Automatic multimodal detection for long-term seizure documentation in epilepsy.

OBJECTIVE: This study investigated sensitivity and false detection rate of a multimodal automatic seizure detection algorithm and the applicability to reduced electrode montages for long-term seizure documentation in epilepsy patients. METHODS: An automatic seizure detection algorithm based on EEG, EMG, and ECG signals was developed. EEG/ECG recordings of 92 patients from two epilepsy monitoring units including 494 seizures were used to assess detection performance. EMG data were extracted by bandpass filtering of EEG signals. Sensitivity and false detection rate were evaluated for each signal modality and for reduced electrode montages. RESULTS: All focal seizures evolving to bilateral tonic-clonic (BTCS, n=50) and 89% of focal seizures (FS, n=139) were detected. Average sensitivity in temporal lobe epilepsy (TLE) patients was 94% and 74% in extratemporal lobe epilepsy (XTLE) patients. Overall detection sensitivity was 86%. Average false detection rate was 12.8 false detections in 24h (FD/24h) for TLE and 22 FD/24h in XTLE patients. Utilization of 8 frontal and temporal electrodes reduced average sensitivity from 86% to 81%. CONCLUSION: Our automatic multimodal seizure detection algorithm shows high sensitivity with full and reduced electrode montages. SIGNIFICANCE: Evaluation of different signal modalities and electrode montages paces the way for semi-automatic seizure documentation systems.

Etomidate activates epileptic high frequency oscillations.

OBJECTIVE: The short acting anesthetic etomidate has been shown to provoke epileptic spikes and rarely seizures. Influence of etomidate on the occurrence of epileptic HFO (high frequency oscillations) however is unknown. An HFO inducing effect of etomidate would allow further validation of the substance as a provocation measure in presurgical evaluation as well as provide insights into the common mechanisms of HFO, spike and seizure generation. METHODS: We retrospectively analyzed EEG data from four patients who underwent etomidate activation during invasive video-EEG monitoring with subdural strip electrodes. Spikes were manually selected in raw data, HFO in band pass filtered data (80-250Hz). Rate and spatial distribution of HFO and spikes in three segments were compared: immediately after etomidate administration, as well as during slow wave sleep and while awake. RESULTS: Rates of HFO and spikes increased significantly after etomidate administration: Overall average rates of spikes were 9.7/min during sleep, 10/min while awake and 61.4/min after etomidate. Average HFO rates were 9.5/min during sleep, 8.3/min while awake and 24.4/min after etomidate (p<0.001, non-parametric ANOVA). Spatial distributions of HFO and spikes after administration of etomidate were consistent with the seizure onset zone (SOZ) and area of resection when available (SOZ: two patients; resection: one patient; no information: one patient). Except for spurious events, no additional HFO and spike foci were seen with activation. CONCLUSIONS: Etomidate administration activates spikes and HFO. Spatial distributions do not extend beyond electrodes showing spikes and HFO without Etomidate and seem consistent with the epileptic network. SIGNIFICANCE: Etomidate activation is a safe procedure to provoke not only epileptic spikes but also HFO, which were shown to have a high specificity for the SOZ.

Objective quantification of seizure frequency and treatment success via long-term outpatient video-EEG monitoring: a feasibility study.

A reliable method for the estimation of seizure frequency and severity is indispensable in assessing the efficacy of drug treatment in epilepsies. These quantities are usually deduced from subjective patient reports, which may cause considerable problems due to insufficient or false descriptions of seizures and their frequency. We present data from two difficult-to-treat patients with intractable epilepsy. Pat. 1 has had an unknown number of CP seizures. Here, a prolonged outpatient video-EEG monitoring over 160 h and 137 h (over an interval of three months) was performed with an automated seizure detection method. Pat. 2 suffered exclusively from nocturnal seizures originating from the frontal lobe. In this case, an objective quantification of the efficacy of drug treatment over a time period of 22 weeks was established. For the reliable quantification of seizures, a prolonged outpatient video/video-EEG monitoring was appended after a short-term inpatient monitoring period. Patient 1: The seizure detection algorithm was capable of detecting 10 out of 11 seizures. The number of false-positive events was <0.03/h. It was clearly demonstrated that the patient showed more seizures than originally reported. Patient 2: The add-on medication of lacosamide led to a significant reduction in seizure frequency and to a marked decrease in the mean duration of seizures. The severity of seizures was reduced from numerous hypermotoric seizures to few mild, head-turning seizures. Outpatient monitoring may be helpful to guide treatment for severe epilepsies and offers the possibility to more reliably quantify the efficacy of treatment in the long-term, even over several months.

