Localization of epileptogenic zone based on reconstruction of dynamical epileptic network and virtual resection / 生物医学工程学杂志

Drug-refractory epilepsy (DRE) may be treated by surgical intervention. Intracranial EEG has been widely used to localize the epileptogenic zone (EZ). Most studies of epileptic network focus on the features of EZ nodes, such as centrality and degrees. It is difficult to apply those features to the treatment of individual patients. In this study, we proposed a spatial neighbor expansion approach for EZ localization based on a neural computational model and epileptic network reconstruction. The virtual resection method was also used to validate the effectiveness of our approach. The electrocorticography (ECoG) data from 11 patients with DRE were analyzed in this study. Both interictal data and surgical resection regions were used. The results showed that the rate of consistency between the localized regions and the surgical resections in patients with good outcomes was higher than that in patients with poor outcomes. The average deviation distance of the localized region for patients with good outcomes and poor outcomes were 15 mm and 36 mm, respectively. Outcome prediction showed that the patients with poor outcomes could be improved when the brain regions localized by the proposed approach were treated. This study provides a quantitative analysis tool for patient-specific measures for potential surgical treatment of epilepsy.

Tratamiento quirúrgico de la epilepsia asociada a tumores neuroepiteliales de bajo grado / Surgical treatment of low-grade epilepsy-associated neuroepithelial tumors

Resumen Los tumores cerebrales son una causa importante de las epilepsias de difícil manejo, corresponden a un 20-30 % de los casos de cirugía de epilepsia refractaria. En este grupo de pacientes los tumores neuroepiteliales de bajo grado asociados a epilepsia (LEAT) son la principal causa, siendo los más frecuentes los tumores neuroepiteliales disembrioplásticos (DNT) y ganglioglioma (GG). En el presente artículo revisamos los cambios en la definición de epilepsia refractaria, avances en el diagnóstico por imágenes y el diagnóstico histopatológico con los nuevos marcadores moleculares, que han permitido un diagnóstico cada vez más precoz y certero. Se revisa también la cirugía resectiva que permite en estos casos una libertad de crisis cercana un 70-90% de los pacientes. Los mejores resultados en términos de control de crisis, se pueden alcanzar cuando la cirugía es precoz.

Brain tumors are an important cause of epilepsy that is difficult to manage, accounting for 20-30% of cases of refractory epilepsy surgery. In this group of patients, low-grade epilepsy-associated neuroepithelial tumors (LEAT) are the main cause and the most frequent being dysembryoplastic neuroepithelial tumors (DNT) and ganglioglioma (GG). In this article, we review the changes in the definition of refractory epilepsy, advances in diagnostic imaging, and histopathological diagnosis with new molecular markers, which have allowed for an increasingly early and accurate diagnosis. Resective surgery is also reviewed, allowing in these cases a seizure freedom close to 70-90% of patients. The best outcome in terms of seizure control can be achieved when early surgery is performed.

Tribute to Theodor Kocher: Far Beyond an Anatomical Reference

We know Kocher's name as an anatomical reference in neurosurgery. In fact, Theodor Kocher was a Swiss general surgeon, and his contributions were such that Kocher was honored in 1909 with the Nobel Prize in Medicine and Physiology, and he was the first surgeon to receive this honor. Kocher participated in the initial scientific phase of medicine, livingwith names that are in history, as well as him; Langenbeck and Virchow, Lucke, Billroth, Horsley, Lister, Halstedt, Pasteur, Osler, Lawson Tait, Verneuil, and a long list and other icons of the time. The present account rescues the many important facets and contributions of the Swiss surgeonTheodor Kocher, and his relationship with several of them. Kocher's memory, surgical instruments and literary production are preserved in a small wing of the University of Bern. The present article highlights how intense Kocher's dedication to the medical field was.

History and Evolution of Epilepsy Surgery

The surgical treatment for epilepsy has a worldwide historical relevance for centuries. There are archaeological reports that date it back to ancient Egypt; however, the year 1886 is considered a landmark in the surgical treatment for epilepsy in theModern Age, when the first surgery for the treatment of focal epileptic events was performed successfully. Since then, innumerable related articles have been published evoluonarily. Over the last centuries, new techniques and technologies provided better understanding, diagnosis and management for this disease. Thus, historical and evolutionary knowledge becomes important to let us better understand the current position of the surgery for epilepsy treatment and control.

