Anticipatory anxiety of seizures is associated with ictal emotional distress and amygdala onset seizures.

OBJECTIVE: Anxiety disorders are a frequent psychiatric condition in patients with epilepsy. Anticipatory anxiety of seizures (AAS) is described as a daily persistent fear or excessive worry of having a seizure. AAS seems to be related to "subjective ictal anxiety" reported by patients. The current study aimed to assess the association between objective ictal features and the presence of AAS. METHODS: Ninety-one patients with drug-resistant focal epilepsy underwent a standardized psychiatric assessment, specific for epilepsy, and presurgical long-term video-electroencephalography (EEG) or stereo-EEG (SEEG). We compared seizure semiology and epilepsy features of patients with AAS (n = 41) to those of patients without AAS (n = 50). We analyzed emotional and motor behavior ictal signs as well as ictal consciousness. We further assessed amygdala ictal involvement in seizures recorded with SEEG (n = 28). RESULTS: AAS was significantly associated with the presence of ictal emotional distress; negative emotional behavior (p < .01) and negative emotion were explicitly reported to the examiner during recording (p = .015), regardless of the ictal level of consciousness. Among the patients recorded with SEEG, we found a significant involvement of amygdala within the seizure onset zone (p < .01) for patients with AAS. SIGNIFICANCE: Higher risk of developing AAS is associated with seizures expressing negative emotional symptoms, independently of ictal consciousness level. Persistent interictal fear of seizures might be viewed as the consequence of a reinforcement of the emotional networks secondary to amygdala involvement in seizures of temporal origin. Physicians should screen for AAS not only to assess the impact of epilepsy on daily life, but also as an interictal biomarker of ictal semiology and emotional network involvement at seizure onset.

Working toward the ideal situation: A pragmatic Epi-Psy approach for the diagnosis and treatment of psychogenic nonepileptic seizures.

Medical international guidelines recommend regular psychiatric consultations for patients with epilepsy, in order to detect comorbidities. However, there is a lack of guidance about PNES that constitute both a differential diagnosis and a comorbidity of epilepsy. While waiting for the ideal collaboration between neurologists and psychiatrists, we develop a pragmatic approach. Wrong diagnosis between epilepsy and Psychogenic nonepileptic seizures (PNES) is frequent and may lead to iatrogenic consequences for patients. To limit the risk of misdiagnosis, psychiatrists and neurologists should collaborate and be more trained about epilepsy, PNES, and their comorbidities. We illustrate the aim of this collaboration through the case of a patient, initially diagnosed with epilepsy, then with PNES only and finally with comorbid epilepsy and PNES. The correct final diagnosis would not have been performed without the collaboration of psychiatrists and neurologists, trained in "Epi-Psy" approach.

Respective Contribution of Ictal and Inter-ictal Electrical Source Imaging to Epileptogenic Zone Localization.

Interictal electrical source imaging (ESI) encompasses a risk of false localization due to complex relationships between irritative and epileptogenic networks. This study aimed to compare the localizing value of ESI derived from ictal and inter-ictal EEG discharges and to evaluate the localizing value of ESI according to three different subgroups: MRI lesion, presumed etiology and morphology of ictal EEG pattern. We prospectively analyzed 54 of 78 enrolled patients undergoing pre-surgical investigation for refractory epilepsy. Ictal and inter-ictal ESI results were interpreted blinded to- and subsequently compared with stereoelectroencephalography as a reference method. Anatomical concordance was assessed at a sub-lobar level. Sensitivity and specificity of ictal, inter-ictal and ictal plus inter-ictal ESI were calculated and compared according to the different subgroups. Inter-ictal and ictal ESI sensitivity (84% and 75% respectively) and specificity (38% and 50% respectively) were not statistically different. Regarding the sensitivity, ictal ESI was never higher than inter-ictal ESI. Regarding the specificity, ictal ESI was higher than inter-ictal ESI in malformations of cortical development (MCD) (60% vs. 43%) and in MRI positive patients (49% vs. 30%). Within the ictal ESI analysis, we showed a higher specificity for ictal spikes (59%) and rhythmic discharges > 13 Hz (50%) than rhythmic discharges < 13 Hz (37%) and (ii) for MCD (60%) than in other etiologies (29%). This prospective study demonstrates the relevance of a combined interpretation of distinct inter-ictal and ictal analysis. Inter-ictal analysis gave the highest sensitivity. Ictal analysis gave the highest specificity especially in patients with MCD or a lesion on MRI.

