Testing an Adapted Auditory Verbal Learning Test Paradigm for fMRI to Lateralize Verbal Memory in Patients with Epilepsy.

BACKGROUND AND PURPOSE: fMRI is a noninvasive tool for predicting postsurgical deficits in candidates with pharmacoresistant temporal lobe epilepsy. We aimed to test an adapted paradigm of the Rey Auditory Verbal Learning Test to evaluate differences in memory laterality indexes between patients and healthy controls and its association with neuropsychological scores. MATERIALS AND METHODS: We performed a prospective study of 50 patients with temporal lobe epilepsy and 22 healthy controls. Participants underwent a block design language and memory fMRI. Laterality indexes and the hippocampal anterior-posterior index were calculated. Language and memory lateralization was organized into typical and atypical on the basis of laterality indexes. A neuropsychological assessment was performed with a median time from fMRI of 8 months and was compared with fMRI performance. RESULTS: We studied 40 patients with left temporal lobe epilepsy and 10 with right temporal lobe epilepsy. Typical language occurred in 65.3% of patients and 90.9% of healthy controls (P = .04). The memory fMRI laterality index was obtained in all healthy controls and 92% of patients. The verbal memory laterality index was bilateral (24.3%) more frequently than the language laterality index (7.69%) in patients with left temporal lobe epilepsy. Atypical verbal memory was greater in patients with left temporal lobe epilepsy (56.8%) than in healthy controls (36.4%), and the proportion of bilateral laterality indexes (53.3%) was larger than right laterality indexes (46.7%). Atypical verbal memory might be associated with higher cognitive scores in patients. No relevant differences were seen in the hippocampal anterior-posterior index according to memory impairment. CONCLUSIONS: The adapted Rey Auditory Verbal Learning Test paradigm fMRI might support verbal memory lateralization. Temporal lobe epilepsy laterality influences hippocampal memory laterality indexes. Left temporal lobe epilepsy has shown a higher proportion of atypical verbal memory compared with language, potentially to memory functional reorganization.

Gliomatosis cerebri and Rasmussen's encephalitis: Two different entities causing refractory epilepsy. Comparison through two clinical cases.

BACKGROUND AND IMPORTANCE: Rasmussen's Encephalitis (RE) is a chronic and progressive childhood disease caused by an inflammatory disorder that affects a cerebral hemisphere. On the other hand, Gliomatosis Cerebri (GC) is a rare primary neoplastic glial process with a diffuse and infiltrative growth. CLINICAL PRESENTATION: We present two clinical cases with a history of continuous focal epilepsy refractory to antiepileptic drugs. They share similar clinical and radiologic features, but a different histopathological diagnosis. A brain biopsy was needed to distinguish GC from a RE. CONCLUSION: The debut of a drug-resistant epilepsy with focal seizures and an ipsilateral progressive hemiparesis suggests the diagnosis of RE. However, there are other entities such as GC, which, despite its rarity, should be considered in the differential diagnosis. So, in some cases, histological diagnosis is needed.

VNS and pregnancy: A multicentric experience of four cases.

BACKGROUND: Vagus nerve stimulation system (VNS) has been employed worldwide as adjunctive therapy in drug-resistant epileptic patients. Only nine previous pregnancies with six-positive outcomes have been reported in women with epilepsy treated with VNS since 1998. AIMS OF THE STUDY: To communicate the experience of pregnancies in women treated with VNS in our country. METHODS: Clinical data of four female patients treated with VNS during pregnancy and delivery in five gestations is described. RESULTS: Four pregnancy outcomes were positive and one ended in spontaneous abortion, probably more related to the use antiepileptic drugs than VNS itself. Two births were vaginal and the other two with cesarean section. None of the complications during delivery were attributed to VNS. No teratogenicity was documented. CONCLUSIONS: Based on our experience VNS constitutes a safe therapy for the treatment of drug-resistant epilepsy in women of childbearing potential and during pregnancy and delivery. Larger series will be useful to confirm this finding.

