospatial material. Two matched learning tasks, using abstract words versus abstract designs, were administered to patients with unilateral neocorticectomy (NCE; Dublin), selective amygdalohippocampectomy (AHE; Zurich) or anterior temporal-lobe resection invading the amygdala and hippocampus (ATL; Montreal). Data were analysed according to side and type of resection. Learning and recall for words was impaired in groups with resection from the left temporal lobe, irrespective of whether mediobasal structures were spared or temporal neocortex was spared. All right-resection groups were unimpaired. Learning for abstract designs was impaired across all trials in the right AHE and NCE groups, and on the last two trials in the right ATL group. Restricted deficits of lower magnitude were observed on some trials in left-resection groups. These results show a partial dissociation between side of excision and type of material, but the finding of similar deficits in all resection types was unexpected. We propose that excision from either the hippocampal region or temporal neocortex may result in a disconnection, giving a similar functional outcome, as both types of resection interrupt a circuit likely to be essential for normal storage and retrieval of information.

Sodium amobarbital memory tests: what do they predict?

Severe transient postoperative memory deficits among epilepsy patients with resection from one temporal lobe may be indicative of increased risk for amnesia had more extensive removal of mesial structures occurred. Immediate postoperative testing may provide some validation for risk of amnesia as predicted by the intracarotid sodium amobarbital memory test (IAP-M). Thirty patients (24 not considered at risk for amnesia and 5 who failed the IAP-M) were tested on the first, second, and third days following resection from the right or left temporal lobe. Results suggest that the IAP-M paradigm used does not necessarily predict postoperative memory performance.

Assessment of the functional effect of the intracarotid sodium amobarbital procedure using co-registered MRI/HMPAO-SPECT and SEEG

We studied the functional effect of injection of sodium amobarbital (SA) in 10 patients with intractable epilepsy. During the intracarotid amobarbital procedure, we measured delta activity in EEG recording from implanted electrodes and regional cerebral blood flow (rCBF) using HMPAO-SPECT co-registered with MRI. SA injection resulted in an increase in delta activity and a decrease in rCBF in all areas examined. Direct functional changes were observed in structures perfused by the carotid artery injected. In addition, we observed indirect effects, probably owing to deafferentation of neuronal pathways connecting these structures to ipsilateral and contralateral regions, including middle and posterior hippocampus.

Bilateral parasagittal parietooccipital polymicrogyria and epilepsy

We describe 9 patients with a bilateral malformation of cortical development, centered around the parasagittal and mesial aspects of the parietooccipital cortex, with magnetic resonance imaging findings suggestive of polymicrogyria. No familial distribution or etiologic factors were identified. Location in a watershed area between anterior and posterior cerebral arteries suggests postmigratory perfusion failure as the underlying cause. In most patients the malformation was detected by magnetic resonance imaging after computed tomography scans with 10-mm-thick sections were considered normal. Seizures, present in all, had started between the ages of 20 months and 15 years (mean, 9 years) and were intractable in 7. Complex partial seizures with or without minor automatisms were the most frequent ictal pattern. In only 4 patients these were preceded by symptoms indicating posterior onset. Interictal electroencephalograms showed both diffuse and bilateral parietooccipital or temporal abnormalities. The range of IQ scores indicated average intelligence to mild retardation. Several patients presented deficits on neuropsychological tasks requiring performance under time constraints, suggesting that the malformation may result in cognitive slowing. Early diagnosis of this malformation may be difficult because of the lack of neurological signs, relatively late seizure onset, difficulty in localizing seizure onset, and inability to recognize the cortical abnormality on computed tomography scans.