Interictal psychiatric comorbidities of drug-resistant focal epilepsy: Prevalence and influence of the localization of the epilepsy.

Psychiatric comorbidities are 2 to 3 times more frequent in patients with epilepsy than in the general population. This study aimed to prospectively assess the following: (i) the prevalence of specific and nonspecific interictal psychiatric comorbidities in a population of patients with drug-resistant focal epilepsy and (ii) the influence of epilepsy lateralization and localization on these psychiatric comorbidities. In this prospective monocentric study, we collected demographic data, characteristics of the epilepsy, interictal psychiatric comorbidities, mood, anxiety, and alexithymia dimensions. We used criteria from Diagnostic and Statistical Manual of Mental Disorders IV ( DSM IV) (Mini International Mental Interview (MINI)), diagnosis criteria for specific comorbidities, and validated mood and anxiety scales (general and specific for epilepsy). Among the 87 enrolled patients (39 males, 48 females), 52.9% had at least one psychiatric comorbidity. The most common comorbidity was anxiety disorder (28.7% according to the MINI, and 38.4% screening by the Generalized Anxiety Disorder 7 (GAD 7)). Mood disorders were the second most frequent psychiatric comorbidity: 21.8% of our patients had interictal dysphoric disorders (IDDs), 16.1% presented major depressive disorders according to the MINI, and 17.2% screening by the Neurological Disorders Depression Inventory for Epilepsy (NDDIE). Patients with temporal lobe epilepsy had a higher prevalence of psychiatric comorbidities than patients with extratemporal lobe epilepsy (p = 0.002), which is probably related to a higher rate of anxiety disorders in this subgroup (p = 0.012). Prevalence of psychiatric disorders prior to epilepsy in patients was higher in right- than in left-sided epilepsy (p = 0.042). No difference was found according to limbic involvement at seizure onset. Overall, this article highlighted a very high proportion of anxiety disorders in these patients with drug-resistant focal epilepsy and the necessity to systematically detect them and thus lead to a specific treatment.

Discrimination of a medial functional module within the temporal lobe using an effective connectivity model: A CCEP study.

The temporal lobe is classically divided in two functional systems: the ventral visual pathway and the medial temporal memory system. However, their functional separation has been challenged by studies suggesting that the medial temporal lobe could be best understood as an extension of the hierarchically organized ventral visual pathway. Our purpose was to investigate (i) whether cerebral regions within the temporal lobe could be grouped into distinct functional assemblies, and (ii) which regions were central within these functional assemblies. We studied low intensity and low frequency electrical stimulations (0.5 mA, 1 Hz, 4 ms) performed during sixteen pre-surgical intracerebral EEG investigations in patients with medically intractable temporal or temporo-occipital lobe epilepsies. Eleven regions of interest were delineated per anatomical landmarks such as gyri and sulci. Effective connectivity based on electrophysiological feature (amplitude) of cortico-cortical evoked potentials (CCEPs) was evaluated and subjected to graph metrics. The amplitudes discriminated one medial module where the hippocampus could act as a signal amplifier. Mean amplitudes of CCEPs in regions of the temporal lobe showed a generalized Pareto distribution of probability suggesting neural synchronies to be self-organized critically. Our description of effective interactions within the temporal lobe provides a regional electrophysiological model of effective connectivity which is discussed in the context of the current hypothesis of pattern completion.

Cost-effectiveness analysis of epilepsy surgery in a controlled cohort of adult patients with intractable partial epilepsy: A 5-year follow-up study.

