Atypical Presentations of Childhood Simple Partial Seizures: a Case Series.

Childhood epilepsy can masquerade as a variety of psychiatric disorders or behavioural abnormalities. Differentiating between simple partial seizure and psychiatric disorders remains a challenge. We report on three children with simple partial seizure, each presented atypically with migraine, tingling sensations, and/or crying spells. When dealing with atypical symptomatology, clinicians should utilise a multidirectional, rather than unidirectional, diagnostic approach when making their diagnosis.

Surgical treatment of temporal lobe epilepsy: comparative results of selective amygdalohippocampectomy versus anterior temporal lobectomy from a referral center in Brazil / Tratamento cirúrgico da epilepsia do lobo temporal: resultados comparativos da amigdalohipocampectomia seletiva versus lobectomia temporal anterior em um centro de referência no Brasil

Abstract Background Temporal lobe epilepsy (TLE) is a high prevalence neurological disorder. Surgery has emerged as a promising treatment. Objective The objective of this work is to compare the surgical results of anterior temporal lobectomy (ATL) versus selective amygdalohippocampectomy (SAH) in a cohort of 132 patients. Methods We performed a retrospective study of 146 patients operated for TLE from 2008 to 2019. Initially, 13 patients were excluded from the study due to insufficient medical record data or follow-up loss. One patient was excluded from the analysis of the results due to death in the first postoperative week. We used the ILAE scale to classify seizure control after surgery. In patients with left hippocampal sclerosis, SAH was performed and in right temporal lobe epilepsy, ATL was the approach of choice. Results The mean follow-up time after surgery was 57.2 months (12-137). In our data analysis, we found that the group of patients undergoing ATL had a higher prevalence of being completely seizure-free (ILAE I) (57.1% versus 31%) and a higher rate of satisfactory seizure control (88.6% versus 69.3%) p = 0,006, when compared with patients undergoing SAH. Conclusions The literature is still controversial about seizure control concerning the technique used due to the lack of a robust methodology. Our data analysis identified the superiority of ATL over SAH in seizure outcomes. ATL may be the best option for adequately controlling seizures with minimal additional morbidity in countries with a cost limitation for extended propaedeutics.

Resumo Antecedentes A epilepsia do lobo temporal (TLE) é uma desordem neurológica de alta prevalência. A cirurgia surgiu como um tratamento promissor. Objetivo O objetivo deste trabalho é comparar os resultados da lobectomia temporal anterior (ATL) versus amigdalohipocampectomia seletiva (SAH) em uma coorte de 132 pacientes. Métodos Realizamos um estudo retrospectivo de 146 pacientes operados por TLE de 2008 a 2019. Inicialmente, 13 pacientes foram excluídos por insuficiência de dados em prontuário ou perda de seguimento. Um paciente foi excluído da análise por óbito na primeira semana de pós-operatório. Usamos a escala ILAE para classificar o controle das crises após a cirurgia. Em pacientes com esclerose hipocampal à esquerda, foi realizada a SAH, e na epilepsia do lobo temporal à direita, a ATL foi a abordagem de escolha. Resultados O tempo médio de seguimento após a cirurgia foi de 57,2 meses (12-137). Em nossa avaliação, encontramos que o grupo de pacientes submetidos à ATL apresentou maior prevalência de ausência total de crises (ILAE I) (57,1% versus 31%) e maior taxa de controle satisfatório da epilepsia (88,6% versus 69,3%) p = 0,006, quando comparado ao grupo submetido à SAH. Resultados A literatura ainda é controversa em relação à redução das crises de acordo com a técnica utilizada devido a falta de uma metodologia robusta. Nosso estudo identificou superioridade da ATL sobre a SAH nos desfechos convulsivos. ATL pode ser a melhor opção para controlar adequadamente as convulsões com morbidade adicional mínima em países com limitação de custo para propedêutica estendida.

Cannabis-based magistral formulation is highly effective as an adjuvant treatment in drug-resistant focal epilepsy in adult patients: an open-label prospective cohort study.

INTRODUCTION: The safety and efficacy of a formulation high in cannabidiol (CBD) and low in ∆9-tetrahydrocannabinol (THC) to treat drug-resistant epilepsy have been examined previously in children, but not in adult population. The aim of this study was to evaluate whether CBD-rich oil, as an add-on treatment to conventional antiepileptic drugs, was effective, safe, and well-tolerated in adults with drug-resistant focal epilepsy (DRFE). METHODS: An open-label, prospective cohort, single-center in adult patients with DRFE, were receiving stable doses of antiepileptic drugs (AEDs). A cannabis based-magistral formulation (CBMF) (100 mg/ml CBD and THC <1.9 mg/ml) was administrated 0.1 ml sublingually every 12 hours, up-titrated weekly. The primary outcome was to establish a reduction in seizures frequency >50% at 12 weeks. Adverse-drug reactions monitoring was done. p-value <0.05 was statistically significant. RESULTS: Between August 2020 and July 2022, 44 (38.6%) patients completed >3 months of follow-up. The median daily dose of CBD was 200 mg, that of THC was 4 mg, and that of CBD per kilogram of weight was 3.7 mg. The median number of seizures per month before CBD treatment was 11, and after CBD treatment was 2.5 (p<0.001). A reduction in seizures >50% at 12 week was achieved in 79.5% of the patients. The median percentage change in seizure frequency per month was 84.1% at 12 weeks. Five patients reported any adverse-drug reactions. CONCLUSION: The CBMF is a highly effective and safety therapy to treat adult patients with DRFE. The reduction in seizures frequency is maintained over time.

A clinical evaluation of gelastic and dacrystic seizures: a multicenter study / Uma avaliação clínica das crises gelásticas e dacrísticas: um estudo multicêntrico

Abstract Background Gelastic seizures are extremely rare, short-lasting, unprovoked, and uncontrollable laughing attacks. We conducted this retrospective evaluation to determine whether these symptoms, manifesting in different forms, such as cheerful laughter, laughing, smiling, and sobbing had any value in terms of etiology or localization. Methods A total of 31 patients who exhibited bouts of laughing or crying and who were under follow-up between 2000 and 2019 at tertiary epilepsy centers were included in the study. Laughing seizures were divided into three groups in terms of semiology (i.e., laughter with mirth, laughter without mirth, and smile). Dacrystic seizures were accompanied by some gelastic seizures and were divided into two groups in terms of semiology (i.e., weeping loudly [motor and voice-sobbing] and crying). Results Of the 27 patients with laughing seizures, 12 had seizures that manifested with smiling, 7 had seizures that manifested with laughing and mirth, and 8 had seizures that manifested with laughter without mirth. Dacrystic-gelastic seizures were observed in four patients, among whom 2 patients had crying and laughter without mirth and 2 patients had weeping loudly and laughter without mirth episodes. Conclusion Gelastic and dacrystic seizures often suggest hypothalamic hamartomas, in the literature. This rare ictal behavior can originate from different cortical locations and lesions of a different nature. However, we found that gelastic seizures with smiling were a more homogenous group with regard to location in the temporal lobe, which we aimed to show by evaluating the patients included in this study.

