Intracranial monitoring contributes to seizure freedom for temporal lobectomy patients with nonconcordant preoperative data.

OBJECTIVE: The question of whether a patient with presumed temporal lobe seizures should proceed directly to temporal lobectomy surgery versus undergo intracranial monitoring arises commonly. We evaluate the effect of intracranial monitoring on seizure outcome in a retrospective cohort of consecutive subjects who specifically underwent an anterior temporal lobectomy (ATL) for refractory temporal lobe epilepsy (TLE). METHODS: We performed a retrospective analysis of 85 patients with focal refractory TLE who underwent ATL following: (a) intracranial monitoring via craniotomy and subdural/depth electrodes (SDE/DE), (b) intracranial monitoring via stereotactic electroencephalography (sEEG), or (c) no intracranial monitoring (direct ATL-dATL). For each subject, the presurgical primary hypothesis for epileptogenic zone localization was characterized as unilateral TLE, unilateral TLE plus (TLE+), or TLE with bilateral/poor lateralization. RESULTS: At one-year and most recent follow-up, Engel Class I and combined I/II outcomes did not differ significantly between the groups. Outcomes were better in the dATL group compared to the intracranial monitoring groups for lesional cases but were similar in nonlesional cases. Those requiring intracranial monitoring for a hypothesis of TLE+had similar outcomes with either intracranial monitoring approach. sEEG was the only approach used in patients with bilateral or poorly lateralized TLE, resulting in 77.8% of patients seizure-free at last follow-up. Importantly, for 85% of patients undergoing SEEG, recommendation for ATL resulted from modifying the primary hypothesis based on iEEG data. SIGNIFICANCE: Our study highlights the value of intracranial monitoring in equalizing seizure outcomes in difficult-to-treat TLE patients undergoing ATL.

Effect of automatic injectors on the injection latency, safety, and seizure onset zone localization of ictal single photon emission computed tomography studies in adult epilepsy monitoring unit.

BACKGROUND: Ictal Single Photon Emission Computed Tomography (iSPECT) is one of the established tools utilized in the presurgical evaluation of patients with drug-resistant epilepsy (DRE). Timely isotope injection for an iSPECT is critical for optimal yield but poses logistical challenges when done manually. We aim to evaluate the added value of automatic iSPECT injectors (ASIs) in overcoming such challenges. METHODS: We retrospectively reviewed all cases admitted to the University of Pittsburgh Medical Center (UPMC) Epilepsy Monitoring Unit from Jan 1, 2010, through Dec 31, 2016, who underwent an iSPECT. We compared the manually injected iSPECTs with those performed with ASIs. RESULTS: A total of 123 iSPECTs were reviewed. The manually injected iSPECT group consisted of 35 patients (median age, 35 years; and 19 males). The automatically injected iSPECT group consisted of 88 patients (median age, 36 years; and 46 males). The two groups were comparable in age, gender, epilepsy treatment, focal features on neuropsychological testing (NPT), EEG, and MRI, and temporal origin of seizures (p > 0.05). Compared to manually injected iSPECTs, automatically injected ISPECTs' median injection latency (IL) was shorter (18.5 vs. 60 s, p < 0.001); the ratio of IL/total duration of seizure was lower (0.395 vs. 0.677, p < 0.001); postictal injections were less frequent (4 (4.5 %) vs. 7 (20 %), p = 0.007); the number of isotope spills was less (zero vs. 3, p = 0.022); and successfully localizing iSPECTs were more prevalent (81.8 % vs. 62.9 %, p = 0.025), even after adjusting for focal features on NPT, EEG, and MRI, the temporal origin of seizures, and seizure duration (OR of 5.539, 95 %CI = 1.653-18.563, p = 0.006). CONCLUSIONS: Utilization of ASIs leads to a significant shortening of iSPECT IL with less postictal injections, provides a safer injection option for the EMU staff, and leads to a significant improvement in the number of successfully localizing iSPECTs.

Evidence-based guidelines for the management of epilepsy.

Approximately 50 million people live with epilepsy worldwide. The aim of this review is to present an overview of the current evidence and management recommendations for evaluation and treatment of patients with epilepsy. Systematic literature reviews were undertaken. A review of contemporary published evidence-based guidelines (American Academy of Neurology, American Epilepsy Society, and the Indian Epilepsy Society) and published peer reviewed scientific publications was done. The guideline is addressed to all clinicians who manage epilepsy patients. Evidence-based recommendations are provided for the evaluation and treatment of the first seizure, use of antiepileptic medications, treatment of status epilepticus, use of epilepsy surgery, and the management of epilepsy in specific populations as well as in unique clinical situations such as neurocysticercosis infestation, brain tumor and human immunodeficiency virus infection. It also addresses the special considerations in women with epilepsy.

A Survey of Neurophysiology Fellows in the United States.

PURPOSE: Fellowship training in Clinical Neurophysiology (CNP) is often sought following Neurology residency. However, data documenting the reasons for choosing CNP fellowship, and experiences therein, are sparse. METHODS: Current Neurophysiology fellows across the United States participated in a 17-item, Internet-based survey. Data regarding demographics, reasons for choosing fellowship, adequacy of training, and future plans were collected. RESULTS: Among respondents (n = 49), 84% graduated from a US medical school. Personal interest in CNP was the most common reason for choosing the fellowship. Program choice was guided by location and clinical strength of the program. Choosing a program based on clinical strength was likely to result in higher satisfaction scores. Overall, most (87%) were satisfied with their current program giving a satisfaction score of 4 or 5 on a 1-5 Likert scale. Lesser time spent in the epilepsy monitoring unit and EEG was also associated with higher satisfaction scores-these were also the areas that seemed to be most stressed during training. No differences emerged between male and female respondents in their answers to the various survey questions. CONCLUSIONS: The authors encountered a group of academically minded CNP trainees who are satisfied with their choice of fellowship, the current application process, and training received. Most intend to have a future in academic medicine. The CNP areas that seem to need further development in providing a well-rounded fellowship include training in sleep, evoked potentials, and intraoperative monitoring. The findings would be informative to future fellowship trainees and to program officers.

Functional connectivity estimated from intracranial EEG predicts surgical outcome in intractable temporal lobe epilepsy.

This project aimed to determine if a correlation-based measure of functional connectivity can identify epileptogenic zones from intracranial EEG signals, as well as to investigate the prognostic significance of such a measure on seizure outcome following temporal lobe lobectomy. To this end, we retrospectively analyzed 23 adult patients with intractable temporal lobe epilepsy (TLE) who underwent an invasive stereo-EEG (SEEG) evaluation between January 2009 year and January 2012. A follow-up of at least one year was required. The primary outcome measure was complete seizure-freedom at last follow-up. Functional connectivity between two areas in the temporal lobe that were sampled by two SEEG electrode contacts was defined as Pearson's correlation coefficient of interictal activity between those areas. SEEG signals were filtered between 5 and 50 Hz prior to computing this correlation. The mean and standard deviation of the off diagonal elements in the connectivity matrix were also calculated. Analysis of the mean and standard deviation of the functional connections for each patient reveals that 90% of the patients who had weak and homogenous connections were seizure free one year after temporal lobectomy, whereas 85% of the patients who had stronger and more heterogeneous connections within the temporal lobe had recurrence of seizures. This suggests that temporal lobectomy is ineffective in preventing seizure recurrence for patients in whom the temporal lobe is characterized by weakly connected, homogenous networks. This pilot study shows promising potential of a simple measure of functional brain connectivity to identify epileptogenicity and predict the outcome of epilepsy surgery.