Septal Rupture During Early Pregnancy and Successful Delivery in Monozygotic Dichorionic Diamniotic Twin After a Single Blastocyst Transfer.

The frequency of twins resulting from a single embryo transfer has been reported to be 1.56%, with the majority being monochorionic. We present a case of septal rupture at 8 weeks of gestation and successful delivery at 36 weeks of gestation of a monozygotic dichorionic diamniotic twin after a single blastocyst transfer. This report could partially clarify the pathogenesis of monozygotic twins and septal disruption. A 37-year-old woman with 9 months of primary infertility was referred to our department. After seven cycles of artificial insemination, she underwent her first in vitro fertilization. Ten cumulous-oocyte complexes were retrieved, of which three were fertilized, and three blastocysts were cryopreserved. The first single blastocyst transfer in a hormone replacement cycle resulted in a dichorionic diamniotic twin pregnancy. Transvaginal ultrasound at 7 weeks and 4 days gestation revealed a size difference in the gestational sacs and a disruption of the inter-amniotic membrane between the two gestational sacs at 8 weeks and 6 days. Both fetuses were seen in the larger gestational sac; however, the umbilical cord of the migrated fetus was from the original gestational sac. Both fetuses developed without discordancy or obvious anomalies. At 36 weeks and 6 days of gestation, the patient underwent cesarean delivery, resulting in the birth of two viable male infants without any congenital anomalies (weighing 2256 g and 2456 g). Two amniotic cavities existed; however, no chorionic villi were present. There have been many reports on septal disruption in monochorionic diamniotic twins; however, only two cases of dichorionic diamniotic twins have been reported. Furthermore, the onsets in both reports were after the second trimester of pregnancy. This report presents the first case of septal disruption in dichorionic diamniotic twins during the first trimester.

Impact of Diagnosis and Treatment of Chronic Endometritis on Outcomes Before Starting Assisted Reproductive Technology: A Retrospective Study.

This study aimed to investigate the effect of diagnosis and treatment of chronic endometritis (CE) on the outcome of assisted reproductive technology (ART) with or without repeated implantation failure (RIF). This retrospective analysis included patients who underwent pathological examination for diagnosis of CE at Yamagata University Hospital. The examination was performed for all patients planned for ART with or without RIF. Patients who were examined within 6 months of the first oocyte retrieval or embryo transfer were included. We counted the number of CD138-positive cells within the endometrial stroma in patients' specimens and analyzed the patients' clinical information. Clinical rates of pregnancy and implantation were determined. A total of 80 women met the inclusion criteria: 13 CE-negative patients (17.3%) and 67 CE-positive patients (83.7%). A significant decrease was noted in the CD138-positive cell count between the first biopsy and second biopsy after CE treatment (p < 0.001). In addition, no significant differences were noted in ongoing pregnancy rates between the CE-negative patients and those who underwent CE treatment. The CD138-positive cell counts at first biopsy tended to be lower in each pregnancy group than in the non-pregnancy group. For patients planned to undergo ART, examination for diagnosis of CE with or without RIF could be considered. Pathological CD138-positive cell counts were considered useful for CE diagnosis and treatment decision-making. The study findings suggest the efficacy of antimicrobial agents in CE treatment, contributing to improved pregnancy outcomes.

Uneven interhemispheric connections between left and right primary sensori-motor areas.

To clarify the characteristics of interhemispheric connections, we investigated cortico-cortical evoked potentials (CCEP) in human. Fourteen patients with temporal lobe epilepsy who underwent invasive EEG monitoring with bilaterally implanted subdural electrodes were studied. Electric pulse stimuli were given in a bipolar fashion at two adjacent electrodes on and around the motor area (MA) or sensory area (SA), and CCEP responses were recorded by averaging electrocorticograms from the contralateral hemisphere. Seventy-two pairs of electrodes were stimulated, and 468 recordings were analyzed. Fifty-one of 468 recordings demonstrated CCEP responses. Of 51 responses, 16 consisted of an initial positive triphasic wave (Type 1), 27 had an initial negative biphasic wave (Type 2), and 8 showed an initial positive biphasic wave (type 3). The mean latencies of the earliest peaks were 13.1, 28.9, and 29.4 ms in Types 1, 2, and 3 responses, respectively. The responses were more frequently evoked by stimulating facial MA (f-MA) and nonfacial MA (nf-MA) than by stimulating SA or noneloquent area. In both f-MA and nf-MA stimulation, the responses were more frequently recorded at the contralateral f-MA than at the contralateral nf-MA or other areas. SA stimulation never evoked CCEP responses at the contralateral MA or SA. The amplitudes were maximal when f-MA was stimulated and responses recorded at the contralateral f-MA. These findings suggest that the interhemispheric connections are uneven. Both f-MA and nf-MA send dense interhemispheric connections to the contralateral f-MA. SA may have no or only rare direct connection with the contralateral MA or SA.