[Results of vagal nerve stimulation in patients with pharmacoresistant epilepsy in a national epilepsy referral centre]. / Resultados de la estimulacion del nervio vago en pacientes con epilepsia farmacorresistente en un centro de referencia nacional de epilepsia.

AIM: To describe clinical results and complications derived from vagal nerve stimulation therapy in drug resistant epileptic patients unsuitable for other surgical treatments, since the first implant in an epilepsy national referral centre. PATIENTS AND METHODS: A retrospective analysis of the patients implanted in our centre was held. Data related to baseline characteristics of their epilepsy and therapy complications was collected. RESULTS: 32 new implants in 31 patients are included, mean age of 34 years, 29.3 years of disease evolution, three anti-epileptic drugs at surgery and a postoperative follow-up of 4.03 years. Complex partial seizures types (71.9%) and cryptogenic aetiology (59.4%) were the most frequent. 75% of patients hadn't history of previous epilepsy surgery. 43.8% of patients had a seizure frequency improvement above 50%, with a better response in patients with complex partial seizures (p = 0.22) and cryptogenic aetiology. None statistical significance was found between antiepileptic drugs and seizure frequency. Dysphonia, hoarseness and dysphagia, mostly transient, were the side effects registered. There was an asystole during surgery, completely recovered. One device was replaced due to hardware rupture after a seizure related trauma, one had to be adjusted due to a previous vocal cord paresis, and one dysfunctioning device was removed. In 84.4% the tolerance was excellent. CONCLUSIONS: Vagal nerve stimulation is an effective treatment for significant seizure frequency improvement of resistant patients untreatable with other medical or surgical treatments. Further studies are needed to predict the individual response of each patient to therapy and optimizing indications, therefore contributing to cost/benefit optimization.

TITLE: Resultados de la estimulacion del nervio vago en pacientes con epilepsia farmacorresistente en un centro de referencia nacional de epilepsia.Objetivos. Describir los resultados clinicos y complicaciones derivados de la estimulacion vagal en pacientes con epilepsia farmacorresistente no tributaria de otras modalidades de tratamiento quirurgico, desde el primer implante en un centro de referencia nacional. Pacientes y metodos. Se realizo un analisis retrospectivo de los pacientes implantados en nuestro centro y se extrajeron datos relativos a las caracteristicas basales de su epilepsia y complicaciones derivadas. Resultados. Se incluyeron 32 nuevos implantes en 31 pacientes, con una edad media de 34 años, evolucion de enfermedad de 29,3 años, tres farmacos antiepilepticos prequirurgicos y 4,03 años de seguimiento. Las crisis parciales complejas (71,9%) y criptogenicas (59,4%) fueron el tipo y la etiologia de crisis mas frecuentes. El 75% no tenia antecedentes quirurgicos de epilepsia. Un 43,8% presento mejoria igual o superior al 50%, mayor en las epilepsias parciales complejas (p = 0,22) y la etiologia criptogenica. No se hallo asociacion estadistica entre ajustes de medicacion y frecuencia de las crisis. Los efectos secundarios encontrados fueron disfonia, ronquera y disfagia transitorias, y una asistolia intraoperatoria recuperada. Se realizo un recambio por ruptura de hardware postraumatica. Un paciente con paresia preexistente de cuerda vocal presento estridor laringeo que requirio ajuste de intensidad, y se produjo una retirada del sistema por disfuncion. En el 84,4%, la tolerancia fue excelente. Conclusiones. Constituye un tratamiento efectivo para mejorar significativamente la frecuencia de crisis de los pacientes farmacorresistentes y con contraindicacion para otras modalidades de tratamiento quirurgico. Se precisan futuros estudios para predecir la respuesta individual de cada paciente, optimizar las indicaciones y mejorar la relacion coste/beneficio.