OBJECTIVE: Despite its well-known effectiveness, the cost-effectiveness of epilepsy surgery has never been demonstrated in France. We compared cost-effectiveness between resective surgery and medical therapy in a controlled cohort of adult patients with partial intractable epilepsy. METHODS: A prospective cohort of adult patients with surgically remediable and medically intractable partial epilepsy was followed over 5 years in the 15 French centers. Effectiveness was defined as 1 year without a seizure, based on the International League Against Epilepsy (ILAE) classification. Clinical outcomes and direct costs were compared between surgical and medical groups. Long-term direct costs and effectiveness were extrapolated over the patients' lifetimes with a Monte-Carlo simulation using a Markov model, and an incremental cost-effectiveness ratio (ICER) was computed. Indirect costs were also evaluated. RESULTS: Among the 289 enrolled surgery candidates, 207 were operable-119 in the surgical group and 88 in the medical group-65 were not operable and not analyzed here, 7 were finally not eligible, and 10 were not followed. The proportion of patients completely seizure-free during the last 12 months (ILAE class 1) was 69.0% in the operated group and 12.3% in the medical group during the second year (p < 0.001), and it was respectively 76.8% and 21% during the fifth year (p < 0.001). Direct costs became significantly lower in the surgical group the third year after surgery, as a result of less antiepileptic drug use. The value of the discounted ICER was 10,406 (95% confidence interval [CI] 10,182-10,634) at 2 years and 2,630 (CI 95% 2,549-2,713) at 5 years. Surgery became cost-effective between 9 and 10 years after surgery, and even earlier if indirect costs were taken into account as well. SIGNIFICANCE: Our study suggests that in addition to being safe and effective, resective surgery of epilepsy is cost-effective in the medium term. It should therefore be considered earlier in the development of epilepsy.

Catching the invisible: mesial temporal source contribution to simultaneous EEG and SEEG recordings.

Mesial temporal sources are presumed to escape detection in scalp electroencephalographic recordings. This is attributed to the deep localization and infolded geometry of mesial temporal structures that leads to a cancellation of electrical potentials, and to the blurring effect of the superimposed neocortical background activity. In this study, we analyzed simultaneous scalp and intracerebral electroencephalographic recordings to delineate the contribution of mesial temporal sources to scalp electroencephalogram. Interictal intracerebral spike networks were classified in three distinct categories: solely mesial, mesial as well as neocortical, and solely neocortical. The highest and earliest intracerebral spikes generated by the leader source of each network were marked and the corresponding simultaneous intracerebral and scalp electroencephalograms were averaged and then characterized both in terms of amplitude and spatial distribution. In seven drug-resistant epileptic patients, 21 interictal intracerebral networks were identified: nine mesial, five mesial plus neocortical and seven neocortical. Averaged scalp spikes arising respectively from mesial, mesial plus neocortical and neocortical networks had a 7.1 (n = 1,949), 36.1 (n = 628) and 10 (n = 1,471) µV average amplitude. Their scalp electroencephalogram electrical field presented a negativity in the ipsilateral anterior and basal temporal electrodes in all networks and a significant positivity in the fronto-centro-parietal electrodes solely in the mesial plus neocortical and neocortical networks. Topographic consistency test proved the consistency of these different scalp electroencephalogram maps and hierarchical clustering clearly differentiated them. In our study, we have thus shown for the first time that mesial temporal sources (1) cannot be spontaneously visible (mean signal-to-noise ratio -2.1 dB) on the scalp at the single trial level and (2) contribute to scalp electroencephalogram despite their curved geometry and deep localization.

Intracerebral electrical stimulation of a face-selective area in the right inferior occipital cortex impairs individual face discrimination.

