Memoria episódica verbal en pacientes pediátricos intervenidos de cirugía de la epilepsia del lóbulo temporal: un estudio de seguimiento al año / Verbal episodic memory in children undergoing temporal lobe epilepsy surgery: a one-year follow-up study

Introducción La memoria episódica verbal (MEV) no suele resultar alterada en niños con epilepsia focal sometidos a resecciones del lóbulo temporal izquierdo, a diferencia de lo que cabría esperar si se tratara de un cerebro adulto. Los últimos hallazgos sugieren que la actividad epileptógena en los primeros años de vida disrumpe la lateralización del sistema mnésico, lo que conduce al desarrollo de una representación bilateral de la memoria. El presente estudio pretende analizar si la lateralidad de la epilepsia es un predictor significativo de cara al pronóstico posquirúrgico de la MEV en la cirugía de la epilepsia del lóbulo temporal (ELT) en edad pediátrica. Esta investigación también pretende aportar evidencias sobre la relación de la MEV con otros factores demográficos y clínicos relevantes, como el sexo, la edad de inicio de las crisis, la edad quirúrgica y la duración de la epilepsia, así como estudiar el impacto del rendimiento prequirúrgico en la MEV sobre los resultados posquirúrgicos. Pacientes y métodos Se extrajeron de la base de datos del Hospital Sant Joan de Déu y se analizaron retrospectivamente las puntuaciones prequirúrgicas y al año de seguimiento postoperatorio de una tarea de recuerdo de lista de palabras correspondientes a 25 niños intervenidos de ELT (ELT izquierdo, n = 11; ELT derecho, n = 14). Resultados No se encontraron diferencias intergrupales prequirúrgicas significativas al comparar las puntuaciones en MEV sobre la base de la lateralidad de la epilepsia (p > 0,5). En cuanto al grupo de ELT izquierdo, se encontró una alta correlación negativa entre la edad de inicio y la puntuación prequirúrgica del recuerdo libre a largo plazo (rho = –0,72; p = 0,01). No se encontraron cambios intragrupo significativos entre el pre- y el postoperatorio en relación con el rendimiento en la MEV, independientemente de la lateralidad de la epilepsia (grupo de ELT izquierdo, p > 0,56; grupo de ELT derecho, p > 0,12). Conclusiones ... (AU)

INTRODUCTION Verbal episodic memory (VEM) is often unimpaired in children with focal epilepsy undergoing left temporal lobe resections, unlike what we might expect in the adult brain. The latter findings suggest that epileptiform activity in early life disrupts memory system lateralization, leading to the development of bilateral memory representation. The present study aims to analyze whether the laterality of epilepsy is a major predictor for post-operative VEM prognosis in pediatric temporal lobe epilepsy (TLE) surgery. This research also pretends to provide evidence about the relationship of VEM performance with other relevant demographical and clinical factors such as sex, age at onset of seizures, age at surgery and duration of epilepsy, as well as to study the impact of presurgical VEM performance on postsurgical outcomes. PATIENTS AND METHODS Pre-operative and one-year follow-up post-operative word-list recall scores from 25 children who underwent TLE surgery (left-sided, n = 11; right-sided, n = 14) were extracted from the Hospital Sant Joan de Déu database and were retrospectively analyzed. RESULTS No significant presurgical intergroup differences were found when comparing VEM scores by laterality of epilepsy (p > 0.5). Looking at the left TLE group, a high negative correlation was found between the onset age and the pre-operative long-term free recall score (rho = –0.72, p = 0.01). No significant pre- to post-operative intragroup changes were found regarding VEM performance, regardless of epilepsy laterality (left TLE group, p > 0.56; right TLE group, p > 0.12). CONCLUSIONS The laterality of epilepsy does not show to be a significant factor in and of itself (AU)

Risk factors for drug-resistant epilepsy in adult patients / Factores de riesgo de epilepsia farmacorresistente en pacientes adultos

