[Differential diagnosis of epileptogenic substrates of unknown etiology using a modification of the routine MRI protocol]. / Differentsial'naya diagnostika epileptogennykh substratov neyasnoi etiologii s pomoshch'yu modifikatsii protokola standartnoi MRT.

OBJECTIVE: To evaluate the diagnostic capabilities of modifying the standard MRI protocol as part of an interdisciplinary presurgical examination of patients with epileptogenic substrates of unknown etiology. MATERIAL AND METHODS: The results of dynamic MRI of 8 patients with a referral diagnosis of focal cortical dysplasia (FCD) were analyzed. In 7 patients, epilepsy was the reason for a standard MRI of the brain; in another patient with myasthenia, MRI was performed as part of a comprehensive examination. All patients, in addition to standard MRI, underwent a modification of the real-time scanning protocol to include contrast, tractography (DTI), and perfusion techniques (ASL/DSC). In 1 case, with questionable results, the results of a modification of the standard MRI protocol, high-resolution MRI (HR MRI) and hybrid positron emission CT with 11C-methionine (PET/CT with 11C-MET) were combined. RESULTS: Seven patients underwent epileptic surgery and 1 patient was operated on for a tumor. In 4 out of 8 patients, based on the results of a modification of the standard MRI protocol, radiological signs of a neoplastic process were identified, which suggested a low-grade tumor. One of them needed PET/CT to confirm the assumption. The results of pathomorphological examination correlated with the direct diagnosis for surgical treatment. One of the 4 patients was suspected to have dysembryoplastic neuroepithelial tumor (DNET) based on the results of the protocol modification, which was also confirmed by pathological examination. In another 4 patients in whom it was possible to narrow the differential between FCD type II and DNET based on the results of the modification, FCD IIb was pathomorphologically verified. CONCLUSION: The proposed modification of the standard MRI protocol can significantly facilitate the differential diagnosis between the neoplastic and dysplastic origin of an epileptogenic substrate of unknown etiology, which in turn affects the patient's management tactics.

[The structural basis of epileptogenesis in an adult patient: the comprehensive diagnostics experience]. / Strukturnaya osnova epileptogeneza u vzroslogo patsienta: opyt kompleksnoi diagnostiki.

On the example of the diagnosis of the structural basis of focal epilepsy in an adult patient, the possibilities of a multimodal and interdisciplinary approach to diagnosis, combining the latest methods of neuroimaging with the results of neurophysiological examinations, are considered. The interaction and high qualification of specialists in epileptology, neuroradiology and pathomorphology provide a high probability to determine the cause of the focal forms of epilepsy. Along with the introduction of super-inductive MR systems, it is important to use their capabilities correctly and optimize the scanning protocol for the individual characteristics of the patient. With a long-term pharmacoresistant course of focal epilepsy, accompanied by low quality of life, the progression of neurological deficits and the aggravation of cognitive and personality problems in patients, it becomes obvious that these patients, even with negative results of standard MRI, are candidates for a more in-depth comprehensive examination to identify the structural basis of epileptogenesis and subsequent epileptic surgery. However, the problem of epilepsy pseudoresistance should be considered, when a patient with uncontrolled seizures takes antiepileptic drugs for a long time in inadequate dosages. Modern comprehensive diagnostics offers new rational approaches to antiepileptic therapy indication on the part of the doctor, as well as to improve the patient's compliance to the treatment.

[Features of the neuroradiological picture of ganglioglioma on the example of 20 clinical cases]. / Osobennosti neiroradiologicheskoi kartiny gangliogliomy na primere 20 klinicheskikh sluchaev.

