Outcome after cortico-amygdalo-hippocampectomy in patients with temporal lobe epilepsy and normal MRI.

RATIONALE: We describe seizure and neuropsychological outcome obtained after CAH in patients with TLE and normal MRI evaluated in the modern imaging era. METHODS: Forty-five adult consecutive patients with TLE and normal MRI were studied. All patients had neuropsychological testing, interictal and ictal EEG recordings and MRI. They were divided into two groups: Group 1 (n=18), included patients in whom non-invasive neurophysiological evaluation was lateralizing and Group 2 (n=27) included patients with non-lateralizing neurophysiological data who were submitted to invasive recordings. RESULTS: Seventy-seven percent of the Group 1 patients were rated as Engel I; 11% were rated as Engel II and 11% as Engel III. In Group 2, there were 57% of patients seizure-free, 26% in Engel II and 14% in Engel III. Pre-operatively, mean general IQ was 82 and 78 in Groups 1 and 2, respectively; post-operatively, mean general IQ was respectively 86 and 71. Some degree of verbal memory decline was noted in all patients submitted to dominant temporal lobe resection in both Groups 1 and 2. At last follow-up visit, 22% of Group 1 and 11% of Group 2 patients were receiving no antiepileptic drugs (AED). CONCLUSIONS: Our data showed that patients with TLE and normal MRI could get good surgical results after CAH although 60% of them would need invasive recordings and their results regarding seizure control and cognition were worse than those obtained in patients with MRI defined temporal lobe lesions. Caution should be taken in offering dominant temporal lobe resection to this subset of patients.

Long-term evaluation of physical activity habits after epilepsy surgery / Avaliação dos hábitos de atividade física de pacientes após cirurgia de epilepsia

OBJETIVES: Studies have shown that people with epilepsy have a low degree of participation in physical activities. The purpose of this study was to assess the physical exercise habits in patients after epilepsy surgery using a standardized questionnaire. MMETHODOLOGY: The study population consisted of 102 patients submitted to cortico-amigdalo-hippocampectomy. A questionnaire was designed to assess physical activities participation before and after surgery. Patients were classified as physically active, inadequately active or sedentary. The questionnaire was applied pre-operatively and after a mean of 47 months post-operatively. RESULTS: Forty eight per cent of the patients participated in physical activities before surgery and 56 percent of them did so post-operatively. No considerable changes in physical activity participation were observed after surgery. Additionally, the frequency they needed supervision during exercise, were advised by a physician not to practice exercise or cautioned by a relative or friend against participation in sports did not change significantly after successful epilepsy surgery. Less exercise-related seizures occurred postoperatively. CONCLUSION: Difficulties adapting to seizure freedom and psychosocial and psychiatric co-morbidity might be important factors interfering in these physical activity habits. A multidisciplinary approach might be the only way to try to alter some aspects of these patients' postoperative life style.

OBJETIVOS: Estudos têm mostrado que pessoas com epilepsia apresentam um baixo grau de participação em atividades físicas. O objetivo deste estudo foi verificar os hábitos de atividade em pacientes após cirurgia de epilepsia utilizando um questionário. METODOLOGIA: A população estudada consistiu de 102 pacientes submetidos a cortiço-amigdalo-hipocampectomia. O questionário verificou a participação de atividades físicas antes e depois da cirurgia. Os pacientes foram classificados como ativos, inadequadamente ativos ou sedentários. O questionário foi aplicado antes da cirurgia e depois de um período médio de 47 meses da cirurgia. RESULTADOS: Quarenta e oito por cento dos pacientes participaram de atividades físicas antes da cirurgia e 56 por cento deles após a cirurgia. Não foram observadas alterações significantes na participação de atividades físicas após a cirurgia. Ainda, a frequência de supervisão durante o exercício físico, aconselhamento por um médico, familiares ou amigos em não praticarem exercícios físicos ou atividades esportivas não alterou significantemente depois da cirurgia bem sucedida. Menos crises induzidas por exercício ocorreram no período pós-operatório. CONCLUSÃO: Dificuldades em se adaptarem a ausência de crises ou co-morbidades psicosocial e psiquiátrica podem ser fatores importantes que interferem nos hábitos de atividade física. Uma ação multidisciplinar poderia ser uma estratégia importante para tentar alterar alguns aspectos do estilo de vida destes pacientes após a cirurgia de epilepsia.

