Subclinical epileptiform activity in children with electrical status epilepticus during sleep: effects on cognition and behavior before and after treatment with levetiracetam.

We performed a double-blind placebo-controlled crossover study of the effects of spike activity during sleep and when awake on learning, long-term memory, vigilance and behavior before and after treatment with levetiracetam in children with electrical status epilepticus during sleep. At baseline, verbal learning declined with increasing spike activity, but there were no relations between spike activity and memory, vigilance or behavior. Levetiracetam was effective in reducing sleep-related spike activity, but on a group level, this had no clear effects on behavior, vigilance or learning and memory. Our results do not allow firm conclusions whether to treat nocturnal epileptiform activity or not; larger samples and longer follow-up may be needed.

The effect of levetiracetam on focal nocturnal epileptiform activity during sleep--a placebo-controlled double-blind cross-over study.

Electric Status Epilepticus during Sleep (ESES) occurs in children with and without epilepsy. It may be related to disturbances as autism spectrum disorder, attention-deficit hyperactivity disorder and acquired aphasia (Landau-Kleffner syndrome). Antiepileptic drug (AED) treatment has been reported in small studies without placebo control. This study was designed to assess AED effect in a placebo-controlled double-blind cross-over study. Levetiracetam (LEV) was chosen based on clinical evidence. Eighteen patients fulfilled the inclusion criteria. The mean spike index at baseline was 56, falling to a mean of 37 at the end of the LEV treatment period. Assessed with a 2-way ANOVA, there is a significant treatment effect (p<0.0002). To the best of our knowledge, this is the first placebo-controlled double-blind cross-over study for any AED in patients with ESES. The effect of LEV is comparable with its effect in treatment of epileptic seizures.

An fMRI study of auditory hallucinations in patients with epilepsy.

PURPOSE: The aim of the study was to investigate behavioral and brain activation in nonpsychotic hallucinating individuals. Auditory hallucinations are reported by patients with epilepsy, although less frequent than visual hallucinations are. If behavioral and neuronal activation patterns in hallucinating patients with epilepsy are found to be similar to what has been found in hallucinating patients with schizophrenia, this would support a unique neuronal representation for auditory hallucinations cutting across diagnostic groups. METHODS: We report behavioral and functional magnetic resonance imaging (fMRI) data from six epilepsy patients experiencing auditory hallucinations compared with six healthy control subjects. The participants had to report which of two simultaneously presented simple speech sounds they perceived on each trial, using a dichotic stimulus presentation mode. RESULTS: The results showed that the patients failed to show an expected right ear advantage on the task, and they also showed significantly reduced activation in temporal, frontal, and cingulate cortex areas. DISCUSSION: The results are discussed in relation to a view that neuropsychological and functional neuroimaging indices of auditory hallucinations may be orthogonal to diagnostic category and not unique to patients with schizophrenia.

[Psychogenic non-epileptic seizures]. / Psykogene ikke-epileptiske anfall.

BACKGROUND: Psychogenic non-epileptic seizure is the term used for epilepsy-like seizures assumed to have psychological causes. Many patients with such seizures are misdiagnosed with epilepsy, and are consequently treated with antiepileptic drugs for many years. Assessment of a thorough medical history and ictal EEG-recordings will lead to the right diagnosis in most cases. The article provides an overview of this condition, which often represents large diagnostic and therapeutic challenges and is the most frequent differential diagnosis in epilepsy. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in PubMed up to January 2009. RESULTS: Much literature is available in the field. 10-20 % of those referred to epilepsy centers because of therapy-resistant epilepsy, have psychogenic non-epileptic seizures. 70-80 % of these patients are women. The attacks may resemble all types of epileptic seizures, from absence-like episodes to tonic-clonic-like seizures. INTERPRETATION: Such seizures may have a wide spectre of causes, including chronic psychological conflicts and psychotraumas. Treatment should therefore be tailored to individuals.

An fMRI case study of visual memory in a patient with epilepsy: comparison before and after temporal lobe surgery.