Ictal very low frequency oscillation in human epilepsy patients.

Using intracranial electroencephalographic recordings, we identified a distinct brain activity in 3 patients with refractory epilepsy characterized by very early occurrence from 8 minutes 10 seconds to 22 minutes 40 seconds prior to clinical seizure onset, periodical appearance of slow negative baseline shift, long interpeak interval of 40 to 120 seconds, and disappearance after clinical seizure. We named this activity "very low frequency oscillation" (VLFO), which reflected a dynamic process during the preictal state. This observation may render new insight into epileptogenesis and provide additional information concerning the epileptogenic zone as well as prediction of epileptic seizures.

Successful treatment of epilepsy by resection of periventricular nodular heterotopia.

We report on a case of successful surgical treatment of drug-resistant epilepsy associated with a solitary lesion of periventricular nodular heterotopia (PNH). In the reported patient, intracranial ictal electroencephalography disclosed that seizures did not originate from the heterotopic nodules. However, the seizures were completely suppressed by lesionectomy of PNH alone. Epileptogenesis associated with PNH likely involves a very complex network between PNH and the surrounding cortex, and the disruption of this network may be an effective means of curing intractable, PNH-associated epilepsy.

Early menopause and a low body mass index are associated with an increased risk of coronary heart disease in Japanese women.

OBJECTIVE: The primary objective was to investigate the association between early menopause and cardiovascular disease (CVD) prevalence in Japanese women. The secondary objective was to ascertain the association with CVD risk factors. METHODS: In this cross-sectional study, 7,239 naturally menopausal women from the Yamagata Cohort Study who completed an annual health visit and questionnaire between 2009 and 2015 were divided into three groups according to their age at menopause (women experiencing menopause at <45, 45-49 y, and ≥ 50 y). The diagnosis of coronary heart disease (CHD) and stroke were made by self-report, while hypertension, hyperlipidemia, and diabetes mellitus, were diagnosed by vital signs and laboratory parameters. Logistic regression analysis was used to estimate the associations between age at menopause and CVD prevalence and CVD risk factors. RESULTS: A total of 354 (4.9%) and 156 (2.2%) women reported a history of CHD and stroke, respectively. Women experiencing menopause at <45 years had a higher prevalence of CHD than those experiencing menopause at ≥50 years (OR 1.77, 95% CI 1.07-2.90; P = 0.023). Stroke, hypertension, diabetes mellitus, and hyperlipidemia were equally prevalent among the three groups. Significant interactions were observed between age at menopause and body mass index (BMI) (P = 0.025) and parity (P = 0.025). Among those with a BMI < 18.5 or parity ≥2, women experiencing menopause at <45 years had a significantly higher prevalence of CHD than those experiencing menopause at ≥50 years. CONCLUSION: Early menopause and low BMI were associated with CHD in Japanese women.

Contribution of subtraction ictal SPECT coregistered to MRI to epilepsy surgery: a multicenter study.

