Changes in Central Auditory Processing in Patients with Mesial Temporal Lobe Epilepsy after Anterior Temporal Lobectomy with Amygdalohippocampectomy

BACKGROUND AND PURPOSE: This study aimed to determine the effects of anterior temporal lobectomy with amygdalohippocampectomy (ATL-AH) on central auditory processing (CAP) in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (mTLE-HS), and to identify factors that may contribute to the postoperative worsening of CAP. METHODS: Frequency-pattern, duration-pattern, and dichotic tests were performed before and after epilepsy surgery in 22 patients with normal hearing according to pure-tone audiometry. RESULTS: No significant difference in CAP scores was detected between pre- and postoperative tests, but there was a strong association between surgery in the language-dominant temporal lobe and postoperative worsening in the non-dominant-side dichotic test (p<0.05). The probability of a decreased performance in a non-dominant-side dichotic test after surgery was 7.5-fold greater in patients who underwent surgery on the dominant temporal lobe compared with the nondominant temporal lobe. No significant association of postoperative worsening in CAP with the verbal, nonverbal intelligence quotient, or right- or left-side lobectomy was noted. CONCLUSIONS: These results suggest that ATL-AH on the dominant side in patients with mTLE-HS worsens the CAP ability in the non-dominant-side dichotic test.

Preserved Hippocampal Glucose Metabolism on 18F-FDG PET after Transplantation of Human Umbilical Cord Blood-derived Mesenchymal Stem Cells in Chronic Epileptic Rats

Human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs) may be a promising modality for treating medial temporal lobe epilepsy. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a noninvasive method for monitoring in vivo glucose metabolism. We evaluated the efficacy of hUCB-MSCs transplantation in chronic epileptic rats using FDG-PET. Rats with recurrent seizures were randomly assigned into three groups: the stem cell treatment (SCT) group received hUCB-MSCs transplantation into the right hippocampus, the sham control (ShC) group received same procedure with saline, and the positive control (PC) group consisted of treatment-negative epileptic rats. Normal rats received hUCB-MSCs transplantation acted as the negative control (NC). FDG-PET was performed at pre-treatment baseline and 1- and 8-week posttreatment. Hippocampal volume was evaluated and histological examination was done. In the SCT group, bilateral hippocampi at 8-week after transplantation showed significantly higher glucose metabolism (0.990 +/- 0.032) than the ShC (0.873 +/- 0.087; P < 0.001) and PC groups (0.858 +/- 0.093; P < 0.001). Histological examination resulted that the transplanted hUCB-MSCs survived in the ipsilateral hippocampus and migrated to the contralateral hippocampus but did not differentiate. In spite of successful engraftment, seizure frequency among the groups was not significantly different. Transplanted hUCB-MSCs can engraft and migrate, thereby partially restoring bilateral hippocampal glucose metabolism. The results suggest encouraging effect of hUCB-MSCs on restoring epileptic networks.

Seizure Frequencies and Number of Anti-epileptic Drugs as Risk Factors for Sudden Unexpected Death in Epilepsy

The purpose of this study was to investigate the association between clinical variables and sudden unexpected death in epilepsy (SUDEP) and identify risk factors for SUDEP. SUDEP is one of the most frequent causes of death in patients with epilepsy. Previous studies have reported possible risk factors associated with SUDEP, but there need to be elucidated yet. The cases were 26 patients with SUDEP and three control patients were included for each case, matched for age, sex, and date of initial clinical visit. All demographic and clinical characteristics, including age, sex, disease duration, classification of epilepsy, age at seizure onset, kind and number of antiepileptic drugs, were compared between cases and controls. Seizure frequency was higher in SUDEP cases than in controls (P=0.035). Univariate analysis using conditional logistic regression showed that higher seizure frequency (odds ratio [OR]=3.1, P=0.021) and the number of antiepileptic drugs (AEDs) (OR=2.0, P=0.009) were significantly associated with SUDEP. Only the number of AEDs remained significant in multivariate analysis (OR=1.8, P=0.026). Frequent seizures and multi-drug therapy were associated with SUDEP. This may suggest that the severity of epilepsy is associated with SUDEP, regardless of the type of AED used.

