ILAE neuroimaging task force highlight: Subcortical laminar heterotopia.

The ILAE Neuroimaging Task Force publishes educational case reports that highlight basic aspects of neuroimaging in epilepsy consistent with the ILAE's educational mission. Subcortical laminar heterotopia, also known as subcortical band heterotopia (SBH) or "double cortex," is an intriguing and rare congenital malformation of cortical development. SBH lesions are part of a continuum best designated as agyria-pachygyria-band-spectrum. The malformation is associated with epilepsy that is often refractory, as well as variable degrees of developmental delay. Moreover, in an increasing proportion of cases, a distinct molecular-genetic background can be found. Diagnosing SBH can be a major challenge for many reasons, including more subtle lesions, and "non-classic" or unusual MRI-appearances. By presenting an illustrative case, we address the challenges and needs of diagnosing and treating SBH patients in epilepsy, especially the value of high-resolution imaging and specialized MRI-protocols.

Neurocysticercosis and epilepsy: Imaging and clinical characteristics.

The ILAE Neuroimaging Task Force aimed to publish educational case reports highlighting basic aspects related to neuroimaging in epilepsy consistent with the educational mission of the ILAE. Neurocysticercosis (NCC) is highly endemic in resource-limited countries and increasingly more often seen in non-endemic regions due to migration. Cysts with larva of the tapeworm Taenia solium lodge in the brain and cause several neurological conditions, of which seizures are the most common. There is great heterogeneity in the clinical presentation of neurocysticercosis because cysts vary in number, larval stage, and location among patients. We here present two illustrative cases with different clinical features to highlight the varying severity of symptoms secondary to this parasitic infestation. We also present several examples of imaging characteristics of the disease at various stages, which emphasize the central role of neuroimaging in the diagnosis of neurocysticercosis.

Ictal ECG-based assessment of sudden unexpected death in epilepsy.

Introduction: Previous case-control studies of sudden unexpected death in epilepsy (SUDEP) patients failed to identify ECG features (peri-ictal heart rate, heart rate variability, corrected QT interval, postictal heart rate recovery, and cardiac rhythm) predictive of SUDEP risk. This implied a need to derive novel metrics to assess SUDEP risk from ECG. Methods: We applied Single Spectrum Analysis and Independent Component Analysis (SSA-ICA) to remove artifact from ECG recordings. Then cross-frequency phase-phase coupling (PPC) was applied to a 20-s mid-seizure window and a contour of -3 dB coupling strength was determined. The contour centroid polar coordinates, amplitude (alpha) and angle (theta), were calculated. Association of alpha and theta with SUDEP was assessed and a logistic classifier for alpha was constructed. Results: Alpha was higher in SUDEP patients, compared to non-SUDEP patients (p < 0.001). Theta showed no significant difference between patient populations. The receiver operating characteristic (ROC) of a logistic classifier for alpha resulted in an area under the ROC curve (AUC) of 94% and correctly classified two test SUDEP patients. Discussion: This study develops a novel metric alpha, which highlights non-linear interactions between two rhythms in the ECG, and is predictive of SUDEP risk.

A Peri-Ictal EEG-Based Biomarker for Sudden Unexpected Death in Epilepsy (SUDEP) Derived From Brain Network Analysis.

Sudden unexpected death in epilepsy (SUDEP) is the leading seizure-related cause of death in epilepsy patients. There are no validated biomarkers of SUDEP risk. Here, we explored peri-ictal differences in topological brain network properties from scalp EEG recordings of SUDEP victims. Functional connectivity networks were constructed and examined as directed graphs derived from undirected delta and high frequency oscillation (HFO) EEG coherence networks in eight SUDEP and 14 non-SUDEP epileptic patients. These networks were proxies for information flow at different spatiotemporal scales, where low frequency oscillations coordinate large-scale activity driving local HFOs. The clustering coefficient and global efficiency of the network were higher in the SUDEP group pre-ictally, ictally and post-ictally (p < 0.0001 to p < 0.001), with features characteristic of small-world networks. These results suggest that cross-frequency functional connectivity network topology may be a non-invasive biomarker of SUDEP risk.