OBJECTIVE: To analyze the images obtained during pre-surgical neuroimaging in patients with gangliomas for the presence of specific signs and verification of the neoplastic process. MATERIAL AND METHODS: The results of presurgical MRI (3.0, 1.5 Tesla) of 20 patients with gangliomas were analyzed to identify specific signs of a neuronal-glial tumor and verify the neoplastic process based on the results obtained and a review of the literature. In addition to high-resolution MRI (HR MRI), various protocol modifications were applied to patients with epileptogenic pathological substrates of unclear etiology, including tractography (DTI) and contrast-free MR perfusion (ASL). In 5 cases, a multi-modal study was performed that combined the results of CT, routine MRI, HR MRI, functional MRI (fMRI) in various combinations and PET CT. RESULTS AND CONCLUSION: In 17 cases, patients underwent epileptic surgery. Three patients without epilepsy were operated on for a tumor diagnosed by radiological examination. In all 20 cases, gangliogliomas were verified, including 1 anaplastic, 1 infantile desmoplastic, and another patient had histological samples showing signs of a composite tumor. Combination with FCD IIIb was observed in 3 cases. Two patients had a double pathology (cases of tumors combination with lissencephaly and neuronal heterotopia) and another had a composite neuronal-glial tumor. In 15 cases, gangliogliomas showed neuroradiological features typical for dysembryoplastic neuroepithelial tumor (DNT) such as multicystic, nodular, and diffuse (dysplastic) described in the literature. In addition, in 9 cases, they had significant signs of neoplastic process such as contrast enhancement, continued growth and remodeling of the underlying bone. Verification of the neoplastic process based on the results of neuroradiological studies was difficult in 6 cases. In 2 cases, it was not possible to confirm the presence of neoplasm by radiological methods, and in 1 patient, the verification of the tumor during differential diagnosis took more than 8 years. The most common differential diagnosis was performed with DNT and FCD type IIb, which have a number of similar neuroradiological features.

[The use of low-field MRI for visualization of epileptogenic brain lesions in children]. / Primenenie nizkoinduktivnoi magnitno-rezonansnoi tomografii dlia vizualizatsii strukturnykh épileptogennykh porazhenii golovnogo mozga u detei.

AIM: To analyze MR-images of patients with focal epilepsy using a method close to the protocol of epileptic scanning on a MRI-device with the magnetic field tension of 0.4 Tesla. MATERIAL AND METHODS: MRI data of 50 children who underwent examination due to difficult-to-treat or drug-resistant forms of focal epilepsy were analyzed. MRI study was conducted using open-ended device of static magnetic field HITACHI 'APERTO' with the magnetic field tension of 0.4 Tesla. The thickness of the slices and the scan step was performed at 3.0 and 3.5 mm with the use of special positioning of slices in the coronal and axial projections, T2, T1, STIR, FLAIR weighted images (WI) perpendicular and parallel to the long axis of the hippocampus. RESULTS: Potentially epileptogenic structural changes were identified in 37 patients. Abnormalities of brain development of different severity were identified in 16 patients. In 21 cases, the changes were due to the consequences of cerebral vascular catastrophes, neuroinfections, brain traumas affecting the cortical plate. A method close to the epileptic scanning protocol allowed the identification of signs of acute cerebral catastrophes in two patients. In 8 patients, potentially epileptogenic changes after false-negative descriptions of the results of previous MRI studies were newly identified. The most difficult for the diagnosis was the visualization of small structural changes in mediobasal regions of the temporal lobes. Confirmation of this supposition according to the recommended thorough investigation was obtained only in 5 out of 12 patients with suspected small-bore pathological changes in mediobasal temporal regions. CONCLUSION: Low-tension technique approximated to the epileptic scanning protocol does not allow the reliable diagnosis of small and similar in signal characteristics changes in the visualization of mediobasal temporal lobes regions. It was not possible to reliably differentiate some cortical-subcortical neoplastic formations from various forms of focal cortical dysplasia.

[Treatment of epilepsy in children with brain tumors]. / Lechenie epilepsii u detei s opukholyami golovnogo mozga.