PET/MRI and PET/MRI/SISCOM coregistration in the presurgical evaluation of refractory focal epilepsy.

We aimed to investigate the usefulness of coregistration of positron emission tomography (PET) and magnetic resonance imaging (MRI) findings (PET/MRI) and of coregistration of PET/MRI with subtraction ictal single-photon emission computed tomography (SPECT) coregistered to MRI (SISCOM) (PET/MRI/SISCOM) in localizing the potential epileptogenic zone in patients with drug-resistant epilepsy. We prospectively included 35 consecutive patients with refractory focal epilepsy whose presurgical evaluation included a PET study. Separately acquired PET and structural MRI images were coregistered for each patient. When possible, ictal SPECT and SISCOM were obtained and coregistered with PET/MRI. The potential location of the epileptogenic zone determined by neuroimaging was compared with the seizure onset zone determined by long-term video-EEG monitoring and with invasive EEG studies in patients who were implanted. Structural MRI showed no lesions in 15 patients. In these patients, PET/MRI coregistration showed a hypometabolic area in 12 (80%) patients that was concordant with seizure onset zone on EEG in 9. In 7 patients without MRI lesions, PET/MRI detected a hypometabolism that was undetected on PET alone. SISCOM, obtained in 25 patients, showed an area of hyperperfusion concordant with the seizure onset zone on EEG in 7 (58%) of the 12 of these patients who had normal MRI findings. SISCOM hyperperfusion was less extensive than PET hypometabolism. A total of 19 patients underwent surgery; 11 of these underwent invasive-EEG monitoring and the seizure onset zone was concordant with PET/MRI in all cases. PET/MRI/SISCOM coregistration, performed in 4 of these patients, was concordant in 3 (75%). After epilepsy surgery, 13 (68%) patients are seizure-free after a mean follow-up of 4.5 years. PET/MRI and PET/MRI/SISCOM coregistration are useful for determining the potential epileptogenic zone and thus for planning invasive EEG studies and surgery more precisely, especially in patients without lesions on MRI.

Simple fMRI postprocessing suffices for normal clinical practice.

BACKGROUND AND PURPOSE: Whereas fMRI postprocessing tools used in research are accurate but unwieldy, those used for clinical practice are user-friendly but are less accurate. We aimed to determine whether commercial software for fMRI postprocessing is accurate enough for clinical practice. METHODS: Ten volunteers underwent fMRI while performing motor and language tasks (hand, foot, and orolingual movements; verbal fluency; semantic judgment; and oral comprehension). We compared visual concordance, image quality (noise), voxel size, and radiologist preference for the activation maps obtained by using Neuro3D software (provided with our MR imaging scanner) and by using the SPM program commonly used in research. RESULTS: Maps obtained with the 2 methods were classified as "partially overlapping" for 70% for motor and 72% for language paradigm experiments and as "overlapping" in 30% of motor and in 15% of language paradigm experiments. CONCLUSIONS: fMRI is a helpful and robust tool in clinical practice for planning neurosurgery. Widely available commercial fMRI software can provide reliable information for therapeutic management, so sophisticated, less widely available software is unnecessary in most cases.

Successful outcome of episodes of status epilepticus after vagus nerve stimulation: a multicenter study.

BACKGROUND AND PURPOSE: Vagus nerve stimulation (VNS) has been reported to be a safe and effective treatment for drug-resistant epilepsy. The aim of this study is to describe the effect of VNS in patients with a history of repeated episodes of status epilepticus (SE) before implantation. METHODS: From a total of 83 adult patients with drug-resistant epilepsy who had VNS implanted in four tertiary centers in Spain between 2000 and 2010, eight had a previous history of repeated episodes of SE. We performed a retrospective observational study analyzing the outcome of seizures and episodes of SE after implantation. Stimulation was started at the usual settings, and intensity increased according to clinical response and tolerability. RESULTS: Regarding the eight patients with a history of SE, the mean age at time of VNS implantation was 25.1 [14-40] years. Duration of epilepsy until the implantation was 21.7 [7-39.5] years, and they had been treated with a mean of 12 antiepileptic drugs [10-16]. Mean follow-up since implantation was 4.15 [2-7.5] years. Average seizure frequency decreased from 46 to 8.2 per month. Interestingly, four of the eight patients remained free of new episodes of SE after implantation, and in two additional patients, the frequency decreased by >75%. Adverse effects were mild or moderate in intensity and included mainly coughing and dysphonia. CONCLUSION: In those patients with refractory epilepsy and history of SE who are not surgical candidates, VNS is a safe and effective method to reduce seizure frequency and episodes of SE.

