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PubMed1999

Spitting automatism in complex partial seizures: a nondominant temporal localizing sign?

PURPOSE: Spitting as an ictal automatism has been rarely reported. We aimed to establish its potential lateralizing and localizing significance. METHODS: Review of patients undergoing surgery for intractable epilepsy at two comprehensive epilepsy centers. RESULTS: Five patients were found who had spitting as a stereotyped automatism of their complex partial seizures. All had evidence of right temporal ictal onset and underwent resective surgery. Two had tumors; one, a cavernous angioma; one, hippocampal gliosis, and one, hippocampal sclerosis. We found no instances of ictal spitting in patients with left hemisphere onset. CONCLUSIONS: Spitting as an automatism in complex partial seizures, although uncommon, may be a localizing sign to the nondominant temporal lobe.

Adult↗
PubMed2003

The role of stereotactic radiosurgery for low-grade astrocytomas.

OBJECT: This study was conducted to examine the role of radiosurgery in the management of patients with recurrent or unresectable low-grade astrocytomas. METHODS: During a 13-year interval, 49 patients underwent stereotactic radiosurgery as part of multimodal treatment of their recurrent or unresectable low-grade astrocytomas. Thirty-seven of these patients (median age 14 years) harbored pilocytic astrocytomas and 12 patients harbored World Health Organization (WHO) Grade II fibrillary astrocytomas (median age 25 years). Tumors involved the brainstem in 22 cases, cerebellum in four, thalamus in six, temporal lobe in five, frontal lobe in four, and parietal lobe in three, as well as the hypothalamus, corpus callosum, insular cortex, optic tract, and third ventricle in one patient each. Each diagnosis was confirmed with the aid of stereotactic biopsy sampling in 17 patients, open biopsy sampling in five, partial resection in 13, and near-total resection in 14. Multimodal treatment included fractionated radiotherapy in 14 patients, stereotactic intracavitary irradiation in five, chemotherapy in two, cyst drainage in eight, ventriculoperitoneal shunt placement in five, and additional cytoreductive surgery in five. Tumor volumes ranged from 0.42 to 45.1 cm3. The median radiosurgical dose to the tumor margin was 15 Gy (range 9.6-22.5 Gy). After radiosurgery, serial neuroimaging demonstrated complete tumor resolution in 11 patients, reduced tumor volume in 12, stable tumor volume in 10, and delayed tumor progression in 16. No procedure-related death was encountered. Forty-five of 49 patients are alive at a median follow-up period of 32 months after radiosurgery and 63 months after diagnosis. Sixteen patients participated in follow-up review for more than 60 months. Three patients died of local tumor progression. CONCLUSIONS: Stereotactic radiosurgery is a potential alternative or adjunctive intervention in the management of selected patients with pilocytic or WHO Grade II fibrillary astrocytomas, usually performed for small-volume tumors in an attempt to avoid larger-field fractionated radiotherapy.

Adolescent↗
PubMed2002

Gamma-Knife radiosurgery of mesiotemporal tumour epilepsy observations and long-term results.

PURPOSE: The efficacy of radiosurgery in cases of mesiotemporal tumours associated with long standing epilepsy has not clearly been documented up to now. The authors present a retrospective analysis of 19 cases treated by Gamma-Knife radiosurgery (GKRS) for mesiotemporal tumour epilepsy. METHODS: Between 1992 and 1997 19 patients (12 male and 7 female) with a mean age of 31 years (5-72) and mesiotemporal tumour-induced epilepsy of a mean duration of 8.6 years (0.9-28) were treated by GKRS. All tumours were within the mesiotemporal structures and the pathohistology proven by biopsy or resective procedure revealed 15 (79%) low grade astrocytomas, 3 (16%) gangliogliomas and 1 (5%) cavernoma. Beside tumour control, the main aim of GKRS was alleviation of epilepsy by irradiating the presumed epileptic foci outside the tumour volume. The 50% isodose volumes surrounding the tumours measured a mean of 6.2 ccm (1.1-18 ccm). Doses given at marginal isodoses ranged from 12 to 30 Gy (mean 17.3 Gy). The outcome with respect to epileptic seizures was evaluated by the Engel classification. RESULTS: After a follow-up (FU) of 1.7 to 9.7 years (mean 6.5 years) 11 patients (57.9%) were significantly ameliorated (Engel I and Engel II), 7 patients (36.8%) worthwhile improved (Engel III) and 1 patient (5.3%) unchanged. In 11 patients (58%) radiosurgically induced image changes were seen on MRI. INTERPRETATION: Although microsurgical approach guided by electrocorticography (EcoG) is the state of art for treatment of mesiotemporal tumour epilepsy, GKRS can be used as a non-invasive, safe and effective alternative to resective surgery for selected cases.

