RESUMO
BACKGROUND: Lamotrigine does not affect cognition in healthy adult volunteers or adult patients with epilepsy, but its effect on cognition in children is uncertain. OBJECTIVE: To compare the effect of lamotrigine and placebo on cognition in children with well-controlled or mild epilepsy. METHOD: In a double-blind, placebo-controlled, crossover study, 61 children with well-controlled or mild epilepsy were randomly assigned to add-on therapy with either lamotrigine followed by placebo or placebo followed by lamotrigine. Each treatment phase was 9 weeks, the crossover period 5 weeks. A neuropsychological test battery was performed during EEG monitoring at baseline and at the end of placebo and drug phases. The paired Student' t test was used for statistical analysis for neuropsychological data (two tailed) with a p value of 0.01 considered significant. Carryover and period effect were analyzed with generalized linear modeling (SPSS 10). RESULTS: Forty-eight children completed the study. Seizure frequency was similar during both treatment phases. No significant difference was found in continuous performance, binary choice reaction time, verbal and nonverbal recognition, computerized visual searching task, verbal and spatial delayed recognition, and verbal and nonverbal working memory between placebo and lamotrigine treatment phase. There was no significant carryover and period effect when corrected for randomization. CONCLUSION: Lamotrigine exhibits no clinically significant cognitive effects in adjunctive therapy for children with epilepsy.
Assuntos
Anticonvulsivantes/farmacologia , Cognição/efeitos dos fármacos , Triazinas/farmacologia , Adolescente , Anticonvulsivantes/efeitos adversos , Anticonvulsivantes/uso terapêutico , Criança , Estudos Cross-Over , Método Duplo-Cego , Eletroencefalografia , Feminino , Humanos , Lamotrigina , Masculino , Memória/efeitos dos fármacos , Tempo de Reação/efeitos dos fármacos , Reconhecimento Psicológico/efeitos dos fármacos , Comportamento Espacial/efeitos dos fármacos , Resultado do Tratamento , Triazinas/efeitos adversos , Triazinas/uso terapêuticoRESUMO
Electrical impedance tomography (EIT) has the potential to produce images during epileptic seizures. This might improve the accuracy of the localization of epileptic foci in patients undergoing presurgical assessment for curative neurosurgery. It has already been shown that impedance increases by up to 22% during induced epileptic seizures in animal models, using cortical or implanted electrodes in controlled experiments. The purpose of this study was to determine if reproducible raw impedance changes and EIT images could be collected during epileptic seizures in patients who were undergoing observation with video-electroencephalography (EEG) telemetry as part of evaluation prior to neurosurgery to resect the region of brain causing the epilepsy. A secondary purpose was to develop an objective method for processing and evaluating data, as seizures arose at unpredictable times from a noisy baseline. Four-terminal impedance measurements from 258 combinations were collected continuously using 32 EEG scalp electrodes in 22 seizure episodes from 7 patients during their presurgical assessment together with the standard EEG recordings. A reliable method for defining the pre-seizure baseline and recording impedance data and EIT images was developed, in which EIT and EEG could be acquired simultaneously after filtering of EIT artefact from the EEG signal. Fluctuations of several per cent over minutes were observed in the baseline between seizures. During seizures, boundary voltage changes diverged with a standard deviation of 1-54% from the baseline. No reproducible changes with the expected time course of some tens of seconds and magnitude of about 0.1% could be reliably measured. This demonstrates that it is feasible to acquire EIT images in parallel with standard EEG during presurgical assessment but, unfortunately, expected EIT changes on the scalp of about 0.1% are swamped by much larger movement and systematic artefact. Nevertheless, EIT has the unique potential to provide invaluable neuroimaging data for this purpose and may still become possible with improvements in electrode design and instrumentation.