Consentimiento informado en pacientes con epilepsias intratables / Informed consent in patients with intractable epilepsy

La ética médica aborda, entre otros aspectos, la relación médico-paciente, de la cual se deriva el término consentimiento informado como su máxima expresión. La epilepsia afecta al 1-2 por ciento de la población mundial, y en la búsqueda de soluciones a esta enfermedad los sujetos son involucrados en diferentes tipos de estudios. En el presente trabajo se realiza una breve revisión de algunos aspectos éticos relacionados con la aprobación dada por los pacientes que padecen epilepsia o su representante legal para participar en estudios que presuponen la realización de exámenes diagnósticos y el empleo de formas novedosas de tratamiento, lo que se materializa a través del consentimiento informado. Especialmente, se hace referencia a la participación de los pacientes en ensayos clínicos y el manejo de las pacientes que quedan embarazadas en el transcurso del ensayo clínico, los efectos adversos de la medicación y de la cirugía de epilepsia(AU)

Medical Ethics addresses, among other aspects, the doctor-patient relationship from which the term informed consent is derived as its maximum expression. Epilepsy affects 1-2 percent of the world population, and in the search for solutions to this disease the subjects are involved in different types of studies. In the present paper, a brief review of some ethical aspects related to the approval given by patients suffering from epilepsy or their legal representative to participate in studies that presuppose the performance of diagnostic tests and the use of novel forms of treatment. This is materialized through informed consent. Especially, there is a reference to the participation of patients in clinical trials, and the management of patients who become pregnant during the clinical trial, the adverse effects of medication, and epilepsy surgery(AU)

Implementing an epilepsy surgery center. Initial experience at a university hospital in Brazil / Implementação de um centro de cirurgia de epilepsia. Experiência inicial em um hospital universitário no Brasil

ABSTRACT Epilepsy is a serious neurological condition, often without a full and effective treatment. In some cases, surgery is beneficial, despite being underused. Our aim herein is to describe the implementation of an epilepsy surgery center in a federal university hospital, sharing the initial experience gained, as well as describing the main challenges and first results. Methods: Experience report of an epilepsy surgery center implementation. Retrospective review of 13 drug-resistant patients who underwent surgical treatment. Results: Thirteen patients underwent surgical epilepsy treatment, five patients categorized as the International League Against Epilepsy class 1, two in class 2, three in class 3, zero in class 4, and two in class 5; with a 30.76% complication rate. Conclusion: Despite the challenges, it was possible to implement an epilepsy surgery center with favorable results and acceptable incidence of complications, which were not higher than the incidences found in more experienced centers.

RESUMO Epilepsia é um problema neurológico sério e para o qual não há um tratamento efetivo e definitivo. Apesar de o tratamento cirúrgico ser bastante benéfico em alguns casos, ainda é subutilizado. O objetivo deste trabalho é descrever a implementação de um Centro de Cirurgia de Epilepsia em um Hospital Universitário Federal, divulgar a experiência inicial obtida, os principais desafios, as dificuldades e os resultados iniciais. Método: Relato da experiência na implementação do Centro de Epilepsia. Análise retrospectiva de série de treze pacientes com epilepsia resistente a medicação e que foram submetidos a tratamento cirúrgico. Resultados: Treze pacientes submetidos a tratamento cirúrgico, 5 com a Liga Internacional Contra Epilepsia classe 1, 2 com classe 3, três com classe 3, zero com classe 4 e 2 com classe 5; com uma taxa de complicação de 30, 76%. Conclusão: Apesar das dificuldades, foi possível a implementação de um Centro de Cirurgia de Epilepsia com resultados favoráveis e taxas de complicação não superiores aos centros de países desenvolvidos.