Mesial atrophy and outcome after amygdalohippocampectomy or temporal lobe removal

We studied 74 consecutive patients with temporal lobe epilepsy who were treated surgically and in whom the volumes of mesial temporal structures were determined preoperatively by magnetic resonance imaging. We divided the patients into three groups according to the volumetric findings: unilateral (63.5% of the patients), bilateral (23%), or no atrophy (13.5%) of the amygdala-hippocampal formation. Two distinct surgical approaches were used: selective amygdalohippocampectomy (n = 37) or anterior temporal lobe resection (n = 37). Outcome was assessed at least 1 year after surgery, according to Engel's modified classification. Patients with unilateral mesial temporal atrophy had significantly better results compared with the other two groups (p < 0.001): We found excellent results (class I or II outcome) in 93.6% of the patients with unilateral atrophy, in 61.7% of those with bilateral atrophy, and in 50% of the group with no significant atrophy of mesial temporal structures. The two different surgical techniques were equally effective, regardless of the pattern of atrophy. In conclusion, magnetic resonance volumetric studies in temporal lobe epilepsy proved to be an important preoperative prognostic tool for surgical treatment, but they did not provide guidance for selecting one surgical approach compared to the other.

Significance of mesial temporal atrophy in relation to intracranial ictal and interictal stereo EEG abnormalities

We studied 31 consecutive patients with temporal and extratemporal epilepsy who underwent presurgical evaluation with stereotaxic depth EEG (SEEG) to assess the relationships between amygdalo-hippocampal (AM-HF) atrophy and the location of SEEG seizure onset and SEEG interictal abnormalities. Scalp EEG recordings with sphenoidal electrodes had shown bitemporal ictal or interictal epileptic abnormalities in all. Patients underwent high quality MRI scans, including MRI volumetric measurements of mesial temporal structures. None had foreign tissue lesions. The final conclusions of the SEEG investigation coincided with the lateralization obtained by MRI volumetric measurements in the eight patients who had significant unilateral atrophy of the amygdala, hippocampus or both (> 2 SD below the mean of controls). In these patients with unilateral atrophy, all or > 75% of clinical seizures originated from the atrophic side. The seven patients with bilateral, but significantly asymmetrical, mesial atrophy had bilateral seizure onsets with > 70% originating from the more atrophic side in four, from the less atrophic side in two, and without predominance in one. The one patient with severe bilateral symmetrical atrophy had seizures originating equally from both sides. Five patients had no atrophy on MRI, but depth electrodes revealed predominant unilateral ictal temporal onsets in four of them. There was no significant correlation between the frequency of SEEG interictal spikes and the amount of AM-HF atrophy. However, we found a significant correlation between the severity of SEEG background disturbance in AM and HF and the degree of atrophy of these structures. Patients with unilateral atrophy were more frequently free of seizures after surgery than those with bilateral or no atrophy (P < 0.05). We conclude that unilateral mesial atrophy predicts ipsilateral mesial SEEG seizure onset despite bitemporal extracranial EEG foci. However, in patients with significant bilateral mesial atrophy, SEEG seizures may originate from either side, even in the presence of significant asymmetry. Finally, the identification of unilateral mesial atrophy has prognostic importance.

Performance of healthy subjects and patients with resection from the anterior temporal lobe on matched tests of verbal and visuoperceptual learning

We examined the equivalence of three matched forms of the Rey Auditory Verbal Learning Test (RAVLT) and three parallel forms of a new nonverbal analog, the Aggie Figures Learning Test (AFLT). One hundred and fourteen healthy subjects, primarily college students, were administered corresponding forms of the two tasks. For both tasks the three forms proved to be well-matched; as well, overall performance on the RAVLT was comparable to that on the AFLT. The two tasks were also administered to 23 patients with anterior resection from the left or right temporal lobe (ATL). Findings showed that right ATL patients were significantly impaired on the learning trials of the AFLT as compared to their learning on the RAVLT; they showed little forgetting of figures or words over a 20-min delay interval. By contrast, left ATL patients showed severe forgetting of words as compared to figures, but their learning curve for the RAVLT did not differ from that on the AFLT.