Assuntos
Mapeamento Encefálico/métodos , Impedância Elétrica , Epilepsia/diagnóstico , Epilepsia/fisiopatologia , Interpretação de Imagem Assistida por Computador/métodos , Pletismografia de Impedância/métodos , Tomografia/métodos , Adulto , Algoritmos , Eletrodos , Feminino , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Couro Cabeludo/fisiopatologia , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: To determine whether it is worth pursuing surgery for the treatment of epilepsy in patients with normal neuroimaging. METHODS: Two patient populations were studied: (1) 136 consecutive patients who were surgically treated; (2) 105 consecutive patients assessed with chronically implanted intracranial electrodes within the same period. Sixty patients belonged to both groups, and included all 21 patients who had normal neuroimaging. RESULTS: There were no differences in the proportion of patients with favourable outcome between those with normal and those with abnormal neuroimaging, irrespective of whether intracranial recordings were required. Among the 19 operated patients with normal neuroimaging, 74% had a favourable outcome (Engel's seizure outcome grades I and II), and among the 93 patients with abnormal neuroimaging, 73% had favourable outcome (p = 0.96). In patients with temporal resections, 92% of the 13 patients with normal neuroimaging had a favourable outcome, whereas among the 70 patients with abnormal neuroimaging, 80% had a favourable outcome (p = 0.44). In patients with extratemporal resections, two of the six patients with normal neuroimaging had a favourable outcome, while 12 of the 23 patients with abnormal neuroimaging had a favourable outcome (p = 0.65). Among the 105 patients studied with intracranial electrodes, five suffered transitory deficits as a result of implantation, and two suffered permanent deficits (one hemiplegia caused by haematoma and one mild dysphasia resulting from haemorrhage). CONCLUSIONS: It is worth pursuing surgery in patients with normal neuroimaging because it results in good seizure control and the incidence of permanent deficits associated with intracranial studies is low.
Assuntos
Encéfalo/anatomia & histologia , Epilepsia/epidemiologia , Epilepsia/cirurgia , Imageamento por Ressonância Magnética , Adolescente , Adulto , Criança , Pré-Escolar , Eletrodos Implantados , Epilepsia/fisiopatologia , Epilepsia do Lobo Temporal/epidemiologia , Epilepsia do Lobo Temporal/fisiopatologia , Epilepsia do Lobo Temporal/cirurgia , Feminino , Hemiplegia/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
OBJECTIVE: To assess the value of single-pulse electrical stimulation (SPES) to identify frontal epileptogenic cortex during presurgical assessment. METHODS: SPES (1-millisecond pulses, 4 to 8 mA, 0.1 Hz) has been used during chronic recordings in 30 patients with intracranial electrodes in the frontal lobes. As a result of presurgical assessment, 17 patients were considered to have frontal epilepsy and 13 extrafrontal epilepsy. RESULTS: Two types of responses to SPES were seen: 1) early responses: starting immediately after the stimulus and considered as normal responses; 2) late responses: two types of responses seen in some areas after the initial early response: a) delayed responses: spikes or sharp waves occurring between 100 milliseconds and 1 second after stimulation. Frontal delayed responses were seen in 11 frontal patients and 1 extrafrontal patient, whereas extrafrontal delayed responses were seen in 1 frontal and 10 extrafrontal patients. b) Repetitive responses: two or more consecutive sharp-and-slow-wave complexes, each resembling the initial early response. Repetitive responses were seen only when stimulating the frontal lobes of 10 frontal patients. Among the 17 frontal patients, 13 had late responses exclusively in the epileptogenic frontal lobe, whereas only 3 showed them in both frontal lobes. Frontal late responses were associated with neuropathologic abnormalities, and complete resection of abnormal SPES areas was associated with good postsurgical seizure outcome. CONCLUSIONS: Single-pulse electrical stimulation (SPES) could be an important additional investigation during presurgical assessment to identify frontal epileptogenicity. SPES can be useful in patients who have widespread or multiple epileptogenic areas, normal neuroimaging, or few seizures during telemetry.