Introduction Drug-resistant epilepsy occurs in about 30% of epilepsy patients. It has been suggested that etiology or seizure type would increase the risk of pharmacoresistance. This study aims to compare the characteristics of patients with drug-sensitive epilepsy with patients with drug-resistant epilepsy to identify risk factors. Patient and methods A multicentric cohort study was conducted between 2019 and 2022. We included patients >18 years-old with epilepsy but excluded psychogenic non-epileptic seizures and less than 2 years of follow-up. Results We included 128 patients, of whom 46 had drug-resistance epilepsy, and 82 responding to medication. Both groups showed similar characteristics. Febrile seizures (OR: 7.25), focal epilepsy (OR: 2.4), focal seizures with loss of consciousness (OR: 2.36), structural etiology (OR: 2.2) and abnormal MRI (OR: 4.6) were significant risk factors for drug-resistance epilepsy. Conclusion Following other studies, we observed that factors such as epilepsy type, seizure type, structural etiology, abnormal MRI, and febrile seizure increased the risk for drug-resistance epilepsy, in our population (AU)

Introducción La epilepsia farmacorresistente se presenta en aproximadamente 30% de los pacientes que padecen epilepsia. Se ha sugerido que la etiología o el tipo de crisis aumentarían el riesgo de farmacorresistencia. El objetivo de este estudio es comparar las características de los pacientes con epilepsia fármacosensible con las de los pacientes con epilepsia farmacorresistente para identificar los factores de riesgo. Pacientes y métodos Se realizó un estudio de cohorte multicéntrico entre 2019 y 2022. Se incluyeron pacientes >18 años con epilepsia pero se excluyeron las crisis psicógenas no epilépticas y menos de dos años de seguimiento. Resultados Se incluyeron 128 pacientes, de los cuales 46 tenían epilepsia farmacorresistente y 82 respondían a la medicación. Ambos grupos mostraron características similares. Las crisis febriles (OR: 7,25), la epilepsia focal (OR: 2,4), las crisis focales con pérdida de conciencia (OR: 2,36), la etiología estructural (OR: 2,2) y la resonancia magnética anormal (OR: 4,6) fueron factores de riesgo significativos de epilepsia farmacorresistente. Conclusión Siguiendo otros estudios, observamos que factores como el tipo de epilepsia, el tipo de crisis, la etiología estructural, la RM anormal y las crisis febriles aumentaban el riesgo de epilepsia farmacorresistente, en nuestra población (AU)

Risk factors for drug-resistant epilepsy in adult patients.

INTRODUCTION: Drug-resistant epilepsy occurs in about 30% of epilepsy patients. It has been suggested that etiology or seizure type would increase the risk of pharmacoresistance. This study aims to compare the characteristics of patients with drug-sensitive epilepsy with patients with drug-resistant epilepsy to identify risk factors. PATIENT AND METHODS: A multicentric cohort study was conducted between 2019 and 2022. We included patients >18 years-old with epilepsy but excluded psychogenic non-epileptic seizures and less than 2 years of follow-up. RESULTS: We included 128 patients, of whom 46 had drug-resistance epilepsy, and 82 responding to medication. Both groups showed similar characteristics. Febrile seizures (OR: 7.25), focal epilepsy (OR: 2.4), focal seizures with loss of consciousness (OR: 2.36), structural etiology (OR: 2.2) and abnormal MRI (OR: 4.6) were significant risk factors for drug-resistance epilepsy. CONCLUSION: Following other studies, we observed that factors such as epilepsy type, seizure type, structural etiology, abnormal MRI, and febrile seizure increased the risk for drug-resistance epilepsy, in our population.

Prospective study of the modified Atkins diet in adult drug-resistant epilepsy: effectiveness, tolerability, and adherence.