Efficacy and safety of pallidal stimulation in primary dystonia: results of the Spanish multicentric study.

BACKGROUND: Dystonia is a complex clinical syndrome originated by a wide range of aetiologies. The diagnosis of dystonia is made after the evaluation of aetiological, phenomenological and genetic factors. Medications, except in patients with dopa-responsive dystonia, are of limited efficacy. Botulinum toxin injections are not applicable to patients with generalised dystonia, since many muscular groups contribute to disability. Clinical studies in children and adults with primary generalised dystonia (PGD) have reported beneficial effects of bilateral GPi deep brain stimulation (DBS) in both motor symptoms and disability produced by dystonia as well as a favourable impact of DBS in the health-related quality of life (HRQoL). Some clinical aspects of GPi stimulation in primary dystonia still remain controversial such as the influence of disease duration or age at onset in determining the postoperative clinical outcome. RESULTS: The authors report the results of a multicentric study designed to assess the tolerability and clinical effects of bilateral pallidal DBS on motor impairment, functional disability, quality of life, pain and mood in patients with medically refractory primary generalised or segmental dystonia.

[Anesthesia considerations for deep-brain stimulation in a patient with type-2 pantothenate kinase deficiency (Hallervorden-Spatz disease)]. / Consideraciones anestésicas en una paciente con déficit de pantotenato cinasa tipo 2 (enfermedad de Hallervorden-Spatz) para estimulación cerebral profunda.

Neurodegeneration associated with pantothenate kinase deficiency is an autosomal recessive condition caused by mutations in the pantothenate kinase 2 gene (PANK2). Clinical characteristics include progressive motor impairment and dementia. Medical treatment is limited and the dystonia tends to be refractory, making stereotactic surgery with placement of deep-brain electrodes an option that is being adopted with greater frequency in these patients. We report the case of a 32-year-old woman with severe dystonia associated with PANK2 protein deficiency. The patient was scheduled for stereotactic bilateral placement of electrodes in the medial globus pallidus, guided by computed tomography and under general anesthesia, to treat the debilitating dystonia and generalized stiffness associated with her condition. Anesthesia was maintained with propofol, rocuronium and remifentanil in perfusion during the intervention, which was uneventful. After the procedure, the patient was transferred to the intensive care unit and sedation was provided with remifentanil to allow slow, gradual emergence from anesthesia. The patient was discharged from hospital after placement of the implanted pulse generator, and subsequent follow-up showed improvement of the dystonia.

Consideraciones anestésicas en un paciente con déficit de pantotenato cinasa (enfermedad de Hallervorden-Spatz) para estimulación cerebral profunda / Anesthesia considerations for deep-brain stimulation in a patient with type-2 pantothenate kinase deficiency (Hallervorden-Spatz disease)

