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PubMed1990

Surgery for refractory epilepsy.

Over a six-year period, 130 patients with medically intractable epilepsy were assessed for possible surgical treatment. Initial assessment comprised full neurological and neuropsychological examination, computed tomographic and magnetic resonance imaging brain scanning, and simultaneous video and surface plus sphenoidal electroencephalographic (EEG) recordings of typical seizures. Forty-one patients (32%) underwent further video and EEG recordings of their seizures with depth (intracerebral) or strip (subdural) electrodes. After these assessments 46 patients (35%) underwent surgery, and follow-up for six months to six years is reported in 41 patients. Of 30 patients who underwent temporal lobe surgery, 21 (70%) are free of seizures and four have had significant seizure reduction, meaning that 83% benefited from surgery. Optimal results were obtained for complex partial seizures when depth electrode recordings were obtained and when abnormal tissue was removed. Six extratemporal resections abolished seizures in two patients, and four others showed worthwhile improvement. Five patients underwent corpus callosotomy, resulting in a worthwhile improvement in three and modest improvement in two patients. No deaths or major complications occurred. It is concluded that surgical intervention can be beneficial for up to 30% of patients with medically intractable epilepsy, and referral of these patients to an appropriate institution is encouraged.

Brain↗

PubMed2006

Hemifacial motor and crying seizures of temporal lobe onset: case report and review of electro-clinical localisation.

OBJECTIVE: To report a case of temporal lobe epilepsy with clinical presentation of paroxysmal episodes of "tightness" over the right hemiface, and ictal crying, and review electroclinical localisation of this phenomenon. METHODS: Clinical semiology, neurophysiological localising tests, and epilepsy surgery outcome are reported in a subject presenting with paroxysmal right hemifacial movements and ictal crying. Pertinent past reports of somato-motor signs and ictal crying in temporal lobe epilepsy are reviewed and the findings correlated with proposed human facial cortical representation. RESULTS: Simple partial seizures caused by temporal lobe epilepsy presented with right sided tonic facial movements and ictal crying. Intracranial EEG monitoring documented a left medial temporal onset of seizures that remained asymptomatic until they propagated to the left cingulate region. Anterior temporal lobectomy with resection of the amygdala and anterior hippocampus resulted in cessation of seizures. CONCLUSIONS: This is a rare example of epileptic seizures of medial temporal onset presenting with isolated somato-motor manifestations and ictal crying. Anatomical-electrical-clinical correlations with cortical regions controlling facial movements were highly suggestive that this case represents secondary activation of "emotional" motor cortex M3 and M4 (rostral and caudal cingulate motor cortex), giving rise to focal hemifacial movements and ictal crying.

Adult↗

PubMed1991

Secondary epileptogenesis in cerebral arteriovenous malformations.

There is debate as to whether secondary epileptogenesis occurs in humans. As part of a series of patients with cerebral arteriovenous malformations and epilepsy, we identified two patients with probable secondary epileptogenesis in the mesiotemporal regions, ipsilateral but anatomically distant from an arteriovenous malformation causing seizures. Both patients had arteriovenous malformations outside the mesiotemporal region and resection of the arteriovenous malformation and epileptogenic areas identified by electrocorticography produced initial freedom from seizures. Three to 6 months later both patients developed a different seizure pattern that proved to be mesiotemporal in origin by video/electroencephalogram (one with depth electrodes) and both patients are seizure free after a second resection of anterotemporal and mesiotemporal regions. Findings indicating a secondary epileptogenic focus include (1) different seizure type by patient history, (2) second seizure type by ictal video/electroencephalographic recordings, and (3) lack of pathologic abnormalities in the resected mesiotemporal specimens.

Adult↗

PubMed1999

MRI assessment of the anatomy of optic radiations after temporal lobe epilepsy surgery.