INTRODUCTION: Drug-resistant epilepsy presents high worldwide prevalence and is difficult to control despite the wide variety of available antiepileptic drugs (AED). The modified Atkins diet (MAD) is an additional treatment alternative. Several studies have addressed the use of the ketogenic diet and MAD in children with drug-resistant epilepsy, but insufficient research has been conducted into adults with the same condition. OBJECTIVE: To evaluate the effectiveness and tolerability of, and adherence to, the MAD in adults with drug-resistant epilepsy. MATERIAL AND METHODS: We conducted a 6-month pre-post prospective study at a reference hospital. Patients were prescribed the MAD with limited carbohydrate intake and unlimited fat intake. We conducted clinical and electroencephalographic follow-up according to the relevant guidelines, and assessed adverse effects changes in laboratory findings, and adherence. RESULTS: Thirty-two patients with drug-resistant epilepsy were included in the study. Patients' mean age was 30 years, mean disease progression time was 22 years, and all patients had focal or multifocal epilepsy. Thirty-four percent of patients presented > 50% decreases in overall seizure frequency (P =  .001); seizure control was greater in the first month and subsequently declined. These patients presented weight loss (RR: 7.2; 95% CI, 1.3-39.5; P = .02), good to fair adherence only in the first and third months (RR: 9.4; 95% CI, 0.9-93.6; P = .04 and RR: 0.4; 95% CI, 0.30-0.69; P = .02, respectively). Tolerability data showed that the MAD is safe: adverse effects were minor and short-lived in most cases, with the exception of mild to moderate hyperlipidaemia in one-third of patients. The adherence rate was 50% at the end of the study. CONCLUSIONS: In adults with drug-resistant focal epilepsy, the MAD showed adequate tolerability and moderate but decreasing effectiveness and adherence, probably due to a preference for a carbohydrate-based diet.

Retos en el diagnóstico y tratamiento de la Encefalitis de Rasmussen de inicio tardío: Reporte de tres casos / Challenges in diagnosis and treatment of late-onset Rasmussen encephalitis: Report of three cases

RESUMEN La encefalitis de Rasmussen es una entidad clínica poco frecuente caracterizada por epilepsia focal farmacorresistente, creciente déficit neurológico y hemiatrofia cerebral progresiva. Los abordajes diagnóstico y terapéutico son complejos, más aún en pacientes con inicio tardío de la enfermedad (adolescencia y adultez), en los cuales el cuadro clínico podría ser atípico cuando comparado con su presentación en niños. Se reporta una serie de tres casos clínicos de encefalitis de Rasmussen de inicio tardío, confirmados con evaluaciones histopatológicas e inmunohistoquímicas y en los cuales se obtuvo mejoría clínica tras ser intervenidos quirúrgicamente. Se efectúa también una revisión de la literatura sobre la evolución clínica y alternativas terapéuticas para el manejo de este tipo de presentación.

SUMMARY Rasmussen's encephalitis is an unusual clinical entity characterized by drug-resistant focal epilepsy, neurological deficit and progressive cerebral hemiatrophy. The diagnostic and therapeutic approach is complex, even more so in patients with Rasmussen's encephalitis of late onset (in adolescence and adulthood) whose clinical picture could be atypical when compared with its occurrence in children. We report a series of three clinical cases of late-onset Rasmussen's encephalitis confirmed by histopathology and immunohistochemistry evaluations and in which clinical improvement was achieved after surgical interventions. Literature reviews on the clinical evolution and therapeutic alternatives for this type of presentation are included.

Volume of hippocampal activation as a determining factor for the lateralisation of the epileptogenic zone in patients with drug-resistant mesial temporal lobe epilepsy.

INTRODUCTION: Approximately 30% of patients with mesial temporal lobe epilepsy (MTLE) will develop drug resistance, which requires early surgical treatment. The success of the surgical procedure largely depends on the correct lateralisation of the epileptogenic zone, which can only be determined in 70% of patients with such conventional diagnostic tools as video electroencephalography and volumetric structural magnetic resonance imaging. We evaluated the performance of a memory functional magnetic resonance imaging (fMRI) paradigm in lateralising the epileptogenic zone in patients with drug-resistant MTLE. METHODS: We included 18 patients with MTLE attended at the Instituto Neurológico Colombiano in Medellin (Colombia) between 2018 and 2019. The volume of functional activation in both temporal lobes was determined with a memory fMRI paradigm. A concordance analysis was performed to compare the performance of fMRI against that of conventional tests. RESULTS: In patients with left MTLE, lower total activation was found in the hemisphere ipsilateral to the epileptogenic zone as compared to the contralateral hemisphere (121.15 ± 16.48 voxels vs 170.23 ± 17.8 voxels [P < .001]), showing substantial concordance with conventional tests. Patients with right MTLE displayed lower hippocampal activation ipsilateral to the epileptogenic zone (18.5 ± 3.38 voxels vs 27.8 ± 3.77 voxels in the contralateral hippocampus [P = .048]), showing moderate concordance with conventional tests. CONCLUSIONS: These findings suggest that lower functional activation as determined by a memory fMRI paradigm has a high level of concordance with conventional tests for lateralising the epileptogenic zone in patients with drug-resistant MTLE.