A retrospective, real-world experience of perampanel monotherapy in patient with first new onset focal seizure: A Thailand experience.

OBJECTIVE: Real-world data on efficacy and tolerability of perampanel (PER) monotherapy in treatment-naïve patients with focal onset seizures (FOS) and/or focal-to-bilateral tonic-clonic seizures (FBTCS) to assess efficacy effectiveness and tolerability. METHODS: This is a retrospective review of study patients with new FOS with or without FBTCS, aged ≥15 years, who had been prescribed PER as monotherapy. Treatment outcome included retention rate, responder, and seizure-free rate at observational point 3, 6, and 12 months (OP3, OP6, and OP12). Treatment-emergent adverse events (TEAEs) and adverse drug reactions were recorded. RESULTS: A total of 41 patients enrolled in the study (male:female; 17:22, mean age =46.1 ± 21.8 years), with new FOS and/or FBTCS. The proportions of individuals remaining on PER monotherapy at 3, 6, and 12 months were evaluated. The median PER dosage was 4 mg (range 2-8 mg). The retention rates at OP3, OP6, and OP12 were 88%, 73%, and 61%, respectively. The seizure freedom rates at OP3, OP6, and OP12 were 78%, 80%, and 76%, respectively. About 14% had discontinued the PER monotherapy because of lack of efficacy. Sixteen individuals (41%) had TEAEs; common AEs were dizziness, somnolence, and ataxia; and only one case had depression. The AEs with somnolence and ataxia were found higher in elderly (15% and 30%) than adult patients (7% and 3%), respectively. Only 14% had intolerant adverse events, and it was found higher in elderly (23%). SIGNIFICANCE: Real-world data of PER monotherapy in treatment-naïve patients with focal onset seizures demonstrated good effectiveness and a good safety profile at relatively low doses. By starting with low dosage and slow titration of PER help to minimize the impact of adverse effects, maximize adherence, and increase patient retention. PER has a once-daily dosing schedule that supports patient adherence contributes to achieving seizure freedom.

Imaging characteristics of temporopolar blurring in the context of hippocampal sclerosis.

We present an illustrative case to address anterior temporal lobe atrophy with poor delineation of the temporopolar gray-white matter interface based on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in patients with temporal lobe epilepsy associated with hippocampal sclerosis (TLE-HS). A 52-year-old woman with pharmacoresistant seizures since the age of six months underwent a previous MRI scan using a suboptimal protocol which was reported as unremarkable. MRI performed according to an epilepsy protocol showed classic signs of left HS and ipsilateral temporal polar atrophy with blurring of the gray-white matter boundary on FLAIR images. She underwent a left amygdalohippocampectomy and anterior temporal resection and remains seizure-free after 24 months. Histopathological analyses showed HS and no signs of focal cortical dysplasia (FCD). Blurring and atrophy of the ipsilateral temporal pole are common in TLE-HS and often misinterpreted as FCD. This relates to delayed myelination in patients with seizures before the age of two, is more pronounced on FLAIR sequences, and gives a false impression of cortical thickening. However, the T1-weighted images show a relatively well-demarcated cortical-subcortical transition and normal cortical thickness. By contrast, the cortical thickening in FCD is observed on both T1-weighted and FLAIR images. Since FCD also occurs in temporal lobe regions, it is important to differentiate the extra-hippocampal MRI abnormalities in TLE-HS from those likely to be FCD. This case highlights the importance of evaluation based on detailed imaging, which should always be conducted considering the EEG, seizure semiology, and other clinical information.

ILAE Neuroimaging Task Force Highlight: harnessing optimized imaging protocols for drug-resistant childhood epilepsy.

