Rey-Osterrieth complex figure test: Comparison of traditional and qualitative scoring systems after unilateral temporal lobectomy.

OBJECTIVE: We compared the performance on the Rey-Osterrieth Complex Figure Test (ROCF) of patients that had undergone unilateral anterior temporal lobectomy under both Taylor's and Loring's scoring systems to identify the sensitivity and specificity of each item for differentiating visuospatial memory deficits. METHOD: We administered the ROCF to evaluate the visual memory of 37 left anterior temporal lobectomy (LATL) and 38 right anterior temporal lobectomy (RATL) patients with unilateral temporal lobe epilepsy who had undergone a standard unilateral anterior temporal lobectomy between 1996 and 2010. Fisher's exact and Qui-Quadrado tests were used to analyze the relationships between the qualitative variables. The Mann-Whitney U test was used to compare the quantitative variables from the right and left sides. RESULTS: RATL patients performed worse than LATL patients based on the total score for delayed recall (DR) (p = 0.012). The scoring system's showed a specificity of 97.2% & 78.9% and sensitivity of 10.5% & 62.2% on DR, for the Taylor and Loring systems respectively. Our detailed analysis of certain items showed that some differed between the groups in terms of the presence/absence, correct reproduction, and errors of those items. Loring' errors I, IV, and X on DR and errors IV and X on immediate recall were more frequent in the RATL group. CONCLUSIONS: The use of these two scoring systems combined may help maximize sensitivity and specificity with clinical populations. Further, our analyses showed that items could be clustered better and different weights could be given to them to maximize sensitivity and specificity.

Relationship between hippocampal subfields and Verbal and Visual memory function in Mesial Temporal Lobe Epilepsy patients.

OBJECTIVE: High-resolution protocols used in magnetic resonance imaging (MRI) currently enable the detailed analysis of the hippocampus along with its subfield segmentation. The relationship between episodic memory and the hippocampus is well established, and there is growing evidence that some specific memory processing steps are associated with individual hippocampal segments, but there are inconsistencies in the literature. We focused our analysis on hippocampal subfield volumetry and neuropsychological visual and verbal memory tests in patients with temporal lobe epilepsy (TLE) presenting with unilateral hippocampal atrophy. METHODS: The study involved a cohort of 62 patients with unilateral TLE, including unilateral hippocampal atrophy (29 on the left side) based on MRI and unequivocal ipsilateral ictal onsets based on surface video electroencephalography recordings. The hippocampal subfield volumes were evaluated using FreeSurfer version 7.1. We used the Rey-Auditory Verbal Learning Test to evaluate short-term (A1), learning (ΣA1-A5), immediate (A6), and delayed (A7) recall of episodic verbal memory. We used the Rey-Osterrieth Complex Figure Test to evaluate the immediate and delayed recall of visual memory. We analyzed the correlations between the asymmetry index scores for the hippocampal subfield volumes of thecornu ammonis (CA)1, CA2/3, and CA4 and memory test performance. RESULTS: Moderate associations were established between the CA2/3 asymmetry index scores and visual memory in TLE (both right and left hippocampal atrophy), as well as visual memory and CA4 in the right atrophy cases. The CA1 asymmetry index scores did not correlate with any of the memory test results. We did not find any significant correlation between verbal memory tests and specific hippocampal subfields. CONCLUSIONS: The use of high-resolution MRI protocols andin vivo automated segmentation processing revealed moderate associations between hippocampal subfields and memory parameters. Further investigations are needed to establish the utility of these results for clinical decisions.

Nonverbal fluency assessed by the five-point test in epilepsy patients with unilateral mesial temporal sclerosis-a Brazilian study.

OBJECTIVE: To investigate the performance of epilepsy patients diagnosed with unilateral mesial temporal sclerosis (MTS) on a nonverbal fluency measure using the five-point test (FPT). Our secondary aim was to investigate any differences in FPT and verbal fluency test (VFT) scores between left and right MTS. We hypothesized that scores on the FPT, commonly utilized in the assessment of individuals with presumed frontal lobe damage, would be lower in patients with temporal lobe dysfunction. METHOD: One hundred eighty patients diagnosed with temporal lobe epilepsy (TLE) and 150 healthy controls (HCs) were included in this retrospective study. We analyzed correlations between scores obtained from FPT and phonemic and semantic VFT, and scores according to the lateralization of epileptogenic focus in the TLE group. RESULTS: Overall, the TLE patients had lower performance than the HCs on the FPT, but no differences were observed on perseverance rates (p = 0.992). Statistically significant difference was found in both sections of the VFT in association with the lateralization of the epileptogenic zone (p < 0.001). As for the FPT, differences did not reach statistical significance (p = 0.0857). CONCLUSIONS: Our results support the hypothesis of involvement of the temporal areas on tasks such as the FPT, despite the lack of a lateralizing effect. Our findings also contribute to better understanding of the role of the FPT in assessment of executive function in patients with unilateral MTS, and provide further psychometric data on a native Brazilian population.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy / Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

ABSTRACT Objective To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). Method This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas – UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. Result Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients’ dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). Conclusion Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

RESUMO Objetivo Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS). Método Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas. Resultados Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004). Conclusão Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy.