La neurodegeneración asociada al déficit de pantotenatocinasa es una entidad autosómica recesiva secundariaa las mutaciones del gen pantotenato cinasa 2(PANK2). Clínicamente se caracteriza por anormalidadesprogresivas del movimiento y demencia. El tratamientomédico de la enfermedad es limitado y la distoníasuele ser refractaria, por lo cual la cirugíaestereotáctica con colocación de electrodos cerebralesprofundos es una opción terapéutica cada vez más usadaen estos pacientes. Describimos una paciente de 32 añosde edad con distonía severa asociada a déficit dePANK2. Fue programada para tomografía computarizadaestereotáctica y colocación bilateral de electrodos ennúcleo pálido medial, bajo anestesia general para tratarla distonía debilitante y la rigidez generalizada asociadaa su enfermedad. Durante la intervención se realizó elmantenimiento anestésico con propofol, rocuronio yremifentanilo en perfusión, sin ninguna incidencia a destacardurante el procedimiento. Tras la intervención lapaciente fue trasladada a la unidad de cuidados intensivosbajo sedación farmacológica con remifentanilo paraproceder a una educción lentamente progresiva. Lapaciente pudo ser dada de alta tras la colocación delgenerador y en el seguimiento posterior se ha evidenciadomejoría de los movimientos distónicos(AU)

Neurodegeneration associated with pantothenate kinasedeficiency is an autosomal recessive condition caused bymutations in the pantothenate kinase 2 gene (PANK2).Clinical characteristics include progressive motorimpairment and dementia. Medical treatment is limited andthe dystonia tends to be refractory, making stereotacticsurgery with placement of deep-brain electrodes an optionthat is being adopted with greater frequency in thesepatients. We report the case of a 32-year-old woman withsevere dystonia associated with PANK2 protein deficiency.The patient was scheduled for stereotactic bilateralplacement of electrodes in the medial globus pallidus,guided by computed tomography and under generalanesthesia, to treat the debilitating dystonia and generalizedstiffness associated with her condition. Anesthesia wasmaintained with propofol, rocuronium and remifentanil inperfusion during the intervention, which was uneventful.After the procedure, the patient was transferred to theintensive care unit and sedation was provided withremifentanil to allow slow, gradual emergence fromanesthesia. The patient was discharged from hospital afterplacement of the implanted pulse generator, and subsequentfollow-up showed improvement of the dystonia(AU)

La hemisferectomía funcional también es eficaz en pacientes adultoscon epilepsia catastrófica / Successful functional hemispherectomy in adult patients with refractory epilepsy

Introducción. La hemisferectomía es una técnica quirúrgica empleada para tratar epilepsias farmaco resistentes en el contexto de síndromes hemisféricos difusos. La mayoría de las series de pacientes hemisferectomizados incluyen preferentemente pacientes en edad pediátrica. Métodos. Presentamos nuestra serie de cuatro pacientes adultos sometidos a hemisferectomía funcional para el tratamiento de su epilepsia refractaria tras realizarse una evaluación prequirúrgica completa. En tres pacientes la epilepsia era secundaria a un infarto dela arteria cerebral media y en uno a una encefalitis de Rasmussen. Resultados. Tras la cirugía tres pacientes permanecieron libres de crisis a lo largo del período de seguimiento (13-26 meses) y en el cuarto se consiguió una reducción >75% en su frecuencia de crisis. En todos los pacientes hubo una mejoría en su calidad de vida. Las complicaciones precoces tras la cirugía fueron una crisis tónico clónica aislada en un paciente y un estatus epiléptico precoz probablemente secundario a fiebre y meropenem que dismunuye el umbral convulsivo. El único déficit neurológico permanente que se produjo fue una hemianopsia en un paciente. Conclusión. La hemisferectomía funcional debe considerarse una opción quirúrgica en pacientes con epilepsia refractaria secundaria a lesiones hemisféricas extensas y que estén afectos previamente de hemiparesias graves (AU)