The ILAE Neuroimaging Task Force aims to publish educational case reports highlighting basic aspects related to neuroimaging in epilepsy consistent with the educational mission of the ILAE. Previous quantitative MRI studies have established important imaging markers of epilepsy-related pathology, including features sensitive to hippocampal cell loss and reactive astrogliosis. Here, we review the case of a female with pediatric drug-resistant epilepsy. Throughout her course of treatment, she had seven MRI investigations at several centers; the first three did not follow optimized epilepsy imaging protocols whereas the remaining four adhered to HARNESS-MRI protocols ( har monized n euroimaging of e pilepsy s tructural s equences). Visual inspection of a set of HARNESS-MR images revealed conspicuous left hippocampal hyperintensity which may have been initially overlooked on non-optimized MR images. Quantitative analysis of these multimodal imaging data along hippocampal subfields provided clear evidence of hippocampal sclerosis, with increased atrophy, increased mean diffusivity, increased T2-FLAIR signal, and lower qT1 values observed in the anterior portions of the left, compared to the right hippocampus. The patient underwent a left anterior temporal lobectomy with amygdalohippocampectomy at age 16 years. Histopathology of the resected specimen also confirmed hippocampal sclerosis with widespread gliosis and focal neuronal loss in the hippocampal subfields overlapping with regions of multimodal quantitative alterations. The patient remains seizure-free one year after surgery. Collectively, this case highlights the need for optimized data acquisition protocols early in the treatment of epilepsy and supports quantitative analysis of MRI contrasts to enhance personalized diagnosis and prognosis of drug-resistant patients with epilepsy.

Optimal Use of Perampanel in Asian Patients with Epilepsy: Expert Opinion.

Perampanel is a once-daily, first-in-class AMPA receptor antagonist approved for the treatment of epilepsy and exhibits broad-spectrum efficacy in a range of seizure types when used as both monotherapy and adjunctive therapy. Clinical studies and real-world evidence have demonstrated the advantages of initiating perampanel at low doses and utilizing a slow titration strategy. Initiating perampanel at an early stage has also been shown to be associated with better patient outcomes. However, the optimal use and place of perampanel in clinical practice has not yet been clearly defined for the Asian patient population. Use of perampanel in clinical practice varies markedly across the Asia region because of variation in knowledge, attitudes, and practice. There is currently no specific guidance on best practices for prescribing perampanel in Asian patients or how to optimize treatment strategies to maximize adherence. A group of epilepsy experts attended a virtual meeting in September 2020 to discuss their experience with using perampanel in the Asian practice setting, including their views regarding appropriate patient populations, optimal starting and maintenance doses, optimal titration regimens, key barriers to adherence, and prevention and management of adverse events. This article summarizes key clinical and real-world evidence for perampanel and consolidates the experts' opinions on optimization of perampanel prescribing and adherence in real-world practice, providing practical strategies for clinicians to implement to improve outcomes for people with epilepsy in Asia.

Thai National Guideline for Nuclear Medicine Investigations in Epilepsy.

Epilepsy is a disorder of the brain, which is characterized by recurrent epileptic seizures. These patients are generally treated with antiepileptic drugs. However, more than 30% of the patients become medically intractable and undergo a series of investigations to define candidates for epilepsy surgery. Nuclear Medicine studies using Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) radiopharmaceuticals are among the investigations used for this purpose. Since available guidelines for the investigation of surgical candidates are not up-to-date, The Nuclear Medicine Society of Thailand, The Neurological Society of Thailand, The Royal College of Neurological Surgeons of Thailand, and The Thai Medical Physicist Society has collaborated to develop this Thai national guideline for Nuclear Medicine study in epilepsy. The guideline focuses on the use of brain perfusion SPECT and F-18 fluorodeoxyglucose PET (FDG-PET), the mainly used methods in day-to-day practice. This guideline aims for effective use of Nuclear Medicine investigations by referring physicians e.g. epileptologists and neurologists, radiologists, nuclear medicine physicians, medical physicists, nuclear medicine technologists and technicians.

Delta-gamma phase-amplitude coupling as a biomarker of postictal generalized EEG suppression.