OBJECTIVE: The aim of this study was to determine the course of the temporal optic radiations. MATERIAL AND METHODS: Eighteen patients were included in this prospective study. All of them underwent a temporal lobectomy for epilepsy, including the mesial temporal structures and a variable extent of lateral neocortex (from 2 to 7 cm behind the temporal tip). An MRI was performed 2 months postoperatively, allowing assessment of the extent of lateral resection. Postoperative visual fields were determined by automatic static perimetry (ASP). RESULTS: (1) No patient complained of a disabling visual field deficit. (2) ASP, a highly sensitive technique, however, detected postoperative visual field deficits in 83% of patients, confined to the superior homonymous field contralateral to the resection. (3) A strong correlation was found between the presence of a visual field deficit and the extent of laterotemporal resection. (4) The smallest anteroposterior resection resulting in a field defect was limited to 20 mm from the temporal tip. CONCLUSION: (1) This study confirms a strong correlation between postoperative visual field deficits and the extent of lateral neocortical temporal resection. (2) The anterior limit of Meyer's loop is likely to be located more rostrally than previously believed. (3) Despite this, lateral resection remains useful in some cases for seizure control.

Adult↗

PubMed2026

Granger connectivity and graph-theoretical analysis of scalp EEG across the preictal to ictal transition for presurgical evaluation.

OBJECTIVE: To assess the feasibility of estimating lateralization and localization of the epileptogenic zone (EZ) in temporal and extratemporal lobe epilepsy by combining Electric Source Imaging (ESI) with functional connectivity analysis of high-density EEG from the preictal to the ictal phase. METHODS: Adults with drug-resistant focal epilepsy and at least one recorded seizure during 40- or 64 channels EEG monitoring were retrospectively included. Granger causality and hubness centrality were computed over the 10-s preictal interval and the first 5 s of the ictal period, with ictal onset defined as the first EEG change identified by experienced epileptologists. The reference standard for EZ localization was based on resective surgical outcome or stereo-EEG findings. RESULTS: Thirteen patients (7 females; median age 35 years) were included. Connectivity analyses showed higher concordance with clinical findings during the preictal phase than during the ictal phase for both lateralization (91% vs 46%) and localization (73% vs 27%). Performance was highest in temporal (7/7 lateralization; 6/7 localization) and frontal lobe epilepsy (2/2 for both), and lower in parieto-occipital epilepsy (1/2 and 0/2, respectively). In two cases with poor surgical outcome or no surgical indication, connectivity findings were discordant with clinical estimates. CONCLUSIONS: Connectivity analysis across the preictal to ictal transition provides relevant lateralizing and localizing information, particularly in temporal and frontal lobe epilepsy, and may reveal clinically meaningful discordance. SIGNIFICANCE: Integrating high-density EEG, ESI, and functional connectivity during the phase preceding the first EEG change may support non-invasive presurgical evaluation.

Humans↗

PubMed2000

Surgical treatment of temporal tumors associated with epilepsy in children.

Seizures are a frequent sign of cerebral supratentorial tumors in children, especially when the location of the neoplasm is the temporal lobe. We report a series of 37 pediatric patients with temporal epileptogenic tumors. They represent 80.4% of children affected by temporal neoplasms, confirming the high incidence of seizures when neoplasms are located in this cerebral area. There was a slight male predominance. Epilepsy was the first symptom in all the patients of our series, as well as the only clinical manifestation present until surgery in 62% of patients. In the remaining children, hemiparesis, intracranial hypertension, psychosocial or neuropsychological disabilities, and delayed milestones arose before diagnosis and surgical treatment. The most frequent type of seizures was the partial complex (56%), but simple partial or generalized fits, as well as more than one type of seizures, were observed. The medial temporal structures were those more commonly involved, although seizures were observed also in cases where they were spared by tumors located exclusively in the temporal neocortex. On histology, most of the tumors showed a benign phenotype. Tumor resection was complete in 60% of cases; the excision of the tumor was incomplete in subjects whose lesion involved surgically inaccessible cerebral regions, as language areas, insular structures, and basal nuclei. As for epilepsy, 26 among the 32 long-term survivors can be classified in class I of Engel's classification; 4 of them did not receive any antiepileptic treatment. Four patients showed a significant reduction in the frequency of their fits. In 2 subjects, only the frequency of seizures was minimally reduced after tumor excision; in both, a partial removal of their tumor was performed. The relationship among the results on epilepsy and the extent of surgery removal of the tumor, brain tissue removal if any, frequency of seizures in the preoperative period and the time interval between the first epileptic manifestation and surgery show that the most significant prognostic element predictive of a good control of seizures is radical resection of the tumor.