OBJECTIVE: To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). METHOD: This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas - UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. RESULT: Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients' dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). CONCLUSION: Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

Cognitive impairment and antiphospholipid syndrome: is paradoxical embolism the rule?

OBJECTIVE: Although cognitive decline (CD) is described in antiphospholipid syndrome (APS), its physiopathology is unknown. Paradoxical embolization (PE) is related to CD in Alzheimer disease. The objective of this study was to determine whether PE plays a role in CD in APS patients through a significant right-to-left shunt (sRLS). METHODS: A total of 27 patients diagnosed with APS without a history of stroke were tested for the presence of an sRLS using a contrast-enhanced transcranial Doppler (cTCD) ultrasound. Cognitive decline was assessed using the mini mental state examination (MMSE), the Montreal cognitive assessment (MoCA), and a battery of neuropsychological tests. RESULTS: Of the 27 patients, 19 (70%) had a non-sRLS condition (≤ 10 high-intensity transient signs [HITS] on cTCD), and 8 (30%) had an sRLS. Patients with more than 10 years of scholarship performed significantly better on both the MMSE (P = 0.048) and MoCA (P = 0.03). Individuals of the non-sRLS group with more than 10 years of scholarship had better performances on the five-point test (FPT) when compared with the sRLS group (P = 0.01). CONCLUSIONS: Patients without sRLS and with more years of education exhibited a better performance in cognitive tests than sRLS patients.

The contribution of neuropsychology to diagnostic assessment in epilepsy.

Neuropsychology plays a vital role in the treatment of epilepsy, providing information on the effects of seizures on higher cortical functions through the measurement of behavioral abilities and disabilities. This is accomplished through the design, administration and interpretation of neuropsychological tests, including those used in functional neuroimaging or cortical mapping and in intracarotid anesthetic procedures. The objective of this paper is to define and summarize in some detail the role and methods of neuropsychologists in specialized epilepsy centers. Included are information and recommendations regarding basic ingredients of a thorough neuropsychological assessment in the epilepsy setting, as well as suggestions for an abbreviated alternative exam when needed, with emphasis on functions associated with specific brain regions. The paper is intended for novice and experienced neuropsychologists to enable them to develop or evaluate their current practices, and also for other clinicians, who seek a better understanding of the methodology underlying the neuropsychological input to their work.

Video-EEG in the pursuit of documented coexistence of epileptic and psychogenic nonepileptic seizures: how long is too long? - a case report / Vídeo-EEG em busca da real necessidade da documentação em crises epilépticas e não-epilépticas psicogênicas: quanto tempo é demasiado longo? - relato de caso

Continuous Vídeo-EEG monitoring remains the gold-standard tool to confirm or disregard the diagnosis of epilepsy in selected cases in which a differential diagnosis is required and not clearly established in the basis of outpatient procedures. However, it may be a tiresome and stressful experience for patients and it is certainly an expensive test. Thus, we wonder how far (considering both financial and emotional costs) should we pursue the goal of documenting all suspicious events. An illustrative case is presented.

Monitorização continua com Video-EEG permanece como método de eleição no diagnóstico de epilepsia, em casos selecionados onde o diagnóstico diferencial não pode ser perfeitamente definido com base em procedimentos ambulatoriais. Entretanto, a monitorização contínua pode constituir uma experiência cansativa e estressante para os pacientes, além de custo envolvido. Considerando estes custos (emocional e financeiro) é especulada a real necessidade da documentação de todos os eventos suspeitos. Um caso ilustrativo é apresentado.

Psychogenic nonepileptic seizures: an overview / Crises não-epilépticas psicogênicas: uma revisão

Pyschogenic nonepileptic seizures (PNES) are common and potentially harmful - both physically and emotionally - events. They are often under or misdiagnosed. Not only neurologists managing epilepsy, but also generalists and ER physicians should be aware of its existence, preventing unnecessary tests, as well as, iatrogenic interventions. The assistance provided to these patients is often inadequate, even at larger and busier epilepsy centers. That clearly impacts on the prognosis of this condition, which is fairly difficult to manage per se, yet with the best possible quality of care, including well trained multiprofessional teams.

Crises não-epilépticas psicogênicas (CNEP) são eventos comuns e potencialmente prejudiciais, tanto física quanto emocionalmente. São comumente subdiagnosticas ou mesmo diagnosticas erroneamente. Não apenas neurologistas envolvidos com o tratamento de epilepsia, mas também clínicos gerais e principalmente médicos em unidades de emergência deveriam estar cientes de sua existência, evitando exames desnecessários e possível iatrogênese. A assistência a estes pacientes é frequentemente inadequada, mesmo em grandes centros de atendimento a epilepsia, aspecto que impacta de forma definitiva no prognóstico destes pacientes. O manejo destes casos é habitualmente difícil, mesmo em ambientes com equipes multiprofissionais bem treinadas com este propósito.