During intracerebral stimulation of the right inferior occipital cortex, a patient with refractory epilepsy was transiently impaired at discriminating two simultaneously presented photographs of unfamiliar faces. The critical electrode contact was located in the most posterior face-selective brain area of the human brain (right "occipital face area", rOFA) as shown both by low- (ERP) and high-frequency (gamma) electrophysiological responses as well as a face localizer in fMRI. At this electrode contact, periodic visual presentation of 6 different faces by second evoked a larger electrophysiological periodic response at 6 Hz than when the same face identity was repeated at the same rate. This intracerebral EEG repetition suppression effect was markedly reduced when face stimuli were presented upside-down, a manipulation that impairs individual face discrimination. These findings provide original evidence for a causal relationship between the face-selective right inferior occipital cortex and individual face discrimination, independently of long-term memory representations. More generally, they support the functional value of electrophysiological repetition suppression effects, indicating that these effects can be used as an index of a necessary neural representation of the changing stimulus property.

Right hemispheric dominance of visual phenomena evoked by intracerebral stimulation of the human visual cortex.

Electrical brain stimulation can provide important information about the functional organization of the human visual cortex. Here, we report the visual phenomena evoked by a large number (562) of intracerebral electrical stimulations performed at low-intensity with depth electrodes implanted in the occipito-parieto-temporal cortex of 22 epileptic patients. Focal electrical stimulation evoked primarily visual hallucinations with various complexities: simple (spot or blob), intermediary (geometric forms), or complex meaningful shapes (faces); visual illusions and impairments of visual recognition were more rarely observed. With the exception of the most posterior cortical sites, the probability of evoking a visual phenomenon was significantly higher in the right than the left hemisphere. Intermediary and complex hallucinations, illusions, and visual recognition impairments were almost exclusively evoked by stimulation in the right hemisphere. The probability of evoking a visual phenomenon decreased substantially from the occipital pole to the most anterior sites of the temporal lobe, and this decrease was more pronounced in the left hemisphere. The greater sensitivity of the right occipito-parieto-temporal regions to intracerebral electrical stimulation to evoke visual phenomena supports a predominant role of right hemispheric visual areas from perception to recognition of visual forms, regardless of visuospatial and attentional factors.

Electrical source imaging in cortical malformation-related epilepsy: a prospective EEG-SEEG concordance study.

OBJECTIVE: Delineation of the epileptogenic zone (EZ) in refractory epilepsy related to malformations of cortical development (MCDs) often requires intracranial electroencephalography (EEG) recordings, especially in cases of negative magnetic resonance imaging (MRI) or discordant MRI and video-EEG findings. It is therefore crucial to promote the development of noninvasive methods such as electrical source imaging (ESI). We aimed to (1) analyze the localization concordance of ESI derived from interictal discharges and EZ estimated by stereo-EEG (SEEG); (2) compare the concordance of ESI, MRI, and electroclinical correlations (ECCs) with SEEG-EZ; and (3) assess ESI added value in the EZ localization. METHODS: We prospectively analyzed 28 consecutive patients undergoing presurgical investigation for MCD-related refractory epilepsy in 2009-2012. ESI derived from 64-channel scalp EEG was interpreted with blinding to, and subsequently compared with, SEEG-estimated EZ. Anatomic concordance of ESI with SEEG-EZ was compared with that of video-EEG and MRI. We further assessed ESI added value to ECC and MRI. RESULTS: Twelve patients (43%) had temporal and 16 (57%) had extratemporal epilepsy. MRI was negative in 11 (39%) and revealed a cortical malformation in 17 (61%). ESI was fully concordant with the EZ in 10 (36%) and partly concordant in 15 (53%). ECC presented a full and partial concordance with EZ in 11% and 82% of cases, respectively, and MRI in 11% and 46%, respectively. Of 11 patients with negative MRI, ESI was fully concordant with the EZ in 7 (64%) and partly concordant in 4 (36%). ESI correctly confirmed restricted or added localizations to ECC and MRI in 12 (43%) of 28 patients and in 8 (73%) of 11 patients with negative MRI. SIGNIFICANCE: ESI contributes to estimating the EZ in MCD-related epilepsy. The added value of ESI to ECC is particularly high in patients with MCD and negative MRI, who represent the most challenging cases for epilepsy surgery. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Intracranial evaluation of the epileptogenic zone in regional infrasylvian polymicrogyria.