Hemispherectomy in treatment of seizures: current perspectives of the indications, techniques and complications: literature review

Introducción: A hemisferectomía es un procedimiento valioso en el tratamiento de trastornos convulsivos causados por desordenes hemisféricos unilaterales. El hemisferectomía anatómica se ha utilizado para este fin desde 1938, sin embargo, se abandonó este procedimiento después de informes de complicaciones postoperatorias causadas por hemosiderosis superficial, ependimitis e hidrocefalia obstructiva. Así que, se ha mostrado en la literatura modificaciones en las indicaciones y técnicas de hemisferectomía anatómica cuya finalidad es la de reducir la incidencia de esta complicación sin dejar de lograr control de las convulsiones. Sobre la base de la literatura, la hemisferectomía mejora la calidad de vida de los pacientes que tiene la indicación para realizar este procedimiento, ya que permite reducir la frecuencia de las convulsiones, si tónica o átona, tónico-clónicas Objetivo: El objetivo de esta revisión de la literatura es discutir los detalles técnicos, modalidades, riesgos, complicaciones, resultados y de pronóstico de hemisferectomía basado en la revisión crítica de la literatura. Casuística y Métodos: Se realizó la consulta bibliográfica, utilizando la base de datos MEDLINE, LILACS, SciELO, que utiliza el lenguaje como criterios de selección, la elección de los artículos recientes preferiblemente en portugués, español o inglés. Conclusión: Según las referencias, hemisferectomía es un procedimiento con buen resultado para las personas con convulsiones derivadas cuando está indicado para casos seleccionados y la tasa de éxito no es proporcional a la extensión de la resección del tejido neuronal. A mayor resección puede o no reducir la frecuencia de las crisis, sin embargo, la incidencia de la morbilidad puede ser mayor.

Background: The hemispherectomy is a valuable procedure in the management of seizure disorders caused by unilateral hemispheric disease. The anatomical hemispherectomy has been used for this purpose since 1938, however, it was abandoned after reports of postoperative complications caused by superficial hemosiderosis, ependymitis and obstructive hydrocephalus. So that, it has been showed modifications in the techniques of hemispherectomy whose the purpose is reduce the incidence of this complications while still achieving seizure control. Based on literature, the hemispherectomy improves the quality of life of patients that has the indication to perform this procedure because it allows reducing the frequency of seizures, whether tonic or atonic, tonic-clonic. Aim: The aim of this literature review is discuss the indications, technical details, modalities, risks, complications, results as well de prognosis of callosotomy based on critical literature review and the authors experience. Casuistry and Methods: It was performed bibliographical consultation, using the databases MEDLINE, LILACS, SciELO, utilizing language as selection criteria, choosing preferably recent articles in Portuguese, Spanish or English. Conclusion: According to references, the functional hemispherectomy has a good outocome for those with seizures arisin when indicated to selected cases and the success rate is not proportional to the extent of neuronal tissue resection. So that, a greater resection cannot necessarily reduce the seizure frequency, however the morbidity may also be larger.

Refractory epilepsy in children with brain tumors. The urgency of neurosurgery / Epilepsia refratária em crianças com tumores cerebrais. A urgência de neurocirurgia

ABSTRACT In order to verify indications for surgery, 27 patients with refractory epileptic seizures and brain tumor, aged up to 19 years at the time of surgery, were studied between 1996 and 2013 and followed up for at least one year. The mean interval between the onset of seizures and the diagnosis of the tumor was 3.6 years, and from diagnosis to the surgery, 18 months. The location of the tumor was in the temporal lobe in 16, with ganglioglioma and dysembryoplastic neuroepithelial tumors being the most frequent. Among the patients, 92.5% and 90.4% were seizure-free in the first and fifth year after surgery, respectively. Twelve of 16 children were successful in becoming drug-free, with complete withdrawal by 3.2 years. Surgery proved to be potentially curative and safe in these cases, suggesting that the tumor diagnosis and surgery cannot be postponed.

RESUMO A fim de verificar os aspectos da indicação cirúrgica, vinte e sete pacientes com epilepsia refratária secundária a tumor cerebral, com idade de até 19 anos na cirurgia, operados entre 1996 e 2013 e seguidos por pelo menos um ano, foram estudados. O intervalo médio entre o início das crises e o diagnóstico do tumor foi de 3,6 anos, e deste para a cirurgia, 18 meses. A localização do tumor foi lobo temporal em 16, sendo ganglioglioma e DNET os tipos mais frequentes. Entre os pacientes, 92,5% e 90,4% estavam livres de crises no primeiro e no quinto ano após a cirurgia, respectivamente. Doze de 16 crianças obtiveram sucesso na retirada de drogas, com a média de tempo de 3,2 anos após o procedimento. A cirurgia provou ser potencialmente curativa e segura nestes casos, o que sugere que perante o diagnóstico de tumor esta não pode ser adiada.