Neurosyphilis Presenting with Multiple Cranial Neuropathy

Neurosyphilis can present with various clinical symptoms. We report a patient with multiple cranial neuropathy that, mimicked tuberculosis, but was finally diagnosed as neurosyphilis. A 38-year-old man was admitted due to subacutely progressive hearing loss. Brain MRI revealed multiple dural enhanced masses on contrast-enhanced T1 weighted images. Brain biopsy of the dural enhanced lesion revealed chronic granulomatous inflammation with coagulation necrosis, compatible with syphilitic gumma. Serum venereal disease research laboratory and fluorescent treponemal antibody absorption test results were positive. Treatment with penicillin resolved the patient's symptom.

Prophylactic Effect of Erythropoietin Injection to Prevent Acute Mountain Sickness: An Open-Label Randomized Controlled Trial

This study was performed to evaluate whether increasing hemoglobin before ascent by prophylactic erythropoietin injections prevents acute mountain sickness (AMS). This open-label, randomized, controlled trial involved 39 healthy volunteers with hemoglobin or =3 were present. Immediate descent criteria followed US Army recommendations. Two groups differ in hemoglobin levels on day 29 (15.4+/-1.1 vs 14.2+/-1.0 g/dL, P=0.001). At ABC, erythropoietin group had a significantly lower mean LLS, AMS incidence, and number of subjects who met immediate descent criteria. Multiple logistic regression analysis showed that SaO2<87% and control group, but not hemoglobin<15.0 g/dL, independently predicted satisfaction of immediate descent criteria. Erythropoietin-related adverse effects were not observed. In conclusion, erythropoietin may be an effective prophylaxis for AMS.(Clinical Trial Registry Number; NCT 01665781).

Combined Muscle Motor and Somatosensory Evoked Potentials for Intramedullary Spinal Cord Tumour Surgery

PURPOSE: To evaluate whether intraoperative neurophysiologic monitoring (IONM) with combined muscle motor evoked potentials (mMEPs) and somatosensory evoked potentials is useful for more aggressive and safe resection in intramedullary spinal cord tumour (IMSCT) surgery. MATERIALS AND METHODS: We reviewed data from consecutive patients who underwent surgery for IMSCT between 1998 and April 2012. The patients were divided into two groups based on whether or not IONM was applied. In the monitored group, the procedures were performed under IONM using 75% muscle amplitude decline weaning criteria. The control group was comprised of patients who underwent IMSCT surgery without IONM. The primary outcome was the rate of gross total excision of the tumour on magnetic resonance imaging at one week after surgery. The secondary outcome was the neurologic outcome based on the McCormick Grade scale. RESULTS: The two groups had similar demographics. The total gross removal tended to increase when intraoperative neurophysiologic monitoring was used, but this tendency did not reach statistical significance (76% versus 58%; univariate analysis, p=0.049; multivariate regression model, p=0.119). The serial McCormick scale score was similar between the two groups (based on repeated measure ANOVA). CONCLUSION: Our study evaluated combined IONM of trans-cranial electrical (Tce)-mMEPs and SEPs for IMSCT. During IMSCT surgery, combined Tce-mMEPs and SEPs using 75% muscle amplitude weaning criteria did not result in significant improvement in the rate of gross total excision of the tumour or neurologic outcome.

Kinetics of T-cell-based assays on cerebrospinal fluid and peripheral blood mononuclear cells in patients with tuberculous meningitis