Asociación entre los polimorfismos genéticos de nucleótido único en genes transportadores ABC con la epilepsia farmacorresistente en la población española / Association between single nucleotide genetic polymorphisms in ABC transporter genes with drug-resistant epilepsy in the Spanish population

Introducción: El 30% de los pacientes con epilepsia no responde al tratamiento farmacológico. La presencia de polimorfismos genéticos de nucleótido único (SNP) en el individuo puede influir en la variabilidad de respuesta al tratamiento farmacológico. La hipótesis de transportadores plantea que la presencia de SNP en los genes que codifican las proteínas ABC repercutiría en la biodisponibilidad de los fármacos anticrisis en el foco epileptógeno, lo que ocasionaría refractariedad. El objetivo del presente estudio fue evaluar la asociación de 13 polimorfismos en los genes ABCB1, ABCC2, ABCC5 y ABCG2 con la epilepsia farmacorresistente (EFR) en población española. Sujetos y métodos: Se realizó un estudio de casos y controles que incluyó a 327 pacientes con epilepsia: 227 farmacorresistentes y 100 farmacocontrolados según los criterios de la Liga Internacional contra la Epilepsia. En el ADN de leucocitos de sangre periférica extraído se estudiaron los polimorfismos en los genes transportadores ABC. Se utilizó la plataforma tecnológica iPlex® Gold y Mass ARRAY. Se compararon las frecuencias alélicas y genotípicas del grupo de casos y del de controles, el valor de p, la odds ratio y los intervalos de confianza al 95%. Resultados: La frecuencia alélica y genotípica del presente estudio fue similar a la comunicada en las bases de datos poblacionales. En los SNP estudiados no se encontraron diferencias significativas (p > 0,05) en todos los modelos de herencia analizados. Conclusiones: Nuestros resultados sugieren que no existe asociación entre los polimorfismos analizados en los genes ABC con la EFR en población española. Sin embargo, otros estudios adicionales confirmarán o descartarán estos resultados.(AU)

Introduction: Almost a third of all patients with epilepsy (30%) fail to respond to pharmacological treatment. The presence of single nucleotide polymorphisms (SNPs) in the individual may influence the variability of the response to drug treatment. The transporter hypothesis posits that the presence of SNPs in the genes encoding ABC proteins would affect the bioavailability of antiseizure drugs at the epileptogenic focus, giving rise to refractoriness. The aim of the present study was to evaluate the association of 13 polymorphisms in the ABCB1, ABCC2, ABCC5 and ABCG2 genes with drug-resistant epilepsy (DRE) in a Spanish population. Subjects and methods: A case-control study was conducted involving 327 patients with epilepsy: 227 resistant to drug therapy and 100 in whom their medication enabled them to control their symptoms, according to International League Against Epilepsy criteria. In the peripheral blood leukocyte DNA that was extracted, polymorphisms in the ABC transporter genes were studied. The iPlex® Gold and Mass ARRAY technology platform was used. The allele and genotypic frequencies of the case and control groups, p-value, odds ratio and 95% confidence intervals were compared. Results: The allele and genotypic frequency of the present study was similar to that reported in population-based databases. For the SNPs studied, no significant differences (p > 0.05) were found in any of the inheritance models analysed. Conclusions: Our results suggest that there is no association between the polymorphisms analysed in the ABC genes and DRE in the Spanish population. Nevertheless, further studies will confirm or refute these results.(AU)

Eficacia de la zonisamida en un caso de enfermedad de Lafora y breve revisión en la epilepsia mioclónica progresiva / Efficacy of zonisamide in a case of Lafora disease and brief review in progressive myoclonic epilepsy