Assuntos
Eletrodiagnóstico/métodos , Epilepsia/diagnóstico , Epilepsia/fisiopatologia , Lobo Frontal/fisiopatologia , Cuidados Pré-Operatórios/métodos , Adolescente , Adulto , Estimulação Elétrica/instrumentação , Estimulação Elétrica/métodos , Eletrodos Implantados/normas , Eletrodiagnóstico/instrumentação , Eletroencefalografia , Epilepsia/cirurgia , Potenciais Evocados/fisiologia , Feminino , Lobo Frontal/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/instrumentação , Tempo de Reação , Técnicas Estereotáxicas , Resultado do TratamentoRESUMO
In men with a clinical diagnosis of benign prostatic hyperplasia (BPH), polytomous logistic regression analysis was conducted to evaluate associations between two silent polymorphisms in SRD5A1 (codon positions 30 and 116), two polymorphisms in SRD5A2 (Val89Leu substitution and C to T transition in intron 1), a trinucleotide (CAG)n repeat in androgen receptor (AR), and an Arg492Cys substitution in ADRA1A and clinical parameters that characterize severity of BPH. Candidate gene selection was based on two mechanistic pathways targeted by pharmacotherapy for BPH: (1) androgen metabolic loci contributing to prostate growth (static obstruction); and (2) factors affecting smooth muscle tone (dynamic obstruction). Polymorphisms in SRD5A2 were not associated with severity of BPH; however, SRD5A1 polymorphisms were associated with severity of BPH. The process(es) in which these silent single-nucleotide polymorphisms (SNPs) influence BPH phenotypes is unknown and additional studies will be needed to assess whether these SNPs have direct functional consequences. The characterization of additional molecular factors that contribute to static and dynamic obstruction may help predict response to pharmacotherapy and serve to identify novel drug targets for the clinical management of BPH.
Assuntos
3-Oxo-5-alfa-Esteroide 4-Desidrogenase/genética , Hiperplasia Prostática/genética , Receptores Androgênicos/genética , Idoso , Códon/genética , Humanos , Masculino , Tono Muscular/fisiologia , Músculo Liso/fisiologia , Polimorfismo Genético , Polimorfismo de Nucleotídeo Único/genética , Próstata/anatomia & histologia , Hiperplasia Prostática/enzimologia , Repetições de TrinucleotídeosRESUMO
OBJECTIVE: To compare the neuropsychological effects of temporal lobectomy (TL) and amygdalohippocampectomy (AH), depending on whether the patients had passed or failed the Wada test. METHODS: We compared changes in neuropsychological scores in patients who underwent TL (n = 91) or AH (n = 15), and had passed or failed the Wada test. Comparisons were carried out in all 106 patients and among the 20 patients who failed the Wada test (12 who had TL and 8 who had AH). RESULTS: No patient became globally amnesic after surgery. Among all patients, no differences were found in pre-surgical or change scores (percentage of change after surgery compared with preoperative values) of neuropsychological tests between patients who underwent TL or AH. Among patients who failed the Wada test, those in the TL group showed higher visual memory impairment (p<0.05). There was a strong trend suggesting that TL is associated with higher verbal memory deficits than AH (p = 0.07). Of those TL patients who failed the Wada test, the contralateral Wada score correlated with change scores in verbal intelligence quotient (p<0.01), and there was a strong trend towards a correlation with the logical memory immediate recall version subtest of the Wechsler Memory Scale (p = 0.06). CONCLUSIONS: No profound changes in intelligence quotient or memory scores were found after TL or AH. Nevertheless, patients who underwent TL and failed the Wada test showed more deficits than those who passed the test or those who had AH. The presence of a correlation between contralateral Wada scores and verbal deficits in TL patients who failed the Wada test but not among AH patients suggests that, if temporal surgery is required, AH might be preferred to TL in patients who fail the Wada test.