BACKGROUND/AIMS: The goal of this study was to monitor tuberculosis (TB)-specific T-cell responses in cerebrospinal fluid-mononuclear cells (CSF-MCs) and peripheral blood mononuclear cells (PBMCs) in patients with tuberculous meningitis (TBM) over the course of anti-TB therapy. METHODS: Adult patients (> or = 16 years) with TBM admitted to Asan Medical Center, Seoul, South Korea, were prospectively enrolled between April 2008 and April 2011. Serial blood or CSF samples were collected over the course of the anti-TB therapy, and analyzed using an enzyme-linked immunosorbent spot (ELISPOT) assay. RESULTS: Serial ELISPOT assays were performed on PBMCs from 17 patients (seven definite, four probable, and six possible TBM) and CSF-MC from nine patients (all definite TBM). The median number of interferon-gamma (IFN-gamma)-producing T-cells steadily increased during the first 6 months after commencement of anti-TB therapy in PBMCs. Serial CSF-MC ELISPOT assays revealed significant variability in immune responses during the first 6 weeks of anti-TB therapy, though early increases in CSF-MC ELISPOT results were associated with treatment failure or paradoxical response. CONCLUSIONS: Serial analysis of PBMCs by ELISPOT during the course of treatment was ineffective for predicting clinical response. However, increases in TB-specific IFN-gamma-producing T-cells in CSF-MC during the early phase of anti-TB therapy may be predictive of clinical failure.

Anti-LGI1 Antibody Autoimmune Encephalitis Which Manifests Faciobrachial Dystonic Seizure

Anti-LGI1 (leucine-rich glioma inactivated-1) antibody encephalitis is one of autoimmune encephalitis. We report a 66-year-old man who presented with frequent, brief dystonic seizures which involve predominantly ipsilateral face and arm without cognitive impairment. Brain MRI showed normal finding. Serum and CSF tests revealed anti-LGI1 antibody. His symptom was not relieved by antiepileptic drugs, but completely controlled after immunotherapy. This case indicates that recognition of the brief, dystonic seizures should do tests for anti-LGI1 antibodies.

Neurotoxicity Induced by Cefepime in a Patient with Minimal Change Disease / 대한신장학회지

A 71-year-old woman with minimal change disease visited our clinic complaining of pleuritic chest pain. Cefepime was given under the impression that she had pneumonia. Three days after cefepime administration, she became unconscious. A brain MRI scan was non-revealing and an EEG showed triphasic waves. As there was no evidence of septic, uremic or hepatic encephalopathy, we suspected cefepime-induced neurotoxicity. Cefepime was stopped and she underwent hemodialysis to decrease the blood levels of the drug. Following hemodialysis, she regained consciousness.

Tuberculous Meningoencephalitis Complicated by Subarachnoid Hemorrhage

Tuberculous meningoencephalitis (TBM) is often complicated by various neurologic manifestations including ischemic infarctions. However, intracerebral hemorrhage in TBM has rarely been described. We report a 30-year-old woman with TBM who developed subarachnoid, intraventricular, and intracerebral hemorrhage, and finally died in spite of treatment with antituberculous and steroid therapy. Autopsy findings revealed multifocal thrombotic occlusion of the arteries and thinning of the vessel walls secondary to tuberculous vasculitis.

Surgical Treatment of Intractable Frontal Lobe Epilepsy / 대한간질학회지

PURPOSE: Frontal lobe epilepsy is difficult to be managed with medical or surgical treatment. So the authors analyzed and reviewed the clinical results of the frontal lobe epilepsy patients who underwent surgical treatment. METHODS: From 1996 to 2004, Thirty-nine patients were treated surgically. The authors reviewed retrospectively the radiological, clinical and pathological data of the patients. The surgical outcome was classified using Engel's classification. RESULTS: The mean follow-up period is 70.5 (+/-29.7) months. The preoperative MR image was normal in 19 cases and abnormal in 20 cases. There were 11 encephalomalacias, 4 cortical dysplasias and 5 brain tumors. The postoperative pathological finding was normal in 5 cases and abnormal finding in 34. There were 20 cortical dysplasias, 4 encephalomalacias, 3 gliosises, 2 fibrous scars, 2 cavernous malformations, 1 dysembryoplastic neuroepithelial tumor, 1 paragonimiasis and 1 venous thrombosis. The postoperative surgical outcomes were as follows: Class I, 41%; Class II, 25.6%; Class III, 20.5%; Class IV, 12.8%. CONCLUSIONS: The surgical outcomes of frontal lobe epilepsy have improved, compared with previous series. The pathological abnormality was observed in large portion of the frontal lobe epilepsy patients.

