Testing an Adapted Auditory Verbal Learning Test Paradigm for fMRI to Lateralize Verbal Memory in Patients with Epilepsy.

BACKGROUND AND PURPOSE: fMRI is a noninvasive tool for predicting postsurgical deficits in candidates with pharmacoresistant temporal lobe epilepsy. We aimed to test an adapted paradigm of the Rey Auditory Verbal Learning Test to evaluate differences in memory laterality indexes between patients and healthy controls and its association with neuropsychological scores. MATERIALS AND METHODS: We performed a prospective study of 50 patients with temporal lobe epilepsy and 22 healthy controls. Participants underwent a block design language and memory fMRI. Laterality indexes and the hippocampal anterior-posterior index were calculated. Language and memory lateralization was organized into typical and atypical on the basis of laterality indexes. A neuropsychological assessment was performed with a median time from fMRI of 8 months and was compared with fMRI performance. RESULTS: We studied 40 patients with left temporal lobe epilepsy and 10 with right temporal lobe epilepsy. Typical language occurred in 65.3% of patients and 90.9% of healthy controls (P = .04). The memory fMRI laterality index was obtained in all healthy controls and 92% of patients. The verbal memory laterality index was bilateral (24.3%) more frequently than the language laterality index (7.69%) in patients with left temporal lobe epilepsy. Atypical verbal memory was greater in patients with left temporal lobe epilepsy (56.8%) than in healthy controls (36.4%), and the proportion of bilateral laterality indexes (53.3%) was larger than right laterality indexes (46.7%). Atypical verbal memory might be associated with higher cognitive scores in patients. No relevant differences were seen in the hippocampal anterior-posterior index according to memory impairment. CONCLUSIONS: The adapted Rey Auditory Verbal Learning Test paradigm fMRI might support verbal memory lateralization. Temporal lobe epilepsy laterality influences hippocampal memory laterality indexes. Left temporal lobe epilepsy has shown a higher proportion of atypical verbal memory compared with language, potentially to memory functional reorganization.

Detection of epileptogenic focus with two new methods of processing of SPECT and PET cerebral images: PET-Analysis and PISCOM. / Detección del foco epileptógeno mediante dos nuevos métodos de procesamiento de imágenes SPECT y PET cerebral: PET-Analysis y PISCOM.

Functional neuroimaging with positron emission tomography with 18F-fluorodeoxyglucose (PET-18F-FDG) and perfusion single photon emission computerized tomography (SPECT) are increasingly more essential for presurgically locating the epileptogenic focus. We present the case of an 18-year-old male with epileptic seizures refractory to antiepileptic treatment. Magnetic resonance (MR) showed dysplasia in the posterior right insular cortex. Subtraction of ictal SPECT co-registered to MR (SICOM) detected a focal increase of uptake in the left fronto-parietal cingulate and PET-FDG showed normal distribution of the radiotracer. The posterior right insula was resected with histopathological results of grade I ganglioglioma according to the World Health Organization classification. The patient made favourable post-surgical progress, and remains seizure-free after 5 years (Engel I). Retrospective analysis of this case with two new image processing methods (PET analysis and PET interictal subtracted ictal SPECT coregistered with MR [PISCOM]) correctly localized the epileptogenic focus in the posterior right insular cortex.

[Patient safety in psychiatric hospitalization - What incidents are reported and managed?] / Qué se notifica y gestiona en seguridad del paciente en hospitalización psiquiátrica.