Assuntos
Amobarbital , Dano Encefálico Crônico/diagnóstico , Epilepsia do Lobo Temporal/cirurgia , Testes Neuropsicológicos/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Adolescente , Adulto , Tonsila do Cerebelo/fisiopatologia , Tonsila do Cerebelo/cirurgia , Dano Encefálico Crônico/fisiopatologia , Dano Encefálico Crônico/psicologia , Dominância Cerebral/fisiologia , Epilepsia do Lobo Temporal/fisiopatologia , Epilepsia do Lobo Temporal/psicologia , Feminino , Seguimentos , Hipocampo/fisiopatologia , Hipocampo/cirurgia , Humanos , Inteligência/fisiologia , Masculino , Memória de Curto Prazo/fisiologia , Pessoa de Meia-Idade , Reconhecimento Visual de Modelos/fisiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/psicologia , Retenção Psicológica/fisiologia , Lobo Temporal/fisiopatologia , Lobo Temporal/cirurgia , Aprendizagem Verbal/fisiologiaRESUMO
The authors conducted a randomized trial of second-line anticonvulsant treatments for neonates. The response to treatment was assessed using continuous video-EEG because the clinical diagnosis of seizure in neonates is known to be unreliable. Of 27 neonates with EEG-confirmed seizures, 5 were excluded because of protocol violations, and 11 responded to phenobarbitone in a dose of 40 mg/kg as first line. Three of five neonates treated with lignocaine responded. Six neonates were treated with benzodiazepines as second line: None responded, and their neurodevelopmental outcome was poor.
Assuntos
Anticonvulsivantes/uso terapêutico , Eletroencefalografia , Epilepsia/tratamento farmacológico , Clonazepam/uso terapêutico , Resistência a Medicamentos , Epilepsia/congênito , Feminino , Humanos , Recém-Nascido , Lidocaína/uso terapêutico , Masculino , Midazolam/uso terapêutico , Fenobarbital/uso terapêutico , Transtornos Psicomotores/etiologia , Falha de Tratamento , Gravação em VídeoRESUMO
OBJECTIVES: To assess the efficacy of vagus nerve stimulation (VNS) in patients with medically and surgically intractable complex partial seizures (CPS). PATIENTS AND METHODS: Sixteen patients with previous temporal [15] and frontal [one] resections were treated with VNS between 1994 and 1999 at King's College Hospital, London, UK. Post-operative video-electroencephalogram telemetry had shown that CPS started from the operated side in 12 patients, contralaterally in three and bilaterally independently in one. RESULTS: Three patients (18.75%) had 50% or more reduction in seizure frequency, but one showed severe worsening of epilepsy, which remitted upon VNS discontinuation. The antiepileptic effect of VNS was not different with respect to the type of operation (anterior temporal lobectomy vs amygdalohippocampectomy), the side of operation, or the side of seizure onset. We observed psychotropic effects in two patients with post-ictal psychosis, in two others with depression, and in a child with severe behavioral disorder. CONCLUSIONS: VNS may have a rather limited antiepileptic role to play in patients with persistent seizures following epilepsy surgery, but may independently possess useful antipsychotic and mood-stabilizing properties.
Assuntos
Terapia por Estimulação Elétrica , Epilepsia Parcial Complexa/fisiopatologia , Epilepsia Parcial Complexa/terapia , Transtornos Psicóticos/terapia , Nervo Vago/fisiopatologia , Adolescente , Adulto , Progressão da Doença , Terapia por Estimulação Elétrica/efeitos adversos , Eletrodos Implantados , Eletroencefalografia , Epilepsia Parcial Complexa/complicações , Epilepsia Parcial Complexa/diagnóstico , Feminino , Lobo Frontal/fisiopatologia , Lobo Frontal/cirurgia , Lateralidade Funcional , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Transtornos Psicóticos/etiologia , Lobo Temporal/fisiopatologia , Lobo Temporal/cirurgia , Tomografia Computadorizada de Emissão , Resultado do TratamentoRESUMO
The aim of the present study was to investigate in vivo cortical excitability in the human brain. We studied 45 consecutive patients with refractory epilepsy in whom subdural or intracerebral electrodes were implanted for assessment prior to epilepsy surgery. We compared cortical responses to single pulse stimulation (up to 8 mA, 1 ms duration) in areas where seizure onset occurred, with responses recorded elsewhere. Two main types of responses were seen: (i) 'early responses', spikes and/or slow waves starting within 100 ms after the stimulus which were observed in most regions in all patients; and (ii) 'delayed responses', spikes or sharp waves occurring between 100 ms and 1 s after stimulation which were seen in some regions in 27 patients. The distributions of early and delayed responses were compared with the topography of seizure onset. Whereas early responses were seen in most regions and seem to be a normal response of the cortex to single pulse stimulation, the distributions of delayed responses were significantly associated with the regions where seizure onset occurred. We conclude that the presence of delayed responses can identify regions of hyperexcitable cortex in the human brain. The study of delayed responses may improve our understanding of the physiology and dynamics of neuronal circuits in epileptic tissue and may have an immediate clinical application in assessment of candidates for surgical treatment of epilepsy.