Resumo Antecedentes Crises gelásticas são ataques de riso extremamente raros, de curta duração, não provocados e incontroláveis. Realizamos esta avaliação retrospectiva para determinar se esses sintomas, manifestando-se de diferentes formas, como riso alegre, riso, sorriso e soluço, tinham algum valor em termos de etiologia ou localização. Métodos Foram incluídos no estudo 31 pacientes que apresentavam crises de riso ou choro e que estavam em acompanhamento entre 2000 e 2019 em centros terciários de epilepsia. As crises de riso foram divididas em três grupos em termos de semiologia (ou seja, riso com alegria, riso sem alegria e sorriso). As crises dacrísticas foram acompanhadas por algumas crises gelásticas e foram divididas em dois grupos em termos de semiologia (ou seja, choro alto [motor e soluçar a voz] e choro). Resultados Dos 27 pacientes com crises de riso, 12 tiveram crises que se manifestaram com sorriso, 7 tiveram crises que se manifestaram com riso e alegria e 8 tiveram crises que se manifestaram com riso sem alegria. Crises dácristico-gelásticas foram observadas em quatro pacientes, sendo 2 pacientes com choro e riso sem alegria e 2 pacientes com choro alto e riso sem alegria. Conclusão Crises gelásticas e dacrísticas frequentemente sugerem hamartomas hipotalâmicos, na literatura. Este comportamento ictal raro pode ter origem em diferentes localizações corticais e lesões de natureza diversa. No entanto, verificamos que as crises gelásticas com sorriso foram um grupo mais homogêneo quanto à localização no lobo temporal, o que buscamos evidenciar avaliando os pacientes incluídos neste estudo.

Lamotrigine versus levetiracetam or zonisamide for focal epilepsy and valproate versus levetiracetam for generalised and unclassified epilepsy: two SANAD II non-inferiority RCTs.

BACKGROUND: Levetiracetam (Keppra®, UCB Pharma Ltd, Slough, UK) and zonisamide (Zonegran®, Eisai Co. Ltd, Tokyo, Japan) are licensed as monotherapy for focal epilepsy, and levetiracetam is increasingly used as a first-line treatment for generalised epilepsy, particularly for women of childbearing age. However, there is uncertainty as to whether or not they should be recommended as first-line treatments owing to a lack of evidence of clinical effectiveness and cost-effectiveness. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of lamotrigine (Lamictal®, GlaxoSmithKline plc, Brentford, UK) (standard treatment) with levetiracetam and zonisamide (new treatments) for focal epilepsy, and to compare valproate (Epilim®, Sanofi SA, Paris, France) (standard treatment) with levetiracetam (new treatment) for generalised and unclassified epilepsy. DESIGN: Two pragmatic randomised unblinded non-inferiority trials run in parallel. SETTING: Outpatient services in NHS hospitals throughout the UK. PARTICIPANTS: Those aged ≥ 5 years with two or more spontaneous seizures that require anti-seizure medication. INTERVENTIONS: Participants with focal epilepsy were randomised to receive lamotrigine, levetiracetam or zonisamide. Participants with generalised or unclassifiable epilepsy were randomised to receive valproate or levetiracetam. The randomisation method was minimisation using a web-based program. MAIN OUTCOME MEASURES: The primary outcome was time to 12-month remission from seizures. For this outcome, and all other time-to-event outcomes, we report hazard ratios for the standard treatment compared with the new treatment. For the focal epilepsy trial, the non-inferiority limit (lamotrigine vs. new treatments) was 1.329. For the generalised and unclassified epilepsy trial, the non-inferiority limit (valproate vs. new treatments) was 1.314. Secondary outcomes included time to treatment failure, time to first seizure, time to 24-month remission, adverse reactions, quality of life and cost-effectiveness. RESULTS: Focal epilepsy. A total of 990 participants were recruited, of whom 330 were randomised to receive lamotrigine, 332 were randomised to receive levetiracetam and 328 were randomised to receive zonisamide. Levetiracetam did not meet the criteria for non-inferiority (hazard ratio 1.329) in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio vs. lamotrigine 1.18, 97.5% confidence interval 0.95 to 1.47), but zonisamide did meet the criteria (hazard ratio vs. lamotrigine 1.03, 97.5% confidence interval 0.83 to 1.28). In the per-protocol analysis, lamotrigine was superior to both levetiracetam (hazard ratio 1.32, 95% confidence interval 1.05 to 1.66) and zonisamide (hazard ratio 1.37, 95% confidence interval 1.08 to 1.73). For time to treatment failure, lamotrigine was superior to levetiracetam (hazard ratio 0.60, 95% confidence interval 0.46 to 0.77) and zonisamide (hazard ratio 0.46, 95% confidence interval 0.36 to 0.60). Adverse reactions were reported by 33% of participants starting lamotrigine, 44% starting levetiracetam and 45% starting zonisamide. In the economic analysis, both levetiracetam and zonisamide were more costly and less effective than lamotrigine and were therefore dominated. Generalised and unclassifiable epilepsy. Of 520 patients recruited, 260 were randomised to receive valproate and 260 were randomised to receive to levetiracetam. A total of 397 patients had generalised epilepsy and 123 had unclassified epilepsy. Levetiracetam did not meet the criteria for non-inferiority in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio 1.19, 95% confidence interval 0.96 to 1.47; non-inferiority margin 1.314). In the per-protocol analysis of time to 12-month remission, valproate was superior to levetiracetam (hazard ratio 1.68, 95% confidence interval 1.30 to 2.15). Valproate was superior to levetiracetam for time to treatment failure (hazard ratio 0.65, 95% confidence interval 0.50 to 0.83). Adverse reactions were reported by 37.4% of participants receiving valproate and 41.5% of those receiving levetiracetam. Levetiracetam was both more costly (incremental cost of £104, 95% central range -£587 to £1234) and less effective (incremental quality-adjusted life-year of -0.035, 95% central range -0.137 to 0.032) than valproate, and was therefore dominated. At a cost-effectiveness threshold of £20,000 per quality-adjusted life-year, levetiracetam was associated with a probability of 0.17 of being cost-effective. LIMITATIONS: The SANAD II trial was unblinded, which could have biased results by influencing decisions about dosing, treatment failure and the attribution of adverse reactions. FUTURE WORK: SANAD II data could now be included in an individual participant meta-analysis of similar trials, and future similar trials are required to assess the clinical effectiveness and cost-effectiveness of other new treatments, including lacosamide and perampanel. CONCLUSIONS: Focal epilepsy - The SANAD II findings do not support the use of levetiracetam or zonisamide as first-line treatments in focal epilepsy. Generalised and unclassifiable epilepsy - The SANAD II findings do not support the use of levetiracetam as a first-line treatment for newly diagnosed generalised epilepsy. For women of childbearing potential, these results inform discussions about the benefit (lower teratogenicity) and harm (worse seizure outcomes and higher treatment failure rate) of levetiracetam compared with valproate. TRIAL REGISTRATION: Current Controlled Trials ISRCTN30294119 and EudraCT 2012-001884-64. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 75. See the NIHR Journals Library website for further project information.

