Cognitive outcomes following laser interstitial therapy for mesiotemporal epilepsies.

OBJECTIVE: To provide a review of cognitive outcomes across a full neuropsychological profile in patients who underwent laser interstitial thermal therapy (LiTT) for mesiotemporal epilepsy (mTLE). METHODS: We examined cognitive outcomes following LiTT for mTLE by reviewing a consecutive series of 26 patients who underwent dominant or nondominant hemisphere procedures. Each patient's pre- and postsurgical performance was examined for clinically significant change (>1SD improvement or decline on standardized scores), with a neuropsychologic battery that included measures of language, memory, executive functioning, and processing speed. RESULTS: Presurgical performance was largely consistent with previous research, where patients suffering from dominant hemisphere epilepsies demonstrated deficits in verbal learning and memory, whereas patients with nondominant hemisphere scored lower on visually mediated tests. Case-by-case review comparing presurgical to postsurgical scores revealed clinically significant improvement in both dominant and nondominant patients in learning and memory and other aspects of cognition such as processing speed and executive functioning. Of the few patients who did experience clinically significant decline following LiTT, a greater proportion had undergone dominant hemisphere procedures. CONCLUSIONS: Compared with the outcome literature of dominant open anterior temporal lobectomies (ATLs), where postsurgical decline has been documented in up to 40%-60% of cases, our LiTT case series exhibited a much lower incidence of postoperative language or verbal memory decline. Moreover, promising rates of postoperative improvements were also observed across multiple cognitive domains. Future studies exploring cognitive outcomes following LiTT should include comprehensive neuropsychological findings, rather than only select domains, as clinically significant change can occur in areas other than those typically associated with mesiotemporal structures.

Risk factors for seizures after intracerebral hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study.

OBJECTIVE: We aimed to identify risk factors for seizures after intracerebral hemorrhage, and to validate the prognostic value of the previously reported CAVE score (0-4 points: cortical involvement, age <65, volume >10 mL, and early seizures within 7 days of hemorrhage). PATIENTS AND METHODS: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) was a prospective study of spontaneous intracerebral hemorrhage. We included patients who did not have a prior history of seizure and survived to discharge. Univariate analysis and multiple logistic regression modeling were used to identify risk factors for seizure. RESULTS: From 2010-2015, 3000 cases were recruited, and 2507 patients were included in this study. Seizures after hospital discharge developed in 77 patients 3.1 %). Patients with lobar (cortical) hemorrhage (OR 3.0, 95 % CI 1.8-5.0), larger hematoma volume (OR 1.5 per cm3, 95 % CI 1.2-2.0), and surgical evacuation of hematoma (OR 2.6, 95 % CI 1.4-4.8) had a higher risk of late seizure, and older patients had a lower risk (OR 0.88 per 5-year interval increase, 95 % CI 0.81-0.95). The CAVE score was highly associated with seizure development (OR 2.5 per unit score increase, 95 % CI 2.0-3.2, p < 0.0001). The CAVS score, substituting surgical evacuation for early seizure, increased the OR per unit score to 2.8 (95 % CI 2.2-3.5). CONCLUSIONS: Lobar hemorrhage, larger hematoma volume, younger age, and surgical evacuation are strongly associated with the development of seizures. We validated the CAVE score in a multi-ethnic population, and found the CAVS score to have similar predictive value while representing the current practice of AED use.

Laser thermal ablation for mesiotemporal epilepsy: Analysis of ablation volumes and trajectories.

OBJECTIVE: To identify features of ablations and trajectories that correlate with optimal seizure control and minimize the risk of neurocognitive deficits in patients undergoing laser interstitial thermal therapy (LiTT) for mesiotemporal epilepsy (mTLE). METHODS: Clinical and radiographic data were reviewed from a prospectively maintained database of all patients undergoing LiTT for the treatment of mTLE at the University of Miami Hospital. Standard preoperative and postoperative evaluations, including contrast-enhanced magnetic resonance imaging (MRI) and neuropsychological testing, were performed in all patients. Laser trajectory and ablation volumes were computed both by manual tracing of mesiotemporal structures and by nonrigid registration of ablation cavities to a common reference system based on 7T MRI data. RESULTS: Among 23 patients with at least 1-year follow-up, 15 (65%) were free of disabling seizures since the time of their surgery. Sparing of the mesial hippocampal head was significantly correlated with persistent disabling seizures (p = 0.01). A lateral trajectory through the hippocampus showed a trend for poor seizure outcome (p = 0.08). A comparison of baseline and postoperative neurocognitive testing revealed areas of both improvement and worsening, which were not associated with ablation volume or trajectory. SIGNIFICANCE: At 1-year follow-up, LiTT appears to be a safe and effective tool for the treatment of mTLE, although a longer follow-up period is necessary to confirm these observations. Better understanding of the impact of ablation volume and location could potentially fine-tune this technique to improve seizure-freedom rates and associated neurologic and cognitive changes.

