Long-Term Outcome of Temporal Lobe Epilepsy Surgery in 621 Patients With Hippocampal Sclerosis: Clinical and Surgical Prognostic Factors.

Temporal lobe epilepsy (TLE) is the most common type of focal epilepsy and is frequently drug-resistant (DR) to antiseizure medication (ASM), corresponding to approximately one-third of the cases. When left inadequately treated, it can worsen the quality of life, cognitive deficits, and risk of death. The standard treatment for drug-resistant TLE is the surgical removal of the structures involved, with good long-term outcome rates of 60-70 % and a low rate of adverse effects. The goal of successful treatment is sustained seizure freedom. In our study, we evaluated sustained long-term (up to 23 years) surgical outcomes in 621 patients with DR-TLE associated with hippocampal sclerosis, who underwent a temporal lobectomy. We analyzed the main predictive factors that influence the surgical outcome related to seizure control, through a longitudinal and retrospective study, using a multivariable regression model. We found that 73.6% of the patients were free from disabling seizures (Engel Class I), maintained over time in 65% of patients followed up to 23 years after surgery. We found that four independent variables predicted seizure outcomes. The presence of dysmnesic and olfactory aura predicted a less favorable outcome. The history of febrile seizure and the surgical technique predicted a good outcome. Regarding the type of surgical technique, the standard anteromesial temporal lobectomy (ATL) led to significantly better outcomes (78.6% Engel Class I) when compared to the selective amygdalohippocampectomy via subtemporal approach (67.2% Engel Class I; p = 0.002), suggesting that the neuronal networks involved in the epileptogenic zone may be beyond mesial temporal structures. The multivariable regression model with the above-mentioned predictor variables revealed an ExpB = 3.627 (N = 621, p < 0.001), indicating that the model was able to distinguish between patients with a seizure-free. We conclude that epilepsy surgery is a safe procedure, with low rates of postoperative complications and good long-term results.

Improving surgical outcome with electric source imaging and high field magnetic resonance imaging.

While most patients with focal epilepsy present with clear structural abnormalities on standard, 1.5 or 3 T MRI, some patients are MRI-negative. For those, quantitative MRI techniques, such as volumetry, voxel-based morphometry, and relaxation time measurements can aid in finding the epileptogenic focus. High-field MRI, just recently approved for clinical use by the FDA, increases the resolution and, in several publications, was shown to improve the detection of focal cortical dysplasias and mild cortical malformations. For those cases without any tissue abnormality in neuroimaging, even at 7 T, scalp EEG alone is insufficient to delimitate the epileptogenic zone. They may benefit from the use of high-density EEG, in which the increased number of electrodes helps improve spatial sampling. The spatial resolution of even low-density EEG can benefit from electric source imaging techniques, which map the source of the recorded abnormal activity, such as interictal epileptiform discharges, focal slowing, and ictal rhythm. These EEG techniques help localize the irritative, functional deficit, and seizure-onset zone, to better estimate the epileptogenic zone. Combining those technologies allows several drug-resistant cases to be submitted to surgery, increasing the odds of seizure freedom and providing a must needed hope for patients with epilepsy.

Epilepsia resistente ao tratamento farmacológico: bases para a condução diagnóstica e possibilidades terapêuticas / Drug resistant epilepsy: bases for the diagnostic process and therapeutic options

Epilepsias refratárias a dois esquemas medicamentosos são consideradas resistentes ao tratamento farmacológico. Nestes casos, o médico deve realizar uma ampla revisão diagnóstica, excluindo outros paroxismos. A cirurgia ressectiva deve ser cogitada nas epilepsias focais. Outras intervenções terapêuticas são possíveis, dependendo da situação específica.

Epilepsy refractory to two drug regimens is labeled as drug resistant. In these cases, the physician should perform a comprehensive diagnosis revision, excluding other paroxysms. Ressective surgery must be cogitated in focal epilepsies. Other therapeutic interventions are possible, depending on the specific situation.

Manejo da meningite aguda no adulto / Management of acute meningitis in adults

Meningite é uma doença causada pela inflamação das membranas que envolvem o cérebro e a medula espinhal, usualmente consequência da infecção do líquor por vírus ou bactérias. A severidade da doença e o tratamento da meningite diferem conforme a etiologia. Este artigo visa estabelecer um algoritmo para a avaliação e tratamento das principais causas de meningite.

Meningitis is a disease caused by the inflammation of the membranes that involve the brain and spinal cord, usually a consequence of the infection of the cerebrospinal fluid by viruses and bacteria. The severity of the disease and the treatment differ according to the etiology. This article aims to be a guide to the evaluation and treatment of the most common causes of meningitis.