Adolescent↗
PubMed2001

Late seizure recurrence after multiple subpial transections.

We studied long-term outcome (range, 28-89 months; mean, 56 months) after multiple subpial transections (MST) for medically refractory epilepsy. Forty-three (79.6%) of 54 patients had a consistent significant reduction in seizure frequency, and 27 (50%) of the 54 were either entirely seizure free or virtually so. However, 10 (18.5%) patients sustained an increase in seizure frequency several years after surgery, after showing initial postoperative improvement. This suggests that late seizure recurrence is a more important problem in cases in which MST has been performed than for pure resections.

Cerebral Cortex↗
PubMed1987

Relationships between neuropathology and cognitive functioning in temporal lobectomy patients.

Cognitive functions were examined before operation and 4 weeks after operation with respect to pathology in 40 patients who underwent temporal lobectomy for epilepsy. Hippocampal sclerosis was associated with febrile convulsions, an earlier onset of regular seizures, poorer preoperative intelligence and with a tendency towards greater cognitive improvement across the operation than found in patients with tumour-like malformations or non-specific pathology. Damage to the amygdala was associated with a poorer outcome for the retention in memory of verbal and non-verbal material. The absence of any specific abnormality in the resected tissue was not associated with a poorer cognitive outcome 4 weeks after the operation.

Adult↗
PubMed1999

[Clinical experience of image-guided neurosurgery with a frameless navigation system (StealthStation)].

We have applied the frameless navigation system (StealthStation) to various neurosurgical procedures to examine its usefulness. The system consists of a UNIX based workstation that creates triplanar and 3-dimensional images; an infrared optical digitizer with camera array; a reference-light-emitting diode (LED) array (e.g., reference array); and pointer probe modified by the addition of LEDs. This system was used to assist in placing a minimal skin incision and craniotomy in 4 cases, to determine the tumor/brain interface in 2 cases, to target the subcortical lesion in one case, and to correlate bony structure with a skull base tumor in 3 cases. The combined use with magnetic source imaging of the somatosensory cortex allowed a fast orientation of eloquent areas in 2 cases with peri-Rolandic tumor. This system, thus, was proved to be a useful adjunct to open-tumor biopsy or resection.

Adult↗
PubMed2004

Chronic temporal lobe epilepsy: spatial extent and degree of metabolic dysfunction studied with magnetic resonance spectroscopy (MRS).

INTRODUCTION: Proton magnetic resonance spectroscopy ((1)H MRS) has been proposed as a lateralizing method for the presurgical evaluation of patients with medically intractable temporal lobe epilepsy (TLE). Studies have shown correlations between temporal lobe (TL) NAA and seizure frequency, and TL NAA/Cr and the duration of epilepsy in patients with TLE. This latter finding may suggest that progressive neuronal dysfunction may occur in both temporal lobes in patients with TLE, even when the seizures originate in only one temporal lobe. We analyzed our data in an attempt to find a possible correlation between extension of neuronal dysfunction based on NAA measures and duration of epilepsy. METHODS: We studied 45 consecutive patients with the diagnosis of TLE, who were referred for presurgical evaluation. Duration of epilepsy was defined as the interval between the age of seizure onset and the time of the MRS examination. All studies were performed in the inter-ictal state, prior to intracranial monitoring or resection. We performed two-tailed Pearson correlation analysis between ipsilateral NAA/Cr and extension of the abnormality (voxels involved) and the duration of the seizure disorder in years. RESULTS: The average duration of epilepsy in this group was 20 years. No significant correlation was found between duration of epilepsy and mean hippocampal NAA/Cr (r=-.131, p=.390); nor was a correlation found between duration of epilepsy in years or the extent of metabolic lesion (voxels involved) (r=-.264, p=.079). CONCLUSIONS: Hippocampal NAA/Cr does not correlate with duration of epilepsy in TLE. Our findings suggest that cross-sectional group measures of hippocampal neuronal function do not suggest damage progression.