OBJECTIVE: A multicenter prospective study was performed to assess the additional value of a subtraction ictal SPECT coregistered to MRI (SISCOM) technique to traditional side-by-side comparison of ictal- and interictal SPECT images in epilepsy surgery. METHODS: One hundred and twenty-three patients with temporal and extratemporal lobe epilepsy who had undergone epilepsy surgery after evaluation of scalp ictal and interictal electroencephalogram (EEG), MRI, and ictal and interictal SPECT scans were followed up in terms of postsurgical outcome for a period of at least 1 year. Three reviewers localized the epileptogenic focus using ictal and interictal SPECT images first by side-by-side comparison and subsequently by SISCOM. Concordance of the localization of the epileptogenic focus by SPECT diagnosis with the surgical site and inter-observer agreement between reviewers was compared between side-by-side comparison and SISCOM. Logistic regression analysis was performed in predicting the surgical outcome with the dependent variable being the achievement of a good postsurgical outcome and the independent variables using the SISCOM, side-by-side comparison of ictal and interictal SPECT images, MRI, and scalp ictal EEG. RESULTS: The SISCOM presented better concordance in extratemporal lobe epilepsy and less concordance in temporal lobe epilepsy than side-by-side comparison. Inter-observer concordance was higher in SISCOM than in side-by-side comparison. Much higher concordance of the epileptogenic focus by SPECT diagnosis with the surgical site was obtained in patients with good surgical outcome than in those with poor surgical outcome. These differences in concordance between good and poor surgical outcomes were greater in SISCOM than in side-by-side comparison. Logistic regression analysis showed the highest odds ratio of 12.391 (95% confidence interval; 3.319, 46.254) by SISCOM evaluation for concordance of the epileptogenic focus with the surgical site in predicting good surgical outcome. CONCLUSIONS: A SISCOM technique of ictal and interictal SPECT images provides higher predictive value of good surgical outcome and more reliability on the diagnosis of the epileptogenic focus than side-by-side comparison in medically intractable partial epilepsy.

Successful management of cutaneous lymphangitis carcinomatosa arising from cervical cancer with paclitaxel-cisplatin and bevacizumab combination therapy: a case report and review of the literature.

BACKGROUND: Globally, cervical cancer is the fourth most common cancer in women. Here, we report a case of cutaneous lymphangitis carcinomatosa arising from cervical cancer, an extremely rare and treatment-resistant condition. CASE PRESENTATION: A 64-year-old Japanese woman presented with genital bleeding. She was diagnosed as having stage IB1 squamous cell cervical cancer and subsequently treated with radiotherapy. Approximately 2 years after the curative radiotherapy, she developed itching, skin rash, and small nodules on her left femoral and pubic area. Slight 18F-fluorodeoxyglucose uptake was detected at her left femoral skin on positron emission tomography with computed tomography. A histopathological examination was performed on a biopsy sample from an erythematous macule on her left femoral skin and vulva. Consequently, she was diagnosed as having cutaneous lymphangitis carcinomatosa arising from cervical cancer. Paclitaxel (135 mg/m2), cisplatin (50 mg/m2), and bevacizumab (15 mg/kg) combination therapy was administered every 21 days. Both itching and rash improved after three treatment cycles. After the completion of six cycles, skin erythema in the femoral and vulval area disappeared completely. Our patient experienced a 25-month symptom-free interval after the last chemotherapy session. CONCLUSION: Our findings suggest that combination chemotherapy plus bevacizumab is an effective therapeutic option in patients with cutaneous lymphangitis carcinomatosa arising from cervical cancer.

Posterior cortex epilepsy secondary to ulegyria: is it a surgically remediable syndrome?

PURPOSE: To examine whether surgery is indicated for posterior cortex epilepsy secondary to ulegyria. PATIENTS AND METHODS: Ten patients who underwent surgery for posterior cortex epilepsy with ulegyria and were followed for more than 2 years were included. All patients underwent comprehensive presurgical evaluations. Five patients underwent intracranial electroencephalography (EEG) studies. The posterior cortex including the magnetic resonance imaging (MRI) lesion was resected in all patients. Postoperative follow-up period was 2-12 (mean 6) years. RESULTS: Nine patients had a history of perinatal distress including asphyxia and prolonged labor. Age at seizure onset was 5-11 years, except one patient. Three patients had visual field defects preoperatively. Ulegyria was unilateral in four patients and bilateral but unilateral-predominant in six patients. In most of the cases, the lesions were in the posterior cerebral artery area or the watershed area between middle cerebral and posterior cerebral arteries. In four of five patients who underwent intracranial EEG, seizure onset zones extended outside the lesions. Postoperative seizure outcome was Engel's class I in seven cases, and class III in three cases. Three of four patients whose seizure onset zones were not completely resected achieved class I outcome. Four of six patients with bilateral lesions achieved class I outcome. CONCLUSION: Ulegyria due to perinatal distress is considered to be a major cause of posterior cortex epilepsy. Long-term postoperative seizure outcome is favorable. Resection of MRI lesion is important for seizure relief. Bilateral lesions should not be excluded from surgical indication. The usefulness of intracranial EEG may be limited.