Introducción: La epilepsia mioclónica progresiva constituye un grupo complejo de enfermedades neurodegenerativas clínica y genéticamente heterogéneas que asocian mioclonías espontáneas o inducidas por la acción y el deterioro neurológico progresivo. Dentro de estas entidades se encuentra la enfermedad de Lafora, una patología autosómica recesiva causada por mutación en el gen responsable de la síntesis de una proteína llamada laforina (EPM2A) o el gen responsable de la síntesis de la proteína malina (EPM2B o NHLRC1). Son entidades cuyas crisis, en especial las mioclonías, son frecuentemente resistentes a los fármacos anticrisis epilépticas. Caso clínico: Presentamos el caso de una paciente con diagnóstico de enfermedad de Lafora que, tras varios regímenes terapéuticos ineficaces, presentó buena respuesta a la introducción de la zonisamida, con una respuesta favorable mantenida en el tiempo. Asimismo, hacemos una breve revisión de la eficacia de la zonisamida en cuadros de epilepsia mioclónica progresiva. Conclusión: La zonisamida puede ser una buena alternativa en el tratamiento de cuadros con epilepsia mioclónica progresiva.(AU)

INTRODUCTION: Mioclonic progressive epilepsy (MPE) includes a clinical and genetical heterogeneous group of neuro­degenerative disorders that associate spontaneous and action-induced myoclonus as well as progressive cognitive impairment. Lafora`s disease is a subtype of MPE with autosomical recessive inheritance due to a mutation in EPM2A or EPM2B genes. Seizures, especially myoclonus, are often refractary to antiepileptic drugs (AD). CASE REPORT: In this article we report a patient with Lafora´s disease diagnosis, previously resistant to several AD tested with good and sustained response to zonisamide. Indeed, we describe a brief review about the efficacy of zonisamida in MPE. CONCLUSION. Zonisamide may be considered as a good therapeutic alternative in MPE.(AU)

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: experience at an epilepsy centre.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia / Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre

Objetivo: La estereoelectroencefalografía (E-EEG) es una técnica de evaluación prequirúrgica en pacientes con epilepsia focal refractaria de difícil localización (EFRDL) que permite explorar con electrodos profundos regiones cerebrales de difícil acceso y la profundidad de la corteza. Esta técnica, en auge en centros internacionales, apenas se ha desarrollado en España. Describimos nuestra experiencia con la E-EEG en la evaluación de pacientes con EFRDL. Material y métodos: En los últimos 8 años, 71 pacientes con EFRDL fueron evaluados con E-EEG en nuestro centro. Analizamos prospectivamente los resultados obtenidos en la localización, los resultados quirúrgicos y las complicaciones asociadas a la técnica. Resultados: La mediana de edad fue de 30 años (rango 4-59 años), 27 pacientes eran mujeres (38%). La RM cerebral fue negativa en 45 pacientes (63,4%). Se implantaron 627 electrodos (mediana de 9 electrodos por paciente, rango 1-17), con un 50% de implantaciones multilobares. En 64 (90,1%) pacientes se localizó la zona epileptógena (ZE), siendo extratemporal o temporal plus en el 66% de los casos. En 55 pacientes de los 61 intervenidos el seguimiento fue superior al año: en el último año de seguimiento 32/55 pacientes (58,2%) estaban libres de crisis (Engel I) siendo los resultados favorables (Engel I-II) en el 76,4% de las intervenciones. Tres pacientes (4,2%) presentaron una hemorragia cerebral. Conclusión: La E-EEG permite localizar la ZE en pacientes en quienes anteriormente no era posible, ofreciendo unos resultados quirúrgicos superiores a otras técnicas invasivas y una tasa de complicaciones relativamente baja. (AU)

Objective: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. Material and methods: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. Results: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. Conclusion: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications. (AU)

Cardiovascular response to stress in patients with drug-resistant epilepsy: preliminary data / Respuesta cardiovascular al estrés en pacientes con epilepsia farmacorresistente: datos preliminares