Epilepsy monitoring for therapy: challenges and perspectives.

The aim of the treatment of epilepsies is to control seizures without causing adverse effects in order to reach the best possible quality of life. Towards this aim diagnostic monitoring has become an increasingly important clinical tool, because seizures are transient events difficult to observe. Three major topics are discussed in this paper: (1) DIFFERENTIAL DIAGNOSIS: patients with difficult to treat epilepsies or unexplained paroxysmal events are referred to sophisticated monitoring units because they may have non-epileptic seizures or inaccurate classification of their epileptic seizures. (2) Evaluation of antiepileptic drugs: a prerequisite for the development of antiepileptic drugs it is desirable to employ objective measures to quantify efficacy, which can be achieved with the aid of diagnostic and therapeutic intensive seizure analysis including neuropsychological testing. (3) Automated computer supported seizure detection in emergency cases: for the quantification of frequency and severity of epileptic seizures in difficult to treat epilepsies (e.g. non-convulsive status epilepticus), adequate algorithms can be applied to long-term EEG recordings. These methods can be of assistance, as essential and practical tools, in the decision making during diagnostic monitoring by providing more objective results.

Interictal triple ECoG characteristics of temporal lobe epilepsies: An intraoperative ECoG analysis correlated with surgical outcome.

OBJECTIVE: Recent reports showed that intraoperative ECoG activities can be analysed with respect to more complex spike patterns. We have systematically investigated different characteristic epileptiform activities in intraoperative ECoG and correlated them to postoperative outcome. METHODS: Intraoperative ECoG findings of patients with non-tumorous epilepsies (20 patients with Engel outcome 1a, 20 patients with Engel outcome 2-4) were analysed in order to differentiate ECoG characteristics in temporal lobe epilepsies (TLE). RESULTS: In addition to focal spiking with or without propagation, focal slowing in the theta or delta range and so-called ictaform ECoG patterns were found. These ictaform patterns occurred in 40% of the patients with TLE. CONCLUSIONS: Leading spikes in combination with focal slowing and ictaform patterns can contribute to a better delineation of mesial temporal epileptic activity in the anterior-posterior alignment. They provide an additional information which can be used for the extent of resection. SIGNIFICANCE: If the resected area included the anterior mesial regions, where interictal spikes, ictaform activity and slowing were localized, the postoperative outcome was good.

An efficient, robust and fast method for the offline detection of epileptic seizures in long-term scalp EEG recordings.

OBJECTIVE: A robust and fast algorithm for the offline detection of epileptic seizures in scalp EEG is described. It is aimed for seizure detection with high sensitivity and low number of false detections in long-term EEG data without a priori information. METHODS: To capture the characteristic electrographic changes of seizures, we developed an efficient method based on power spectral analysis techniques. The integrated power is calculated in two frequency bands for three multi-channel seizure detection montages (referenced against the average of Fz-Cz-Pz, common average, bipolar) using the same parameters for all montages and all patients taking into account an appropriate artifact rejection. RESULTS: A total of 3248 h of scalp recordings containing 148 seizures from 19 patients were examined. The averaged sensitivity was 90.9% and selectivity (false-positive errors/h, FPH) was 0.29/h of the Fz-Cz-Pz montage; the other montages yielded lower sensitivities but even better selectivity values. CONCLUSIONS: Taking into account that the method has been performed in a standardized way with fixed parameters for all patients and montages the obtained values for sensitivity are quite high while the selectivity is acceptably low. The parameters can additionally be tuned to patient specific seizures. It is assumed that this may further improve the seizure detection performance. SIGNIFICANCE: The proposed method may enhance the clinical use for the detection of seizures in scalp EEG long-term monitoring during presurgical evaluation.

Periventricular nodular heterotopia: A challenge for epilepsy surgery.