BACKGROUND AND METHODS: The SANAD II trial was a clinical trial designed to identify the most clinically effective and cost-effective treatment for adults and children aged > 5 years with newly diagnosed epilepsy. There are two main epilepsy types: focal and generalised. In focal epilepsy, seizures start at a single place in the brain (a focus), whereas in generalised epilepsy seizures start in both sides of the brain at the same time. Anti-seizure medications are the main treatment. For people with newly diagnosed epilepsy, the first anti-seizure medication should control the seizures as quickly as possible while avoiding side effects. The first-choice treatments are lamotrigine (Lamictal®, GlaxoSmithKline plc, Brentford, UK) for focal epilepsy and valproate (Epilim®, Sanofi SA, Paris, France) for generalised epilepsy (however, the latter should be avoided in women who could become pregnant). A number of newer anti-seizure medications have been approved for NHS use, but it is unclear whether or not they should be used as first-line treatments. The SANAD II trial focused on the new medicines levetiracetam (Keppra®, UCB Pharma Ltd, Slough, UK) and zonisamide (Zonegran®, Eisai Co. Ltd, Tokyo, Japan). We recruited 1510 people aged ≥ 5 years with newly diagnosed epilepsy: 990 with focal epilepsy and 520 with generalised or unclassified epilepsy. FINDINGS: FOCAL EPILEPSY: People starting treatment with levetiracetam or zonisamide were significantly less likely to have a 12-month remission from seizures than people starting treatment with lamotrigine, unless they were changed to another anti-seizure medication. Side effects that were thought to be caused by anti-seizure medications were reported by 33% of participants starting lamotrigine, 44% of those starting levetiracetam and 45% of those starting zonisamide. The cost-effectiveness analyses showed that neither levetiracetam nor zonisamide is value for money for the NHS when compared with lamotrigine. The SANAD II findings do not support the use of levetiracetam or zonisamide as first-line treatments in focal epilepsy. FINDINGS: GENERALISED AND UNCLASSIFIABLE EPILEPSY: People starting treatment with levetiracetam were significantly less likely to have a 12-month remission from seizures than people starting valproate, unless they were changed to another anti-seizure medication. Side effects that were thought to be caused by anti-seizure medications were reported by 37% of participants starting valproate and 42% of participants starting levetiracetam. The cost-effectiveness analyses showed that levetiracetam is not good value for money for the NHS when compared with valproate. The SANAD II findings do not support the use of levetiracetam as a first-line treatment for newly diagnosed generalised epilepsy. Importantly, our results will inform treatment decisions for women, who may choose a less effective treatment that is safer in pregnancy.

Relationship of white matter hyperintensities with clinical features of seizures in patients with epilepsy / A relação das hiperintensidades da substância branca com as características clínicas das crises em pacientes com epilepsia

ABSTRACT Background: Although epilepsy is primarily known as a cortical disorder, there is growing body of research demonstrating white matter alterations in patients with epilepsy. Objective: To investigate the prevalence of white matter hyperintensities (WMH) and its association with seizure characteristics in patients with epilepsy. Methods: The prevalence of WMH in 94 patients with epilepsy and 41 healthy controls were compared. Within the patient sample, the relationship between the presence of WMH and type of epilepsy, frequency of seizures, duration of disease and the number of antiepileptic medications were investigated. Results: The mean age and sex were not different between patients and healthy controls (p>0.2). WMH was present in 27.7% of patients and in 14.6% of healthy controls. Diagnosis of epilepsy was independently associated with the presence of WMH (ß=3.09, 95%CI 1.06-9.0, p=0.039). Patients with focal epilepsy had higher prevalence of WMH (35.5%) than patients with generalized epilepsy (14.7%). The presence of WMH was associated with older age but not with seizure characteristics. Conclusions: WMH is more common in patients with focal epilepsy than healthy controls. The presence of WMH is associated with older age, but not with seizure characteristics.

RESUMO Antecedentes: Embora a epilepsia seja principalmente conhecida como um distúrbio cortical, há um crescente corpo de pesquisas que demonstra alterações na substância branca em pacientes com epilepsia. Objetivo: Investigar a prevalência de hiperintensidades da substância branca (WMH) e sua associação com características das crises em pacientes com epilepsia. Métodos: A prevalência de WMH em 94 pacientes com epilepsia e 41 controles saudáveis ​​foi comparada. Na amostra de pacientes, foi investigada a relação entre a presença de WMH e o tipo de epilepsia, a frequência das crises, a duração da doença e o número de medicamentos antiepilépticos. Resultados: A média de idade e o sexo não diferiram entre pacientes e controles saudáveis ​​(p>0,2). WMH estava presente em 27,7% dos pacientes, enquanto em 14,6% dos controles saudáveis. O diagnóstico de epilepsia foi independentemente associado à presença de WMH (ß=3,09, IC95% 1,06-9,0, p=0,039). Pacientes com epilepsia focal apresentaram maior prevalência de WMH (35,5%) do que pacientes com epilepsia generalizada (14,7%). A presença de WMH foi associada à idade avançada, mas não a características das crises. Conclusões: Pacientes com epilepsia focal têm WMH mais comum do que controles saudáveis. A presença de WMH está associada à idade avançada, mas não a características das crises epilépticas.