Intracranial EEG findings in patients with lesional lateral temporal lobe epilepsy.

PURPOSE: Intracranial EEG in patients with lesional lateral temporal lobe epilepsy is rarely reported. Therefore, the number of patients with seizures arising independently from ipsilateral mesial structures or contralateral hemisphere has not been clarified. We analyzed the intracranial EEG of cases with localized lesion in the lateral temporal cortex. METHODS: We studied 15 patients who satisfied the following criteria: (1) MRI depicted a lesion less than 4cm in diameter located lateral to the collateral sulcus and at least 3cm posterior to the temporal pole; (2) intracranial EEG with electrodes placed on bilateral temporal lobes captured at least one complex partial seizure; and (3) postoperative follow-up period of 2 years or longer. The mean age of seizure onset was 16.6 years (range, 11-25) and that at surgery was 26.7 years (range, 16-36). RESULTS: A total of 147 complex partial seizures, 51 simple partial seizures, 16 secondarily generalized seizures, and over 80 subclinical seizures were recorded. On the lesional side, many clinical seizures were recorded from the lateral cortex. Independent of the lateral temporal onset seizures, ictal discharges originating from the mesial temporal structures were recorded in 7 of 15 patients (47%). Moreover, onset of ictal discharges from the contralateral temporal lobe was recorded in 7 of 15 patients (47%). Interictal spikes from ipsilateral mesial structures were recorded in all patients. The presence of ipsilateral mesial onset seizures was not associated with hippocampal neuron losses. CONCLUSION: Intracranial EEG analysis revealed that approximately one-half of the patients with structural lesions in the lateral cortex showed independent epileptogenic areas in ipsilateral mesial structures. Although ictal discharges originating from the contralateral temporal lobe were recorded in a half of these patients, this finding does not constitute a contraindication of resective surgery. Interictal spike is not an indicator of whether mesial structures should be resected.

Extraoperative functional mapping of motor areas in epileptic patients by high-frequency cortical stimulation.

OBJECT: The aim of this study was to investigate the usefulness of a short train of high-frequency (500 Hz) cortical stimulation to delineate the primary motor cortex (MI), supplementary motor area (SMA), primary somatosensory cortex (SI), supplementary sensory area (SSA), negative motor area (NMA), and supplementary negative motor area (SNMA) in patients with epilepsy who were undergoing functional mapping. METHODS: Seventeen patients were studied, all of whom underwent functional mapping using 50-Hz electrical stimulation. After these clinical evaluations, cortical stimulations with a short train of electrical pulses at 500 Hz were performed through subdural electrodes placed at the MI, SMA, SI, SSA, NMA, and SNMA, which had been identified by 50-Hz stimulation, and surrounding cortical areas, while surface electromyography readings were recorded. RESULTS: Stimulation of the MI elicited motor evoked potentials (MEPs) in contralateral muscles. Stimulation of the SMA also induced MEPs in contralateral muscles but with longer latencies compared with the MI stimulation. Stimulation of the SMA did not elicit MEPs in ipsilateral muscles. Stimulation of the SI, SSA, NMA, and SNMA did not induce MEPs in any muscle. In one patient, MEPs were elicited without seizure induction by 500-Hz stimulation of the electrodes, whereas a 50-Hz stimulation of the same electrodes induced his habitual seizures. CONCLUSIONS: Extraoperative high-frequency stimulation with MEP monitoring is a useful complementary method for cortical mapping without inducing seizure. Stimulation of SMA induces MEPs in contralateral muscles, with longer latencies compared with the stimulation of MI. This finding may be useful for the differentiation between MI and SMA, especially in the foot motor areas.