Pharmacoresistant focal epilepsies due to periventricular nodular heterotopia are a diagnostic and therapeutic challenge because of the need of invasive presurgical diagnostics and the selection of an optimal surgical approach. Invasive investigations in previous studies showed that focal epileptic activity can be correlated predominantly either with one of the nodular heterotopia or with neocortical epileptogenic zones distant to the periventricular nodules. Up to now, invasive recordings were required for localization of epileptic activity and its correlation to heterotopia. The following case presentation reports on a non-invasive approach using magnetic source imaging (MSI) combined with intraoperative ECoG. MSI combines preoperative data from magnetic resonance imaging (MRI) with magnetoencephalography (MEG). The MSI data for definition of the localization of the epileptic activity and functional important areas were coregistered with the intraoperative high-field-MRI and diffusion tensor imaging-based fiber tracking (DTI) of the visual pathway using a neuronavigational system. A neuronavigation-guided surgical resection of the epileptogenic area was performed leaving the heterotopia and the visual tract fibers intact. Postoperatively preservation of the visual fields was documented and the frequency of seizures was markedly reduced.

Epilepsy surgery, resection volume and MSI localization in lesional frontal lobe epilepsy.

To verify whether interictal noninvasive information detected by magnetoencephalography (MEG) recordings can contribute to localize focal epileptic activity relevant for seizure generation in lesional frontal lobe epilepsy, magnetic source imaging (MSI) localizations of epileptic discharges were compared to the extent of neurosurgical resection and postoperative outcome. Preoperative MEG spike localizations were displayed in postoperative magnetic resonance imaging (MRI) scans to check whether dipole sites were located within the resection cavity. Moreover, MEG localizations were compared with results of prolonged video-EEG monitoring and, in three cases, with invasive EEG recordings. Our results in five cases with lesional frontal lobe epilepsy showed that good surgical outcome could be achieved in those patients where the majority of MEG spike localizations were located within the resected brain volume.

Magnetic brain source imaging of focal epileptic activity: a synopsis of 455 cases.

Epilepsy surgery is based upon the minute assessment of brain tissue generating epileptic activity. A number of diagnostic methods are employed in the process of presurgical evaluation, supplying information on various morphological and functional aspects, ultimately integrated into the general result fundamental to the final treatment decision. Magnetic source imaging (MSI), combining structural (MRI) and functional (MEG) data, has been playing an increasingly important role among the tools of presurgical epilepsy evaluation. However, in spite of a considerable number of publications, the samples used have hardly exceeded 50 cases. Therefore, we present a synopsis of 455 epilepsy patients who underwent MSI investigations. Analysis of this substantial data revealed that the average sensitivity of MEG for specific epileptic activity was 70%. Among 131 patients who underwent surgical therapy in addition to antiepileptic drug medication, MSI identified the lobe to be treated in 89%, with results for extratemporal cases being even superior to those with temporal lobe surgery. Introducing a measure to quantify the contribution of MSI to the general result of presurgical evaluation that was applied to 104 patients, the results showed that MSI supplied additional information in 35% and information crucial to final decision making in 10%. Accuracy as well as contribution findings underlined MSI appropriateness even for extratemporal epilepsies, which otherwise frequently prove difficult with respect to focus localization.

Magnetoencephalography in extratemporal epilepsy.

Epilepsy surgery candidates with extratemporal foci represent a particular diagnostic and therapeutic challenge, because of anatomic and functional features of the pertaining areas. In the last decade, novel developments in the field of electrophysiological techniques have offered new approaches to detailed localization of specific epileptic discharges as well as eloquent regions. Magnetoencephalography, in combination with neuroimaging data and simultaneously recorded EEG, yields promising results to clarify centers of epileptic activity and their relationship to structural abnormalites and functionally significant areas. Examples are given to illustrate the range of applications of this method as a contribution to routine presurgical evaluation.

Motor, somatosensory and auditory cortex localization by fMRI and MEG.

Functional magnetic resonance imaging (fMRI) and magnetoencephalography (MEG) were performed in six subjects during self-paced finger movement performance, tactile somatosensory stimulation and binaural auditory stimulation using identical stimulation paradigms. Both functional imaging modalities localized brain activity in adjacent areas of anatomically correct cortex. The mean distances measured between fMRI activity and the corresponding MEG dipoles were 10.1 mm (motor), 10.7 mm (somatosensory), 13.5 mm (auditory right hemisphere) and 14.3 mm (auditory left hemisphere). The distances found may reflect the correlation between electrophysiological and hemodynamic responses due to the different underlying substrates of neurophysiology measured by fMRI and MEG: BOLD contrast vs neuronal biomagnetic activity.