PURPOSE: To define the relationship between the epileptogenic zone and the polymicrogyric area using intracranial electroencephalography (EEG) recordings in patients with structural epilepsy associated with regional infrasylvian polymicrogyria (PMG). METHODS: We retrospectively reviewed the medical charts, scalp, and intracranial video-EEG recordings, neuroimaging findings, and neuropsychological evaluations of four patients with refractory temporal lobe epilepsy related to PMG who consequently underwent resective surgery. KEY FINDINGS: High-resolution magnetic resonance imaging (MRI) revealed temporal lobe PMG in all cases, accompanied by hippocampal malrotation and closed lip schizencephaly in 3/4 cases, respectively. In intracranial recordings, interictal spike activity was localized within the PMG in only 2/4 and within the amygdala, hippocampus, and entorhinal cortex in all cases. In the first patient, two epileptogenic networks coexisted: the prevailing network initially involved the mesial temporal structures with spread to the anterior PMG; the secondary network successively involved the anterior part of the PMG and later the mesial temporal structures. In the second patient, the epileptogenic network was limited to the mesial temporal structures, fully sparing the PMG. In the third patient, the epileptogenic network first involved the mesial temporal structures and later the PMG. Conversely, in the last case, part of the PMG harbored an epileptogenic network that propagated to the mesial temporal structures. Consistent with these findings a favorable outcome (Engel class I in three of four patients; Engel class II in one of four) at last follow-up was obtained by a resection involving parts of the PMG cortex in three of four and anteromesial temporal lobe structures in another three of four cases. SIGNIFICANCE: Infrasylvian PMG displays a heterogeneous epileptogenicity and is occasionally and partially involved in the epileptogenic zone that commonly includes the mesial temporal structures. Our results highlight the intricate interrelations between the MRI-detectable lesion and the epileptogenic zone as delineated by intracranial recordings. Seizure freedom can be accomplished as a result of a meticulous intracranial study guiding a tailored resection that may spare part of the PMG.

Direct evidence of nonadherence to antiepileptic medication in refractory focal epilepsy.

The adherence to medication in drug-resistant focal epilepsy (RFE) remains largely unknown. The present work aimed to assess the frequency of recent adherence to antiepileptic drugs (AEDs) in patients with RFE. This prospective observational study screened all patients with RFE, admitted to the Nancy University Hospital between April 2006 and September 2008, for a 5-day hospitalization without AED tapering. The adherence to AEDs was assessed by measuring serum drug levels on day 1 (reflecting the recent "at home" adherence) and day 5 (reflecting the individual reference concentration when drug ingestion was supervised). A patient was considered nonadherent if at least one of their serum drug levels was different between days 1 and 5. The day-1 value was considered different from day 5 when it was at least 30% lower (underdosed) or 30% higher (overdosed). Nonadherent patients were classified as under-consumers in the case of one or more underdosed day-1 values, over-consumers in the case of one or more overdosed day-1 values, or undefined if they exhibited both underdosed and overdosed day-1 values. Forty-four of the 48 screened patients were included. Eighteen (40.9%) of 44 patients were nonadherent. Among them, 12 (66.7%) were over-consumers, 4 (22.2%) were under-consumers, and 2 (11.1%) were undefined nonadherents. The study indicates that recent adherence to antiepileptic medication in this group of patients with RFE is poor. Overconsumption is the most frequent form of nonadherence in this population and should be specifically assessed to prevent its possible consequences in terms of AEDs dose-dependent adverse events.

[Adherence to medication and epilepsy: a current issue]. / Adhésion au traitement médicamenteux et épilepsie : un enjeu d'actualité

As in other chronic diseases, adherence to medication in epilepsy is critical for seizure control. Its assessment remains challenging in research as in clinical practice. Recent evidences showed another face of nonadherence: the overconsumption of antiepileptic drugs. Some educational interventions with easy implementation were found to be effective in improving adherence and should be therefore more used in everyday practice.