Adolescent↗

PubMed2003

Complex partial seizures and depression.

A long-recognized association exists between epilepsy and affective disturbance, especially depression. People with complex partial seizures that result from temporal lobe seizure foci are highly vulnerable to psychiatric disorders. Accurate diagnosis of such disorders is an important key to treatment. Interictal depression or dysphoria is the most clinically significant problem of this type. Pharmacotherapeutic treatments that have positive effects in other types of depressive illness are also effective for depression associated with epilepsy. Electroconvulsive therapy is helpful to some patients with depression that is refractory to drug treatment or psychotherapy. Surgical resection of seizure foci may lead to psychiatric improvement for some individuals, but can also have psychiatric complications.

Anticonvulsants↗

PubMed1998

Hearing preservation despite labyrinthectomy for resection of giant cholesteatoma with middle fossa extension.

A case is described of an extensive acquired cholesteatoma of the middle ear cleft which had invaded the middle cranial fossa and produced a mass effect on the temporal lobe. It had also extended into the labyrinth without causing elevation in the bone conduction threshold. Furthermore, even after total bony labyrinthectomy, there was very little elevation in these thresholds. The literature relating to hearing preservation after labyrinthectomy is reviewed.

Adult↗

PubMed2004

White matter fiber dissection of the optic radiations of the temporal lobe and implications for surgical approaches to the temporal horn.

OBJECT: The aim of this anatomical study was to define more fully the three-dimensional (3D) relationships between the optic radiations and the temporal horn and superficial anatomy of the temporal lobe by using the Klingler white matter fiber dissection technique. These findings were correlated with established surgical trajectories to the temporal horn. Such surgical trajectories have implications for amygdalohippocampectomy and other procedures that involve entering the temporal horn for the resection of tumors or vascular lesions. METHODS: Ten human cadaveric hemispheres were prepared with several cycles of freezing and thawing by using a modification of the method described by Klingler. Wooden spatulas were used to strip away the deeper layers of white matter progressively in a lateromedial direction, and various association, projection, and commissural fibers were demonstrated. As the dissection progressed, photographs of each progressive layer were obtained. Special attention was given to the optic radiation and to the sagittal stratum of which the optic radiation is a part. The trajectories of fibers in the optic radiation were specifically studied in relation to the lateral, medial, superior, and inferior walls of the temporal horn as well as to the superficial anatomy of the temporal lobe. In three of the hemispheres coronal sections were made so that the relationship between the optic radiation and the temporal horn could be studied more fully. In all 10 hemispheres that were dissected the following observations were made. 1) The optic radiation covered the entire lateral aspect of the temporal horn as it extends to the occipital horn. 2) The anterior tip of the temporal horn was covered by the anterior optic radiation along its lateral half. 3) The entire medial wall of the temporal horn was free from optic radiation fibers, except at the level at which these fibers arise from the lateral geniculate body to ascend over the roof of the temporal horn. 4) The superior wall of the temporal horn was covered by optic radiation fibers. 5) The entire inferior wall of the temporal horn was free from optic radiation fibers anterior to the level of the lateral geniculate body. CONCLUSIONS: Fiber dissections of the temporal lobe and horn demonstrated the complex 3D relationships between the optic radiations and the temporal horn and superficial anatomy of the temporal lobe. Based on the results of this study, the authors define two anatomical surgical trajectories to the temporal horn that would avoid the optic radiations. The first of these involves a transsylvian anterior medial approach and the second a pure inferior trajectory through a fusiform gyrus. Lateral approaches to the temporal horn through the superior and middle gyri, based on the authors' findings, would traverse the optic radiations.

Amygdala↗

PubMed2004

Insulin signaling pathways in cortical dysplasia and TSC-tubers: tissue microarray analysis.