Introduction. Functional hemispherectomy is a surgical technique used to treat refractory epilepsies in the setting of extensive unilateral hemispheric lesions. Most series of hemispherectomies include mainly pediatric patients. Methods. We report our series of four adult patients that have undergone functional hemispherectomy for their refractory epilepsy. Each one had a complete presurgical evaluation including video EEG, neuropsychological testing and anatomical and functional neuroimaging. In three of them, the epilepsy was secondary to a middle cerebral artery infarction. One patient had Rasmussen encephalitis. Results. After surgery, three patents have become completely seizure free (follow up 13-26 months). The fourth patient has had more than 75% reduction in seizure frequency. All of them have had significant improvement in their quality of life. Early complications included an isolated tonic-clonic generalized seizure(one patient), and status epilepticus in another patients related to infection and use of meropenem. Only one patient has presented hemianopia as a permanent neurological deficit after surgery. Conclusions. Functional hemispherectomy is a good surgical option in the setting of large unilateral hemispheric lesions causing hemiparesis and intractable seizures, even in adult patients (AU)

[Successful functional hemispherectomy in adult patients with refractory epilepsy]. / La hemisferectomía funcional también es eficaz en pacientes adultos con epilepsia catastrófica.

INTRODUCTION: Functional hemispherectomy is a surgical technique used to treat refractory epilepsies in the setting of extensive unilateral hemispheric lesions. Most series of hemispherectomies include mainly pediatric patients. METHODS: We report our series of four adult patients that have undergone functional hemispherectomy for their refractory epilepsy. Each one had a complete presurgical evaluation including video EEG, neuropsychological testing and anatomical and functional neuroimaging. In three of them, the epilepsy was secondary to a middle cerebral artery infarction. One patient had Rasmussen encephalitis. RESULTS: After surgery, three patents have become completely seizure free (follow up 13-26 months). The fourth patient has had more than 75% reduction in seizure frequency. All of them have had significant improvement in their quality of life. Early complications included an isolated tonic-clonic generalized seizure (one patient), and status epilepticus in another patients related to infection and use of meropenem. Only one patient has presented hemianopia as a permanent neurological deficit after surgery. CONCLUSIONS: Functional hemispherectomy is a good surgical option in the setting of large unilateral hemispheric lesions causing hemiparesis and intractable seizures, even in adult patients.

Parry Romberg syndrome and linear scleroderma in coup de sabre mimicking Rasmussen encephalitis.

We present one patient with Parry Romberg syndrome and another with linear scleroderma in coup de sabre, with focal neurologic deficits and intractable seizures arising from the hemisphere ipsilateral to the cutaneous lesion. Brain MRI showed progressive hemispheric atrophy. Pathology after functional hemispherectomy showed chronic inflammatory features suggestive of Rasmussen encephalitis.

Alteraciones de la migración neuronal: una causa de epilepsia farmacorresistente curable / Neuronal migration disorders: a cause of curable medication resistant epilepsy

Introducción. La displasia cortical focal es una alteraciónde la migración neuronal que se manifiesta con crisis epilépticashabitualmente farmacorresistentes. La mejoría en las técnicasde neuroimagen durante los últimos años ha permitido el diagnósticoy tratamiento quirúrgico de algunos pacientes tratados en politerapiadurante muchos años con mal control de las crisis. Caso clínico.Varón de 22 años con crisis epilépticas desde los 18 meses,refractario a múltiples combinaciones de fármacos antiepilépticos(FAE) orales con electroencefalogramas que mostraban descargasfrontales, punta-onda rápida, de mayor expresión izquierda y técnicasde neuroimagen repetidamente normales. Tras su último ingresopor reagudización de las crisis se repitió el estudio de neuroimageny se observó displasia cortical focal frontal izquierda, por loque se inició valoración neuroquirúrgica. En la actualidad, seis mesesdespués de la intervención, el paciente no ha presentado nuevascrisis epilépticas y se ha iniciado la reducción del tratamiento conFAE orales. Conclusión. Resulta necesario repetir estudios de neuroimagenen pacientes estudiados previamente ante la posibilidadde rescatar de la refractariedad a un grupo de pacientes condenadosa mal control de sus crisis junto con los efectos secundarios demuchos de los FAE