We report fMRI activation data for a female patient with epilepsy, who was tested before and 2 years after resection surgery, to assess changes in fMRI activation. Areas within her right ATL/MTL were removed during surgery, including the right hippocampus. A visuo-spatial task was used in which novel and familiar pictures of objects, animals, scenes and buildings were randomly presented. Half of the pictures were novel to the patient, while half of the pictures were familiar pictures from the same stimulus categories. Despite unchanged visuo-spatial IQ-scores and equal performance on the fMRI task pre- and post-surgery, there was evidence of changes in functional organization of the brain as seen in the pre- versus post-surgery fMRI data. It is suggested that maintenance of memory performance from pre- to post-surgery might be due to functional reorganization in the brain, as evidenced in the fMRI data.

Long-term seizures and quality of life after epilepsy surgery compared with matched controls.

OBJECTIVE: We compared long-term seizure outcome and health-related quality of life (HRQoL) of patients who underwent epilepsy surgery and matched medically treated nonsurgical controls with intractable epilepsy. METHODS: Medically treated controls were identified for patients operated on for epilepsy between January 1, 1949 and December 31, 1992. We used a matched cohort design, matching for age, sex, and seizure type. The analysis was based on 70 complete matching pairs. HRQoL was assessed with the Quality of Life in Epilepsy Inventory 89 questionnaire an average of 15 years after surgery. RESULTS: Among surgery patients, 48% were seizure-free during the previous year compared with 19% of the controls (P = 0.0004). Fewer surgery patients used antiepileptic drugs (70%) than controls (93%). The odds of being seizure-free were higher for surgery patients in total and in subgroups divided according to length of follow-up. The mean HRQoL for surgery patients was higher in five of the 17 Quality of Life in Epilepsy Inventory 89 dimensions and worse in none. Among patients with more than 7 years of follow-up, HRQoL was better in three dimensions and worse in none. Among patients with 7 years of follow-up or less, HRQoL was better in two dimensions and worse in the language dimension of the Quality of Life in Epilepsy Inventory 89. CONCLUSION: After an average of more than 15 years of follow-up, epilepsy surgery patients had fewer seizures, used less antiepileptic medication, and had better HRQoL in several dimensions of the Quality of Life in Epilepsy Inventory 89 instrument than matched medically treated controls with refractory epilepsy, although possibly at a slight disadvantage in the language dimension among those with 7 years of follow-up or less.

Changes in verbal and nonverbal memory following anterior temporal lobe surgery for refractory seizures: effects of sex and laterality.

We studied the effects on verbal and nonverbal memory of anterior temporal lobe (ATL) surgery for epilepsy in 91 patients (46 men, 45 women), all of whom had left-hemisphere dominance for speech. Patients were divided into four groups according to sex and laterality of the excision. The memory tasks were administered shortly before surgery, 6 months postoperatively, and at a 2-year follow-up. Test scores were submitted to repeated-measures analyses of variance. We found that men treated with left temporal resection declined significantly in long-delay verbal memory after surgery, whereas no clear pre- to postoperative sex differences were found with respect to other verbal memory scores. Only the results on long-delay verbal memory confirm previous findings, showing a greater vulnerability of verbal memory to left ATL surgery in men than in women. Women with left temporal excisions obtained particularly poor scores on a long-delay nonverbal memory test preoperatively, but improved their performance on this test significantly after surgery. The seemingly gradual improvement during the 2-year follow-up suggests a plastic process.

Selective posterior cerebral artery amobarbital test: its role in presurgical memory assessment in temporal lobe epilepsy.