To evaluate the possible roles of the Akt/PKB-mTOR-p70S6K-S6 and cap-dependent translation (eIF4G) pathways in the pathogenesis of tuberous sclerosis complex (TSC)-associated cortical tubers and focal cortical dysplasia (FCD), we performed qualitative and semiquantitative immunohistochemical evaluation on surgically resected corticectomy specimens to detect phosphorylated molecules as activated downstream targets of the signaling pathways. A tissue microarray paraffin block was constructed from 63 archival specimens of surgically resected TSC tubers, FCDs with balloon cells, cortical dysplasia without balloon cells, and histologically normal-appearing neocortex obtained from cases with Rasmussen encephalitis, cystic-gliotic encephalopathy, and temporal lobe epilepsy. Abnormal neuroglial cells were positive for phospho-S6 and phospho-eIF4G with various staining intensities in FCDs and TSC tubers. Both proteins were much less abundantly expressed in normal-appearing neocortex. Phospho-mTOR expression was observed in neurons in all groups. The expression of phospho-S6 and phospho-eIF4G was associated with dysplastic lesions (p < 0.05), and the cytoplasmic phospho-p70S6K expression was most specific for and abundant in TSC tubers and much less prominent in other groups (p < 0.01). These results suggest that constitutive activation of cytoplasmic p70S6K plays a pivotal role in the pathogenesis of TSC tubers and that FCDs possess a distinct mechanism for activation of S6 and eIF4G.

Adolescent↗

PubMed1992

Melanotic cerebral ganglioglioma: evidence for melanogenesis in neoplastic astrocytes.

A composite melanotic glial-ganglionic tumor was resected from a 17-year-old girl who presented with a 5-year history of epilepsy. Grossly, the tumor was partly cystic, partly solid, located superficially in the temporal lobe. Histologically, its glial component was composed of spindle and pleomorphic cells, including tumor giant cells, which were associated with Rosenthal fibers, eosinophilic granular bodies and marked desmoplasia. The cells had immunohistochemical and ultrastructural features of astrocytes, and some were invested by incomplete basal lamina. Thus, the tumor had many features in common with pleomorphic xanthoastrocytoma. However, its most striking feature was the presence of melanin pigment in numerous neoplastic cells. Immunoelectron microscopy revealed glial fibrillary acidic protein-positive intermediate filaments in tumor cells bearing melanosomes and premelanosome, proving their astrocytic nature. This case demonstrates, for the first time, melanosomal melanogenesis in human cells with astrocytic phenotype, and provides additional evidence for the ability of central neuroepithelial cell derivatives to produce melanin.

Adolescent↗

PubMed1990

Determination of precise focus distribution and tailored lobectomy in temporal lobe epilepsy.

For the purpose of precise localization of epileptic foci, combined depth and subdural electrodes were applied to patients with intractable complex partial seizures. To determine speech-related areas, extraoperative functional mapping of the temporal lateral cortex was also carried out through the subdural electrodes. Based on these data, the extent of surgical resections was tailored to include as much of the epileptogenic areas as possible, while preserving the functionally essential zones of the lateral cortex. The results thus acquired have been satisfactory in terms of seizure control and the preservation of speech function.

Dominance, Cerebral↗

PubMed1996

[Huge skull base neurofibroma: case report].

A case of a huge skull base neurofibroma completely resected by a combined subtemporal-infratemporal and basal subfrontal approach is reported. A 32-year-old female complained of left facial paresthesia and deformity since several months before. Neurological examination revealed hypesthesia in the distribution of the left trigeminal nerve second branch. CT and MRI images showed a huge tumor in the infratemporal fossa, parapharyngeal space and middle fossa extending into the cavernous sinus, compressing the left temporal lobe and distorting the left hypothalamus and the brain stem. The patient tolerated trial balloon occlusion of the left internal carotid artery for 45 minutes. Transmaxillary biopsy revealed the tumor to be a neurofibroma. Through a combined basal subfrontal and a subtemporal-infratemporal approach in two staged operations, total tumor resection was performed. This tumor originated at the second branch of the trigeminal nerve. We recommend these combined approaches and two staged operations for such a huge skull base tumor as presented in this case.

Adult↗

PubMed2001

GABA uptake and heterotransport are impaired in the dentate gyrus of epileptic rats and humans with temporal lobe sclerosis.