EEG slow waves and memory performance during the intracarotid amobarbital test

During intracarotid sodium amobarbital (ISA) testing, EEG slow waves appear in the injected hemisphere and usually also contralaterally. They are frequently used to estimate duration of drug effect and thus the window of valid memory testing, but the relationship between slow waves and memory performance is not established. In 50 tests, we examined recognition for stimuli presented after amobarbital injection in relation to the quantified EEG. Performance was compared for injection ipsilateral versus contralateral to epileptic focus, with slow waves present bilaterally, unilaterally, or dissipated. Results showed that memory was impaired after injections contralateral to the focus when slow waves were present on the side of the focus (contralateral to injection). Injection contralateral to focus did not interfere with memory if slow waves were not also present, and slow waves contralateral to injection did not interfere with memory if the focus was not also present. This result emphasizes the functional significance of slow waves, which probably reflect decreased neuronal functioning.

Atrophy of mesial structures in patients with temporal lobe epilepsy: cause or consequence of repeated seizures?

We studied 70 epileptic patients by using magnetic resonance imaging volumetric measurements of amygdala (AM) and hippocampal formation (HF). Fifty patients presented with intractable temporal lobe epilepsy (TLE), 10 patients had focal extratemporal lobe epilepsy, and 10 had generalized epilepsy. In 91% of the 45 TLE patients without foreign tissue lesions, there was significant smallness of the AM and/or HF coinciding with the side of electroencephalographic seizure onset. No significant smallness or asymmetry was demonstrated in patients with focal extratemporal or generalized epilepsy. We performed a linear regression analysis, plotting the number of years of recurrent seizures and the estimated seizure frequency against the volumes of the AM and HF. There was no correlation between either of these two parameters and AM or HF volume (p > 0.9). There was also no correlation between the patient's age and volumetric measurements of AM or HF, nor did these measurements correlate with the occurrence of generalized seizures. On the other hand, patients with antecedent prolonged febrile convulsions in early childhood had significantly smaller AM and HF, compared with those without such a history (p < 0.001). The findings indicate that repeated seizures or longer duration of epilepsy do not cause increased atrophy of AM or HF that is measurable by volumetric magnetic resonance imaging.

Odor recognition memory in humans: role of right temporal and orbitofrontal regions

Odor memory was studied in 121 patients with unilateral cerebral excision from temporal, frontal, frontotemporal, or centroparietal areas, and 20 control subjects. Odors were presented birhinally, and half were named, to examine the effect of verbal labelling. Testing was by yes-no recognition immediately after presentation, 20 min later, and after 24 hr, using eight different targets and eight new foils each time. The results showed impairment only after excision from the right temporal or right orbitofrontal cortex. All groups showed significant forgetting over time, and verbalized odors were recognized more efficiently than unlabelled ones. The findings, suggesting a right hemisphere predominance in odor memory, support similar results for odor discrimination.

Early childhood prolonged febrile convulsions, atrophy and sclerosis of mesial structures, and temporal lobe epilepsy: an MRI volumetric study

We performed MRI volumetric measurements of the amygdala (AM) and hippocampal formation (HF) in a group of 43 patients with temporal lobe epilepsy not controlled by optimal drug treatment. Fifteen patients (35%) had a history of prolonged febrile convulsions (PFC) in early childhood; 30 patients underwent surgery, and histopathology was available in twenty-four. The mean values of AM and HF volumes ipsilateral to the EEG focus were significantly smaller than those of normal controls. The volumetric measurements showed a more pronounced atrophy of the AM in patients with a history of PFC, although the HF volumes were also smaller in this group. Patients with a history of PFC had a higher proportion of more severe mesial temporal sclerosis (MTS) compared with those with no PFC. These findings confirm a correlation between early childhood PFC, the severity of atrophy of mesial structures, and MTS.

