Results of surgery in patients with bilateral independent temporal lobe spiking (BITLS) with normal MRI or bilateral mesial temporal sclerosis (MTS) investigated with bilateral subdural grids

PURPOSE: The introduction of new technologies in the clinical practice have greatly decreased the number of patients submitted to invasive recordings. On the other hand, some patients with refractory temporal lobe epilepsy have normal MR scans or bilateral potentially epileptogenic lesions. This paper reports the results of invasive neurophysiology and surgical outcome in such patients. METHOD: Sixteen patients were studied. Eleven had normal MRI (Group I) and five had bilateral mesial temporal sclerosis (Group II). All patients had BITLS and non-localizatory seizures on video-EEG monitoring. All patients were implanted bilaterally with 32-contacts subdural grids. They were submitted to a cortico-amygdalo-total hippocampectomy at the side defined by chronic electrocorticography (ECoG). RESULTS: In Group I, seizures came from a single side in nine patients. In nine patients, seizures started at one side, spread to the ipsolateral contacts and contralaterally afterwards. On the other hand, in two Group I patients seizures started in one mesial region and spread to the contralateral parahippocampus and neocortex before spreading to ipsolateral contacts. All patients in Group II had seizures starting unilaterally with focal EcoG onset in the mesial regions. Eight Group I patients are seizure-free and three are in Engel's class II. Eighty percent of Group II patients are seizure-free after surgery and one patient is in Engel's class II. CONCLUSION: Good surgical results can be obtained in patients with BITLS. Patients with normal MRI seem to have a worse prognosis when compared to patients with unilateral or even bilateral MTS. Extensive subdural coverage is essential in patients with normal MRI

Metástase cerebral de carcinoma de endométrio. Contribuições fisiopatológicas, diagnósticas e terapêuticas a propósito de um caso / Brain metastasis from endometrial carcinoma - Contributions to pathophysiology, diagnosis and management. A case reported

As metástase cerebrais de carcinoma endometrial (CE) são incomuns - provavelmente em virtude do baixo tropismo de suas células pelo sistema nervoso central (SNC) - e poucos casos são descritos detalhadamente na literatura. Acredita-se que tumores mais invasivos e indiferenciados apresentem maior probabilidade de metastizarem. Embora a presença de uma lesão encefálica em uma paciente com CE seja altamente sugestiva de metástase, em razão de sua raridade, outros diagnósticos devem ser considerados. Por outro lado, a hipótese de metástase cerebral de CE deve ser considerada em casos em que não se identifica o foco primário. É possível que a expressão de receptores de progesterona, o gene HER-2/Neu e mutações no gene p53 estejam relacionadas à ocorrência de metástases centrais. A propósito de um caso, os autores discutem aspectos diagnósticos e terapêuticos e tentam contribuir para um melhor entendimento da fisiopatologia da doença.

Paradigms for subdural grids' implantation in patients with refractory epilepsy

RATIONALE: The need for invasive monitoring in patients with refractory epilepsy has been greatly reduced by the introduction of new technologies such as PET, SPECT and MRI in the clinical practice. On the other hand, 10 to 30 percent of the patients with refractory epilepsy have non-localizatory non-invasive preoperative work-up results. This paper reports on the paradigms for subdural electrodes implantation in patients with different refractory epileptic syndromes. METHODS: Twenty-nine adult refractory epileptic patients were studied. Patients were divided into five different epileptic syndromes that represented the majority of the patients who needed invasive recordings: bitemporal (Group I; n=16 ), bi-frontal-mesial (Group II, n=5), hemispheric (Group III; n=2), anterior quadrant (Group IV; n=3) and posterior quadrant (Group V; n=3). All of them were submitted to extensive subdural electrodes' implantation (from 64 to 160 contacts) covering all the cortical surface potentially involved in epileptogenesis under general anesthesia. Results: All patients tolerated well the procedure. There was no sign or symptom of intracranial hypertension except for headache in 22 patients. In all except one Group II patient, prolonged electrocorticographic monitoring using the described subdural cortical coverage patterns was able to define a focal area amenable for resection. In all Groups II-V patients cortical stimulation was able to adequately map the rolandic and speach areas as necessary. CONCLUSION: Despite recent technological advances invasive neurophysiological studies are still necessary in some patients with refractory epilepsy. The standardization of the paradigms for subdural implantation coupled to the study of homogeneous patients' populations as defined by MRI will certainly lead to a better understanding of the pathophysiology involved in such cases and an improved surgical outcome

Secondary bilateral synchrony due to front-mesial lesions: an invasive recording study

Frontal lobe epilepsies may present difficulties in focus localization in the pre-operative work-up for epilepsy surgery. This is specially treu in patients with normal MRIs. We report on a 16 years-old girl that started with seizures by the age of 8 years. They were brief nocturnal episodes with automatisms such as bicycling and boxing. Seizure frequency ranged from 4-10 per night. Scalp EEG showed few right frontal convexity spiking and intense secondary bilateral syncrhony (SBS). High resolution MRI directed to the frontal lobes was normal. Ictal SPECT suggested a right fronto-lateral focus. Ictal video-EEG showed no focal onset. She was submitted to invasive recordings after subdural plates implantation. Electrodes covered all the frontal convexity and mesial surface bilaterally. Ictal recordings disclosed stereotyped seizures starting from the right mesial frontal. Using a high-resolution tool to measure intra and interhemispheric latencies, the timing and direction of seizure spread from the right fronto-mesial region were studied. Motor strip mapping was performed by means of electrial simulation. She was submitted to a right frontal lobe resection, 1,5 cm ahead of the motor strip and has been seizure free since surgery (8 months). Pathological examination found a 4 mm area of cortical dysplasia. Invasive studies are needed to allow adequate localization in patients with non-localizatory non-invasive work-up and may lead to excellent results in relation to seizures after surgery.

Qualidade de vida de pacientes submetidos a cirurgia de epilepsia / Quality of life of patients after epilepsy surgery

Epilepsia refratária ao tratamento medicamentoso é condiçao que interfere direta e negativamente na qualidade de vida dos pacientes, dificultando-lhes principalmente a integraçao social. O tratamento cirúrgico tem se mostrado eficaz no controle das crises em casos refratários, ocupando lugar importante no tratamento das epilepsias. Avaliamos a qualidade de vida de pacientes epilépticos, antes e após o tratamento cirúrgico, através de um questionário sobre qualidade de vida, adaptado do QOLIE-10 aplicado em 12 indivíduos epilépticos adultos, operados consecutivamente. O questionário, com 10 perguntas, envolvendo aspectos psicossociais e relacionados às drogas antiepilépticas, foi respondido no período pré-cirúrgico e repetido num intervalo médio de 8 meses após a cirurgia. Na comparaçao do questionário no período pré-operatório com o período pós-operatório, observamos diferenças estatisticamente significantes em 70 por cento das perguntas, mostrando melhora da qualidade de vida após a cirurgia. Nestes casos, a terapêutica cirúrgica tem forte impacto na qualidade de vida.

Sindrome do túnel do tarso: aspectos clínicos, diagnósticos e terapêuticos / Tarsal tunnel syndrome: clinical and surgical features

Os autores descrevem 5 casos de doentes com quadro clínico e eletromiográfico de síndrome do túnel do tarso, tratados cirurgicamente através de neurólise do nervo tibial no ponto de compressao. Os aspectos da anatomia da regiao, fisiopatologia, indicaçao cirúrgica e resultados sao discutidos.