Postictal generalized EEG suppression is the state of suppression of electrical activity at the end of a seizure. Prolongation of this state has been associated with increased risk of sudden unexpected death in epilepsy, making characterization of underlying electrical rhythmic activity during postictal suppression an important step in improving epilepsy treatment. Phase-amplitude coupling in EEG reflects cognitive coding within brain networks and some of those codes highlight epileptic activity; therefore, we hypothesized that there are distinct phase-amplitude coupling features in the postictal suppression state that can provide an improved estimate of this state in the context of patient risk for sudden unexpected death in epilepsy. We used both intracranial and scalp EEG data from eleven patients (six male, five female; age range 21-41 years) containing 25 seizures, to identify frequency dynamics, both in the ictal and postictal EEG suppression states. Cross-frequency coupling analysis identified that during seizures there was a gradual decrease of phase frequency in the coupling between delta (0.5-4 Hz) and gamma (30+ Hz), which was followed by an increased coupling between the phase of 0.5-1.5 Hz signal and amplitude of 30-50 Hz signal in the postictal state as compared to the pre-seizure baseline. This marker was consistent across patients. Then, using these postictal-specific features, an unsupervised state classifier-a hidden Markov model-was able to reliably classify four distinct states of seizure episodes, including a postictal suppression state. Furthermore, a connectome analysis of the postictal suppression states showed increased information flow within the network during postictal suppression states as compared to the pre-seizure baseline, suggesting enhanced network communication. When the same tools were applied to the EEG of an epilepsy patient who died unexpectedly, ictal coupling dynamics disappeared and postictal phase-amplitude coupling remained constant throughout. Overall, our findings suggest that there are active postictal networks, as defined through coupling dynamics that can be used to objectively classify the postictal suppression state; furthermore, in a case study of sudden unexpected death in epilepsy, the network does not show ictal-like phase-amplitude coupling features despite the presence of convulsive seizures, and instead demonstrates activity similar to postictal. The postictal suppression state is a period of elevated network activity as compared to the baseline activity which can provide key insights into the epileptic pathology.

ILAE Neuroimaging Task Force highlight: Review MRI scans with semiology in mind.

The ILAE Neuroimaging Task Force aims to publish educational case reports highlighting basic aspects related to neuroimaging in epilepsy consistent with the educational mission of the ILAE. It is important to obtain MRI scans early in the clinical course of epilepsy, using an optimized protocol. Furthermore, it is critical that MRI scans are reviewed by experts who have been provided with all the clinical information and results from other investigations. We report a patient with a 21-year history of drug-resistant seizures who was admitted from another centre for presurgical evaluation. She had four previous MRI scans from this centre which were reported as unremarkable. However, a review of the MRI scan obtained on the day of admission, with the patient's ictal semiology in mind, resulted in identification of an epileptogenic lesion which was later confirmed by video-EEG monitoring and interictal PET. This lesion was present on all previous MRI scans and showed no change. The patient underwent lesionectomy, and histopathology of the resected specimen was consistent with a dysembryoplastic neuroepithelial tumour. The patient remains seizure-free, 2.5 years after surgery. This case highlights the importance of obtaining detailed descriptions of seizure semiology and considering them when reviewing MR images.

Transitions between neocortical seizure and non-seizure-like states and their association with presynaptic glutamate release.

The transition between seizure and non-seizure states in neocortical epileptic networks is governed by distinct underlying dynamical processes. Based on the gamma distribution of seizure and inter-seizure durations, over time, seizures are highly likely to self-terminate; whereas, inter-seizure durations have a low chance of transitioning back into a seizure state. Yet, the chance of a state transition could be formed by multiple overlapping, unknown synaptic mechanisms. To identify the relationship between the underlying synaptic mechanisms and the chance of seizure-state transitions, we analyzed the skewed histograms of seizure durations in human intracranial EEG and seizure-like events (SLEs) in local field potential activity from mouse neocortical slices, using an objective method for seizure state classification. While seizures and SLE durations were demonstrated to have a unimodal distribution (gamma distribution shape parameter >1), suggesting a high likelihood of terminating, inter-SLE intervals were shown to have an asymptotic exponential distribution (gamma distribution shape parameter <1), suggesting lower probability of cessation. Then, to test cellular mechanisms for these distributions, we studied the modulation of synaptic neurotransmission during, and between, the in vitro SLEs. Using simultaneous local field potential and whole-cell voltage clamp recordings, we found a suppression of presynaptic glutamate release at SLE termination, as demonstrated by electrically- and optogenetically-evoked excitatory postsynaptic currents (EPSCs), and focal hypertonic sucrose application. Adenosine A1 receptor blockade interfered with the suppression of this release, changing the inter-SLE shape parameter from asymptotic exponential to unimodal, altering the chance of state transition occurrence with time. These findings reveal a critical role for presynaptic glutamate release in determining the chance of neocortical seizure state transitions.