Assuntos
Encéfalo/fisiopatologia , Córtex Cerebral/fisiopatologia , Eletroencefalografia , Epilepsia/diagnóstico , Convulsões/fisiopatologia , Adolescente , Adulto , Estimulação Elétrica/métodos , Epilepsia/fisiopatologia , Potenciais Evocados/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Especificidade de Órgãos , Tempo de ReaçãoRESUMO
AIMS: To evaluate the effectiveness of phenobarbitone as an anticonvulsant in neonates. METHODS: An observational study using video-EEG telemetry. Video-EEG was obtained before treatment was started, for an hour after treatment was given, two hours after treatment was given, and again between 12 and 24 hours after treatment was given. Patients were recruited from all babies who required phenobarbitone (20-40 mg/kg intravenously over 20 minutes) for suspected clinical seizures and had EEG monitoring one hour before and up to 24 hours after the initial dose. An EEG seizure discharge was defined as a sudden repetitive stereotyped discharge lasting for at least 10 seconds. Neonatal status epilepticus was defined as continuous seizure activity for at least 30 minutes. Seizures were categorised as EEG seizure discharges only (electrographic), or as EEG seizure discharges with accompanying clinical manifestations (electroclinical). Surviving babies were assessed at one year using the Griffiths neurodevelopmental score. RESULTS: Fourteen babies were studied. Four responded to phenobarbitone; these had normal or moderately abnormal EEG background abnormalities and outcome was good. In the other 10 babies electrographic seizures increased after treatment, whereas electroclinical seizures reduced. Three babies were treated with second line anticonvulsants, of whom two responded. One of these had a normal neurodevelopmental score at one year, but the outcome for the remainder of the whole group was poor. CONCLUSION: Phenobarbitone is often ineffective as a first line anticonvulsant in neonates with seizures in whom the background EEG is significantly abnormal.
Assuntos
Anticonvulsivantes/uso terapêutico , Fenobarbital/uso terapêutico , Convulsões/tratamento farmacológico , Deficiências do Desenvolvimento/diagnóstico , Eletroencefalografia/métodos , Seguimentos , Humanos , Lactente , Recém-Nascido , Estudos Prospectivos , Resultado do Tratamento , Gravação de VideoteipeRESUMO
OBJECTIVE: To evaluate the cardiac autonomic effects of abrupt withdrawal of carbamazepine (CBZ) during sleep in patients with epilepsy. BACKGROUND: The pathophysiology of sudden unexpected death in epilepsy (SUDEP) is uncertain, with ictal or peri-ictal cardiorespiratory compromise appearing probable. Risk factors for SUDEP include multiple antiepileptic drugs (AED), poor compliance, and abrupt AED withdrawal. The spectral analysis of the beat-to-beat heart rate variability (HRV) displays two main components: low frequency (LF), representing sympathetic and parasympathetic influence and high frequency (HF), representing parasympathetic influence. The LF/HF ratio is commonly regarded as an indicator of sympathovagal balance. METHOD: Twelve patients with medically intractable seizures underwent abrupt withdrawal of CBZ to facilitate seizure recording during controlled circuit TV-EEG monitoring. Continuous EKG recording was begun 24 hours before CBZ reduction. Spectral analysis of the HRV was performed during selected samples of non-REM sleep before and after CBZ reduction. Analyses were made at least 6 hours after from (complex) partial and 12 hours from generalized seizures. RESULTS: The mean LF/HF ratio before withdrawal of CBZ was 2.15 compared with a ratio of 2.65 on day 4 after withdrawal, an increase of 19% (geometric mean; 95% CI, 2% to 34%; Wilcoxon test, z = 2.36; p = 0.018). The ratio increased in 10 patients compared with a decrease in only one patient. CONCLUSION: Abrupt withdrawal of CBZ leads to enhanced sympathetic activity in sleep as evidenced by increased LF/HF ratios. Increased sympathetic activity in the setting of seizure-induced hypoxia could predispose to SUDEP.