Stress is a risk factor for cardiovascular diseases in the general population. Epilepsy has been considered a suitable model of chronic stress with a higher incidence of cardiovascular mortality than the general population. This study provides preliminary data about cardiovascular response to a cognitive stressor and a neuropsychological assessment in patients with epilepsy. It also explores the relationship between cardiovascular response and cognitive performance, depending on the side of seizure focus. Thirty-five patients with drug-resistant epilepsy, 17 with epileptogenic area (EA) in the left hemisphere (LH) and 18 with EA in the right hemisphere (RH), underwent a cognitive stressor and a neuropsychological assessment. The cardiovascular response was recorded throughout both conditions. Results showed that a long-lasting neuropsychological assessment was capable of producing a hemisphere-modulated cardiovascular response with heart rate (HR) decreases (and R-R interval increases) more pronounced in the LH patients than in the RH patients at the post-assessment period (p = .05 and p = .01, respectively). The hemisphere of EA moderated the relationship between cardiovascular response and cognitive performance (for all, p < .03). Our findings may have clinical implications from a preventive perspective since the EA hemisphere may be a relevant factor for coping with stress in people with drug-resistant epilepsy.(AU)

El estrés es un factor de riesgo para las enfermedades cardiovasculares en la población general. La epilepsia se ha considerado un modelo adecuado de estrés crónico, con mayor incidencia de mortalidad cardiovascular que la población general. Este estudio proporciona datos preliminares sobre la respuesta cardiovascular ante un estresor cognitivo y una evaluación neuropsicológica en pacientes con epilepsia, explorando las relaciones entre la respuesta cardiovascular y el rendimiento cognitivo dependiendo del hemisferio responsable de la epilepsia. Treinta y cinco pacientes con epilepsia farmacorresistente, 17 con el área epileptógena (AE) en el hemisferio izquierdo (HI) y 18 con AE en el hemisferio derecho (HD), se sometieron a un estres cognitivo y una evaluación neuropsicológica. La respuesta cardiovascular se registró durante toda la sesión en ambas condiciones. Los resultados mostraron que una evaluación neuropsicológica de larga duración fue capaz de producir una respuesta cardiovascular modulada por el hemisferio, con disminuciones de la frecuencia cardíaca (y aumentos del intervalo RR) más pronunciadas en el período post-evaluación en pacientes con epilepsia del HI que en pacientes con epilepsia del HD (p = .05, p = .01, respectivamente). El hemisferio del AE moderó la relación entre la respuesta cardiovascular y el rendimiento cognitivo (para todos, p < .03). Nuestros hallazgos podrían tener implicaciones clínicas desde una perspectiva preventiva, ya que sugieren que el hemisferio del AE podría ser un factor relevante en el afrontamiento del estrés en personas con epilepsia farmacorresistente.(AU)

Efectividad y seguridad de la cirugía para la epilepsia en niños. Experiencia de un hospital terciario en Ecuador / Safety and effectiveness of surgery for epilepsy in children. Experience of a tertiary hospital in Ecuador

Introducción: Existe suficiente evidencia sobre la utilidad de la cirugía como alternativa terapéutica para pacientes con epilepsia farmacorresistente, sin embargo este tratamiento es subutilizado especialmente en países en desarrollo. El objetivo de este trabajo fue determinar la efectividad y seguridad de la cirugía de epilepsia en un hospital terciario de Ecuador.MétodosSe describe el resultado de la cirugía de epilepsia en 27 niños y adolescentes en el Hospital Baca Ortiz, de Quito, Ecuador, teniendo en cuenta las siguientes variables antes y después de la cirugía: reducción de la frecuencia de crisis, Engel posquirúrgico, mejoría en la calidad de vida y presencia de complicaciones graves por la cirugía.ResultadosSe realizaron 21 callosotomías y seis cirugías resectivas. La frecuencia de crisis media se redujo de 465 mensual antes de la cirugía a 37,2 mensual después de la misma (p<0,001), mientras que la puntuación en la escala de calidad de vida aumentó de 12,6 a 37,2 puntos (p<0,001), el 72,7% de los pacientes mejoró la calidad de vida. Entre las cirugía resectivas, en dos epilepsias del lóbulo temporal y una del cuadrante posterior se logró Engel Ia, una hemisferotomía por encefalitis de Rasmusen quedó en Engel IIa y dos hamartomas hipotalámicos, uno logró Engel III y otro Engel Ia pero falleció a mediano plazo por complicación posquirúrgica. La otra complicación grave fue un hidrocéfalo que llevó a la muerte a un lactante con espasmos infantiles refractarios sometido a callosotomía.ConclusiónEl resultado favorable se observó en el 92,5% de los pacientes. (AU)