MRI essentials in epileptology: a review from the ILAE Imaging Taskforce.

Magnetic resonance imaging (MRI) plays a central role in the management and evaluation of patients with epilepsy. It is important that structural MRI scans are optimally acquired and carefully reviewed by trained experts within the context of all available clinical data. The aim of this review is to discuss the essentials of MRI that will be useful to health care providers specialized in epilepsy, as outlined by the competencies and learning objectives of the recently developed ILAE curriculum. This review contains information on basic MRI principles, sequences, field strengths and safety, when to perform and repeat an MRI, epilepsy MRI protocol (HARNESS-MRI) and the basic reading guidelines, and common epileptic pathologies. More advanced topics such as MRI-negative epilepsy, functional MRI and diffusion-weighted imaging are also briefly discussed. Although the available resources can differ markedly across different centers, it is the hope that this review can provide general guidance in the everyday practice of using MRI for patients with epilepsy.

Cross-Frequency Coupling Features of Postictal Generalized EEG Suppression State.

In patients with epilepsy, convulsive seizures are often followed by a postictal generalized EEG suppression (PGES) state characterized by reduced background activity. Recent studies found a correlation between seizure termination state and PGES duration, and suggested that PGES is the result of the cessation of neuronal activity. To test that assertion, we investigated ten seizure records obtained from intracranial EEG (iEEG) from six patients, four of which had Engel Class 1 surgical outcome. In each case expert neurologists identified the most likely seizure onset electrode. We found the iEEG equivalent of PGES and an artifact-free preictal quiescent state of the same window size. Using index of cross-frequency coupling (ICFC) we identified the degree of coupling and dominant frequency bands involved in PGES and preictal quiescent states, and quantified the areas of high ICFC. We found that there was an increase in the degree of coupling between the 0.5-1.5Hz with high gamma frequency bands in the PGES states. We found that among all of the patients, as well as in Engel Class 1 patients specifically, the change in the quantified area of high ICFC was significant (p <; 0.05) between PGES and preictal quiescent states. Furthermore, we were able to identify whether a recording was from a depth or subdural electrode, or whether it was from seizure onset zone or not using ICFC markers in PGES. This suggests that there are frequency coupling markers that successfully identify PGES and that there are underlying dynamics that occur in this seemingly quiet postictal state.

Depression in people with epilepsy: How much do Asian colleagues acknowledge it?

PURPOSE: The purpose of this review was to investigate the prevalence of depression in people with epilepsy (PWE) in different countries in Asia. METHODS: We searched the electronic database PubMed on June 13, 2017 for articles in English that included the following search terms: "epilepsy" AND "depression" AND "country name" for all Asian countries since 1947. Relevant original studies from Asia were included if they reported the prevalence of depression in PWE. Papers studying special populations (e.g., elderly, veterans, etc.) were not included. In addition, experts in epilepsy field were invited from some Asian countries for an in-depth assessment. RESULTS: Six hundred eighty-seven papers were reviewed and 26 related studies were included in this study. Depression is highly prevalent in PWE in different countries in Asia and the prevalence rates are consistent with rates reported in the literature from other countries: overall, about 25% of PWE suffer from depression. CONCLUSION: In Asian countries, as elsewhere, depression is common in PWE. High quality data is scarce in many countries and validated screening tools [e.g., Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)] to appropriately investigate the prevalence of depression in PWE are still lacking in many languages. Considering the high prevalence of depression among PWE, routine and periodic screening of all PWE for early detection and appropriate management of depression would be a reasonable approach.