Intracranial Ictal EEG Patterns Predicting the Surgical Outcome and the Yield of Intracranial Electrodes in Patients with Temporal Lobectomy

BACKGROUND: Analysis of intracranial ictal patterns may help to predict surgical outcomes. We investigated intracranial EEG patterns to correlate with surgical outcomes and compared the yield of 'subdural electrodes alone (SE)' versus 'combined depth and subdural electrodes (CDSE)' for ictal lateralization in temporal lobe epilepsy (TLE). METHODS: We reviewed a total of 95 seizures recorded by bilateral temporal depth and subdural electrodes in 25 TLE patients who underwent surgery. We classified surgical outcomes as 'seizure-free' or 'not-seizure-free'. Each seizure was analyzed based on the presence or absence of peri-ictal discharges, ictal distribution, waveform patterns, onset frequency and involved number of electrodes, and interhemispheric propagation time (IHPT). The accuracy of lateralizing seizure foci by CDSE was compared to that by SE. RESULTS: 20 patients (80.0%) were 'seizure-free' and 5 (20.0%) were 'not-seizure-free'. The presence of peri-ictal discharges (p<0.001), distribution of depth only or depth and medial electrodes (p<0.001) and higher onset frequency (p=0.021) were associated with 'seizure-free' outcomes. Ictal onset pattern with fast spike trains was common in 'seizure-free', whereas pattern with rhythmic activity was common in 'not-seizure-free' (p=0.005). SE correctly lateralized in 18 of 20 patients, and incorrectly lateralized in the remaining 2 patients, but CDSE correctly lateralized in all 20 patients. CONCLUSIONS: Some intracranial ictal patterns were significantly correlated with good surgical outcomes. These findings suggest that the analysis of ictal EEG patterns help to predict surgical outcomes. CDSE is more accurate for the lateralization of seizure foci compared to SE.

Determining Brain Death

Brain death is a clinical diagnosis. The three cardinal findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. The clinical examination of the brainstem includes testing of brainstem reflexes, determination of the patient's ability to breath spontaneously, and evaluation of the motor response to pain. Spontaneous and reflex movements originating from the spinal cord neurons may occur in brain-dead patients. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis. In some countries including Korea, our country, confirmatory tests are required by law when determining brain death. However, a confirmatory test is not usually mandatory except for patients in whom specific components of clinical testing cannot be evaluated reliably.

Ictal Spitting in a Patient with Dominant Temporal Lobe Epilepsy: Discrepancy between Epileptogenic and Symptomatogenic Areas for Spitting Automatism

Ictal spitting is an unusual manifestation that originates from the non-dominant hemisphere, but rarely from the dominant hemisphere. In the latter case, it has not been well defined as to whether symptomatogenic area for ictal spitting originates from the dominant hemisphere. We present a patient with ictal spitting. Intracranial EEG demonstrated a left hippocampal onset with propagation to the right hemisphere, and subsequent ictal spitting development. Even in dominant hemispheric seizures, the non-dominant hemisphere is a symptomatogenic area for ictal spitting.

The Related Factors to Atypical Language Dominance in Patients with Epileptic Foci in the Left Hemisphere

BACKGROUND: Several studies have revealed the increased incidence of atypical language dominance in patients with left hemisphere epileptic foci. We retrospectively investigated the incidence and related factors for language dominance shift determined by intracarotid amobarbital procedure (IAP) in patients with left hemispheric epilepsies. METHODS: We included 222 epileptic patients with epileptic foci in left hemisphere whose language dominance was determined by IAP at Asan Medical Center from 1994 to 2004. The items on the language test in IAP included spontaneous speech (6 items), understanding (2 items), and repetition (2 items). Language lateralization index (LI) was computed according to the formula L=(Score IAP right-Score IAP left)/(Score IAP right+Score IAP left). Clinical information was obtained from medical records including age, gender, age at onset of epilepsy, duration of epilepsy, frequency of seizures, risk factors, onset age of risk factors, and lateralization of MRI or EEG. RESULTS: Of the 222 patients (male 110 patients, 49.5%), complete left language dominance was 142 patients (64.0%), and complete right hemispheric language dominance was 29 patients (13.1%). Seizure onset age, onset age of risk factors, handedness and MRI lesions (hippocampal atrophy or left extensive lesion) had statistically significant association with atypical language dominance. On a linear regression analysis, the significant predictors of the atypical language dominancy were handedness and left extensive lesion (R2=.64). CONCLUSIONS: Atypical language dominancy in patients with left epileptic foci was highly correlated with non-right handedness and extensive lesion on the left hemisphere.