Perampanel: Does it have broad-spectrum potential?

This article reviews the profile of perampanel, a novel noncompetitive α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate (AMPA) receptor antagonist, and its role as a potential broad-spectrum antiepileptic drug in the treatment of epilepsy. For this narrative review, data were collected using specified search criteria. Articles reporting the evidence for perampanel's efficacy from preclinical models, phase 3 clinical studies, observational studies, and descriptive evidence were included. AMPA receptors play a key role in mediating the action of glutamate at the excitatory synapse. Preclinical research showed the AMPA receptor blockade to constitute a promising target for antiepileptic drug therapy. In animal models, perampanel proved to be protective against seizures and reduce seizure severity and duration. Four phase-3 randomized controlled trials (3 in patients with focal seizures and one in primary generalized tonic-clonic seizures in idiopathic generalized epilepsy) have been completed. In focal (partial) onset seizures, perampanel (4, 8, and 12 mg) significantly reduced seizure frequency per 28 days (23.3%-28.8% vs 12.8%; P < .01) and responder rates (≥50% reduction in seizures) (28.5%-35.3% vs 19.3%; P < .05) compared with placebo. In primary generalized tonic-clonic seizures, perampanel 8 mg resulted in greater reduction in seizure frequency per 28 days (-76.5% vs -38.4%; P < .0001) and responder rate (64.2% vs 39.5%; P = .0019) than placebo. The efficacy, safety, and tolerability of perampanel have been reproduced in real-world clinical practice, and the agent has been shown to be effective in other epilepsy syndromes. Perampanel is a potentially broad-spectrum antiepileptic drug with a novel mechanism of action that may be a useful addition for patients with epilepsy with various seizure types. The availability of novel antiepileptic drugs for epilepsy treatment enables more individualized treatment for these patients.

[BRAF V600E mutation and clinicopathologic characteristics in 250 cases of brain tumors associated with epilepsy].

Objective: To investigate the clinicopathologic characteristics and BRAF V600E mutation of brain tumors associated with epilepsy. Methods: Totally 250 patients with brain tumors associated with epilepsy were included from March 2008 to August 2017 retrospectively at Sanbo Brain Hospital, Capital Medical University.The clinical manifestations, histological features and BRAF V600E mutation results were collected and analyzed. Results: There were 132 males and 118 females, and the male to female ratio was 1.1∶1.0. The age of patients ranged from 2 to 67 years(mean 22 years). The tumors had obvious local space occupying effect on MRI. The temporal lobe was the most common site (44.4%, 111/250). There were 58.4% (146/250) of ganglioglioma (GG), 24.0% (60/250) of dysembryoplastic neuroepithelial tumor (DNT), 12.8% (32/250) of pleomorphic xanthoastrocytoma(PXA), 4.0% (10/250) of angiocentric glioma (AG) and 0.8% (2/250) of papillary glioneuronal tumor (PGNT). Mixed GG, PXA and DNT morphological structures were found in 9 of patients. Among 250 cases, 35 cases were accompanied by focal cortical dysplasia(FCD). BRAF V600E was seen in 43 of 74 (58.1%) GG and 13 of 28 (46.4%) PXA. The most common pathologic grade of GG, DNT, AG and PGNT was WHO I. Some of the tumor cells from GG (34 cases) showed higher proliferative activity (WHO Ⅱ/Ⅲ). Most cases of PXA were WHOⅡand high proliferative activity was seen in nine cases. Conclusions: The association of low-grade glioneuronal tumors with intractable epilepsy was well-recognized. The most common low-grade glioneuronal tumors were GG.GG may occur in any part of the central nervous system, with a predilection for temporal lobe. Each type of low-grade glioneuronal tumors has its own unique histological morphology, but some may show complex features with 2 or 3 mixed components. The occurrence of BRAF V600E mutations in GG is common, and their detection may be valuable for the diagnosis and treatment in GG.

[Neuropathologic study of massive subcortical heterotopia].

Objective: To investigate the clinicpathologic features and probable mechanisms of massive subcortical heterotopia. Methods: Clinical data, histologic features and neuropathologic data were analyzed in five cases of massive subcortical heterotopia collected from Xuanwu Hospital, Capital Medical University from January 2014 to October 2017. Results: All five patients (three males and two females) had a history of refractory epilepsy with a mean period of 15.4 years (range 7 to 21 years). The median age at surgery was 28.6 years(range 20 to 39 years). Magnetic resonance imaging showed that the lesions were located in the temporal lobe (two cases), parietal lobe (one case), both temporal and occipital lobes (one case) and both temporal and parietal lobes (one case). Pathologic examination disclosed that massive gray matter in subcortical and deep white matter with various shape and size. Moreover, one case also showed subpial and periventricular heterotopias and polymicrogyria. Polymicrogyria or hippocampal sclerosis were seen in the remaining three cases. None of the five patients experienced seizure attacks during the follow-up period. Conclusions: Heterotopia is malformations due to abnormal neuronal migration. Massive subcortical heterotopia due to widespread abnormal neuronal migration is relatively rare. The mechanism of heterotopia together with polymicrogyria needs further discussion.

[Rasmussen syndrome: a clinicopathologic study of four cases].

Objective: To investigate the clinicopathologic features of Rasmussen syndrome (RS) and to raise awareness of this rare disease. Methods: Clinicopathologic data of 4 cases of RS were retrospectively analyzed at Beijing Haidian Hospital from 2008 to 2016. Results: The clinical manifestations included epilepsia partialis continua and progressive neurologic deficits in all patients.MRI demonstrated unihemispheric focal cortical atrophy in all cases. The histopathologic changes included variable degrees of lymphocytic infiltrate within the cortex, subarachnoid space and perivascular cuffing.Microglial nodules and neuronophagia were seen. Mild to severe neuronal loss was noted with variable degrees of reactive gliosis. Spongy edema and cavitation were observed in focal cortex. Inflammation involving hippocampus was seen in one case. Three cases were accompanied by focal cortical dysplasia (FCD) Ⅲd. Immunohistochemical staining showed that the infiltrative lymphocytes were positive for CD3, CD8, granzyme B and TIA1 and the proliferating microglial cells were positive for CD68. NeuN positive neurons decreased significantly and reactive astrocytes were GFAP positive. Conclusions: Pathologic changes of RS are similar to viral encephalitis and the inflammation is progressive and multifocal involving the hemisphere. The diagnosis of RS relies on pathologic features combined with clinical findings and neuroradiological examinations.