In vivo dialysis and in vitro electrophysiological studies suggest that GABA uptake is altered in the dentate gyrus of human temporal lobe epileptics characterized with mesial temporal sclerosis (MTLE). Concordantly, anatomical studies have shown that the pattern of GABA-transporter immunoreactivity is also altered in this region. This decrease in GABA uptake, presumably due to a change in the GABA transporter system, may help preserve inhibitory tone interictally. However, transporter reversal can also occur under several conditions, including elevations in [K(+)]o, which occurs during seizures. Thus GABA transporters could contribute to seizure termination and propagation through heterotransport. To test whether GABA transport is compromised in both the forward (uptake) and reverse (heterotransport) direction in the sclerotic epileptic dentate gyrus, the physiological effects of microapplied GABA and nipecotic acid (NPA; a compound that induces heterotransport) were examined in granule cells in hippocampal slices from kainate (KA)-induced epileptic rats and patients with temporal lobe epilepsy (TLE). GABA- and NPA-induced responses were prolonged in granule cells from epileptic rats versus controls (51.3 and 31.3% increase, respectively) while the conductance change evoked with NPA microapplication was reduced by 40%. Furthermore the ratio of GABA/NPA conductance, but not duration, was significantly >1 in epileptic rats but not controls, suggesting a compromise in transporter function in both directions. Similar changes were observed in tissue resected from epileptic patients with medial temporal sclerosis but not in those without the anatomical changes associated with MTLE. These data suggest that the GABA transporter system is functionally compromised in both the forward and reverse directions in the dentate gyrus of chronically epileptic tissue characterized by mesial temporal sclerosis. This alteration may enhance inhibitory tone interically yet be permissive for seizure propagation due to a decreased probability for GABA heterotransport during seizures.

Animals↗

PubMed2001

Temporal lobe epilepsy due to hippocampal sclerosis in pediatric candidates for epilepsy surgery.

OBJECTIVE: To characterize the clinical, EEG, MRI, and histopathologic features and explore seizure outcome in pediatric candidates for epilepsy surgery who have temporal lobe epilepsy (TLE) caused by hippocampal sclerosis (HS). METHODS: The authors studied 17 children (4 to 12 years of age) and 17 adolescents (13 to 20 years of age) who had anteromesial temporal resection between 1990 and 1998. RESULTS: All patients had seizures characterized by decreased awareness and responsiveness. Automatisms were typically mild to moderate in children and moderate to marked in adolescents. Among adolescents, interictal spikes were almost exclusively unilateral anterior temporal, as opposed to children in whom anterior temporal spikes were associated with mid/posterior temporal, bilateral temporal, extratemporal, or generalized spikes in 60% of cases. MRI showed hippocampal sclerosis on the side of EEG seizure onset in all patients. Fifty-four percent of children and 56% of adolescents had significant asymmetry of total hippocampal volumes, whereas the remaining patients had only focal atrophy of the hippocampal head or body. Subtle MRI abnormalities of ipsilateral temporal neocortex were seen in all children and 60% of adolescents studied with FLAIR images. On histopathology, there was an unexpectedly high frequency of dual pathology with mild to moderate cortical dysplasia as well as HS, seen in 79% of children and adolescents. Seventy-eight percent of patients were free of seizures at follow-up (mean, 2.6 years). A tendency for lower seizure-free outcome was observed in patients with bilateral temporal interictal sharp waves or bilateral HS on MRI. The presence of dual pathology did not portend poor postsurgical outcome. CONCLUSIONS: TLE caused by HS similar to those in adults were seen in children as young as 4 years of age. Focal hippocampal atrophy seen on MRI often was not reflected in total hippocampal volumetry. Children may have an especially high frequency of dual pathology, with mild to moderate cortical dysplasia as well as HS, and MRI usually, but not always, predicts this finding. Postsurgical seizure outcome is similar to that in adult series.

Adolescent↗

PubMed2002

Interaction of cognitive aging and memory deficits related to epilepsy surgery.