Early seizure propagation from the occipital lobe to medial temporal structures and its surgical implication.

Intracranial EEG documentation of seizure propagation from the occipital lobe to medial temporal structures is relatively rare. We retrospectively analyzed intracranial EEG recorded with electrodes implanted in the medial temporal lobe in patients who underwent occipital lobe surgery. Four patients with occipital lesions, who underwent intracranial EEG monitoring with intracerebral electrodes implanted in the medial temporal lobe prior to occipital lobe surgery, were studied. Subdural electrodes were placed over the occipital lobe and adjacent areas. Intracerebral electrodes were implanted into bilateral hippocampi and the amygdala in three patients, and in the hippocampus and amygdala ipsilateral to the lesion in one. In light of the intracranial EEG findings, the occipital lobe was resected but the medial temporal lobe was spared in all patients. The follow-up period ranged from six to 16 years, and seizure outcome was Engel Class I in all patients. Sixty six seizures were analyzed. The majority of the seizures originated from the occipital lobe. In complex partial seizures, ictal discharges propagated to the medial temporal lobe. No seizures originating from the temporal lobe were documented. In some seizures, the ictal-onset zone could not be identified. In these seizures, very early propagation to the medial temporal lobe was observed. Interictal spikes were recorded in the medial temporal lobe in all cases. Intracranial EEG revealed very early involvement of the medial temporal lobe in some seizures. Seizure control was achieved without resection of the medial temporal structures.

Usefulness of 123I-iomazenil single-photon emission computed tomography in discriminating between mesial and lateral temporal lobe epilepsy in patients in whom magnetic resonance imaging demonstrates normal findings.

OBJECT: To provide greater accuracy in determining the epileptogenic zone during preoperative evaluation, the authors retrospectively examined 123I-iomazenil single-photon emission computed tomography (IMZ SPECT) studies obtained in patients with temporal lobe epilepsy (TLE) in whom there was no evidence of an abnormality on magnetic resonance (MR) images. METHODS: Twelve patients, seven with mesial TLE (MTLE) and five with lateral TLE (LTLE), satisfied the criteria for inclusion in the study. The IMZ SPECT findings in these patients were reviewed retrospectively, and a comparison was made between findings in patients with MTLE and those in patients with LTLE. RESULTS: The IMZ SPECT studies demonstrated decreased IMZ uptake in the ipsilateral mesial temporal region and the anterobasal temporal lobe in all patients who had MTLE on only one side. On the other hand, IMZ SPECT examinations revealed low IMZ uptake in the ipsilateral lateral temporal lobe in four of five patients with LTLE in whom abnormal findings were restricted to the lateral neocortex. In the remaining patient with LTLE, abnormally low IMZ uptake was found in both mesial and lateral temporal lobes, although pure LTLE was diagnosed by an invasive electroencephalographic evaluation; this patient's habitual seizures continued even after temporal lobectomy, although his mesial structures were spared. CONCLUSIONS: The authors report characteristics of IMZ SPECT findings that differed between patients with MTLE and those with LTLE. The IMZ SPECT examinations proved useful for preoperative evaluation and, to a certain extent, for discrimination between MTLE and LTLE in cases in which MR imaging demonstrated normal findings. The results of this study suggest that IMZ SPECT findings may reflect localization of the epileptogenic zone.

Bilateral symmetric tonic posturing suggesting propagation to the supplementary motor area in a patient with precuneate cortical dysplasia.

We report a patient manifesting seizures with bilateral symmetric tonic posturing, which were markedly reduced after resection of the left precuneus. A 16-year-old man had sudden onset, complex partial seizures with bilateral symmetric tonic posturing since the age of eight years. Magnetic resonance fluid-attenuated inversion-recovery imaging revealed a hyperintense lesion in left precuneus. In almost all focal seizures recorded during an invasive EEG evaluation, ictal onset was detected from the inferomesial aspect of the lesion, but fast paroxysmal discharges from the ipsilateral supplementary motor area (SMA) were observed just before the clinical onset. After surgical excision of the EEG onset zone, including the lesion, seizure frequency was markedly (> 95%) reduced. By the 20th month after surgery, there were only brief nocturnal seizures involving slight elevation of both shoulders and slight abduction of both arms, with preservation of consciousness occurring once every few days. Invasive EEG findings and surgical outcome suggested that the epileptic activity originating from the epileptogenic zone may have propagated to the symptomatogenic zone including mainly the ipsilateral SMA. In summary, we report an interesting case of bilateral symmetric tonic posturing suggesting propagation to the SMA. MRI and invasive EEG confirmed the epileptogenic focus as a precuneate cortical dysplasia lesion.[Published with video sequences].