Intracerebral Correlates of Scalp EEG Ictal Discharges Based on Simultaneous Stereo-EEG Recordings.

BACKGROUND AND OBJECTIVES: It remains unknown to what extent ictal scalp EEG can accurately predict the localization of the intracerebral seizure onset in presurgical evaluation of drug-resistant epilepsies. In this study, we aimed to define homogeneous ictal scalp EEG profiles (based on their first ictal abnormality) and assess their localizing value using simultaneously recorded scalp EEG and stereo-EEG. METHODS: We retrospectively included consecutive patients with drug-resistant focal epilepsy who had simultaneous stereo-EEG and scalp EEG recordings of at least 1 seizure in the epileptology unit in Nancy, France. We analyzed 1 seizure per patient and used hierarchical cluster analysis to group similar seizure profiles on scalp EEG and then performed a descriptive analysis of their intracerebral correlates. RESULTS: We enrolled 129 patients in this study. The hierarchical cluster analysis showed 6 profiles on scalp EEG first modification. None were specific to a single intracerebral localization. The "normal EEG" and "blurred EEG" clusters (early muscle artifacts) comprised only 5 patients each and corresponded to no preferential intracerebral localization. The "temporal discharge" cluster (n = 46) was characterized by theta or delta discharges on ipsilateral anterior temporal scalp electrodes and corresponded to a preferential mesial temporal intracerebral localization. The "posterior discharge" cluster (n = 42) was characterized by posterior ipsilateral or contralateral rhythmic alpha discharges or slow waves on scalp and corresponded to a preferential temporal localization. However, this profile was the statistically most frequent scalp EEG correlate of occipital and parietal seizures. The "diffuse suppression" cluster (n = 9) was characterized by a bilateral and diffuse background activity suppression on scalp and corresponded to mesial, and particularly insulo-opercular, localization. Finally, the "frontal discharge" cluster (n = 22) was characterized by bilateral frontal rhythmic fast activity or preictal spike on scalp and corresponded to preferential ventrodorsal frontal intracerebral localizations. DISCUSSION: The hierarchical cluster analysis identified 6 seizure profiles regarding the first abnormality on scalp EEG. None of them were specific of a single intracerebral localization. Nevertheless, the strong relationships between the "temporal," "frontal," "diffuse suppression," and "posterior" profiles and intracerebral discharge localizations may contribute to hierarchize hypotheses derived from ictal scalp EEG analysis regarding intracerebral seizure onset.

Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering.

BACKGROUND: Psychogenic non-epileptic seizures (PNES) or attacks consist of paroxysmal behavioural changes that resemble an epileptic seizure but are not associated with electrophysiological epileptic changes. They are caused by a psychopathological process and are primarily diagnosed on history and video-EEG. Clinical presentation comprises a wide range of symptoms and signs, which are individually neither totally specific nor sensitive, making positive diagnosis of PNES difficult. Consequently, PNES are often misdiagnosed as epilepsy. The aim of this study was to identify homogeneous groups of PNES based on specific combinations of clinical signs with a view to improving timely diagnosis. METHODS: The authors first retrospectively analysed 22 clinical signs of 145 PNES recorded by video-EEG in 52 patients and then conducted a multiple correspondence analysis and hierarchical cluster analysis. RESULTS: Five clusters of signs were identified and named according to their main clinical features: dystonic attack with primitive gestural activity (31.6%); pauci-kinetic attack with preserved responsiveness (23.4%); pseudosyncope (16.9%); hyperkinetic prolonged attack with hyperventilation and auras (11.7%); axial dystonic prolonged attack (16.4%). When several attacks were recorded in the same patient, they were automatically classified in the same subtype in 61.5% of patients. CONCLUSION: This study proposes an objective clinical classification of PNES based on automatic clustering of clinical signs observed on video-EEG. It also suggests that PNES are stereotyped in the same patient. Application of these findings could help provide an objective diagnosis of patients with PNES.