Influence of genetic and non-genetic factors on phenytoin-induced severe cutaneous adverse drug reactions.

PURPOSE: The purpose of this study was to investigate the association of genetic factors including variants in HLA-B and CYP2C genes and non-genetic factors with phenotype-specific phenytoin (PHT)-induced severe cutaneous adverse reactions (SCARs) in Thai patients. METHODS: Thirty-six PHT-induced SCAR cases (15 Stevens-Johnson syndrome (SJS) and 21 drug rash with eosinophilia and systemic symptoms (DRESS)/drug hypersensitivity syndrome (DHS)) and 100 PHT-tolerant controls were studied. Variants in HLA-B, CYP2C9, and CYP2C19 genes were genotyped. Fisher's exact test and multiple logistic regression analysis were performed to test the association of genetic and non-genetic factors with specific type of SCARs. RESULTS: Multiple logistic regression models showed that genetic and non-genetic factors associated with PHT-induced SCARs were specified to its phenotype. HLA-B*13:01, HLA-B*56:02/04, CYP2C19*3, and omeprazole co-medication were strong risk factors of DRESS/DHS (adjusted OR = 13.29, p = 0.0001; adjusted OR = 56.23, p = 0.0007; adjusted OR = 6.75, p = 0.0414; and adjusted OR = 9.21, p = 0.0020, respectively). While CYP2C9*3 and having Chinese ancestry were significant risk factors of SJS (adjusted OR = 10.41, p = 0.0042 and adjusted OR = 5.40, p = 0.0097, respectively). Combined genetic and non-genetic risk factors optimized sensitivity and increased specificity for predicting PHT-induced SCARs. CONCLUSION: This study showed that distinct genetic markers were associated with phenotype-specific PHT-induced SCARs. Non-genetic factor, omeprazole co-medication, was strongly associated with PHT-induced DRESS/DHS in addition to variants in HLA-B and CYP2C genes. Combined markers may be better predictors for PHT-induced SCARs.

Epileptogenic Source Imaging Using Cross-Frequency Coupled Signals From Scalp EEG.

OBJECTIVE: The epileptogenic zone (EZ) is a brain region containing the sources of seizure genesis. Removal of the EZ is associated with cessation of seizures after resective surgical procedures, as measured by Engel Class I score. This study describes a novel EEG (electroencephalography) source imaging (ESI) method which uses cross-frequency coupled potential signals (SCFC) derived from scalp EEG. METHODS: Scalp EEG were recorded from ten patients (20 seizures) suffering from epilepsy. The S CFC were constructed from the phase and amplitude of the lower and higher frequency rhythms at electrographic seizure onset. ESI was then performed using the SCFC. Validation of the technique was facilitated by forward and inverse computer modeling of known cortical sources, and the correspondence of the ESI with EZ in resected regions of patients. RESULTS: For ten seizures sampled at or above 500 Hz from four patients, all estimated sources lay within the resected region, emphasizing the clinical importance of higher sampling rates. The SCFC demonstrated significant advantages over the "raw" scalp EEG, indicating its robust noise performance. Modeling investigations indicated that a signal-to-noise ratio above 0.2 was sufficient to achieve successful localization regarding EMG artifacts. CONCLUSION: The association of the estimated sources to the EZ suggests that cross-frequency coupling is a feature of the brain's neural networks, not of artifactual activity. The SCFC can effectively extract brain signals from a noisy background. SIGNIFICANCE: We propose this approach to enhance the placement of intracranial electrode for surgical intervention.

Global Outcomes of Epilepsy Surgery in Drug-Resistant Focal Epilepsy: A Longitudinal Survey.