Microwave oven injuries in patients with complex partial seizures.

Microwave ovens are often recommended as a safe cooking alternative for persons with epilepsy. We report four patients who suffered serious burns to their hands while handling microwave-heated liquids during a complex partial seizure (CPS). Injuries were due to the contact of the skin with a very hot container. The fact that all patients held on to the hot containers despite being burned and that they did not remember experiencing any pain at the time of the accident indicates that neither high temperatures nor pain will prevent patients who are having a CPS from suffering this type of injury. Unfortunately, there is no foolproof way to prevent the individual from opening the oven and removing its contents during a CPS. The only solution for this problem is "prevention"-individuals with poorly controlled CPS should be cautioned about these risks. The use of microwave settings that permit the heating but not boiling of liquids and the use of gloves while heating food and liquids to scalding temperatures may minimize the risk of this type of injury.

Risk of aspiration pneumonia after an epileptic seizure: a retrospective analysis of 1634 adult patients.

We reviewed the incidence of aspiration pneumonia secondary to seizures in three populations of patients with chronic epilepsy: 733 outpatients seen in an Epilepsy Foundation clinic; 806 adult patients admitted to two university video telemetry units; and 95 institutionalized, profoundly retarded adult patients with chronic epilepsy. Two of the 733 adults who had seizures in the outpatient setting and 2 of the 806 patients who had one or more epileptic seizures in the telemetry units developed aspiration pneumonia. In the 95 institutionalized patients, there were 17 instances of aspiration pneumonia after a generalized seizure and 32 instances of aspiration unrelated to seizures over a 12-month period. Our findings suggest that aspiration pneumonia is not a common complication of seizures in otherwise healthy adults. The increased incidence of aspiration in developmentally delayed individuals seems to derive from a combination of factors. Increased oral secretions, impaired swallowing mechanisms, and difficulty in attaining adequate patient positioning significantly increased the risk of aspiration.

Behaviors mimicking seizures in institutionalized individuals with multiple disabilities and epilepsy: a video-EEG study.

We reviewed 824 video-EEG telemetry requests of institutionalized patients with epilepsy, searching for evaluations of "new seizure types" identified by staff (caregivers, teachers, therapists, LPNs, RNs). Of the 63 newly identified "seizure types," epilepsy was confirmed in 4 (6.3%); 59 represented nonepileptic events. Causes for diagnostic confusion in the profoundly retarded included stereotypic repeated blinking, swallowing, buccolingual movements, spontaneous grimacing, periods of apparent psychomotor arrest and increased muscle tone, dystonic posturing, and irascible personality emerging after reduction of sedatives. Three cases of "startle seizures" were due to dystonic posturing caused by the unexpected contact of body with water during bath. Episodes of decreased daytime alertness ("somnolence") were erroneously attributed to "absence seizures" in eight cases by staff supervising tasks requiring sustained attention (i.e., school, workshop). In less impaired patients, self-stimulation, self-abuse, and ataxia with falls were the more common diagnoses. Simulation of seizures, a somewhat uncommon finding in this population, was the diagnosis in 3 cases. All were high functioning and appeared to simulate seizures to avoid work. Our findings suggest that the de novo appearance of a "new seizure type" in these patients, particularly in cases with a well-established seizure pattern, is uncommon. Four patients in whom the "new event" was confirmed to be epileptic had preexisting secondarily generalized seizures. What the staff identified was the variable clinical progression of seizures probably due to medication changes. Different fragments of the seizure appear to have occurred at different times with variable intensity and duration. A single seizure type may have appeared to be a variety of attacks because of this fragmented presentation.

The Case for Different Severity of Burns in "Contagious" versus "Possession" Seizures.

Serious seizure-related burns are reportedly common in cultures that use ground fire for cooking, heating, or ceremonial purposes. The seriousness of injuries in these cases has been ascribed to the reluctance of bystanders to assist individuals having a seizure either because of fear of contagion (Africa, New Guinea highlands) or because of fear of revenge by the occult (Haiti). We report four Haitian patients who fell into open fires during an epileptic seizure in religious gatherings. Patients were almost immediately rescued from the fire. In contrast to the African and New Guinean patients where upper body involvement was common, burns in these four patients were of moderate severity and involved primarily the lower body. The fear of contagion and belief in magic are interesting notions, but do not explain the different severity and distribution of injuries in these patients. A more likely explanation is that seizures in the African and New Guinean patients occurred while the patient and family were asleep, which probably delayed the rescue, whereas the Haitian patients were helped within moments of falling into the fire in their seizure. The position of the patient at the onset of the seizure is probably what determined the primary areas of thermal injury, and the time to rescue determined their severity and extension.