Introduction: There is sufficient evidence on the usefulness of surgery as a therapeutic alternative for patients with drug-resistant epilepsy; however this treatment is underutilized, especially in developing countries.MethodsWe describe the outcomes of epilepsy surgery in 27 paediatric patients at Hospital Baca Ortiz in Quito, Ecuador. Our analysis considered the following variables: reduction in seizure frequency, surgery outcome according to the Engel classification, improvement in quality of life, and serious complications due to surgery.Results21 corpus callosotomies and 6 resective surgeries were performed. The mean seizure frequency decreased from 465 per month before surgery to 37.2 per month thereafter (p<.001); quality of life scale scores increased from 12.6 to 37.2 (p<.001), and quality of life improved in 72.7% of patients. Regarding resective surgery, 2 patients with temporal lobe epilepsy and one with posterior quadrant epilepsy achieved Engel class IA, and one patient undergoing hemispherotomy due to Rasmussen encephalitis achieved Engel class IIA. Two patients underwent surgery for hypothalamic hamartoma: one achieved Engel III and the other, Engel IA; however, the latter patient died in the medium term due to a postoperative complication. The other major complication was a case of hydrocephalus, which led to the death of a patient with refractory infantile spasms who underwent corpus callosotomy.ConclusionsFavourable outcomes were observed in 92.5% of patients. (AU)

Safety and effectiveness of surgery for epilepsy in children. Experience of a tertiary hospital in Ecuador. / Efectividad y seguridad de la cirugía para la epilepsia en niños. Experiencia de un hospital terciario en Ecuador.

INTRODUCTION: There is sufficient evidence on the usefulness of surgery as a therapeutic alternative for patients with drug-resistant epilepsy; however this treatment is underutilized, especially in developing countries. METHODS: We describe the outcomes of epilepsy surgery in 27 paediatric patients at Hospital Baca Ortiz in Quito, Ecuador. Our analysis considered the following variables: reduction in seizure frequency, surgery outcome according to the Engel classification, improvement in quality of life, and serious complications due to surgery. RESULTS: 21 corpus callosotomies and 6 resective surgeries were performed. The mean seizure frequency decreased from 465 per month before surgery to 37.2 per month thereafter (p<.001); quality of life scale scores increased from 12.6 to 37.2 (p<.001), and quality of life improved in 72.7% of patients. Regarding resective surgery, 2 patients with temporal lobe epilepsy and one with posterior quadrant epilepsy achieved Engel class IA, and one patient undergoing hemispherotomy due to Rasmussen encephalitis achieved Engel class IIA. Two patients underwent surgery for hypothalamic hamartoma: one achieved Engel III and the other, Engel IA; however, the latter patient died in the medium term due to a postoperative complication. The other major complication was a case of hydrocephalus, which led to the death of a patient with refractory infantile spasms who underwent corpus callosotomy. CONCLUSIONS: Favourable outcomes were observed in 92.5% of patients.

Epilepsia farmacorresistente. Experiencia quirúrgica en el Instituto de Neurología y Neurocirugía (2012-2018) / Drug-resistant epilepsy. Experience with surgical treatment at the Institute of Neurology and Neurosurgery, Havana, Cuba (2012-2018)

RESUMEN Introducción: La epilepsia es la alteración neurológica más frecuente en la población general. El objetivo de la cirugía de epilepsia es garantizar la ausencia o disminución de crisis, lo que se logra en el 80 % de los pacientes. Objetivo: Evaluar la evolución posquirúrgica y factores de buen pronóstico de los pacientes intervenidos de epilepsia farmacorresistente (EFR) en el Instituto de Neurología y Neurocirugía. Material y Métodos: Se realizó un estudio observacional descriptivo retro y prospectivo en el Instituto de Neurología y Neurocirugía entre enero de 2012 a mayo de 2018. Resultados: La edad del 44,8 % de los pacientes estuvo entre 21 y 30 años, el 62,1 % era del sexo masculino y el 82,8 % tenía color de piel blanca, el 31 % presentó entre 11 y 20 años de evolución. En el 75,9 % la epilepsia era lesional, el 55,2 % con localización temporal y en el 86,2 % se demostró congruencia clínica. Se utilizaron técnicas resectivas en 87,6 %. El 82,8 % no presentó crisis postoperatorias. En 62,1 % no se presentaron complicaciones. A los 3, 6 y 12 meses después de la intervención entre el 55 al 82 % de los pacientes estudiados se clasificaron como Engel clase I y clase II. Conclusiones: En nuestro estudio predominó la utilización de técnicas resectivas y la ausencia de crisis posterior a la cirugía. No se registró relación significativa entre la evolución posquirúrgica, la etiología de la epilepsia y la congruencia clínica. La presencia de lesión focal en el lóbulo temporal constituyó un factor de buen pronóstico.