Pronóstico en cirugía de epilepsia: ¿puede influir la reserva cognitiva? / Prognosis in EpilepsyÆs surgery: Can Cognitive Reserve influence it?

Hasta un tercio de individuos diagnosticados de epilepsia continúan teniendo crisis a pesar del tratamiento antiepiléptico apropiado. Estos pacientes pueden ser referidos para evaluación pre-quirúrgica y la cirugía es considerada un tratamiento efectivo para epilepsia relacionada a localización refractaria. Los factores que predicen un mejor resultado de la cirugía son contradictorios, y las recomendaciones incluyen evaluación detallada del rendimiento cognitivo antes y después de la cirugía; sin embargo no se considera la evaluación de la reserva cognitiva (RC). La incorporación de un instrumento que valore la RC de los pacientes permitiría incrementar la fuerza predictiva de la evaluación neuropsicológica respecto al pronóstico post-quirúrgico y aportaría a la investigación de los factores neuroprotectores en aquellos pacientes con un perfil de rendimiento cognitivo post-quirúrgico superior a la etapa pre-quirúrgica, y además permitiría conocer cómo la actividad educacional, ocupacional, y de tiempo libre de los pacientes se ven afectadas por la epilepsia y su variación después de la cirugía.

Up to one-third of individuals diagnosed as having epilepsy continue to have seizures despite appropriate antiepileptic drug treatment. Patients with refractory localization-related epilepsy can be referred for presurgical evaluation, and resective surgery is considered an effective treatment for such cases. Predictive factors of a better outcome for epilepsyÆs surgery are contradictory, and recomendations include a detailed assessment of cognitive performance before and after surgery; this process, however does not consider the evaluation of Cognitive Reserve (CR). The use of an instrument that assesses the CR of patient-candidates would increase the predictive power of neuropsychological assessment regarding post-surgical prognosis and outcome; in turn, it could contribute to research of neuroprotective factors in patients with a superior pre- and post-surgical profile of cognitive performance, and also allow knowing how the patientÆs educational and occupational activity, and use of leisure time are affected by epilepsy and its post-surgical variations.

Consideraciones quirúrgicas propias de la epilepsia en niños, comentarios sobre Perú / Surgical considerations of epilepsy in children, comments about Peru

Las epilepsias resistentes a fármacos son aquellas donde hay persistencia de crisis pese a un tratamiento farmacológico óptimo. En niños su tratamiento es diferente al de los adultos, ya que las crisis producen daños encefálicos irrecuperables en un cerebro en desarrollo, por lo que se recomienda plantearla cirugía lo más precoz posible en casos de epilepsia refractaria y con alternativa terapéutica quirúrgica, incluso aunque las crisis lleven pocos meses de evolución. Entre el 25 al 33% de los niños presentan epilepsias resistentes a fármacos y la mitad de ellos son candidatos para iniciar un estudio prequirúrgico. En Perú aproximadamente 650 niños al año necesitarían cirugía, pero solo se operan unos pocos casos al año, si a esto agregamos los casos rezagados de los años anteriores, significa que hay miles de niños que esperan por una cirugía de la epilepsia. Este artículo revisa el estado del arte actual...

Drug resistant epilepsy is defined as the persistence of seizures, despite the optimal antiepileptic treatment. However the approach is different in children because they have a brain that is still developing. The International League Against Epilepsy proposed for these children to ôeliminate seizures as soon as possible to optimize cognitive development, and improve behavior and quality of lifeõ. About 25 to 33% of epileptic children have refractory epilepsy and half of them require a pre-surgical evaluation. Around 650 children in Peru need epilepsy surgery treatment every year, but few patients get access to it. If we include cases of previous years, the waiting list in Peru is over 1,000 children. This paper analyzed the state of art in epilepsy surgery in children...