Effect of hyperventilation on seizure activation: potentiation by antiepileptic drug tapering.

OBJECTIVE: To determine prospectively the efficacy of hyperventilation (HV) to activate epileptic seizures and the contribution of antiepileptic drug tapering. METHODS: Eighty patients with proven epilepsy and referred for long-term video-EEG monitoring were consecutively enrolled from November 2007 to December 2008. A seizure was considered as 'activated' if it occurred during HV or within 5 min after completion. The rate of activated seizures (number of seizures/h) was compared with the rate of spontaneous seizure. The authors finally compared the effect of HV before and during antiepileptic drug (AED) tapering. RESULTS: The authors analysed 247 days of monitoring. Among 52 recorded seizures, 18 were activated by HV. The rate of activated seizure was nine times higher than the rate of control seizures (p=0.001). In the subgroup of patients with no AED tapering, there was no significant activating effect of HV on seizures. In the subgroup undergoing AED tapering, the effect of HV was not significant before (p=0.257) but very significant during AED tapering (p<0.004). DISCUSSION: The findings confirm that hyperventilation is efficient to activate epileptic seizures in epileptic patients referred for long-term video-EEG monitoring and that this activating effect is mainly related to the potentiating effect of AED tapering. Repeated HVs combined with AED tapering increase the rate of recorded seizures and the diagnostic yield of daytime video-EEG monitoring.

Stereoelectroencephalographic language mapping of the basal temporal cortex predicts postoperative naming outcome.

OBJECTIVE: In drug-resistant temporal lobe epilepsy (TLE) patients, the authors evaluated early and late outcomes for decline in visual object naming after dominant temporal lobe resection (TLR) according to the resection status of the basal temporal language area (BTLA) identified by cortical stimulation during stereoelectroencephalography (SEEG). METHODS: Twenty patients who underwent SEEG for drug-resistant TLE met the inclusion criteria. During language mapping, a site was considered positive when stimulation of two contiguous contacts elicited at least one naming impairment during two remote sessions. After TLR ipsilateral to their BTLA, patients were classified as BTLA+ when at least one positive language site was resected and as BTLA- when all positive language sites were preserved. Outcomes in naming and verbal fluency tests were assessed using pre- and postoperative (means of 7 and 25 months after surgery) scores at the group level and reliable change indices (RCIs) for clinically meaningful changes at the individual level. RESULTS: BTLA+ patients (n = 7) had significantly worse naming scores than BTLA- patients (n = 13) within 1 year after surgery but not at the long-term evaluation. No difference in verbal fluency tests was observed. When RCIs were used, 5 of 18 patients (28%) had naming decline within 1 year postoperatively (corresponding to 57% of BTLA+ and 9% of BTLA- patients). A significant correlation was found between BTLA resection and naming decline. CONCLUSIONS: BTLA resection is associated with a specific and early naming decline. Even if this decline is transient, naming scores in BTLA+ patients tend to remain lower compared to their baseline. SEEG mapping helps to predict postoperative language outcome after dominant TLR.

Anticipatory anxiety of epileptic seizures: An overlooked dimension linked to trauma history.

OBJECTIVE: Fear of having a seizure called anticipatory anxiety of epileptic seizure (AAS), constitutes a daily life burden but has been rarely studied. Our aim was to assess the prevalence and the determining factors of AAS in patients with drug-resistant focal epilepsy, a dimension that has not been thoroughly investigated before. METHODS: We conducted an observational, prospective study enrolling patients with drug-resistant focal epilepsy. The psychiatric assessment aimed to evaluate psychiatric comorbidities, trauma history, and quality of life using hetero-evaluation and self-assessment tools. Dimensions of anxiety specifically related to epilepsy (peri-and-inter-ictal) were explored as exhaustively as possible. RESULTS: AAS was found in 53 % of the 87 patients. We compared the two groups of patients: with or without AAS. Patients with AAS had a significantly shorter duration of epilepsy (p = 0.04). There was no difference between groups with respect to psychiatric disorders, except for cannabis dependence, more frequent in patients with AAS (p = 0.02). Compared to patients without AAS, those with AAS presented more subjective ictal anxiety (p = 0.0003) and postictal anxiety (p = 0.02), were more likely to avoid outdoor social situations due to seizure fear (p = 0.001), and had a poorer quality of life (QOLIE emotional well-being; p = 0.03). Additionally, they had experienced more traumatic events in their lifetime (p = 0.005) and reported more frequently a feeling of being unsafe during their seizures (p = 0.00002). SIGNIFICANCE: AAS is a specific dimension of anxiety, possibly linked to trauma history. AAS is strongly linked to subjective ictal anxiety but not to the objective severity of seizures or frequency.