Centro-median stimulation yields additional seizure frequency and attention improvement in patients previously submitted to callosotomy.

RATIONALE: Deep brain stimulation (DBS) has been increasingly used in the treatment of refractory epilepsy over the last decade. We report on the outcome after thalamic centro-median (CM) DBS in patients with generalized epilepsy who had been previously treated with extended callosal section. METHODS: Four consecutive patients with generalized epilepsy who were previously submitted to callosal section and had at least 1 year of follow-up after deep brain implantation were studied. Age ranged from 19 to 44 years. All patients were submitted to bilateral CM thalamic DBS. Post-operative CT scans documented the electrode position in all patients. All patients had pre- and post-stimulation prolonged interictal scalp EEG recordings, including spike counts. Attention level was evaluated by means of the SNAP-IV questionnaire. The pre-implantation anti-epileptic drug regimen was maintained post-operatively in all patients. RESULTS: Post-operative CT documented that all electrodes were correctly located. There was no morbidity or mortality. Seizure frequency reduction ranging from 65 to 95% and increased attention level was seen in all patients. Interictal spiking frequency was reduced from 25 to 95%, but their morphology remained the same. There was re-synchronization of interictal discharges during slow-wave sleep in 2 patients. CONCLUSION: All patients benefit from the procedure. The CM seems to play a role in modulating the epileptic discharges and attention in these patients. On the other hand, it is not the generator of the epileptic abnormality and appeared not to be involved in non-REM sleep-related interictal spiking modulation.

Outcome after cortico-amygdalo-hippocampectomy in patients with severe bilateral mesial temporal sclerosis submitted to invasive recording.

INTRODUCTION: Although some degree of bilateral hippocampal involvement might be frequent in patients with temporal lobe epilepsy, severe bilateral mesial temporal sclerosis (MTS) is very rare. We present our experience while treating patients with severe bilateral MTS submitted to invasive recordings. METHODS: Nine adult patients were studied. All patients had simple and complex partial seizures. All patients had bilateral independent interictal temporal lobe spiking and non-lateralizing video-EEG findings. MRI showed severe bilateral MTS and no other brain lesion. All patients had severe verbal and non-verbal memory deficits. All patients were submitted to invasive recordings after bilateral subdural grids implantation. Cortico-amygdalo-hippocampectomy (CAH) was performed in all patients on the side suggested by invasive recording. Follow-up time ranged from 5 to 10 years. RESULTS: Invasive video-EEG showed exclusively unilateral seizure onset in seven patients; in two patients, seizures originating from both temporal lobes were found (80% of them originated from one side). Five patients were submitted to left and four to right CAH. Seven patients were rendered seizure-free after surgery (Engel I); the other two were rated as Engel II. There was no additional memory decline. There was no surgical morbidity or mortality. Pathological examination showed MTS in all patients. DISCUSSION: Good surgical outcome (77% seizure-free patients) could be obtained even in this apparently unsuitable group of patients. All patients benefit from the procedure. We did not see any cognitive decline in our patients with severe bilateral MTS. Patients with severe bilateral MTS would need invasive recordings despite any findings during surface video-EEG.

Outcome after hemispherectomy in hemiplegic adult patients with refractory epilepsy associated with early middle cerebral artery infarcts.