Reflex Epilepsy Induced by Playing Oriental Card or Board Games

BACKGROUND AND PURPOSE: There are currently few studies on clinical profiles of reflex epilepsy induced by thinking and spatial tasks. We studied the clinical characteristics of reflex epilepsy induced by playing oriental card and board games. METHODS: This study included 17 patients who presented with seizures that occur predominantly while playing games. We collected clinical data via protocol-based interviews. EEGs and brain MRI were performed. RESULTS: All of the subjects were men, and all of them were older than 30 years at the onset of seizure. Thirteen patients (76%) experienced their seizures while playing the oriental card game "Go-stop" and the remaining four patients (24%) experienced them while playing the oriental board game "Baduk". Generalized tonic-clonic seizures were frequently preceded by prodromal symptoms, but myoclonus was not evident. Most patients had no spontaneous seizures and generalized epileptiform discharges on EEGs, and infrequent seizures that were well controlled. CONCLUSIONS: Our patients exhibited some features that differ from those described previously in the literature, suggesting that the clinical spectrum of reflex epilepsy induced by thinking and spatial tasks is wide.

Clinical Experiences with Vagus Nerve Stimulation for Medically Intractable Epilepsy / 대한간질학회지

PURPOSE: Recently, Vagus nerve stimulation (VNS) has been reported to show promising results as an adjunctive therapy for medically intractable seizures. We report early experiences with VNS for medically intractable epilepsy in young adults and pediatric patients. METHODS: Eleven patients ages ranging from 7 years to 29 years underwent implantation of vagal nerve stimulators (Cyberonics, Houston, TX) from September 1999 to April 2003. We reviewed clinical findings in 11 patients and recorded changes of seizure frequency, quality of life (QOL), and antiepileptic drug (AED). RESULTS: The mean age of seizure onset was 4.5 years old (range:3 months-11 years). The seizure duration before VNS was mean 8.7 years (range:1.5-19 years). Seven patients had symptomatic partial epilepsies, and one had cryptogenic partial epilepsy. Unclassified patients had 2 Lennox-Gastaut syndrome and 1 reflex epilepsy. Two patients received total callosotomy for reducing drop attack, but refractory. One patient, who underwent a temporal lobectomy, failed to obtain desirable results. One implantation was performed with total callosotomy, simultaneously. All of implantations were successful, except for one wound revision due to a subcutaneously protruded anchoring device of electrode. About two weeks after the implantation, programming of the stimuli was started and increased the output current to the levels, at which patients was tolerated. The most common adverse effect was hoarseness or voice alteration (44%). Mean reduction of seizure frequency compared with baseline before VNS was 23.6% after 3 months, 33.5% after 6 months, 41.3% after 1 year, and 46.6% at latest follow-up. Three patients had no response to VNS. One patient was added 1 one new AED after VNS. Two patients were reduced 1 or 2 drugs. But there was no correlation between VNS effect and AED change. Six patients had some improvement of QOL. Mean follow-up period, which was 28 months (range:12-48 months). CONCLUSIONS: We concluded that VNS has a role of adjunctive therapy for medically intractable epilepsy and the further studies should be focused on the prediction of unresponsiveness and the adjustment of VNS parameters for maximal efficacy in patients with various backgrounds.