Past Trauma Is Associated With a Higher Risk of Experiencing an Epileptic Seizure as Traumatic in Patients With Pharmacoresistant Focal Epilepsy.

Objective: The present study aimed to evaluate the prevalence of traumatic experienced seizures (TES) and of postepileptic seizure PTSD (PS-PTSD) in patients with pharmacoresistant focal epilepsy and to explore the determining factors of TES. Methods: We conducted an observational study enrolling 107 adult refractory epilepsy patients. We used the DSM-5 criteria of traumatic events and PTSD to define TES and PS-PTSD. We assessed all traumatic life events unrelated to epilepsy, general and specific psychiatric comorbidities, and quality of life. Results: Nearly half (n = 48) of the 107 participants reported at least one TES (44.85%). Among these, one-third (n = 16) developed PS-PTSD. The TES group was more likely to experience traumatic events unrelated to epilepsy (p < 0.001), to have generalized anxiety disorder (p = 0.019), and to have specific psychiatric comorbidities [e.g., interictal dysphoric disorder (p = 0.024) or anticipatory anxiety of seizures (p = 0.005)]. They reported a severe impact of epilepsy on their life (p = 0.01). The determining factors of TES according to the multifactorial model were the experience of trauma (p = 0.008), a history of at least one psychiatric disorder (p = 0.03), and a strong tendency toward dissociation (p = 0.03). Significance: Epileptic seizures may be a traumatic experience in some patients who suffer from pharmacoresistant epilepsy and may be the source of the development of PS-PTSD. Previous trauma unrelated to epilepsy and psychiatric history are determining factors of TES. These clinical entities should be explored systematically.

Source localization of ictal epileptic activity investigated by high resolution EEG and validated by SEEG.

High resolution electroencephalography (HR-EEG) combined with source localization methods has mainly been used to study interictal spikes and there have been few studies comparing source localization of scalp ictal patterns with depth EEG. To address this issue, 10 patients with four different scalp ictal patterns (ictal spikes, rhythmic activity, paroxysmal fast activity, obscured) were investigated by both HR-EEG and stereoelectroencephalography (SEEG). Sixty-four scalp-EEG sensors and a sampling rate of 1kHz were used to record scalp ictal patterns. Five different source models (moving dipole, rotating dipole, MUSIC, LORETA, and sLORETA) were used in order to perform source localization. Seven to 10 intracerebral electrodes were implanted during SEEG investigations. For each source model, the concordance between ictal source localization and epileptogenic zone defined by SEEG was assessed. Results were considered to agree if they localized in the same sublobar area as defined by a trained epileptologist. Across the study population, the best concordance between source localization methods and SEEG (9/10) was obtained with equivalent current dipole modeling. MUSIC and LORETA had a concordance of 7/10 whereas sLORETA had a concordance of only 5/10. Four of our patients classified into different groups (ictal spikes, paroxysmal fast activity, obscured) had complete concordance between source localization methods and SEEG. A high signal to noise ratio, a short time window of analysis (<1s) and bandpass filtering around the frequency of rhythmic activity allowed improvement of the source localization results. A high level of agreement between source localization methods and SEEG can be obtained for ictal spike patterns and for scalp-EEG paroxysmal fact activities whereas scalp rhythmic discharges can be accurately localized but originated from seizure propagation network.