Assuntos
Anticonvulsivantes/efeitos adversos , Carbamazepina/efeitos adversos , Sono/fisiologia , Síndrome de Abstinência a Substâncias/fisiopatologia , Sistema Nervoso Simpático/fisiopatologia , Adolescente , Adulto , Anticonvulsivantes/administração & dosagem , Carbamazepina/administração & dosagem , Eletroencefalografia , Epilepsias Parciais/tratamento farmacológico , Epilepsias Parciais/fisiopatologia , Epilepsia Generalizada/tratamento farmacológico , Epilepsia Generalizada/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema Nervoso Simpático/efeitos dos fármacosRESUMO
Pivotal studies in man require prolonged administration to demonstrate efficacy for most seizure types. Earlier evidence of human efficacy can be of value for decision making, and EEG surrogate endpoints can be of value in this respect. Studies of spontaneous EEG discharges under standard recording conditions can demonstrate meaningful acute EEG effects of antiepileptic drugs (AEDs). These require a rapidly effective formulation of the product, preferably intravenous. The EEG recording conditions are standardised and the subject is required to perform a task to maintain a constant level of vigilance. The outcome measure of efficacy is spike count per minute or, if the discharges are more protracted (as generalised no spike and wave), the percentage of recording time occupied by discharges. Sub-acute experiments are conducted under less rigorously standardised conditions, but over longer periods, using ambulatory monitoring or telemetry to record the EEG. The photoparoxysmal responses (PPRs) of photosensitive subjects, evoked using a standardised stimulation protocol, are subject to less variability than spontaneous epileptiform activity. The PPR is elicited over a range of flash rates that can be used as a measure of sensitivity, and an effective treatment will reduce the range or abolish the PPR. Reduction in photosensitivity is demonstrable after a single dose of various AEDs, at clinically relevant plasma concentrations, even using drugs that are not generally effective for long-term treatment of photosensitive epilepsy. Evoked potential and nerve conduction studies and electronystagmography can be used to assess possible neurotoxicity, and quantitative EEG analysis can be employed to assess sedative effects.
Assuntos
Anticonvulsivantes/farmacologia , Eletroencefalografia/efeitos dos fármacos , Determinação de Ponto Final , Animais , Anticonvulsivantes/uso terapêutico , Anticonvulsivantes/toxicidade , Eletrofisiologia , Potenciais Evocados/efeitos dos fármacos , HumanosRESUMO
PURPOSE: To estimate the significance of residual electrocorticographic and neuropathologic abnormalities on seizure control after surgery for frontal lobe epilepsy with the purpose of determining their relevance in deciding the extent of the surgical procedure. METHODS: The presence of epileptiform discharges in intraoperative electrocorticograms (ECoGs) and the nature and extent of neuropathologic abnormalities were reviewed for 35 patients who underwent frontal lobe resections for the treatment of epilepsy at our institution. The relations between surgical outcome and presence of the following features were studied: (a) presence of abnormal tissue at the limits of the resection; (b) presence of sporadic spikes and seizure patterns in the preresection ECoG; (c) their abolition in the postresection ECoG; and (d) the topography of residual discharges with respect to the margins of the resection. RESULTS: On neuropathologic examination, 18 patients showed focal cortical dysplasia (CD), and 17 showed other abnormalities (non-CD). Ten CD patients and 11 non-CD patients experienced a favourable outcome. Seizure patterns were significantly more common in patients with focal cortical dysplasia than in those without, with a sensitivity of 94% and a specificity of 75%. Abolition of seizure patterns was associated with a favourable surgical outcome (p = 0.031). Abolition of sporadic spikes or their presence in the postresection ECoG did not influence outcome. There was no clear relation between outcome and location of residual sporadic discharges. Seizure patterns persisted in the postresection ECoG in three CD patients, were located at the margins of the resection in all three, and these patients had a poor outcome. Incomplete removal of abnormal tissue was not associated with a poorer outcome in either patient group or in the complete sample. CONCLUSIONS: Seizure patterns were significantly more common in patients with cortical dysplasia, and their abolition on postresection ECoG recordings was associated with a favourable surgical outcome. Persistence of sporadic ECoG spikes and incomplete removal of histologic abnormalities did not affect outcome significantly.