Rasmussen syndrome: a clinicopathologic study of four cases / 中华病理学杂志

Objective@#To investigate the clinicopathologic features of Rasmussen syndrome (RS) and to raise awareness of this rare disease.@*Methods@#Clinicopathologic data of 4 cases of RS were retrospectively analyzed at Beijing Haidian Hospital from 2008 to 2016.@*Results@#The clinical manifestations included epilepsia partialis continua and progressive neurologic deficits in all patients.MRI demonstrated unihemispheric focal cortical atrophy in all cases. The histopathologic changes included variable degrees of lymphocytic infiltrate within the cortex, subarachnoid space and perivascular cuffing.Microglial nodules and neuronophagia were seen. Mild to severe neuronal loss was noted with variable degrees of reactive gliosis. Spongy edema and cavitation were observed in focal cortex. Inflammation involving hippocampus was seen in one case. Three cases were accompanied by focal cortical dysplasia (FCD) Ⅲd. Immunohistochemical staining showed that the infiltrative lymphocytes were positive for CD3, CD8, granzyme B and TIA1 and the proliferating microglial cells were positive for CD68. NeuN positive neurons decreased significantly and reactive astrocytes were GFAP positive.@*Conclusions@#Pathologic changes of RS are similar to viral encephalitis and the inflammation is progressive and multifocal involving the hemisphere. The diagnosis of RS relies on pathologic features combined with clinical findings and neuroradiological examinations.

Neuropathologic study of massive subcortical heterotopia / 中华病理学杂志

Objective@#To investigate the clinicpathologic features and probable mechanisms of massive subcortical heterotopia.@*Methods@#Clinical data, histologic features and neuropathologic data were analyzed in five cases of massive subcortical heterotopia collected from Xuanwu Hospital, Capital Medical University from January 2014 to October 2017.@*Results@#All five patients (three males and two females) had a history of refractory epilepsy with a mean period of 15.4 years (range 7 to 21 years). The median age at surgery was 28.6 years(range 20 to 39 years). Magnetic resonance imaging showed that the lesions were located in the temporal lobe (two cases), parietal lobe (one case), both temporal and occipital lobes (one case) and both temporal and parietal lobes (one case). Pathologic examination disclosed that massive gray matter in subcortical and deep white matter with various shape and size. Moreover, one case also showed subpial and periventricular heterotopias and polymicrogyria. Polymicrogyria or hippocampal sclerosis were seen in the remaining three cases. None of the five patients experienced seizure attacks during the follow-up period.@*Conclusions@#Heterotopia is malformations due to abnormal neuronal migration. Massive subcortical heterotopia due to widespread abnormal neuronal migration is relatively rare. The mechanism of heterotopia together with polymicrogyria needs further discussion.

BRAF V600E mutation and clinicopathologic characteristics in 250 cases of brain tumors associated with epilepsy / 中华病理学杂志

Objective@#To investigate the clinicopathologic characteristics and BRAF V600E mutation of brain tumors associated with epilepsy.@*Methods@#Totally 250 patients with brain tumors associated with epilepsy were included from March 2008 to August 2017 retrospectively at Sanbo Brain Hospital, Capital Medical University.The clinical manifestations, histological features and BRAF V600E mutation results were collected and analyzed.@*Results@#There were 132 males and 118 females, and the male to female ratio was 1.1∶1.0. The age of patients ranged from 2 to 67 years(mean 22 years). The tumors had obvious local space occupying effect on MRI. The temporal lobe was the most common site (44.4%, 111/250). There were 58.4% (146/250) of ganglioglioma (GG), 24.0% (60/250) of dysembryoplastic neuroepithelial tumor (DNT), 12.8% (32/250) of pleomorphic xanthoastrocytoma(PXA), 4.0% (10/250) of angiocentric glioma (AG) and 0.8% (2/250) of papillary glioneuronal tumor (PGNT). Mixed GG, PXA and DNT morphological structures were found in 9 of patients. Among 250 cases, 35 cases were accompanied by focal cortical dysplasia(FCD). BRAF V600E was seen in 43 of 74 (58.1%) GG and 13 of 28 (46.4%) PXA. The most common pathologic grade of GG, DNT, AG and PGNT was WHO I. Some of the tumor cells from GG (34 cases) showed higher proliferative activity (WHO Ⅱ/Ⅲ). Most cases of PXA were WHOⅡand high proliferative activity was seen in nine cases.@*Conclusions@#The association of low-grade glioneuronal tumors with intractable epilepsy was well-recognized. The most common low-grade glioneuronal tumors were GG.GG may occur in any part of the central nervous system, with a predilection for temporal lobe. Each type of low-grade glioneuronal tumors has its own unique histological morphology, but some may show complex features with 2 or 3 mixed components. The occurrence of BRAF V600E mutations in GG is common, and their detection may be valuable for the diagnosis and treatment in GG.

Transtemporal amygdalohippocampectomy: a novel minimally-invasive technique with optimal clinical results and low cost / Amigdalo-hipocampectomia transtemporal: técnica minimamente invasiva com ótimos resultados clínicos e baixo custo

ABSTRACT Mesial temporal sclerosis creates a focal epileptic syndrome that usually requires surgical resection of mesial temporal structures. Objective: To describe a novel operative technique for treatment of temporal lobe epilepsy and its clinical results. Methods: Prospective case-series at a single institution, performed by a single surgeon, from 2006 to 2012. A total of 120 patients were submitted to minimally-invasive keyhole transtemporal amygdalohippocampectomy. Results: Of the patients, 55% were male, and 85% had a right-sided disease. The first 70 surgeries had a mean surgical time of 2.51 hours, and the last 50 surgeries had a mean surgical time of 1.62 hours. There was 3.3% morbidity, and 5% mild temporal muscle atrophy. There was no visual field impairment. On the Engel Outcome Scale at the two-year follow-up, 71% of the patients were Class I, 21% were Class II, and 6% were Class III. Conclusion: This novel technique is feasible and reproducible, with optimal clinical results.