[Treatment guidelines for adult epilepsy].

We reviewed the treatment strategies and choices of drugs for adult patients with epilepsy. As evidence from controlled studies for the older drugs is scarcely available from the literature, we added a clinical study performed in our hospital and an expert consensus study. Published randomized clinical studies revealed carbamazepine (CBZ) to be the treatment of choice, but provided little evidence for the differences in efficacy between phenytoin (PHT), valproate (VPA), phenobarbital (PB) and zonisamide (ZNS). The clinical study in our patients with intractable localization-related epilepsy indicated the superior efficacy of CBZ and PHT over VPA or ZNS. Sixty-nine experts converged on the opinion that monotherapy should be started with VPA for seizures of both idiopathic and symptomatic generalized epilepsy, and with CBZ for seizures of localization-related epilepsy. When the trials with 2-3 monotherapy failed, surgery should be considered for localization-related epilepsy. We proposed practical guidelines for treatment of patients with adult epilepsy, including rehabilitation and care for improvement of quality of life.

Statistical parametric mapping of interictal 123I-iomazenil SPECT in temporal lobe epilepsy surgery.

Brain single photon emission computed tomography (SPECT) for epilepsy is divided into two types (using three radionuclide tracers)-perfusion SPECT (123I-IMP or 99 mTc-ECD), identifying epileptogenic foci by detecting abnormality in regional cerebral blood flow, and 123I-iomazenil SPECT, identifying epileptogenic foci based on distribution of central benzodiazepine receptors. This study aimed to statistically evaluate and compare the SPECT effectiveness for the three tracers. Statistical parametric mapping (SPM) analysis was performed on 30 mesial temporal lobe epilepsy (mTLE) patients. The radionuclide and patient data were categorized as follows: abnormality in the medial temporal lobe on the operated hemisphere (AAA), in the entire temporal lobe on the operated hemisphere (AA), in the dominantly affected temporal lobe on the operated hemisphere (A), in bilateral temporal lobes (B), with no abnormalities in bilateral temporal lobes (C), and with abnormality in the temporal lobe on the nonoperated hemisphere (D). For analyses of (AAA), (AA), and (A), examining the hemisphere containing epileptogenic foci, IMP-SPECT was significantly superior to ECD-SPECT (P<0.05). For (AAA), indicating localization, IMZ-SPECT was significantly superior to the other two (P<0.05). IMP-SPECT was superior for lateralizing and IMZ-SPECT was useful for localizing epileptogenic foci in mTLE patients though the applicability of the results in extratemporal lobe epilepsy is unknown.

Versive seizures in occipital lobe epilepsy: lateralizing value and pathophysiology.

To clarify the value of versive seizures in lateralizing and localizing the epileptogenic zone in patients with occipital lobe epilepsy, we studied 13 occipital lobe epilepsy patients with at least one versive seizure recorded during preoperative noninvasive video-EEG monitoring, who underwent occipital lobe resection, and were followed postoperatively for more than 2 years with Engel's class I outcome. The videotaped versive seizures were analyzed to compare the direction of version and the side of surgical resection in each patient. Moreover, we examined other motor symptoms (partial somatomotor manifestations such as tonic and/or clonic movements of face and/or limbs, automatisms, and eyelid blinking) associated with version. Forty-nine versive seizures were analyzed. The direction of version was always contralateral to the side of resection except in one patient. Among accompanying motor symptoms, partial somatomotor manifestations were observed in only five patients. In conclusion, versive seizure is a reliable lateralizing sign indicating contralateral epileptogenic zone in occipital lobe epilepsy. Since versive seizures were accompanied by partial somatomotor manifestations in less than half of the patients, it is suggested that the mechanism of version in occipital lobe epilepsy is different from that in frontal lobe epilepsy.