PURPOSE: To study the outcome after hemispherectomy (HP) in a homogeneous adult patient population with refractory hemispheric epilepsy. METHODS: Fourteen adult patients submitted to HP were studied. Patients had to be at least 18 years old, and have refractory epilepsy, clearly focal lateralized seizures and unilateral porencephalus consistent with early middle cerebral artery infarct on magnetic resonance imaging (MRI). All patients were submitted to functional hemispherectomy. We analyzed age of seizure onset, age by the time of surgery, gender, seizure type and frequency, interictal and ictal electroencephalography (EEG) findings, MRI and IQ scores preoperatively; seizure frequency, drug regimen, and IQ outcome were studied postoperatively. RESULTS: Mean follow-up was 64 months. All patients had frequent daily seizures preoperatively. All patients had unilateral simple partial motor seizures (SPS); 11 patients had secondarily generalized tonic-clonic (GTC) seizures and five patients had complex partial seizures (CPS), preoperatively. All patients had hemiplegia and hemianopsia. Twelve patients had unilateral EEG findings, and in two epileptic discharges were seen exclusively over the apparently normal hemisphere. Twelve patients were seizure-free after surgery and two patients had at least 90% improvement in seizure frequency. Pre- and postoperative mean general IQ was 84 and 88, respectively. Five of the twelve Engel I patients were receiving no drugs at last follow-up. There was no mortality or major morbidity. CONCLUSIONS: Our results suggest that well-selected adult patients might also get good results after HP. Although good results were obtained in our adult series, the same procedure yielded a much more striking result if performed earlier in life.

Outcome after corticoamygdalohippocampectomy in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis without preoperative ictal recording.

PURPOSE: We report on the surgical outcome obtained in patients with refractory temporal lobe epilepsy with mesial temporal sclerosis (MTS) who were evaluated preoperatively without ictal recording and were submitted to corticoamygdalohippocampectomy. METHODS: Two hundred twelve patients with refractory temporal lobe epilepsy were evaluated by means of clinical history, neurological examination, interictal electroencephalography (EEG), magnetic resonance imaging (MRI), and neuropsychological testing. MRI disclosed unilateral MTS in all patients. All patients were submitted to corticoamygdalohippocampectomy at the side determined by MRI. RESULTS: Interictal EEG showed unilateral temporal lobe spiking in 176 patients; in 36 patients, bilateral discharges were found. Mean follow-up time was 2.7 years. One hundred ninety-four patients (92%) were classified as Engel's class I. Eighteen patients (8%) were rated as Engel's class II. Thirty-two out of 36 patients, in whom bilateral discharges were found, were in Engel's class I. Sixty percent of the patients had an improvement in memory function related to the nonoperated temporal lobe. Fifty-nine percent of the patients had a 10-point increase in general IQ postoperatively. Verbal memory decline was noted in three patients. Pathological examination showed MTS in all patients. CONCLUSIONS: It is possible to adequately select good surgical candidates for temporal lobe resection using MRI and interictal EEG alone. In patients with MRI-defined MTS, we should expect a 90% postoperative remission rate. Cognitive decline was very rarely seen in this patient population. The finding of MTS on MRI is the single most important prognostic factor for good outcome after temporal lobe surgery.

Outcome after extended callosal section in patients with primary idiopathic generalized epilepsy.

PURPOSE: We report the outcome of patients with refractory idiopathic generalized epilepsy (IGE) who were submitted to extended one-stage callosal section. METHODS: Eleven patients with IGE who were submitted to extended one-stage callosal section were studied. Preoperative workup included history and neurologic examination, interictal, and ictal electroencephalography (EEG) recording, high resolution 1.5T magnetic resonance imaging (MRI) and intelligence quotient (IQ) testing. All patients were submitted to extended one-stage microsurgical callosal section, leaving only the splenium intact. RESULTS: Preoperative ictal patterns included repetitive spike and wave or polyspike and wave discharges or fast epileptic recruiting rhythm. MRI showed no focal lesions. Preoperatively, mean general IQ was 85. Postoperatively, at least a 75% reduction in the frequency of generalized tonic-clonic seizures was noted in all patients. In three patients absences disappeared completely, and the others had at least 90% reduction in seizure frequency. Only one patient had myoclonic seizures preoperatively, and these seizures disappeared after callosal section. After surgery, mean general IQ was 89. A very clear increase in attention level was noted in all patients. Postoperative interictal EEG recordings showed rupture of bilateral synchrony in all patients. DISCUSSION: This article reports on a large and homogeneous series of patients with refractory IGE submitted for callosal section. There was a marked decrease in generalized seizure frequency and increase in the attention level in this patient population. Our results suggest that corticocortical interaction might have a role in IGE pathogenesis. Callosotomy is a safe, effective, and underused palliative procedure in these well-selected patients with refractory IGE.