RESUMO A esclerose mesial temporal é uma síndrome epiléptica focal que requer ablação de estruturas mesiais temporais. Objetivo: Descrever e padronizar a técnica operatória e resultados clínicos. Métodos: Série prospectiva de casos de uma única instituição, realizadas por um único cirurgião, de 2006 a 2012. 120 doentes foram submetidos a amigdalo-hipocampectomia transtemporal por acesso mínimo (keyhole). Resultados: 55% eram do sexo masculino, 85% apresentavam doença do lado direito. As primeiras 70 cirurgias tiveram um tempo cirúrgico médio de 2,51 horas, e as últimas 50 cirurgias tiveram um tempo cirúrgico médio de 1,62 horas. Houve morbidade de 3,3%. 5% dos doentes apresentaram atrofia leve de músculo temporal. O controle das convulsões foi avaliado com a Escala de Engel no segundo ano de pós operatorio, 71% eram Classe I, 21% Classe II, 6% Classe III. Conclusão: Esta nova técnica é viável, reprodutível e com resultados clínicos adequados.

Autosomal dominant epilepsy with auditory features: a new LGI1 family including a phenocopy with cortical dysplasia.

We report a new family with autosomal dominant epilepsy with auditory features (ADEAF) including focal cortical dysplasia (FCD) in the proband. We aim to identify the molecular cause in this family and clarify the relationship between FCD and ADEAF. A large Iranian Jewish family including 14 individuals with epileptic seizures was phenotyped including high-resolution 3-T MRI. We performed linkage analysis and exome sequencing. LGI1, KANK1 and RELN were Sanger sequenced. Seizure semiology of 11 individuals was consistent with ADEAF. The proband underwent surgery for right mesiotemporal FCD. 3-T MRIs in four individuals were unremarkable. Linkage analysis revealed peaks on chromosome 9p24 (LOD 2.43) and 10q22-25 (LOD 2.04). A novel heterozygous LGI1 mutation was identified in all affected individuals except for the proband indicating a phenocopy. Exome sequencing did not reveal variants within the chromosome 9p24 region. Closely located variants in KANK1 and a RELN variant did not segregate with the phenotype. We provide detailed description of the phenotypic spectrum within a large ADEAF family with a novel LGI1 mutation that was conspicuously absent in the proband with FCD, demonstrating that despite identical clinical symptoms, phenocopies in ADEAF families may exist. This family illustrates that rare epilepsy syndromes within a single family can have both genetic and structural etiologies.

Rasmussen's encephalitis: a case report / Encefalitis de Rasmussen: reporte de caso

Rasmussen's encephalitis (RE) is a rare but severe immune-mediated brain disorder leading to unilateral hemispheric atrophy, associated progressive neurological dysfunction with intellectual decline, and intractable seizures. It is a well-established cause of pharmacologically intractable epilepsy. The report is on a 17-month-old infant, treated at the Mario Catarino Rivas Hospital Honduras. Family history: grandfather epileptic secondary trauma from 20 years. Personal history: two previous emergency visits (at 16 months and 16 months 8 days) for convulsions for which she was admitted three days and was treated with valproic acid 30 mg/kg per day. The infant is admitted in the emergency, with a history of about three hours after onset of tonic convulsions, focused on left-side with drooling, oculogiros and relaxation of sphincters and fever of 38.5 ° C. Entered as convulsive syndrome in the study, however, as the days passed the number of seizures increased to 60 per day and was gradually presenting alterations in neurodevelopment. MRI reported leukoencephalopathy of undetermined origin and biopsy reported findings consistent with Rasmussen's syndrome. She was treated with immunoglobulin every two weeks for six doses after two months of hospitalization with achieved improvement. Currently, episodes of seizures have decreased significantly and almost not convulsing, she presented alterations in neurodevelopment.

La encefalitis de Rasmussen (ER)es un trastorno poco frecuente pero grave, mediado inmunológicamente, que afecta al cerebro y conduce a la atrofia hemisférica unilateral, disfunción neurológica progresiva asociada con deterioro intelectual y convulsiones intratables. Lactante de 17meses de edad, atendida en el Hospital Mario Catarino Rivas, Honduras. Con antecedentes familiares: abuelo epiléptico secundario a trauma a partir de los 20 años. Antecedentes personales: dos ingresos previos por cuadros convulsivos por los cuales estuvo ingresada tres días, en tratamiento con ácido valproico 30 mg/kg por día. Es recibida en la emergencia, con historia de aproximadamente tres horas de evolución de convulsiones tónicas, focalizadas en hemicuerpo izquierdo con sialorrea, oculogiros y relajación de esfínteres, febril 38,5 °C. Ingresada como síndrome convulsivo en estudio, sin embargo, al pasar los días incrementó el número de convulsiones hasta 60 diarios y progresivamente fue presentando alteraciones en su neurodesarrollo. La Resonancia Magnética reportó leucoencefalopatia de origen no determinado y la biopsia reportó hallazgos compatibles con Síndrome de Rasmussen. Fue tratada con inmunoglobulina cada quince días por seis dosis y después de dos meses de hospitalización, se logró egresar. Actualmente, los episodios de convulsiones han disminuido considerablemente y casi no convulsiona, presenta alteraciones en su neurodesarrollo.