Introduction. Focal cortical dysplasia is a neuronal migration disorder that appears with bouts of epileptic seizuresthat are usually medication resistant. The improvements introduced into neuroimaging techniques in recent years have madeit possible to diagnose and offer surgical treatment to certain patients who have been under polytherapy for many years withpoor control over their seizures. Case report. We report the case of a 22-year-old male with epileptic fits since the age of 18months, who was refractory to multiple combinations of oral antiepileptic drugs (AEDs) with electroencephalograms thatdisplayed frontal, fast spike-wave discharges, with greater expression on the left side and findings from neuroimaging techniquesthat were repeatedly normal. After being readmitted to hospital because his seizures had got worse, the neuroimaging studywas repeated and left frontal focal cortical dysplasia was observed, which led us to start considering neurosurgery. At present,six months after the intervention, the patient has had no further convulsive fits and therapy with oral AEDs is being reduced.Conclusions. Neuroimaging studies must be repeated in patients that have already been examined because in this way it maybe possible to save a group of patients (who would otherwise have to resign to poor control over their seizures as well as theside effects of many AEDs) from becoming medication resistant

[Neuronal migration disorders: a cause of curable medication resistant epilepsy]. / Alteraciones de la migración neuronal: una causa de epilepsia farmacorresistente curable.

INTRODUCTION: Focal cortical dysplasia is a neuronal migration disorder that appears with bouts of epileptic seizures that are usually medication resistant. The improvements introduced into neuroimaging techniques in recent years have made it possible to diagnose and offer surgical treatment to certain patients who have been under polytherapy for many years with poor control over their seizures. CASE REPORT: We report the case of a 22-year-old male with epileptic fits since the age of 18 months, who was refractory to multiple combinations of oral antiepileptic drugs (AEDs) with electroencephalograms that displayed frontal, fast spike-wave discharges, with greater expression on the left side and findings from neuroimaging techniques that were repeatedly normal. After being readmitted to hospital because his seizures had got worse, the neuroimaging study was repeated and left frontal focal cortical dysplasia was observed, which led us to start considering neurosurgery. At present, six months after the intervention, the patient has had no further convulsive fits and therapy with oral AEDs is being reduced. CONCLUSIONS: Neuroimaging studies must be repeated in patients that have already been examined because in this way it may be possible to save a group of patients (who would otherwise have to resign to poor control over their seizures as well as the side effects of many AEDs) from becoming medication resistant.

[The utility of interictal SPECT in temporal lobe epilepsy]. / ¿Es útil la SPECT interictal en la epilepsia del lóbulo temporal?

INTRODUCTION: Interictal brain single photon emission computed tomography (SPECT) is used in the presurgical evaluation of patients with complex partial epilepsy. The aim of the present study was to compare interictal SPECT, MRI and video-electroencephalography (EEG) for seizure focus localization in patients with temporal lobe epilepsy, one year after temporal lobectomy, in order to determine the utility of interictal brain SPECT. PATIENTS AND METHODS: Thirty four consecutive patients with refractory temporal epilepsy were evaluated with video-EEG, MRI and interictal SPECT for seizure focus localization before surgery. Seizure focus was confirmed with the clinical follow-up one year after temporal lobectomy in all patients. MRI and SPECT analysis was performed visually. RESULTS: 31/34 patients were seizure free one year after surgery and the remaining 3 patients remain with seizures occasionally. Video-EEG results coincided with postsurgical seizure focus localization in 31 (91%) patients. MRI localized seizure focus correctly in 30 (88%) patients and was normal in 3 cases. Interictal brain SPECT was normal in 10 patients and showed temporal hypoperfusion consistent with postsurgical seizure focus in 23 (68%) patients. In all patients with abnormalities in the interictal SPECT, seizure focus was identified with video-EEG or MRI. CONCLUSIONS: When MRI and video-EEG localize seizure focus in the same temporal lobe, interictal brain SPECT does not offer any additional information for surgical decision making.