Objective: Epilepsy surgery has been established for treatment of drug-resistant focal epilepsy. We aimed to determine long-term outcomes of epileptic surgery in various aspects including seizure outcome, quality of life, and psychosocial consequences after surgery. Material and Method: A single center, cross-sectional study was conducted. The patients with drug-resistant focal epilepsy who underwent epileptic surgery for at least one year were recruited. Results: Thirty-seven adult drug-resistant epilepsy patients after epileptic surgery were enrolled with an average follow-up period of 5.8 years. Twenty-three (62.2%) had temporal lobe epilepsy (TLE) and 14 (37.8%) had neocortical epilepsy. Four were (10.8%) compatible with lesional negative refractory epilepsy. Hippocampal sclerosis was the most common etiology (45.9%), followed by focal cortical dysplasia/gliosis (21.6%) and brain tumor (21.6%). The three commonest postoperative complications were any medical illnesses (18.9%), memory impairment (18.9%), and visual filed defect (13.5%). Twenty patients (54.1%) had no complications. Seizure outcomes, employment status, quality of life, depression, frank psychosis, and number of antiepileptic drug (AED) between pre- and post-surgical period (interviewing time) were compared. Engel Class I (seizure freedom) was persistently achieved in 19 (51.4%) patients. There were nine (24.3%) patients in Engel Class II, eight (21.6%) in Engel Class III, and one (2.7%) in Engel Class IV. Seizure outcome, quality of life, and self-assessment were improved after epileptic surgery at any age groups, duration of epilepsy, epileptogenic zone, and side of operation. In some subgroups, it was found that income was increased and number of AED was reduced. However, depression and frank psychosis did not change the outcome. On self-assessment, global impression of change in memory showed 27% improvement and 32.4% no change. For language and communication skills, 29.7% was improved but 21.6% was worsened. Conclusion: In this longitudinal study, epilepsy surgery showed improvement in seizure control, quality of life, and some neuropsychological aspects.

Spatial Coherence Profiles of Ictal High-Frequency Oscillations Correspond to Those of Interictal Low-Frequency Oscillations in the ECoG of Epileptic Patients.

GOAL: We have previously demonstrated that the coherence of high-frequency oscillations (HFOs; 80-300 Hz) increased during extratemporal lobe seizures in a consistent and spatially focused electrode cluster. In this study, we have investigated the relationship between cohered HFO intracranial EEG (iEEG) activity with that of slower low-frequency oscillations (LFOs; <80 Hz). METHODS: We applied wavelet phase coherence analysis to the iEEGs of patients with intractable extratemporal lobe epilepsy (ETLE). RESULTS: It was observed that areas on the implanted patient subdural grids, which exhibited strong ictal HFO coherence were similar to tissue regions displaying strong interictal LFO coherence in the 5-12 Hz frequency range, relative to all other electrodes. A positive surgical outcome was correlated with having the clinically marked seizure onset zone(s) in close proximity to HFO/LFO coherence highlighted regions of interest (ROIs). CONCLUSION: Recent studies have suggested that LFOs (in the 8-12 Hz frequency range) play an important role in controlling cortical excitability, by exerting an inhibitory effect on cortical processing, and that the presence of strong theta activity (4-8 Hz) in awake adults is suggestive of abnormal and/or pathological activity. We speculate that the overlapping spatial regions exhibiting increased coherence in both ictal HFOs and interictal LFOs identified local abnormalities that underlie epileptogenic networks. SIGNIFICANCE: Whereas it is worthwhile to note that the small patient group ( n = 7) studied here, somewhat limits the clinical significance of our study, the results presented here suggest targeting HFO activity in the 80-300 Hz frequency range and/or interictal LFO activity in the 5-12 Hz frequency range, when defining seizure-related ROIs in the iEEGs of patients with ETLE.

The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome. MATERIAL AND METHOD: Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) 8 were randomly allocated intofour groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count. RESULTS: Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPVwas reduced and NIHSS, mRS were improved in every studied group. Clopidogrel sign ficantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others. CONCLUSION: Every type of antiplatelets included in this study reduced MPV NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most.