Temporal lobe epilepsy surgery can cause significant memory impairment. This study was intended to examine whether surgery also could affect prognosis of memory in older age. Age regression of verbal memory was examined in 187 patients (before and 1 year after left temporal lobe surgery) and 264 healthy controls. Eighty patients underwent selective amygdalohippocampectomy, and 107 patients underwent anterior two-thirds temporal lobectomy. Amygdalohippocampectomy patients had mesiotemporal epilepsy; anterior two-thirds temporal lobectomy patients had more extramesial or diffuse seizure onset zones. Memory was assessed by word list learning for its more mesial (consolidation/retrieval) and more neocortical (learning) aspects. Patients showed significant preoperative memory impairment. Independent of seizure outcome and surgical approach, surgery had significant negative effects on learning and consolidation/retrieval. In the amygdalohippocampectomy group, preoperative and postoperative age regressions of learning and consolidation/retrieval were not different from those of controls. In the anterior two-thirds temporal lobectomy group, age regression of verbal learning became steeper after surgery, and consolidation/retrieval was negatively correlated with older age and later onset of epilepsy even before surgery. The data confirm that age regression of verbal memory in left temporal lobe epilepsy is similar to that in healthy controls. Both left anterior two-thirds temporal lobectomy and amygdalohippocampectomy worsen verbal learning and memory and bring patients closer to cognitive disability. Particularly in anterior two-thirds temporal lobectomy patients, surgery and reduced capacities for compensation cause acceleration of lifetime memory decline. The results support earlier and tailored epilepsy surgery and suggest that memory prognosis in older age should be considered if more extensive temporal resections would be inevitable.

Adolescent↗

PubMed1998

Unusual association of intractable temporal lobe seizures and intracranial aneurysms in an adolescent: is it a coincidence?

Intracranial aneurysms in the pediatric age group are rare occurrences. They usually present with subarachnoid hemorrhage or mass effect. Their association with epilepsy has rarely been reported; such concurrence may not be a coincidence. We present a 16-year-old girl with a 5-year history of medically intractable complex partial seizures. Preoperative electrophysiological and neuroimaging studies demonstrated an epileptogenic focus and atrophy in the right mesial temporal lobe, and ipsilateral incidental aneurysm at the carotid artery bifurcation. The patient underwent a complete right anterior temporal lobectomy, followed by clipping of the aneurysm. We concluded that the epilepsy management in association with cerebral aneurysms is controversial, but when surgery is indicated, clipping of the aneurysm and resection of the epileptogenic focus may provide the optimal outcome. The relevant literature is reviewed and the possible mechanisms of production of epilepsy by intracranial aneurysms are discussed.

Adolescent↗

PubMed1999

A study of mortality after temporal lobe epilepsy surgery.

OBJECTIVE: To determine early and late mortality in a cohort of 305 consecutive patients who had temporal lobe epilepsy (TLE) surgery over a 20-year period. METHODS: Survival status, cause of death, and postoperative clinical details of those who died were ascertained in a cohort of 305 patients who had TLE surgery. Mortality was related to postoperative seizure status, operative pathology, and side of resection. RESULTS: The survival status of 299 patients was established. Twenty deaths occurred. Mortality was 1 per 136 person-years, with a standardized mortality ratio (SMR) of 4.5 (95% confidence interval [CI], 3.2 to 6.6). Six deaths were sudden and unexpected (SUDEP). The SUDEP rate was 1 per 455 person-years. The overall death and SUDEP rates were lower than those reported for similar patient populations with chronic epilepsy. Mortality in patients who had right-sided resections for mesial temporal sclerosis (MTS) remained considerably elevated with a mortality rate of 1 per 54 person-years, an SMR of 32.0 (95% CI, 24.7 to 40.5), and a SUDEP rate of 1 per 134 person-years. These patients had significantly lower seizure remission rates than left-sided patients, but the excess mortality was not simply explained by those patients whose partial seizures were uninfluenced by surgery. Patients who died had more severe or convulsive seizures despite an overall reduction in seizure frequency. CONCLUSIONS: The present findings confirm previous reports that TLE surgery lowers but does not normalize the overall mortality associated with chronic epilepsy. In patients with right-sided MTS, however, the postoperative mortality has remained similar to other groups with medically intractable seizures.

Adolescent↗