Níveis cardíacos de troponina I em pacientes com epilepsia do lobo temporal refratária após cortico-amígdalo-hipocampectomia / Cardiac troponin I levels in patients with refractory temporal lobe epilepsy after cortico-amygdalo-hippocampectomy

OBJETIVOS: A morte súbita em epilepsia (SUDEP) é a principal causa de morte entre os pacientes com epilepsia. Alterações morfológicas e funcionais do coração estão relacionadas com a SUDEP. Nesse sentido, o objetivo deste estudo foi avaliar a concentração de troponina I, um importante marcador de lesão do miocárdio, em pacientes com epilepsia do lobo temporal de difícil controle e que foram submetidos à ressecção cirúrgica e que não obtiveram sucesso com esta abordagem terapêutica. METODOLOGIA: Onze pacientes participaram do estudo e todos continuaram a apresentar crises após o tratamento cirúrgico. Os valores de troponina I indicativos de lesão seriam aqueles maiores de 1 ng/ml e o valor mínimo detectável pelo kit utilizado em nosso estudo foi de 0,15 ng/ml. RESULTADOS: Apenas três pacientes apresentaram níveis de troponina I detectáveis. Em relação aos níveis detectáveis de troponina I, não encontramos nenhuma relação com sexo, idade e lateralidade da lesão. CONCLUSÕES: APESAr de não termos encontrado resultados positivos em nosso estudo, o papel do coração na SUDEP não pode ser descartado, já que algumas lesões, embora não sendo capazes de alterar os níveis séricos de troponina I, podem ser suficientes na gênese de focos arritmogênicos.

PURPOSE: Sudden unexpected death in epilepsy (SUDEP) is the main cause of death in patients with epilepsy. Morphologic and functional changes in the heart are related to SUDEP. The aim of our study was to verify the concentration of troponin I, an important marker of myocardium damage, in patients with temporal lobe epilepsy who were submitted to surgical resection and were not seizure-free after the procedure. METHODS: Eleven non-consecutive patients participated in the study and all of them presented poor seizure control after surgical procedure. Troponin I levels higher then 1 ng/ml indicate myocardium damage. The detection level of the kit used in our study was 0,15 ng/ml. RESULTS: Only three patients showed detectable troponin I levels. The troponin I levels found in our study is not related with sex, age or side of the lesion. CONCLUSIONS: In spite of we did not find positive results in our study, an active role of the heart in SUDEP cannot be discarded, since some injuries, even so not being capable to modify troponin I levels, can be enough to generate arrhythmogenic foci.

Surgical outcome in patients with refractory epilepsy associated to MRI-defined unilateral mesial temporal sclerosis.

INTRODUCTION: Several pre-operative work-up protocols have been used while selecting epileptic patients for surgery among different centers. The relative value of the different available pre-operative tests is still under discussion. OBJECTIVE: We report on the surgical outcome obtained in patients with refractory temporal lobe epilepsy associated to mesial temporal sclerosis (MTS) and who were evaluated pre-operatively by interictal EEG and MRI alone. METHOD: Forty one patients with refractory unilateral temporal lobe epilepsy were evaluated using interictal EEG and MRI. MRI disclosed unilateral MTS in all patients. All patients had at least 4 interictal EEG recordings. All patients were submitted to cortico-amygdalo-hippocampectomy at the side determined by MRI. RESULTS: Interictal EEG showed unilateral epileptiform discharges compatible with MRI findings in 37 patients; in four out of the 41 patients, bilateral discharges were found. Mean follow-up time was 4.3+/-1.1 years. Thirty-nine patients (95.1%) were classified as Engels Class I (70.6% Engel I-A). Two patients (4.9%) were rated as Engel's Class II. All patients in whom bilateral discharges were found were in Engels Class I. Pathological examination showed MTS in all patients. CONCLUSION: It is possible to adequately select good surgical candidates for temporal lobe resection using MRI and interictal EEG alone. In patients with MRI-defined MTS we should expect a postoperative remission rate higher then 90%. The finding of MTS on MRI is the most important good prognostic factor after temporal lobe resection.