AIM: Symptomatic focal epilepsy is frequently caused by supratentorial brain tumors that may be surgically removed. The authors studied outcomes of surgical treatment depending on the use of electrocorticography c (ECoG). MATERIAL AND METHODS: Seventy-five children, aged 5-7 years, with supratentorial brain tumors were examined. Symptomatic epilepsy was found in 52 (69.3%) patients. Dysembryoplastic neuroepithelial tumors (DNET) and fibrillary astrocytomas were the most epileptogenic tumors. RESULTS AND CONCLUSION: The outcomes on the Engel scale were as follows: in 27 patients with surgical intervention without ECoG: class I - 9 patients, class II - 7 patients, class III - 5 patients, class IV - 6 patients and in 25 patients operated with ECoG: class I - 19 patients, class II - 4 patients and class III - 2 patients. The significant difference (p<0.01) between I+II Engel classes in comparison with III+IV Engel classes in operated patients demonstrated the necessity of ECoG during surgery in the resection of supratentorial brain tumors in patients with symptomatic epilepsy.

[MRI-characteristics of epileptogenic supratentorial brain tumors in children].

OBJECTIVE: To analyze MR-images in patients with symptomatic epilepsy associated with the brain tumor. MATERIAL AND METHODS: MRI results of 52 patients with symptomatic epilepsy operated for tumors of supratentorial localization were analyzed. The most epileptogenic tumors with atypical MRI signs and subtle clinical presentation were identified. All patients with tumors were operated using different methods of surgical intervention. RESULTS: Dysembryoplastic neuroepithelial tumors (DNET), diffuse astrocytomas (DA) and gangliogliomas (GG) were the most frequent epileptogenic tumors. In all the cases of DNET and in 4 patients with GG, epileptic seizures were the first, and in 4 of 5 cases of DIO were the only clinical sign of tumor presence. In DNET, DA and GG, there was an iso- or hypointensive signal on T1 WI and a signal varying in intensity from moderate to hyperintense in T2 and FLAIR WI, while in cases with DNET and GG, no mass effect and perifocal edema was practically seen. The so-called «spume-like¼ (multicystic) structure was most clearly observed in FLAIR WI. No significant changes in the dimensions of the DNET and GG were identified. The combination of DNET with focal cortical dysplasia was noted in one case. In DA, it was difficult to distinguish the perifocal edema from tumorous tissue and normal brain tissues, and the growth potential of malformation was slow. CONCLUSION: Epileptogenic tumors can imitate the x-ray characteristics of each other, and mimicry to gangliogliomas, oligodendrogliomas and astrocytomas Gr I, II, and others. They are the most frequent causes of symptomatic focal epilepsy. The presence of these malformations is necessary to exclude first of all in all cases of pharmacoresistant epilepsy.

[Efficacy and safety of topiramate depending on patient's age and forms of epilepsy].

Seven hundreds and twenty-two epileptic patients receiving topiramate (374 males, 348 females), aged from 3 month to 57 years, were followed with video-EEG control during the period of 2002-2012. Topiramate was effective in 465 (64.4%) patients, and among them the efficacy of monotherapy (72.2%) was higher compared to combined therapy (61.9%). The low efficacy was seen in 198 (27.4%) patients. The aggravation effect was noted in 59 (8.2%) of patients. Drug compliance (for >1 year) was 60.7%. In the group <1 year, the high efficacy was observed in 55.2%, low efficacy - in 34.5%, aggravation - in 10.3%. In the group 1-3 years, these indicators were 54.8%, 31.8% and 13.4%, respectively. In the pediatric population (>3 years), they were 67.3%, 26.2% and 6.5% as well as in the adult population (>18 years) - 82.1%, 16.6% and 1.3%, respectively. Thus, topiramate is a highly effective medication in the therapy of idiopathic generalized epilepsies without absences and in symptomatic/cryptogenic focal forms of epilepsy. The efficacy of topiramate raised with increasing of age while the aggravation risk decreased significantly.