MRI volumetric measurement of amygdala and hippocampus in temporal lobe epilepsy

We performed MRI volumetric measurements of the amygdala (AM), the hippocampal formation (HF), and the anterior temporal lobe in a group of 30 patients with intractable temporal lobe epilepsy (TLE) and in seven patients with extratemporal lobe foci. Measurements were analyzed with a semiautomated software program and the results compared with those of normal controls and correlated with the findings of all other investigations. In particular, we compared the results with the lateralization of epileptic abnormalities in the EEG. Volumetric studies of AM and HF showed lateralization of measurable atrophy consistent with that derived from extracranial and intracranial EEG examinations. The HF volumes were more sensitive and provided a lateralization in 87%. Combined measurements of AM and HF showed lateralization in 93%, always congruent with the results of EEG lateralization. This slight but important additional improvement in discrimination justifies using AM measurements in MRI volumetric studies of mesial temporal structures. Volumetric studies combined with other currently employed noninvasive techniques may diminish the need for invasive methods of investigation in patients with TLE.

Duration of sodium amytal effect: behavioral and EEG measures

In performance of an intracarotid sodium amytal test duration of action is a critical factor since measurements obtained after cessation of action are invalid. Duration of action is often monitored by measuring handstrength contralateral to injection or by visual inspection of amytal-induced EEG slow waves ipsilateral to injection. We describe new objective methods of monitoring drug effect: quantified EEG and sensory discrimination. In a first study of patients with scalp electrodes, the two traditional and the two new measures were compared in 40 injections. Results indicated that the two EEG measures did not differ significantly and estimated a shorter drug effect than the two behavioral measures, which were also not significantly different. The two new measures had a smaller SD, indicating that they may be less erratic. In a second study of 14 patients, using intracerebral electrodes, we showed that slow waves in the frontocentral region lasted as long as the motor and sensory effects, but also that slow waves in the medial temporal region dissipated earlier than the motor and sensory deficits. Our results suggest that motor and sensory measures may overestimate the time in which valid testing can occur if hippocampal function is at issue.

Functional localization and lateralization of human olfactory cortex

Anatomical and physiological investigations in monkeys indicate that olfaction is subserved by several cortical regions. But the areas implicated in the human olfactory system have not been definitively identified by functional criteria. Behavioural evidence has suggested that laterally specialized mechanisms for odour processing may exist, but the neuroanatomical substrate remains unknown. We used positron emission tomography to study the cortical representation of human olfactory processing by comparing cerebral blood flow changes evoked during olfactory stimulation with those of a control task. We report here significant cerebral blood flow increases at the junction of the inferior frontal and temporal lobes bilaterally, corresponding to the piriform cortex, and unilaterally, in the right orbitofrontal cortex. The results complement and extend previous data implicating these regions in olfactory processing, and indicate that a functional asymmetry exists in the human brain favouring the right orbitofrontal area in olfaction.

Intracranial EEG study of brain structures affected by internal carotid injection of amobarbital

Hippocampal function, considered critical in memory processing, is supposedly tested in the intracarotid sodium amobarbital (ISA) procedure; however, since the hippocampus is not completely irrigated by the internal carotid artery, some believe the procedure may be invalid for memory testing. We quantified delta activity in intracerebral EEGs during ISA tests. There was increased delta in ipsilateral structures as follows: amygdala (6.4 minutes), anterior hippocampus (7.2), middle hippocampus (7.4), temporal neocortex (9.1), frontal lobe (8.4), central/parietal area (11.0), and occipital lobe (9.7). Contralateral structures usually (> 64%) showed increased delta lasting 4 to 5 minutes. The ipsilateral hippocampus had delta waves in over 90% of injections. We conclude that the hippocampus is clearly affected by the ISA injection. We argue that the slow waves may not be caused by a direct effect of the drug, but rather by a functional deafferentation due to the profound inactivation of structures surrounding the hippocampus. Similarly, slow waves contralateral to injection may be caused by sudden removal of neuronal input from the regions receiving the amobarbital.