Surgical outcome in patients with refractory epilepsy associated to MRI-defined unilateral mesial temporal sclerosis

INTRODUÇÃO: Protocolos diferentes têm sido utilizados para a investigação pré-operatória de pacientes epilépticos nos diferentes centros. No entanto, o valor relativo de cada teste disponível ainda é controverso na literatura.OBJETIVO: Relatamos os resultados cirúrgicos de pacientes com epilepsia refratária do lobo temporal associada a esclerose hipocampal (EH), cuja investigação pré-operatória consistiu exclusivamente de estudo de eletrencefalograma (EEG) inter-crítico e ressonância magnética (RM). MÉTODO: Foram estudados 41 pacientes com epilepsia refratária do lobo temporal, avaliados pré-operatoriamente somente por meio de EEG interictal e RM encefálica. Foram incluídos somente pacientes em quem a RM mostrava apenas EH unilateral. Todos pacientes possuíam ao menos quatro EEG inter-ictais. Todos os pacientes foram submetidos a córtico-amígdalo-hipocampectomia no lado demonstrado pela RM.RESULTADOS: A análise do EEG interictal revelou atividade epileptiforme unilateral, compatível com os achados da RM em 37 pacientes. Nos outros quatro pacientes, o EEG evidenciou comprometimento bilateral. O tempo médio de seguimento pós-operatório dos pacientes foi 4,3±1,1 anos. No período pós-operatório, 95,1% dos pacientes encontravam-se em classe I de Engel (70,6% em Engel I-A) e 4.9% em classe II de Engel. Todos os pacientes com achados bilaterais ao EEG estavam em classe I de Engel. O estudo anátomo-patológico das amostras cirúrgicas revelou EH em todos os pacientes. CONCLUSÃO: É possível selecionar bons candidatos à ressecção temporal utilizando-se apenas dados de RM e EEG inter-ictal. Nos pacientes com EH unilateral na RM, espera-se um índice de remissão pós-operatória das crises superior a 90%. O achado de EH na RM é, isoladamente, o maior fator indicativo de bom prognóstico após ressecção temporal.

Extended, one-stage callosal section for treatment of refractory secondarily generalized epilepsy in patients with Lennox-Gastaut and Lennox-like syndromes.

PURPOSE: We report on the efficacy and safety of extended one-stage callosal section performed in a large and homogeneous series of patients. METHODS: Seventy-six patients with Lennox-Gastaut (n = 28) and Lennox-like (n = 48) syndrome were studied (42 male patients; mean age, 11.2 years). All patients had multiple seizure types per day, including atonic, tonic-clonic, atypical absence, myoclonic, and tonic seizures. All of them were developmentally impaired. The EEG showed intense secondary bilateral synchrony in all of them. All patients were submitted to an extended, one-stage, callosal section, leaving only the splenium intact. Mean follow-up time was 4.7 years. RESULTS: Worthwhile improvement (>50%) was noted in 69 of 76 patients; 52 patients had a > or =90% reduction in seizure frequency. Seven patients were seizure free after surgery. The seizure patterns most responsive to surgery were atonic (92%), atypical absence (82%), and tonic-clonic (57%) seizures. All patients had some degree of a transient acute postoperative disconnection syndrome. A consistent increase in attention level was observed postoperatively. CONCLUSIONS: We report one of the larger homogeneous series of patients submitted to callosotomy and are the first to report on the effectiveness and safety of performing extended callosal section in a single stage in this patient group. Extended callosal section should be considered a good palliative surgical option for suitable candidates. The increase in attention level was as useful as seizure control in improving quality of life of these patients.