Benign partial epilepsy of childhood with centrotemporal spikes and sleep disorders / Epilepsia parcial benigna da infância com espícula centrotemporal e transtornos do sono / Epilepsia parcial benigna de la infancia con espícula centrotemporal y trastornos del sueño

Objective: Benign partial epilepsy of childhood with centrotemporal spikes (BECTS) is an idiopathic epilepsy that occurs in healthy children with normal neurodevelopment, characterized by seizures and inter-ictal discharges that predominate during nighttime sleep. This research analyzes the prevalence of sleep disorders in patients with BECTS followed in the Department of Pediatric Neurology at the Pequeno Príncipe Children's Hospital from January 2004 to January 2014. Methods: This study is obser- vational and cross-sectional. The medical records of all children with BECTS followed in the aforementioned institution and period were analyzed, and 46 of these patients met the prerequisites to enter the study. During the investigation all children underwent neuroimaging exams (magnetic resonance or computed tomography) and digital electroencephalogram. In clinical evaluations, all patients and their parents were asked about the presence of sleep disorders. Results: To be classified as having BECTS, patients should have normal neural images and all the electroencephalographies (EEG) should have normal background activity with uni- lateral or bilateral spikes in centrotemporal or centrotemporal and parietal regions. All were being treated with antiepileptic drugs. The age of onset of seizures ranged from 62 to 145 months (mean 94.37 ± 21.2 months). Data showed that 33 (71.74%) out of 46 patients had experienced some kind of sleep disorder: insomnia (18 patients/39.13%), nocturnal enuresis (6 patients/13.04%), somnambulism (2 patients/4.35%), night terrors (1 patient/2.17%), nocturnal enuresis and night terrors (2 patients/4.35%), night terrors and somnambulism (2 patients/4.35%), insomnia and nocturnal enuresis (1 patient/2.17%) and insomnia, night terrors and somnambulism (1 patient/2.17%). Conclusions: Most children diagnosed with BECTS in our pediatric neurology service presented with comorbid sleep disorder. The results are consistent with the data collected in the literature, which show that sleep disorders are more common in children with this type of epilepsy than in those neurologically healthy.

Objetivo: A epilepsia parcial benigna da infância com espículas centrotemporais (EPCT) é uma epilepsia idiopática que ocorre em crianças saudáveis com neurodesenvolvimento normal, que se caracteriza por convulsões e descargas interictais que predominam durante o sono noturno. Esta pesquisa analisa a prevalência de transtornos do sono em pacientes com EPCT acompanhados no Departamento de Neurologia Pediátrica do Hospital Infantil Pequeno Príncipe de janeiro de 2004 a janeiro de 2014. Métodos: Este estudo é observacional e transversal. O prontuário clínico de todas as crianças com EPCT acompanhadas na instituição e no período acima mencionados foi analisado e 46 desses pacientes satisfizeram os pré-requisitos para entrar no estudo. Durante a investigação, todas as crianças foram submetidas a exames de neuroimagem (ressonância magnética ou tomografia computadorizada) e a eletroencefalograma digital. Durante as avaliações clínicas, todos os pacientes e seus pais foram perguntados sobre a presença de transtornos do sono. Resultados: Para serem classificados como portadores de EPCT, os pacientes deviam ter imagens neurais normais e todas as eletroencefalografias (EEG) deviam apresentar atividade de fundo normal, com espículas unilaterais ou bilaterais nas regiões centrotemporal ou centrotemporal e parietal. Todos estavam sendo tratados com medicação antiepiléptica. A idade de início das convulsões variou dos 62 aos 145 meses (média 94,37 ± 21,2 meses). Os dados mostraram que 33 (71,74%) dos 46 pacientes tinham algum tipo de transtorno do sono: insônia (18 pacientes/39,13%), enurese noturna (6 pacientes/13,04%), sonambulismo (2 pacientes/4,35%), terrores noturnos (1 paciente/2,17%), enurese noturna e terrores noturnos (2 pacientes/4,35%), terrores noturnos e sonambulismo (2 pacientes/4,35%), insônia e enurese noturna (1 paciente/2,17%) e insônia, terrores noturnos e sonambulismo (1 paciente/2,17%). Conclusões: A maioria das crianças com diagnóstico de EPCT em nosso serviço de neurologia pediátrica apresentou-se com transtornos do sono comórbidos. Os resultados são compatíveis com os dados coletados na literatura, que mostram que os transtornos do sono são mais comuns em crianças com esse tipo de epilepsia do que nas neurologicamente saudáveis.

Objetivo: La epilepsia parcial benigna de la infancia con espículas centrotemporales (EPCT) es una epilepsia idiopática que ocurre en niños saludables con neurodesarrollo normal, que se caracteriza por convulsiones y descargas interictales que predominan durante el sueño nocturno. Esta investigación analiza la prevalencia de trastornos del sueño en pacientes con BECTS acompañados en el Departamento de Neurología Pediátrica del Hospital Pequeno Príncipe desde enero de 2004 a enero de 2014. Métodos: Este estudio es observacional y transversal. El prontuario clínico de todos los niños con EPCT acompañados en la institución y en el período arriba mencionado fue analizado y 46 de esos pacientes cumplieron con los prerrequisitos para entrar en el estudio. Durante la investigación, todos los niños fueron sometidos a exámenes de neuroimagen (resonancia magnética o tomografía computada) y a electroencefalograma digital. Durante las evaluaciones clínicas, todos los pacientes y sus padres fueron preguntados sobre la presencia de trastornos del sueño. Resultados: Para ser clasificados como portadores de EPCT, los pacientes debían tener imágenes neurales normales y todas las electroencefalografías (EEG) debían presentar actividade de fondo normal, con espículas unilaterales o bilaterales en las regiones centrotemporal o centrotemporal y parietal. Todos estaban siendo tratados con medicación antiepiléptica. La edad de inicio de las convulsiones varió de los 62 a los 145 meses (promedio de 94,37 ± 21,2 meses). Los datos mostraron que 33 (71,74%) de los 46 pacientes tenían algún tipo de trastorno del sueño: insomnia (18 pacientes/39,13%), enuresis nocturna (6 pacientes/13,04%), sonambulismo (2 pacientes/4,35%), terrores nocturnos (1 paciente/2,17%), enuresis nocturna y terrores nocturnos (2 pacientes/4,35%), terrores nocturnos y sonambulismo (2 pacientes/4,35%), insomnia y enuresis nocturna (1 paciente/2,17%) e insomnia, terrores nocturnos y sonambulismo (1 paciente/2,17%). Conclusiones: La mayoría de los niños con diagnóstico de EPCT en nuestro servicio de neurología pediátrica se presentó con trastornos del sueño comórbidos. Los resultados son compatibles con los datos colectados en la literatura, que muestran que los trastornos del sueño son más comunes en niños con ese tipo de epilepsia que en los neurológicamente saludables.