PURPOSE: To evaluate the efficacy and risk of complications of selective posterior cerebral artery (PCA) amobarbital anesthesia in memory assessment of patients with epilepsy under consideration for temporal lobe resection. METHODS: Thirty-two candidates for temporal lobectomy in whom conclusive memory assessment could not be obtained by the standard intracarotid amobarbital procedure were submitted to a selective PCA amobarbital test. A mean dose of 75 mg amobarbital was injected via microcatheter into the P2 segment of the PCA. Ten common objects were presented for naming and remembering while the anesthesia was judged efficient. After return to neurologic baseline, recall and recognition memory were assessed. RESULTS: In all of the 32 patients, angiography and PCA anesthesia were successfully accomplished without serious adverse events. All but one of the patients remained alert and cooperative for memory testing under the anesthesia, and 28 of these patients showed adequate memory capacity of the hemisphere contralateral to the side targeted for surgery. So far, 19 patients have proceeded to surgery, and no case of global amnesia or serious, material-specific memory impairment has resulted. Three patients failed the PCA test (fewer than 67% items correctly recognized) and were excluded from surgery, partly on the basis of the PCA test results, but also supported by an overall evaluation of all the diagnostic procedures used. CONCLUSIONS: The selective PCA amobarbital test appears justifiable when performed by interventional neuroradiologists and may significantly reduce the risk of erroneously excluding patients with epilepsy from temporal resection. Further corroboration of the safety of the procedure seems warranted.

Resective surgery for intractable focal epilepsy in patients with low IQ: predictors for seizure control and outcome with respect to seizures and neuropsychological and psychosocial functioning.

PURPOSE: To investigate possible predictive factors for seizure control in a group of children and adults with low IQs (IQ, < or =70) who underwent resective surgery for intractable focal epilepsy and to study outcome with respect to seizures and neuropsychological functioning. We also studied psychosocial outcome in the adult patients. METHODS: Thirty-one patients (eight children younger than 18 years) with a Wechsler Full Scale IQ of 70 or less underwent comprehensive neuropsychological assessments before and 2 years after surgery. Adults also completed the Washington Psychosocial Seizure Inventory (WPSI). Univariate analyses were used to identify variables differentiating between patients who became seizure free and those who did not. Pre- and postoperative test results were compared by t test for dependent samples. RESULTS: Forty-eight percent of the patients became seizure free, 52% of those with temporal lobe resection and 38% of those with extratemporal resection. Only one variable was predictive for seizure outcome: duration of epilepsy. In one third of the patients, who had the shortest duration of epilepsy (<12 years), 80% became seizure free. Significant improvement was seen regarding vocational adjustment in adults (WPSI). Seizure-free adults improved their Full Scale IQ scores. No cognitive changes were found in seizure-free children or in patients who did not become seizure free. CONCLUSIONS: A good seizure outcome was obtained after resective surgery in patients with intractable focal epilepsy and low IQ, provided that treatment was done relatively shortly after onset of epilepsy. No adverse effects were seen on cognitive and psychosocial functioning.

Surgical versus medical treatment for severe epilepsy: consequences for intellectual functioning in children and adults. A follow-up study.

We compared the effects of medical and combined surgical and medical treatment of refractory epilepsy on intellectual functioning in a group of children (n=13) and a group of adults (n=15). The patients were tested with the age-appropriate versions of Wechsler's intelligence scales twice prior to and once after epilepsy surgery. There were no significant differences between the groups in preoperative epilepsy-related variables, including age at onset. The IQ scores were submitted to two-way analyses of variance (ANOVA). We also evaluated individual changes in IQ scores. Adult patients maintained stable levels of performance after drug treatment as well as following surgery, while children declined in Full Scale IQ after both kinds of treatment. Children also declined in Performance IQ, but not in Verbal IQ after drug treatment, and in Verbal IQ, but not in Performance IQ after surgery. Three of six children who underwent a significant decline in Full Scale IQ before surgery did not show any further decline postoperatively. We have proposed a developmental model to account for the different findings in children and adults, and conclude tentatively that refractory, long-standing epilepsy may interfere with intellectual development both during drug treatment and following combined surgical and medical treatment in children, while the impact of long-standing refractory epilepsy of similar severity as in children is not strong enough to reduce intellectual performance in adults, irrespective of treatment modality.