Functional Magnetic Resonance Imaging and surgical planning and outcome in epilepsy / Ressonância magnética funcional no planejamento e resultados cirúrgicos da epilepsia / Resonancia magnética funcional en el planeamiento y resultados quirúrgicos de la epilepsia

Besides mapping eloquent areas such as motor and language cortex for pre-surgical planning, functional magnetic resonance imaging (fMRI) has also been used as a non-invasive technique to predict surgical outcome regarding memory and language deficits. This brief review article will focus on fMRI and the emerging role of electroencephalogram associated to fMRI (EEG-fMRI) in epilepsy surgery...

Além do mapeamento de áreas eloquentes, como córtex motor e de linguagem para o planejamento pré-cirúrgico, a ressonância magnética funcional (RMf) também tem sido usada como uma técnica não-invasiva para prever o resultado cirúrgico sobre déficits de memória e de linguagem. Esta breve revisão incidirá sobre a RMf e o papel emergente do eletroencefalograma acoplado a RMf (EEG-RMf) em cirurgia de epilepsia...

Además del mapeo de áreas elocuentes, como corteza motora y de lenguaje para el planeamiento prequirúrgico, la resonancia magnética funcional (RMf) también viene siendo usada como una técnica no invasiva para prever el resultado quirúrgico sobre déficits de memoria y de lenguaje. Esta breve revisión incidirá sobre la RMf y el papel emergente del electroencefalograma acoplado a RMf (EEG-RMf) en cirugía de la epilepsia...

Neuronavegação em neurocirurgia / Neuronavigation in neurosurgery

A neurocirurgia guiada por imagem permite ao neurocirurgião navegar no interior do crânio, orientado a partir das imagens de tomografia computadorizada (TC) ou ressonância magnética (RM) pré--operatórias, empregando, para isso, sistemas de rastreamento tridimensionais (3D), em tempo real,durante o procedimento cirúrgico. O presente estudo tem como objetivo revisar a literatura acerca dasprincipais aplicações da neuronavegação na neurocirurgia contemporânea. Foi feita uma revisão daliteratura por meio de busca na base de dados PubMed, nos últimos 15 anos, nas línguas portuguesa e inglesa, usando os seguintes termos: neuronavegação/neuronavigation, estereotaxia/stereotaxis, glioma surgery, neuroendoscopia/neuroendoscopy, epilepsy surgery, aneurysm. A neuronavegação auxilia a localização espacial, orientando acessos cirúrgicos, o que melhora a qualidade e a segurança do procedimento. Ressalta-se a importância desta nas cirurgias de gliomas em áreas eloquentes, associada a procedimentos neuroendoscópicos e cirurgia de epilepsia e combinada com ultrassom 3D e/ou RM intraoperatória, com significativa redução da morbidade do ato cirúrgico. O desvio dasestruturas após a abertura do crânio e da dura-máter (?brain shift?) é considerado o fator limitante para o método, impedindo a perfeita correspondência entre imagens pré-operatórias e a neuronavegaçãoem tempo real, o que pode ser minimizado com a realização de RM intraoperatória (renavegação).

The image-guided neurosurgery allows the neurosurgeon to navigate within patient?s skull, using preoperative images as a guide, through the use of 3D tracking systems, during the surgical procedure. This study aims to review the literature on the main applications of neuronavigation in modern neurosurgery. We performed a literature search through the database PubMed in the last 15 years in Portuguese and English, using the following terms: neuronavegação/neuronavigation, estereotaxia/stereotaxis, glioma surgery, neuroendoscopia/neuroendoscopy, epilepsy surgery, aneurysm. Neuronavigation improves the efficacy and security of surgery, with emphasis in surgery of gliomas in or around eloquent areas, association with neuroendoscopy and epilepsy surgery, as well combined with 3D ultrasound and intraoperative MRI. Dislocation of brain and structures after opening cranial vault and dura (?brain shift?) still is a limitation to the perfect correspondence between the surgery and preoperative images of neuronavigation, which can be solved with intraoperative MRI.

