Falsa laterização no EEG de escalpo na epilepsia mesial temporal mesial temporal por esclerose hipocampal: relato de casos / False lateralization on scalp EEG on mesial temporal epilepsy due to hippocampal sclerosis: cases report

A epilepsia do lobo temporal Mesial (ELMT) associada à esclerose hipocanpal(EH) necessita muitas vezes de tratamento cirúrgico. Para tanto, é necessário identificar um foco unilateral das crises. Na maioria das vezes, EH visualizada à RNM se correlaciona com a origem das descargas ao EEG de escalpo. Porém, em uma minoria, o registro de descargas colaterais ao lado da EH deixa dúvida quanto ao foco epileptogênico, cabendo aí uma investigação eletrofisiológica ivasiva, mais fidedigna. O objetivo é relatar três casos em que investigação inicial não confirmou a lateralidade das crises, ilustrando a falsa lateralização no EEG de escalpo na ELMT/EH. Como as descargas da EH provêm de regiões profundas do cérebro, estas poderiam se propagar para o lado contralateral antes de atingir a superfície. Por outro lado, é possível que o estímulo a longo prazo do lobo contralateral possa se transformar em uma área independente de crises (epileptogênese secundária), o que contra-indicaria a cirurgia.

Resection of the lesion in patients with hypothalamic hamartomas and catastrophic epilepsy.

BACKGROUND: Patients with hypothalamic hamartomas (HH) often have severe refractory epilepsy, incapacitating behavioral abnormalities, and cognitive decline. Attempts to control the seizure disorder by resection of apparently epileptogenic mesial temporal or other cortical structures have failed consistently. OBJECTIVE: To report a series of 13 patients in whom the hamartoma itself was resected. METHODS: All patients underwent preoperative evaluation between ages 2 and 33 years and had subtotal or complete resection of the hamartoma. Follow-up ranged from 1 to 5.5 years (mean: 2.8 y). RESULTS: Preoperatively, all patients had variable combinations of gelastic, complex partial, and generalized seizures. Eight had drop attacks. In addition, all had marked behavior abnormalities and cognitive impairment. Postoperatively, two patients are completely seizure-free and 11 are either seizure-free or have achieved a greater than 90% reduction of drop attacks and generalized tonic-clonic seizures. However, minor gelastic, complex partial, and atypical absence seizures have persisted in 11 patients, although at significantly reduced rates. In addition, there has been a dramatic improvement in behavior and cognition. Three patients had an anterior thalamic and one a capsular infarct, which left only minimal long-term deficits. Exact location of the lesion in relation to the interpeduncular fossa and the walls of the third ventricle correlated with extent of excision, seizure control, and complication rate. CONCLUSION: Resection can alleviate both the seizures and the behavioral and cognitive abnormalities of hypothalamic hamartomas, but complications are frequent.

[Neuropathology of hard to control epilepsy. Study of 300 consecutive cases]. / Neuropatologia das epilepsias de difícil controle. Estudo de 300 casos consecutivos.

We report histopathological findings in 300 consecutive surgical specimens from epilepsy surgery during 6 years. Our material was mainly from temporal lobe epilepsy (70.33%). In 44% the diagnosis was hippocampal sclerosis. There were tumors in 15% of cases and neuronal migration disorders in 10%. The most common tumors were gangliogliomas (42.22%) and dysembryoplastic neuroepithelial tumors (20%). We review the more frequent diagnosis in epilepsy surgery based on this series and comparing with literature.

Operative strategies for patients with cortical dysplastic lesions and intractable epilepsy.

Cortical dysplastic lesions (CDLs) are usually identified by magnetic resonance imaging (MRI). Clinical, electrographic and histologic findings suggest that focal CDLs (FCDLs) are highly epileptogenic, often involve the rolandic cortex, and can present variable degrees of histopathologic abnormalities. An ictal or "ictal-like" bursting pattern of electrographic activity was recorded over dysplastic cortex in 65% of our patients. Resective surgery can eliminate or significantly reduce seizure frequency in many medically intractable patients, depending on lesion location, degree, and extent of histopathologic abnormalities. Best results are achieved when complete or major excision of both the MRI-visible lesion and the cortical areas displaying ictal electrographic activity can be performed. This is more likely when the degree of histopathologic abnormality is mild to moderate or when the lesion is in a temporal lobe. More severe histopathologic abnormalities and central insular or multilobar lesions usually lead to less favorable results: either major excision of the visualized lesion is impractical or the lesion is microscopically more extensive than shown by MRI. Multilobar resection or hemispherectomy for patients with infantile spasms associated with CDLs and for patients with hemimegalencephaly are often associated with dramatic improvement in seizure control. Callosotomy can be performed in selected patients with diffuse CDLs who have intractable drop attacks.

Electrographic evidence suggests that human dysplastic cortex is intrinsically epileptogenic

Lesöes displásicas corticais (LDC) estäo frequentemente associadas a epilepsias de difícil controle. Nós descrevemos os correlatos eletrográficos deste alto grau de epileptogenicidade, caracterizado por descargas epileptógenas rítmicas, contínuas ou quase-contínuas, registradas diretamente das LDC durante eletrocorticografia trans-operatória. Esta atividade ictal ou descargas epileptogênicas contínuas (AI/DEC) manifestava-se por um de três padröes: (a) crises eletrográficas repetidas; (b) surtos de polipontas recorrentes; ou (c) espículas rítmicas contínuas ou quase-contínuas. Um ou mais destes padröes estava presente em 23 de 34 pacientes (67 por cento ) com epilepsia partial de difícil controle associada a LDC. Esta AI/DEC era geralmente mais localizada, assim contrastando com a atividade interictal ao eletrocorticograma, que era mais difusa. Nós concluimos que LDC säo altamente e intrinsicamente epileptogênicas e discutimos mecanismos possivelmente relacionados a esta epileptogenicidade intrínsica

Trigonocephaly.

Trigonocephaly has been described either as an isolated anomaly or as part of the clinical spectrum of some well-known syndromes. Treatment, complications, and prognosis are closely related to the manifestations of the associated anomalies. We report on the main types of syndromes with trigonocephaly and the management of this condition.

[Spontaneous intraparenchymatous hematomas. Experience with 134 cases]. / Hematomas intraparenquimatosos espontâneos. Experiência com 134 casos.

One hundred thirty four cases of spontaneous intraparenchymatous hematomas have been studied. They were separated into six groups according to criteria related to topography, level of consciousness, and hematoma volume. Treatment protocols--conservative, conservative with I.C.P. monitoring, and surgical--were different in each group. Results have shown an increased mortality (p < 0.05) among patients whose level of consciousness were more severely compromised, in those older than 50 years old, and in those harbouring quadrilateral, intraventricular or brainstem hematomas. Overall mortality was 26.1%.

Cirurgia de tiroide: o autotransplante de paratireoide para evitar o hipoparatireoidismo. / Thyroid surgery: the autotransplantation of parathyroid for the prevention of hypoparathyroidism

E feita da literatura sobre o autotransplante de paratiroide e os autores sugerem a utilizacao deste procedimento para evitar o hipoparatireoidismo pos-tireoidectomias totais