The long-term efficacy study of surgical treatment of partial seizures with children / 重庆医学

Objective To investigate the long‐term effect of surgical treatment of partial seizures in children .Methods The au‐thor was studying in the University of Stellenbosch ,Tygerberg Children′s Hospital .The clinical data of 158 children with partial seizures selected from June 2005 to June 2008 were retrospective analyzed .The postoperative quality of life ,improvement of IQ and the situation of seizure control ,and affect long‐term efficacy of surgery‐related factors were analyzed .Results The patients were followed up for 5 years .The control rate of seizures of 1 ,3 ,5 years were 100 .00% ,94 .85% ,94 .35% ,MRI findings and the course were control independent risk factors affecting the rate of seizure .The rates of IQ improvement of 1 ,3 ,5 years were 89 .87% , 89 .71% ,88 .71% ,of which preoperative IQ ,disease duration ,age at surgery in children were independent risk factors affecting IQ improvement .life .Quality improvement rate of 1 ,3 ,5 years were 93 .04% ,91 .18% ,90 .32% ,and IQ preoperative ,operative ap‐proach were independent risk factors affecting the quality of life postoperatively .Conclusion The surgery operating as soon as pos‐sible could be better for children to improve the range of lesions ,and also could effectively control seizures ,improving the level of intelligence in children and the quality of life postoperatively .

Expressão hipocampal de genes envolvidos em vias de apoptose em pacientes com epilepsia do lobo temporal / Hippocampal expression of genes in apoptotic pathways in temporal lobe epilepsy patients

A epilepsia do lobo temporal associada à esclerose hipocampal [ELT(EH)] é o tipo mais comum de epilepsia focal que causa crises refratárias. A morte neuronal na EH pode ser desencadeada por danos excitotóxicos e citocinas específicas. Pesquisas em modelos experimentais de crises convulsivas ressaltaram a citocina pleiotrópica fator de necrose tumoral (TNF) como um importante efetor/mediador de neuroinflamação e morte celular. Além disso, esses modelos sugeriram que o TNF possa ter uma ação dicotômica por meio de seus dois receptores: ativação da morte celular programada (via TNFRSF1A) ou atuação na sobrevivência celular (via TNFRSF1B), através do fator nuclear kappa B (NFkB). Klotho (KL), originalmente identificada como uma proteína antienvelhecimento, tem se destacado como um importante hormônio regulador de cálcio e fósforo. Sua função cerebral é desconhecida; porém, camundongos knockout para Kl apresentam características que remetem ao envelhecimento humano, com neurodegeneração e redução de sinapses no hipocampo. Em modelos de doença renal crônica e colite, foi comprovado que o TNF inibe KL através do NFkB. Nosso objetivo é identificar alvos críticos na epileptogênese e na fisiopatologia molecular da ELT(EH). Avaliamos a expressão relativa do RNAm de cinco genes-alvo: TNF, TNFRSF1A, TNFRSF1B, NFKB1 e KL. A expressão gênica foi avaliada em amostras de tecido hipocampal de 14 pacientes com ELT(EH) e comparadas com cinco amostras de controles post mortem. Além disso, ambos os receptores do TNF foram analisados nas amostras hipocampais por imuno-histoquímica. Todos os cinco genes avaliados apresentaram expressão significantemente alterada nos pacientes com ELT(EH) (P<0,05). A expressão de ambos os receptores foi constatada nos tecidos dos pacientes. Este é o primeiro estudo a relacionar KL e epilepsia. Nossos dados reforçam o componente inflamatório da EH e sugerem que o TNF possa inibir a expressão de KL no hipocampo dos pacientes.

Temporal lobe epilepsy associated with hippocampal sclerosis [TLE(HS)] is the most common form of focal epilepsy that causes refractory seizures. Neuronal death in HS can be triggered by excitotoxic damage and specific cytokines. Previous research in seizure models indicates that the pleiotropic cytokine tumor necrosis factor (TNF) as an important effector/mediator of neuroinflammation and cell death. Through its two receptors, TNF can play a dichotomous role in animal seizures: programmed cell death activation (via TNFRSF1A) or cell survival actuation (via TNFRSF1B), through the nuclear factor kappa B (NFkB) activation. Klotho (KL), originally identified as an antiaging protein, is emerging as an important calciophosphoregulatory hormone. Its cerebral function is unclear; however, the Kl knockout mouse exhibits a phenotype resembling human aging presenting neural degeneration and a reduction of synapses in the hippocampus. Studies have demonstrated that TNF downregulates KL through NFkB in animal models of chronic kidney disease and colitis. Our aim is to identify critical targets in epileptogenesis to clarify the molecular pathophysiology in TLE(HS). We evaluated the relative mRNA expression of five target genes: TNF, TNFRSF1A, TNFRSF1B, NFKB1 and KL. Gene expression was performed in resected hippocampal tissue samples from 14 TLE(HS) patients and compared to five post mortem controls. Moreover, an immunohistochemistry assay was done to verify the activation of both TNF receptors in patient and control tissues. We found that all target genes were differentially regulated in the TLE(HS) patients (P<0.05). Both TNF receptors were clearly activated in patient's tissues. This is the first study relating KL to epilepsy. Our data corroborates the prominent role of inflammation in HS and suggests that TNF might affect KL expression in hippocampus.

Crisis gelásticas originadas en lóbulo temporal / Gelastic seizures originating in the temporal lobe

Las crisis gelásticas son una forma rara de epilepsia no convulsiva, más frecuente en población adulta joven y casi exclusiva de hamartomas hipotalámicos; sin embargo, hay otras localizaciones no hipotalámicas poco descritas en las cuales se presentan estas crisis, como el lóbulo temporal. El caso que presentamos muestra una manifestación atípica: un paciente de edad avanzada consultó por cambios en el comportamiento y risas inmotivadas; durante la hospitalización, se estableció la presencia de crisis gelásticas, las cuales fueron atribuidas a zona de gliosis temporal izquierda por antecedente de hematoma epidural en esta localización. Se concluye que este tipo de crisis epiléptica en población de la tercera edad es el resultado de etiologías distintas al hamartoma hipotalámico.

Gelastic seizures are a rare form of non-convulsive seizures, more common in young adults and almost exclusively of endocrine disorders and hypothalamic hamartomas, there another other places for this seizures as the temporal lobe. The case shows an atypical manifestation, an elderly patient who consults for changes in behavior and unmotivated laughter; during hospitalization, showed the presence of gelastic seizures, which were attributed to the left temporal area of gliosis by previous epidural hematoma at this location, we present clinical history, neuroimaging and EEG. In the conclusion on elderly, this type of seizure occurs by different etiologies and no only by hypothalamic hamartoma.