Adolescent↗
PubMed1999

Visual and quantitative ictal EEG predictors of outcome after temporal lobectomy.

PURPOSE: We investigated whether visual and quantitative ictal EEG analysis could predict surgical outcome after anteromesial temporal lobectomy (AMTL) in which mesial structures, basal, and temporal tip cortex were resected. METHODS: We retrospectively reviewed 282 presurgical scalp-recorded ictal EEGs (21- to 27-channel) from 75 patients who underwent AMTL. We examined the pattern of seizure onset (frequency, distribution, and evolution) and estimated the principal underlying cerebral generators by using a multiple fixed dipole model that decomposes temporal lobe activity into four sublobar sources (Focus 1.1). We correlated findings with a 2-year postoperative outcome. RESULTS: Sixteen patients had seizures with a well-lateralized, regular 5 to 9-Hz rhythm at onset, that most often had a temporal or subtemporal distribution. All patients became seizure free after surgery. In 51 patients, seizure onset was remarkable for lateralized slow rhythms (<5 Hz), which sometimes appeared as periodic discharges, were often irregular and stable only for short periods (<5 s), and had a widespread lateral temporal distribution. Among these a favorable surgical outcome was encountered in patients with seizures having prominent anterior-tip sources ( 16 of 17 seizure free), whereas those with dominant lateral or oblique sources had a less favorable outcome (three of 14 and 13 of 18, respectively). Irregular, nonlateralized slowing characterized seizure onsets in eight patients. Three patients became seizure free after surgery. CONCLUSIONS: Both visual and quantitative sublobar source analysis of scalp ictal EEG can predict surgical outcome in most cases after AMTL and complement non-invasive presurgical evaluation.

Electrodes, Implanted↗
PubMedDate not supplied

[Technic for surgical intervention in severe brain contusions and crushing].

Basal contusions of the frontal and temporal lobes of the brain, occurring as a contrecoup as a rule, are particularly severe and are marked by a high mortality. The 10-year practice of the Sklifosovsky Scientific Research Institute of Emergency Aid in the surgical management of cerebral contusion was aimed at the search for a less traumatic craniotomy approach and the most sparing and radical, within reasonable limits, intervention on the cerebral focus. Analysis of the work done enables us to choose the method described in the article, comprising extensive infratemporal craniotomy which excludes the frontal, temporal, and parietal, lobes, and to recommend combining intervention on the focus with internal decompression and active aspiration of the wound discharge from the cranial cavity in the first 24 hours after the operation. The illustrations supplied show the stages of the operation: linear skin incision, incision and separation of the temporal muscle, resection of the squama of the temporal and frontal bones down to the base of the skull. The operation may also be carried out as osteoplasty (sites for forming the trephination openings are shown in Fig. 1, a).

Adolescent↗
PubMed2004

Somatoform disorders after temporal lobectomy.

OBJECTIVE: Depression, anxiety, and psychosis are the most frequent psychiatric disorders after epilepsy surgery. The only new-onset somatoform disorder reported postoperatively is conversion disorder. We identified 10 patients who developed somatoform disorder other than nonconversion epileptic seizures after anterior temporal lobectomy. METHOD: We retrospectively reviewed the charts of 325 anterior temporal lobectomy and 125 extratemporal surgeries between 1991 and 2000. RESULTS: Seven of the patients developed undifferentiated somatoform disorder after anterior temporal lobectomy, 1 had pain and body dysmorphia, another had pain disorder, and another had body dysmorphia alone, but none were found after extratemporal surgeries (chi-square = 3.93; P < or = 0.05). Somatoform disorder was significantly more common in right anterior temporal lobectomy (n = 9) than left anterior temporal lobectomy (n = 1) (chi-square = 6.5; P < or = 0.025). CONCLUSIONS: Our findings suggest that right temporal resection contributes to the development of somatoform disorders in our patients and that right temporal dysfunctions may contribute to idiopathic somatoform disorders.

Adolescent↗
PubMed1997

Neuropsychiatric complications after temporal lobe limbic system surgery.