Cirugía de epilepsia en el Hospital Nacional Guillermo Almenara: primeros siete casos / Epilepsy surgery in Guillermo Almenara Hospital: First seven cases

La epilepsia tiene una incidencia de 1 % en la población, de los cuales un tercio no responde al tratamiento farmacológico, que conlleva a discapacidad y morbilidad secundaria. Los pacientes con epilepsia refractaria requieren un estudio multidisciplinario para el origen de la epilepsia y realizar la resección quirúrgica. En cinco pacientes del Hospital Almenara hicimos la evaluación clínica, neuropsicológica, estudio estructural con resonancia magnética, PET y SPECT y videoelectroencefalografía de cuero cabelludo e intracraneal, con lo que realizamos la cirugía resectiva correspondiente. En 71 % de los pacientes se logró la supresión completa de las crisis epilépticas y en 29 % restantes, la disminución de la frecuencia en 75 %. La morbilidad adicional en los pacientes operados fue leve y manejable. El manejo multidisciplinario y tratamiento quirúrgico de la epilepsia refractaria en el hospital Almenara es altamente eficaz y se requiere la implementación de una unidad de Cirugía de Epilepsia.

Epilepsy has 1 % prevalence, until one third are refractory to pharmacological treatment, so it produces disability, morbidity and mortality. These patients requires multidisciplinary diagnostic approach to localize the origin and ideally resect it. In Almenara Hospital, seven patients has been studied clinically, neuropsychologically, brain imaging: structure magnetic resonance and functional with positron emission tomography and single photon emission computed tomography and video electroencephalography non invasive initially and electrocorticography. After the study we decided and performed respective surgery. In 71 % of patients we have got complete suppression of seizures and in the remain 29 %, more than 75 % in seizure frequency. The side effects were mild and possible to treat. The multidisciplinary approach and surgical treatment of refractory epilepsy in the Almenara Hospital is highly efficient and it is needed to install an Specialized Unit.

EEG in epilepsy: sensibility and specificity / EEG em epilepsia: sensibilidade e especificidade

Objective: the aim of this study was to determine the sensitivity (presence of epileptiform discharges in the EEGs of patientswith epilepsy) and specificity (absence of discharges in the EEGs in people without epilepsy) of EEG. Methodology: all EEGs performed at the Clinic Santa Vitória, in Campina Grande, PB, from April 2001 to April 2010 were reviewed. All recordings were performed in accordance with international standards for fixing the electrodes, minimum time of registration and methods activation (intermittent photic stimulation and hyperventilation). The reports were divided into 1) patients with epilepsy, previously diagnosed by neurologists, and 2) patients without epilepsy. For both groups, we evaluated the sensitivity and specificity of the EEG. We used SPSS for statistical tests. The study was approved by the Ethics Committee of UEPB. 10,408 EEGs were reviewed. Results: epileptiform discharges occurred in 1412 (13.56%). Among those with epilepsy, discharges occurred in 643 (45.57%) - true-positive. Among those who did not have epilepsy, in 54.43% - false positives. From a total of 8,996 (86.44%) EEGs without discharges, 1,276 (14.14%) were from the group of patients with epilepsy - false-negative and 7,720 (85.78%) were from the group of patients without epilepsy - true negative. The positive likelihood ratio test showed that the probability of finding EEG discharges is four times higher among patients with epilepsy compared to those who do not have epilepsy. The negative likelihood ratio test showed no differences between false negative and true negative. In general, a sensitivity of 33.5% and a specificity of 90.9%, with no differences in age and gender was observed. Therefore, EEG showed high specificity but low sensitivity as a diagnostic method in epilepsy...