Assuntos
Eletroencefalografia/estatística & dados numéricos , Epilepsia do Lobo Frontal/patologia , Epilepsia do Lobo Frontal/cirurgia , Lobo Frontal/fisiopatologia , Lobo Frontal/cirurgia , Adolescente , Adulto , Mapeamento Encefálico , Córtex Cerebral/anormalidades , Córtex Cerebral/patologia , Criança , Epilepsia do Lobo Frontal/fisiopatologia , Seguimentos , Lobo Frontal/patologia , Humanos , Monitorização Intraoperatória/estatística & dados numéricos , Período Pós-Operatório , Probabilidade , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVES: To assess the prognostic factors determining seizure remission after temporal lobectomy for intractable epilepsy associated with mesial temporal sclerosis (MTS) at pathology. METHODS: The clinical and investigative features of 116 consecutive patients who had temporal lobe surgery for drug-resistant epilepsy and MTS at pathology were assessed using actuarial statistics and logistic regression analysis. RESULTS: At a median follow-up of 63 months the probability of achieving at least a 1-year period of continuous seizure freedom was 67%. Factors contributing to a favourable outcome were interictal EEG localization to the operated lobe and the absence of secondarily generalized seizures. These were also selected in the multivariate analysis, although at lower statistical significance (P=0.08 and 0.09, respectively). Perinatal complications were associated with a significantly worse outcome but overall, complicated febrile convulsions and congruent neuropsychological deficits were not significantly predictive variables. CONCLUSIONS: The present findings may aid in the non-invasive presurgical assessment of patients with intractable TLE and clinical and neuroimaging evidence of MTS.
Assuntos
Epilepsia/etiologia , Epilepsia/cirurgia , Psicocirurgia/métodos , Lobo Temporal/patologia , Lobo Temporal/cirurgia , Adolescente , Adulto , Anticonvulsivantes/uso terapêutico , Criança , Pré-Escolar , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Estudos de Coortes , Resistência a Medicamentos , Eletroencefalografia , Epilepsia/tratamento farmacológico , Seguimentos , Humanos , Lactente , Recém-Nascido , Testes Neuropsicológicos , Prognóstico , Fatores de Risco , Esclerose/complicações , Esclerose/patologia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
We have considered multiple subpial transection (MST) as a treatment option for Landau-Kleffner syndrome (LKS) for the past 6 years. The effect of this technique on language and cognitive ability, behaviour, seizures, and EEG abnormalities is analysed here. Five children (4 males, 1 female; aged 5.5 to 10 years) underwent MST with sufficiently detailed pre- and postoperative data for analysis. Behaviour and seizure frequency improved dramatically after surgery in all children. Improvement in language also occurred in all children, although none improved to an age-appropriate level. All five had electrical status epilepticus in sleep (ESES) before surgery, which was eliminated by the procedure. One child has had an extension of his MST due to the recurrence of ESES and accompanying clinical deterioration with good effect. An attempt is made to set the effect of MST against the natural history of the condition. MST is an important treatment modality in LKS, although the timing of this intervention and its effect on final language outcome remains to be defined.