Although control of seizure activity is the main goal of temporal lobectomies for complex partial epilepsy, the results of surgery must be viewed within the larger context of possible ramifications of limbic system disruption. The neuropsychiatric complications may be significant and influence the patient's perceived qualify of life, thus detracting from the benefits of seizure control. It is apparent from the previous studies that the modalities affected are influenced by the laterality of the resection, with left-sided lobectomies more often affecting verbal memory and learning, whereas right-sided resections may cause visual/spatial memory and cognitive declines. Preoperative neuropsychologic testing may help to predict these possible complications. General psychosocial function, memory, and cognition all seem to be less affected when complete seizure control is attained, with nearly 80% experiencing no significant change in neuropsychologic testing and the gain and losses being equal in magnitude. Also, younger patients and those with a shorter history of seizure activity may fare better after surgery because of a greater capacity for neuronal plasticity to subserve these functions. These findings support the contention that early diagnosis and surgical treatment may help to minimize potential neuropsychiatric complications in conjunction with improved postoperative seizure control.

Age Factors↗
PubMed2003

Surgery for drug resistant partial epilepsy in children with focal cortical dysplasia: anatomical-clinical correlations and neurophysiological data in 10 patients.

OBJECTIVE: To analyse a population of children with focal cortical dysplasia operated on for drug resistant partial epilepsy, with emphasis on clinical features, seizure semiology, interictal and ictal EEG and stereo EEG findings, histological and topographical characteristics of the lesions, extension and localisation of cerebral excision, and its postoperative effect on seizure frequency. METHODS: 10 patients were studied, aged between 26 months and 11 years (median 6 years). Magnetic resonance imaging (MRI) abnormalities were unilobar (temporal 3, frontal 2), bilobar (2), or multilobar (1); the two patients with negative MRI suffered from frontal seizures. Presurgical diagnostic steps varied in complexity and invasiveness depending on the anatomical/electrical/clinical features of each patient. In four patients they included only scalp video EEG monitoring, and in six, also invasive recordings using stereotactically implanted intracerebral electrodes. Surgery consisted of corticectomy plus lesionectomy in all cases. RESULTS: 70% of the patients were seizure-free after a minimum postoperative follow up of 25 months. These included three patients with temporal lesions and four of seven patients with other lobar or multilobar extratemporal localisation. One patient had improvement in seizure control. Outcome was poor in multilobar patients, but a class Ia outcome was obtained in one case after partial lesionectomy associated with bilobar corticectomy. All patients showed developmental improvement. CONCLUSIONS: Analysis of the data in these patients allowed the production of an "anatomical-clinical concordance" list, which appeared to be correlated with the diagnostic steps performed. Carrying out a stereo EEG exploration in the most complex cases proved useful in defining the epileptogenic zone in extratemporal and multilobar epilepsies. Stereo EEG recordings facilitated a tailored resection of extralesional cortex.

Cerebral Cortex↗
PubMed2000

[Temporal lobe epilepsy: longitudinal clinical, neuropsychological and psychosocial follow-up of surgically and conservatively managed patients].

Little is known about the differential long-term outcome from surgical and nonsurgical therapy in patients with chronic epilepsy. In the present study, 161 surgically or nonsurgically treated patients with drug-resistant temporal lobe epilepsy (TLE) were re-evaluated according to a detailed clinical, neuropsychological, and psychosocial protocol with a mean follow-up interval of 58 months. Freedom from seizures was achieved in 64% of the surgical group; yet 23% of the nonsurgical patients became seizure-free as a result of modifications in drug therapy. Generally, socioeconomic development was poorer in nonsurgical than in surgical patients. Freedom from seizures, employment, and the absence of depression were significant determinants of better quality of life. As for neuropsychological outcome, verbal memory impairment was common after left-sided temporal resection; however, there was no evidence of a marked progression of cognitive impairment after the first postoperative year. In nonsurgical patients, too, cognitive capacities were surprisingly stable over time, although persisting seizures and good baseline performance predicted a poorer neuropsychological outcome.

Adult↗
PubMed1987

Arachnoid cyst of the middle cranial fossa--aplasia of temporal lobe?