Objetivo: o objetivo deste estudo foi verificar a sensibilidade (presença de descargas em EEGs de portadores de epilepsia) e a especificidade (ausência de descargas em EEGs de sem epilepsia) do EEG. Metodologia: foram revisados todos os EEGs realizados na Clínica Santa Vitória, em Campina Grande, PB, no período de abril de 2001 a abril de 2010. Todos os registros foram realizados de acordo com padrões internacionais para a fixação dos eletrodos, tempo mínimo de registro e métodos de ativação (fotoestimulação intermitente e hiperventilação). Os laudos foram divididos em 1) pacientes portadores de epilepsia, previamente diagnosticada por neurologistas, e 2) pacientes sem epilepsia. Para ambos os grupos, estudou-se a sensibilidade e a especificidade do EEG. Foram utilizados testes estatísticos através do programa SPSS. O estudo foi aprovado pelo Comitê de Ética da UEPB. Foram revisados 10.408 EEGs. Resultados: descargas epileptiformes ocorreram em 1412 (13,56%). Dentre os portadores de epilepsia, descargas ocorreram em 643 (45,57%) - verdadeiros-positivos. Dentre os que não apresentam epilepsia, em 54,43% - falsos-positivos. De um total de 8.996 (86,44%) de EEGs sem descargas, 1.276 (14,14%) eram do grupo de portadores de epilepsia - falsos-negativos e 7.720 (85,78%) eram do grupo de pacientes sem epilepsia - verdadeiros-negativos. O teste de verossimilhança positiva revelou que a probabilidade de ocorrerem descargas é quarto vezes maior dentre os portadores de epilepsia, comparados aos que não apresentam epilepsia. Já o teste de verossimilhança negativa não evidenciou diferenças significativas entre falsos-negativos e verdadeiros-negativos. De modo geral, foi observada uma sensibilidade de 33,5% e uma especificidade de 90,9%, sem diferenças quanto à idade e ao gênero. O EEG apresentou, portanto, alta especificidade, mas uma baixa sensibilidade, como método diagnóstico auxiliar nas epilepsias...

Contralateral hippocampal volume influences surgical outcome in patients with MTLE and similar degree of ipsilateral hippocampal atrophy / O volume hipocampal contralatral influencia o desfecho cirúrgico de pacientes com ELTM e grau semelhante de atrofia hipocampal ipsilateral

Objective: to investigate the relationship between hippocampal atrophy (HA) and surgical outcome in patients with mesial temporal lobe epilepsy (MTLE). Methodology: we compared 34 patients free of seizure (GroupA) with 33 patients with persistent seizures after surgery (GroupB). All had preoperative diagnosis of unilateral MTLE by EEG and MRI evidence of unilateral hippocampal sclerosis (HS) by visual analysis. We performed hippocampal volumetry using high resolution T1 MRI (1mm) in all patients and in 30 healthy controls. Results: Z-score (Mean±SD) of affected hippocampus was -2.58±1.29 in GroupA and -2.57±1.47 in Group-B (p=0.98). The Z-Score of contralateral hippocampus was significantly lower in GroupB, compared to GroupA (p=0.038). Grouping all patients, smaller hippocampal volumes in the affected side were associated with history of meningitis (p=0.049), febrile seizures (p=0.049) and absence of family history of epilepsy (p=0.049). Conclusions: Ipsilateral HA was more severe in patients who had febrile seizures and meningitis, and in those without family history of epilepsy, supporting the notion that in the absence of genetic predisposition, more severe cerebral insult is necessary to induce epileptogenesis. Less favorable surgery outcome for unilateral MTLE was associated with smaller hippocampal volumes contralateral to the operated side, suggesting that surgery is less effective when bilateral damage exists, even when it is not detectable by visual MRI analysis...

Objetivo: investigar a relação entre atrofia hipocampal (AH) e resultado cirúrgico de pacientes com epilepsia de lobo temporal mesial (ELTM). Methodology: comparamos 34 pacientes livres de crises (grupoA) com 33 pacientes que permaneceram com crises após cirurgia (GrupoB). Todos apresentavam o diagnóstico pré-operatório de ELTM unilateral por EEG e RM com sinais de atrofia hipocampal (AH) unilateral na análise visual. Realizamos volumetria do hipocampo utilizando imagens T1 de RM de alta resolução (1mm) em todos os pacientes e em 30 controles sadios. Resultados: o Z-score (Média±DP) dos hipocampos afetados foi -2.58±1.29 no GrupoA e -2.57±1.47 no GrupoB (p=0.98). O Z-score dos hipocampos contralaterais foi significativamente menor no grupoB comparado ao grupoA (p=0.038). Agrupando todos os pacientes, volumes hipocampais menores no lado afetado foram associados à história de meningite (p=0.049), crises febris (p=0.049) e ausência de história familiar de epilepsia (p=0.049). Conclusão: AH ipsilateral foi mais acentuada em pacientes com antecedente de crises febris e meningite, e naqueles sem história familiar de epilepsia, reforçando a ideia de que na ausência de predisposição genética, um maior insulto cerebral seria necessário para induzir epileptogenesis. Um resultado cirúrgico menos favorável na cirurgia para ELTM unilateral foi associado a menores volumes hipocampais no lado contralateral ao lado operado, sugerindo que a cirurgia é menos efetiva quando há dano bilateral, mesmo quando não detectado por analise visual...