¿Es útil la SPECT interictal en la epilepsia del lóbulo temporal? / The utility of interictal SPECT in temporal lobe epilepsy

Introducción. La tomografía computarizada por emission de fotón único (SPECT) cerebral interictal se emplea para localizar la zona epileptógena (ZE) en pacientes con crisis parciales complejas (CPC). El objetivo del presente trabajo fue comparar la utilidad de la SPECT interictal, la resonancia magnética (RM) y el vídeo-electroencefalograma (EEG) para lateralizar la ZE en un grupo de pacientes con CPC del lóbulo temporal 1 año después de la intervención quirúrgica. Pacientes y métodos. Se estudiaron con video-EEG, RM y SPECT interictal 34 pacientes consecutivos con CPC del lóbulo temporal. Los hallazgos se confirmaron con la evolución clínica de las crisis epilépticas 1 año después de la lobectomía temporal. La valoración de las imágenes de RM y SPECT se efectúo de forma visual. Resultados. De lso 34 pacientes intervenidos 31 están libres de crisis (estadio I de Engel) y 3 tienen muy pocas crisis incapacitantes (estadio II). La ZE (valorada por vídeo-EEG) coincidió con la localizada mediante el control posquirúrgico en 31 pacientes (91%). La SPECT interictal fue normal en 10 casos y demostró una hipoperfusión temporal que coincidió con la ZE en 23 pacientes (68%). Únicamente en un caso la hipoperfusión de la SPECT no coincidió con la ZE. En todos los casos con anomalías en la SPECT había una lesión en RM o una buena localización por v ídeo-EGG. La RM localizó correctamente la ZE en 30 pacientes (88%) y fue normal en 3 casos (AU)

Introduction: Interictal brain single photon emission computed tomography (SPECT) is used in the presurgical evaluation of patients with complex partial epilepsy. The aim of the present study was to compare interictal SPECT, MRI and video-electroencephalography (EEG) for seizure focus localization in patients with temporal lobe epilepsy, one year after temporal lobectomy, in order to determine the utility of interictal brain SPECT. Patients and methods: Thirty four consecutive patients with refractory temporal epilepsy were evaluated with video-EEG, MRI and interictal SPECT for seizure focus localization before surgery. Seizure focus was confirmed with the clinical follow-up one year after temporal lobectomy in all patients. MRI and SPECT analysis was performed visually. Results: 31/34 patients were seizure free one year after surgery and the remaining 3 patients remain with seizures occasionally. Video-EEG results coincided with postsurgical seizure focus localization in 31 (91%) patients. MRI localized seizure focus correctly in 30 (88%) patients and was normal in 3 cases. Interictal brain SPECT was normal in 10 patients and showed temporal hypoperfusion consistent with postsurgical seizure focus in 23 (68%) patients. In all patients with abnormalities in the interictal SPECT, seizure focus was identified with video-EEG or MRI. Conclusions: When MRI and video-EEG localize seizure focus in the same temporal lobe, interictal brain SPECT does not offer any additional information for surgical decision making (AU)

Cortical laminar necrosis related to prolonged focal status epilepticus.

Cortical laminar necrosis (CLN) is radiologically defined as high intensity cortical lesions on T1 weighted MRI images following a gyral distribution. Histopathologically, CLN is characterised by pannecrosis of the cortex involving neurones, glial cells, and blood vessels. It has been reported to be associated with hypoxia, metabolic disturbances, drugs, and infections. We present two patients who developed CLN and permanent neurological deficits after prolonged and repeated focal status epilepticus. The possible mechanisms leading to CLN in these patients are discussed, together with the implications of prompt and aggressive treatment in similar cases.

Complex motor behaviors in temporal lobe epilepsy.

Complex motor behaviors differing from typical automatisms were found in 12 of 502 patients with temporal lobe epilepsy. Movements involved proximal limb segments (6) or body axis (6) and were often preceded by auras and followed by automatisms. Seven of 12 patients are seizure free after surgery. The other 5 patients declined surgery.