Encoding and Retrieval of Words and Scenes Assessed by Functional MRI in Normal Right-Handed Volunteers / 대한간질학회지

PURPOSE: To find the activation patterns of frontal and medial temporal lobe during memory tasks (encoding and retrieval) with novel stimuli (words, scenes) in normal right-handed volunteers. Another aim is to examine which memory paradigms and processes are effective to activate medial temporal lobe. METHODS: We included 10 right-handed normal volunteers. Stimuli consisted of encoding and retrieval of novel word (15 items)/novel scenes (15 items). During scanning, each stimulus was presented for 2000 ms. Imaging was performed on 1.5 GE scanner. Group analysis was performed in volunteers with SPM 2 (uncorrected p10). RESULTS: Scenes encoding and retrieval activated both medial temporal lobes, more on the right side. Word encoding activated predominantly dominant frontal lobe, but failed to activate the medial temporal lobes. The word stimuli activated more the frontal lobe than the picture stimuli. Retrieval process activated more the medial temporal lobe than encoding process. CONCLUSION: Our results showed that the scenes encoding/retrieval and word retrieval are useful to activate the medial temporal lobe and word encoding is useful for activating dominant frontal lobe. Further studies will be necessary in patient groups with unilateral temporal lobe lesion to document the usefulness of this study.

A Lateralizing Ability of the Wechsler Memory Scale-III in Patients with Mesial Temporal Lobe Epilepsy / 대한간질학회지

PURPOSE: The Wechsler Memory Scale-III (WMS-III) including new visual memory tests was developed to overcome the limitation of WMS-Revised (WMS-R). We examined the utility of the WMS-III in predicting laterality of memory impairment in patients with mesial temporal lobe epilepsy (MTLE). METHODS: We included 49 consecutive patients with unilateral MTLE who had left hemisphere dominance for language by WADA test and underwent temporal lobectomy. Methods of analysis included evaluation of group means on the various indexes and subtest scores of WMS-III, the use of ROC curves, an examination of Auditory-Visual Index (AVI) discrepancy scores and correlation analysis between AVI discrepancy scores and age, onset age of patients. RESULTS: 1) Patients with left MTLE had significantly lower scores on several scores and indexes compared to those with right MTLE. 2) In analysis of ROC curves, the area under the curve and the suggested cutting score were 0.696 and 4 (a sensitivity 0.704, a specificity 0.727) for immediate AVI discrepancy score and 0.702 and 5 (a sensitivity 0.556, a specificity 0.773) for delayed one, respectively. 3) In right MTLE, there was a tendency for linear correlation between AVI discrepancy scores and age at onset. CONCLUSIONS: Overall, WMS-III has limited value in identifying particular memory deficits associated with either left or right temporal lobe dysfunction. AVI discrepancy scores may be more useful to predict right hemispheric dysfunction rather than left ones.

The Contributing Factors to Utilize Complementary and Alternative Medicine in People with Epilepsy / 대한간질학회지

PURPOSE: To determine which factors are influential in complementary and alternative medicine (CAM) utilization in people with epilepsy (PWE). METHOD: The 246 adult PWE (53.7% male, mean age 33.6 years) were recruited from out-patient clinic of a tertiary care hospital. Data about CAM utilization in the last five years and willingness of CAM use in the future were collected via a face-to-face semi-structured interview. RESULTS: 1) The utilization rate of CAM among PWE was 31.3% for the last 5 years. On univariate analyses, it was significantly associated with several variables such as men, younger age, shorter epilepsy duration, higher educational level, higher economic status, and the belief in safety of CAM use. Multivariate analyses identified men (p=.021 OR=2.3 [95% CI=1.1 to 4.9]), higher economic status (p=.010, OR=2.5 [95% CI=1.2 to 5.0]), and the belief in safety of CAM use (p=.001, OR=1.9 [95% CI=1.3 to 2.9]). 2) Out of our participants, 30.5% reported that they were willing to utilize CAM for their epilepsy in the future. Univariate analyses showed that it was related to experience of CAM use in the past, higher economic status, and the belief in safety of CAM use. Multivariate analyses identified experience of CAM use in the past (p=.000, OR=8.4 [95% CI=4.0 to 17.7]) and the belief in safety of CAM use (p=.002, OR=1.7 [95% CI=1.2 to 2.6]). CONCLUSION: One third of PWE reported to have use the CAM in the past or to have willingness of the CAM use in the future. The important factors contributing to the CAM use were gender, economic status, experience of the CAM use in the past, and the belief in safety of the CAM use.