Tratamento cirúrgico da epilepsia refratária: análise de 34 casos atendidos no Hospital das Clínicas da UFMG / Surgical treatment of refractory epilepsy: analysis of 34 cases from the Hospital das Clínicas, Federal University of Minas Gerais

Objetivo: Apresentar dados estatísticos referentes a uma série de casos submetidos ao tratamento cirúrgico da epilepsia refratária no Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG), no período entre 23/11/2007 e 7/12/2010. Métodos: Estudo retrospectivo com análise de prontuários de 34 pacientes e classificação do controle de crises pós-operatório utilizando a Escala de Engel. Resultados: Dos pacientes, 70,5% apresentaram início das crises antes dos 15 anos, sendo o tipo de crise mais comum as crises parciais complexas com generalização secundária, presente em 55% dos casos. Esclerose mesial temporal foi o diagnóstico de base em 79,4% dos pacientes. Houve complicações cirúrgicas em 23,5% dos casos, sendo as mais frequentes as alterações de campo visual (8,8% dos casos). Conclusão: O controle de crises foi compatível com Engel menor ou igual a III em 64,7% dos casos. O tratamento cirúrgico revelou-se eficiente para melhorar o controle de crises em pacientes portadores de epilepsia refratária ao tratamento medicamentoso.

Objective: Presenting statistical data on a series of cases undergoing surgical treatment of epilepsy at the Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG) in the period between 11/23/2007 and 12/7/2010. Methods: Retrospective analysis with charts of 34 patients and classification of seizure control postoperatively using the Engel Scale. Results: 70.5% of the patients had the onset of seizures before 15 years old and the most common type of seizure was complex partial seizure with secondary generalization, presented in 55% of cases. Mesial temporal sclerosis was the underlying diagnosis in 79.4% of patients. There were surgical complications in 23.5% of cases, the most frequent visual changes (8.8% of cases). Conclusion: Seizure control was consistent with Engel III or less in 64.7% of cases. Surgical treatment has proved effective in improving seizure control in patients with medically refractory epilepsy.

Estimulador de nervo vago em paciente com síndrome de Lennox-Gastaut: relato de caso / Vagus nerve stimulator in a patient with Lennox-Gastaut syndrome: case report

A Síndrome de Lennox-Gastaut (SLG) é uma encefalopatia epiléptica grave da infância caracterizada por múltiplos tipos de crises intratáveis, anormalidades cognitivas e comportamentais e alterações eletroencefalográficas características. Na grande maioria dos casos as crises se tornam refratárias mesmo com politerapia, sendo indicado tratamentos alternativos. O uso de calosotomia é descrito para ajudar no controle das crises, entretanto novas terapias como o estimulador de nervo vago (ENV) começaram a ser utilizadas. Neste caso, relatamos um paciente com SLG, que apesar das drogas antiepilépticas apresentava crises diárias, que foi submetido a ENV, com redução das crises. Discutimos o tratamento não farmacológico da SLG, comparando a calosotomia com ENV...

The Lennox-Gastaut Syndrome (LGS) is a severe childhood epileptic encephalopathy characterized by multiple types of intractable seizures, cognitive and behavioral abnormalities and specific electroencephalographic features. Most patients are refractory even with polytherapy, so alternative treatment is indicated. Callosotomy is indicated in these cases, however vagus nerve stimulator (VNS) is a less invasive option. This is a case report of a patient with LGS, which despite antiepileptic drugs had daily seizures, who underwent VNS, with reduction of seizures. We discuss the nonpharmacological treatment of LGS, comparing the callosotomy with VNS...