In 11 cases of intracranial, temporal arachnoid cysts the etiology, clinical and radiographic findings, surgical treatment, and outcome are reviewed in respect of post-traumatic subdural hematoma. Cysts of the middle cranial fossa are susceptible to trauma, which may cause bleeding either into the cyst or into the subdural space. Signs and symptoms of increasing intracranial pressure (ICP), local neurological deficits, and sometimes epileptic seizures may lead to hospitalization. CT or MRI scans are diagnostic in these cases. In cases of intracranial mass lesion with displacement of the midline structures and increasing ICP, osteoplastic craniotomy is performed and the lateral wall of the cyst is resected down to the tentorial notch by a microsurgical procedure, with opening into the basal cisterns. There were no operative or postoperative complications in 11 consecutive cases. However, one boy required a cystoperitoneal shunt 3 months later as a result of hydrocephalus following subdural hematoma. Asymptomatic arachnoid cysts are discussed with respect to brain function and social behavior.

Arachnoid↗
PubMed2002

Intraoperative magnetic resonance for the surgical treatment of lesions producing seizures.

Seizures are a major presenting feature of several non-neoplastic cerebral lesions. We reviewed the experience at the Brigham and Women's Hospital, Boston, on the surgical management of benign intracerebral lesions presenting with seizures with intraoperative magnetic resonance imaging (iMRI) guidance. Our aim was to demonstrate that this is an effective and efficient treatment for these lesions. The histories of thirteen patients who presented with seizures secondary to benign intraaxial lesions treated by craniotomy and resection within the iMRI unit at our institution were reviewed. The surgical results, histology and clinical outcomes were reviewed. The mean follow-up was 22.1 months (range 2-48). In all cases, lesions were accurately located with iMRI. After initial macroscopic resection, 5 cases were found to have residual lesion. All had complete radiological resection at the end of the procedure. At follow-up, five patients had no seizures, 5 had rare seizures and the remaining 3 had worthwhile improvement in seizure frequency. Intraoperative MRI is a safe and effective adjunct for the surgical treatment of benign intracerebral lesions presenting with seizures. It provides effective and efficient intraoperative guidance for planning and approach to the lesion and the assurance that the lesion is totally removed. Surgical resection with iMRI may, therefore, provide a useful approach to these lesions.

Adolescent↗
PubMed2005

Surgery for epilepsy due to cortical malformations: ten-year follow-up.

Children with malformations of cortical development represent a significant proportion of pediatric epilepsy surgery candidates. From a cohort of 40 children operated on between 1980 and 1992 with malformation of cortical development, 38 were alive and had data 10 years after surgery. Age at surgery ranged from 6 months to 18 years (mean, 9.6 years). Thirty-six had partial seizures, and two had infantile spasms; 20 were nonlesional. Pathologic diagnoses were cortical dysplasia (n = 31) and developmental tumor (n = 7). At 10-year follow-up, 15 (40%) were seizure free, 10 (26%) had >90% seizure reduction, and 13 (34%) were improved or unchanged. Children seizure free at two-year follow-up were likely to remain seizure free. Ten-year seizure freedom was 72% in children with developmental tumors and 32% in the cortical dysplasia group. Complete resection was statistically significant for favorable outcome, and no patient with an incomplete resection was seizure free.

Adolescent↗
PubMed2003

Epileptiform synchronization in the human dysplastic cortex.

Taylor's focal cortical dysplasia corresponds to a localized disruption of the normal cortical lamination with an excess of large, aberrant cells. Sustained epileptic discharges originate from the dysplastic neocortex and this tissue retains sufficient connectivity for expressing seizure abnormalities. In this brief review, we summarize the findings obtained by analyzing surgically-resected human tissue with focal cortical dysplasia that was maintained in vitro in a brain slice preparation. These data have been compared with those obtained from human cortex with normal structural organization; such tissue was available from patients undergoing surgery for a variety of neurological disorders, most often for mesial temporal lobe epilepsy. These studies have shown that: (i). slices obtained from focal cortical dysplastic tissue have an intrinsic ability to generate ictal-like epileptiform events when challenged with the convulsant drug 4-aminopyridine; (ii). 4-aminopyridine-induced ictal discharges are not seen in neocortical slices obtained from neocortical samples with no or minimal structural lesion; (iii). these ictal discharges are caused by the activation of excitatory amino acid receptors, and in particular those of the N-methyl-D aspartate type; (iv). focal cortical dysplastic tissue also generates synchronous potentials that are mainly contributed by GABA(A) receptor-mediated conductances.

4-Aminopyridine↗