Clinical significance of ictal high frequency oscillations in medial temporal lobe epilepsy.

OBJECTIVE: To clarify the clinical significance of ictal high frequency oscillations (HFO) in the medial temporal lobe. METHODS: This study included 19 patients who underwent intracranial electrode implantation in bilateral temporal lobes and had at least one seizure recorded at 1kHz sampling rate. The characteristics of ictal HFO in the medial temporal lobe, and the relations between the presence of HFO, pathology, and postoperative seizure outcome were analyzed. RESULTS: Ictal HFO were detected from medial temporal structures in 11 patients with medial temporal lobe epilepsy (MTLE). Among eight patients without HFO, only three were diagnosed with MTLE. Ictal HFO were detected from unilateral medial temporal structures ipsilateral to the side of hippocampal sclerosis (HS). In one patient with bitemporal independent seizure onset, ictal HFO were detected only on the side of HS. HS was detected in all 11 patients with HFO, but in only one of four patients without HFO. Seizure outcome did not differ between patients with and without HFO. CONCLUSIONS: Ictal HFO in the medial temporal lobe may be a specific marker for MTLE with HS. SIGNIFICANCE: Recording of ictal HFO in the medial temporal lobe may be useful for presurgical evaluation of MTLE.

Very high frequency oscillations (over 1000 Hz) in human epilepsy.

OBJECTIVE: High frequency oscillations (HFO) of 100-500Hz have been reported in epileptic human brain. However, the questions of how fast these oscillations can reach, and which frequency range is clinically important remain unanswered. We recorded interictal and ictal very high frequency oscillations (VHFO) of 1000-2500Hz by subdural electrodes using 10kHz sampling rate. We describe the characteristics of VHFO, and discuss their underlying mechanism and clinical significance. METHODS: Five patients with neocortical epilepsy were studied. All patients underwent intracranial EEG monitoring with subdural electrodes. EEG recording with sampling rate of 10kHz was conducted. Histopathology revealed malformation of cortical development in all cases. RESULTS: In four of five patients, very high frequency activities of 1000-2500Hz were detected in highly localized cortical regions (one to four electrodes in individual patient). We named these activities "very high frequency oscillations (VHFO)". Interictally, VHFO appeared intermittently, and were interrupted by spikes. Sustained VHFO without spikes appeared around the start of seizures. CONCLUSIONS: Both interictal and ictal VHFO can be recorded by subdural electrodes. Compared to HFO previously reported, VHFO have much higher frequency, more restricted distribution, smaller amplitude, and different timing of onset. SIGNIFICANCE: Recording of VHFO may be useful for identifying the epileptogenic zone.

Epileptic negative myoclonus: a combined study of EEG and [123I]iomazenil (123I-IMZ) single photon emission computed tomography indicating involvement of medial frontal area.

Negative myoclonus (NM) is a sudden brief atonia in muscle that causes jerky lapses of posture. This study employed an electrophysiological technique (silent-period-locked-averaging (SPLA) electroencephalography (EEG)) and a pharmacodynamic imaging technique (123I-IMZ-SPECT) to examine epileptic NM (ENM). Delayed-phase 123I-IMZ-SPECT images, which reflect the specific binding of the tracers to GABA-A receptors, exhibited significant decrease in the left medial frontal area. The deficit in GABA-A receptors indicated that abnormal synchronization was mediated by the lack of inhibitory postsynaptic mechanism. The SPLA-EEG recorded spike-like notches superimposed on the slope of negative slow activity in the contralateral fronto-central region. The slow activity started around 100 ms before and the peak of the spike-like component was 30 ms before the onset of ENM. Since the 123I-IMZ-SPECT shows the actual distribution of the tracers, the abnormal area associated with ENM in this particular patient was supposed to be on the left medial frontal lobe. Scalp EEG, though it cannot always accurately locate the abnormal area, was highly sensitive to be able to detect electrical activities transmitted through neuronal network or volume conductor. Combined use of the two methods provided high resolution both in spatial and temporal domain.