Assuntos
Córtex Cerebral/cirurgia , Síndrome de Landau-Kleffner/cirurgia , Pia-Máter/cirurgia , Criança , Transtornos do Comportamento Infantil/cirurgia , Cognição , Eletroencefalografia , Feminino , Humanos , Síndrome de Landau-Kleffner/fisiopatologia , Síndrome de Landau-Kleffner/psicologia , Transtornos da Linguagem/cirurgia , Masculino , Resultado do TratamentoRESUMO
The authors report two adult patients with chronic temporal lobe epilepsy and pathologic features consistent with Rasmussen's encephalitis. Although seizures persisted after temporal lobe surgery no progressive cognitive or neurologic deficit has emerged. Prominent auditory auras in each suggested a persisting epileptogenic focus in the superior temporal gyrus. The current findings expand the clinical spectrum of Rasmussen's encephalitis and suggest that chronic nonprogressive encephalitis may serve as the pathologic substrate of medically intractable temporal lobe epilepsy.
Assuntos
Encéfalo/patologia , Encefalite/patologia , Epilepsia do Lobo Temporal/patologia , Adulto , Feminino , Humanos , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: To describe the association between a unilateral mid-temporal rhythmic theta discharge ("psychomotor variant of Gibbs") with neuroimaging-demonstrated underlying mass lesion. METHODS: Standard routine awake and scalp electroencephalography, continuous video-EEG monitoring and magnetic resonance brain imaging were employed in the diagnostic work-up of a 9-year-old boy with a severe behavioural disturbance and episodic outbursts of aggression. RESULTS: EEG showed a unilateral mid-temporal rhythmic discharge which was continuous in drowsiness and which remained confined to the right hemisphere. MRI showed a lesion in the temporal horn of the right lateral ventricle displacing superiorly the white matter stem of the right temporal lobe. CONCLUSION: A rhythmic mid-temporal theta discharge, commonly regarded as a benign EEG variant, may, in some patients, reflect underlying structural pathology. Neuroimaging should be considered particularly when this EEG pattern remains confined to one hemisphere.
Assuntos
Encefalopatias/diagnóstico , Transtornos do Comportamento Infantil/diagnóstico , Lobo Temporal/patologia , Lobo Temporal/fisiopatologia , Ritmo Teta/métodos , Encefalopatias/patologia , Encefalopatias/fisiopatologia , Criança , Transtornos do Comportamento Infantil/patologia , Transtornos do Comportamento Infantil/fisiopatologia , Lateralidade Funcional , Humanos , Imageamento por Ressonância Magnética , Masculino , Monitorização Fisiológica , Gravação em VídeoRESUMO
OBJECTIVES: To evaluate the influence of clinical, investigative, and pathological factors on seizure remission after temporal lobectomy for medically intractable epilepsy associated with focal lesions other than hippocampal sclerosis. METHODS: From a series of 234 consecutive "en bloc" temporal resections for medically intractable epilepsy performed between 1976 and 1995, neuropathological examination disclosed a focal lesion in 80. The preoperative clinical, neuropsychological, interictal EEG, and neuroimaging characteristics of these patients were assembled in a computerised database. The original neuropathological material was re-examined for lesion classification and completeness of removal. The presence of additional cortical dysplasia and mesial temporal sclerosis was also noted. Survival analysis was performed using Kaplan-Meier curves and actuarial statistics. Logistic regression analysis was used to establish the independent significance of the clinical variables. RESULTS: The probability of achieving a 1 year seizure remission was 71% by 5 years of follow up. Factors predicting a poor outcome on multivariate analysis included the need for special schooling and a long duration of epilepsy. Generalised tonic-clonic seizures, interictal EEG discharges confined to the resected lobe, demonstration of the lesion preoperatively on CT, and complete histological resection of the lesion were not predictive of outcome. Neuropsychological tests correctly predicted outcome in left sided cases but apparently congruent findings in right sided resections were associated with a poor outcome. Pathological reclassification established the dysembryoplastic neuroepithelial tumour as the commonest neoplasm (87%) in this series, with a significantly better seizure outcome than for developmental lesions, such as focal cortical dysplasia. CONCLUSIONS: The findings highlight the importance of dysembryoplastic neuroepithelial tumour in the pathogenesis of medically refractory lesional temporal lobe epilepsy and the prognostic significance of preoperative duration of epilepsy emphasises the need for early recognition and surgical treatment. Cognitive and behavioural dysfunction, however, is associated with a lower seizure remission rate, independent of duration of epilepsy.