ABSTRACT Introduction: Epilepsy is the most frequent neurological alteration in the general population. The objective of epilepsy surgery is to guarantee the absence or the decrease of seizures which is achieved in 67 % and 80 % of patients. Objective: To evaluate the surgical outcome and the factors for good outcome in patients with drug-resistant epilepsy (DRE) who underwent surgical treatment at the Institute of Neurology and Neurosurgery. Material and Methods: A retrospective prospective observational study was conducted at the Institute of Neurology and Neurosurgery between January 2012 and May 2018. Results: Of all the patients studied, 44,8 % were between 21 and 30 years old, 62,1 % were male and 82,8 % were white. Also, 31 % were between 11 and 20 years of follow-up. Epilepsy was lesional in 75,9 % of patients whereas in 55,2 % of them it was located in the temporal lobe; clinical congruence was demonstrated in 86,2 % of patients. Resective techniques were used in 87,6 % of them. Besides, 82,8 % had no postoperative seizures. There were no complications in 62,1 % of patients. On the other hand, 55 and 82 % of the patients studied were classified as Engel Class I and Engel Class II at 3, 6 and 12 months after surgical intervention. Conclusions: The use of resective techniques and the absence of seizures after surgery predominated in our study. No significant relationship was found between surgical outcome, etiology of epilepsy and clinical congruence. The presence of a focal lesion of the temporal lobe was a factor for good outcome.

Intravenous immunoglobulin G as adjuvant treatment in drug-resistant childhood epilepsy. / Inmunoglobulina G intravenosa como tratamiento adyuvante en epilepsia infantil farmacorresistente.

BACKGROUND: Epilepsy is the most common neurological disease in childhood; depending on the definition of drug-resistant epilepsy, incidence varies from 10% to 23% in the paediatric population. The objective of this study was to account for the decrease in the frequency and/or monthly duration of epileptic seizures in paediatric patients with drug-resistant epilepsy treated with antiepileptic drugs, before and after adding intravenous immunoglobulin G (iIV IgG). METHODS: This is an analytic, observational, retrospective case-control study. We studied paediatric patients with drug-resistant epilepsy who were treated with IV IgG at the Centro Médico Nacional 20 de Noviembre, in Mexico City, from 2003 to 2013. RESULTS: One hundred and sixty seven patients (19.5%) had drug-resistant epilepsy and 44 (5.1%) started adjuvant treatment with IV IgG. The mean age of patients at the beginning of treatment was 6.12 years±5.14); aetiology was structural acquired in 28 patients (73.6%), genetic in 5 (13.1%), immune in 1 (2.6%), and unknown in 4 (10.5%). At 2 months from starting IV IgG, seizure duration had reduced to 66.66%; the frequency of seizures was reduced by 64% at 4 months after starting treatment (P<.001). CONCLUSIONS: According to the results of this study, intravenous immunoglobulin may be an effective therapy for reducing the frequency and duration of seizures in paediatric patients with drug-resistant epilepsy.

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre. / Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

Anaesthesia management in epilepsy surgery with intraoperative electrocorticography. / Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria.

Epilepsy surgery is a well-established treatment for patients with drug-resistant epilepsy. The success of surgery depends on precise presurgical localisation of the epileptogenic zone. There are different techniques to determine its location and extension. Despite the improvements in non-invasive diagnostic tests, in patients for whom these tests are inconclusive, invasive techniques such intraoperative electrocorticography will be needed. Intraoperative electrocorticography is used to guide surgical resection of the epileptogenic lesion and to verify that the resection has been completed. However, it can be affected by some of the anaesthetic drugs used by the anaesthesiologist. Our objective with this case is to review which drugs can be used in epilepsy surgery with intraoperative electrocorticography.