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.

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.

[Early functional hemispherectomy in hemimegalencephaly associated to refractory epilepsy]. / Hemisferectomia funcional precoce na hemimegalencefalia associada à epilepsia refratária.

Hemimegalencephaly (HME) is a rare congenital brain malformation of unknown etiology. Patients with HME can present with an early onset epileptic syndrome which is often refractory to medical treatment and associated to impaired neurological development. Functional hemispherectomy (FH) has proven to be a valuable treatment alternative in patients with refractory epilepsy in this setting. Very few children operated under the age of 6 months and bearing HME and catastrophic epilepsy (CE) have been described in the literature. This study reports on 2 kids younger than 6 months with HME and CE submitted to FH with good clinical outcome.

Hemisferectomia funcional precoce na hemimegalencefalia associada à epilepsia refratária / Early functional hemispherectomy in hemimegalencephaly associated to refractory epilepsy

A hemimegalencefalia (HME) é malformação congênita cerebral rara de etiologia desconhecida que pode se apresentar com síndrome epiléptica de início precoce e resistente à terapia com anticonvulsivantes, associada a comprometimento significativo do desenvolvimento neuropsicomotor. A hemisferectomia funcional (HF) tem-se mostrado alternativa eficaz nos casos refratários à terapêutica medicamentosa. Em número diminuto, crianças foram operadas antes dos seis meses de idade. Esse estudo relata duas crianças com idade inferior a 6 meses com HME e síndrome epiléptica catastrófica submetidas a HF e com boa evolução clínica.

Seizure-related outcome after corticoamygdalohippocampectomy in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis evaluated by magnetic resonance imaging alone.

OBJECT: The authors conducted a study to assess the efficacy of surgery in patients who underwent magnetic resonance (MR) imaging alone for localization of foci in temporal lobe epilepsy (TLE). METHODS: One hundred patients (43 men, 57 women) with a clinical diagnosis of TLE were prospectively studied (mean age 28 +/- 9 years [+/- standard deviation {SD}]). All patients underwent high-resolution MR imaging, and in all unilateral mesial temporal sclerosis (MTS) was diagnosed by visual inspection. All patients underwent interictal preoperative electroencephalography (EEG) and in 87 patients pre- and 1-year postoperative neuropsychological testing was performed. Both EEG and neuropsychological examinations were conducted in a blinded fashion, and these data were not taken into account during the surgery-related decision-making process. All patients underwent a corticoamygdalohippocampectomy at the side of the MTS. Surgery-related outcome was rated as Class I (seizure free or simple partial seizures only) or Class II (> or = 90% improvement). The follow-up period ranged from 18 to 48 months (mean 24 +/- 5 months [+/-SD]). No patient underwent prolonged video-EEG monitoring, Wada testing, positron emission tomography, or single-photon emission computerized tomography. In eighty-nine patients Class I results were achieved, and 11 Class II results were achieved postoperatively. There was no mortality in this series. Except for in two patients who underwent surgery in the dominant temporal lobe, there was no postoperatively cognitive decline. In these two patients verbal memory decline occurred, which was associated with posterior temporal cortical damage, demonstrated postoperatively on MR imaging. Twenty-five percent of the patients experienced improved memory function related to the nonoperated side, and 54% experienced a 10% gain in general intelligence quotient status. CONCLUSIONS: In patients with clinically suspected TLE, MR imaging alone is able to localize temporal lobe foci correctly. Ruling out pseudoseizures remains the only indication for prolonged video-EEG recordings in this group of patients.

Seizure's outcome after cortical resections including the face and tongue rolandic areas in patients with refractory epilepsy and normal MRI submitted to subdural grids' implantation

PURPOSE: To study the seizure's outcome in patients with refractory epilepsy and normal MRI submitted to resections including the rolandic cortex. METHODS: Four adult patients were studied. All patients had motor or somatosensory simple partial seizures and normal MRI and were submitted to subdural grids' implantation with extensive coverage of the cortical convexity (1 in the non-dominant and 3 in the dominant hemisphere). RESULTS: ECoG was able to define focal areas of seizures' onset in every patient. All patients were submitted to resection of the face and tongue motor and sensitive cortex; two patients had resections including the perirolandic cortex and 2 had additional cortical removals. Three patients are seizures' free and one had a greater then 90 percent reduction in seizure frequency. CONCLUSION: Resections including the face and tongue rolandic cortex can be safely performed even within the dominant hemisphere

Esclerose múltipla: análise clínica e evolutiva de 214 casos / Multiple sclerosis: clinical analysis and development of 214 cases

Os autores apresentam uma série de 214 casos de esclerose múltipla provenientes de levantamento retrospectivo de prontuários na Disciplina de Neurologia da Faculdade de Ciências Médicas da Santa Casa de Säo Paulo e da clínica privada, no período de 1980 a 1993. Os dados encontrados foram analisados quanto a sexo, raça, média de idade de início dos sintomas, sintomas iniciais e sintomas evolutivos da doença. Os resultados foram analisados comparativamente aos encontrados em outras séries nacionais e estrangeiras