INTRODUCTION: Reporting and management systems monitoring patient safety incidents (PSIs) facilitate the understanding of mechanisms of action and allow work on improvement activities to minimise their occurrence. In our country, little is known about the adverse effects of healthcare during psychiatric hospitalisation (PH). The aim of this study is to determine the occurrence and characteristics of the PSIs, as well as the improvement actions resulting from them, in the PH services being offered at the Parc Sanitari Sant Joan de Deu (an institution specialized in mental healthcare). MATERIAL AND METHOD: An observational, descriptive, and cross-sectional study was conducted, covering the period 2013-2016. Analysis was made of the PSIs reported in the following areas of PH: acute and sub-acute (ASA), and medium and long-term stay (MLS). The following variables were identified: number, type and level of harm resulting from the PSIs, professional category of the person declaring the PSI, method of analysis used to investigate the PSI, and improvement actions generated by those PSIs that required either root-cause analysis or audit reports. The chi-squared test was used for statistical purposes when comparing percentages. RESULTS: A total of 2,940 PSIs were reported. The frequency in ASA was significantly higher (7.1 per 1,000 stays) than in MLS (5.3). Almost all (97.6%) of the incidents were related to falls, aggressive and/or disturbed behaviour, mind-altering drugs, self-harm, medication, dangerous objects, and patients escaping. PSIs recording moderate or severe harm were similar in the 2 different areas (16.5% in ASA vs. 14.2% in MLS). A small percentage (1.02%) of the PSIs resulted in root cause analysis or audit reporting, due to their severity, and from those incidents, 56 improvement actions were generated. CONCLUSIONS: PH demonstrates its own characteristics with regard to the type of PSIs and differs from general hospitalisation. Reporting of PSIs is higher in ASA than in MLS, although the level of harm experienced by the patients is similar. There is a clear understanding of reporting in PH, demonstrated by the steady increase in the numbers declared and also highlights the high level of awareness of the nursing staff.

Retrospective study of perampanel efficacy and tolerability in myoclonic seizures.

OBJECTIVES: Perampanel is an antiepileptic drug (AED) approved for add-on treatment of focal seizures (with or without generalization) and primary generalized tonic-clonic (GTC) seizures. Our objective was to explore the effectiveness and tolerability of adjunctive perampanel in patients with drug-resistant myoclonic seizures, after failure of other AEDs. MATERIALS AND METHODS: Retrospective, multicenter, observational study. Data were collected from individual patient clinical files and analysed using appropriate descriptive statistics and inferential analyses. RESULTS: Data are reported for 31 patients with mean age 36.4 years, who had an average epilepsy duration of 18 years, previously taken an average of 5.03 AEDs, and were taking an average of 2.4 AEDs on perampanel initiation. Patients exhibited myoclonic, GTC, absence, tonic and focal seizures, and most had associated cognitive decline and/or ataxia. Median time on perampanel was 6 months, most common dose was 6 mg, and overall retention rate was 84%. The responder rate for myoclonic seizures was defined via reduction of days with myoclonic seizures per month. At 6 months, 15 (48.4%) of the 31 patients were classed as myoclonic seizure responders, 10 (32.3%) were myoclonic seizure free, and 39% saw improvements in functional ability. Of 17 patients with GTC seizures at baseline, 9 (53%) were responders at 6 months, and 8 (47.1%) were seizure free. The most frequent side effects were psychiatric disorders, instability, dizziness and irritability, and mostly resolved with dose reduction. Five patients discontinued perampanel due to side effects. CONCLUSIONS: Perampanel caused clinically meaningful improvements in patients with drug-resistant myoclonic seizures. It was generally well tolerated, but psychiatric and neurological side effects sometimes required follow-up and dose reduction.

Outcome of treatment changes in patients with drug-resistant chronic epilepsy: A tertiary center experience.

BACKGROUND: Previous studies suggest that changing patients' anti-epileptic drug regimen can reduce the frequency of seizures. The approval of new anti-epileptic drugs with different modes of action during the last decades has provided multiple options for the treatment of epilepsy, although the efficacy of these new drugs is controversial. We aimed to determine the effects of adding or changing to a previously untried anti-epileptic drug, including recently approved drugs, on the frequency of seizures in patients with drug-resistant epilepsy. METHODS: We analyzed treatment changes in drug-resistant patients at our outpatient clinic between 2010 and 2015. We classified patients' frequency of seizures after changes as freedom from seizures, ≥50% reduction, <50% reduction, no change, increase in seizures <50% or increase in seizures ≥50%. RESULTS: We analyzed 189 drug changes in 144 consecutive drug-resistant patients followed up for at least 6 months after the change; 138 changes involved administering newly marketed drugs: lacosamide (n=65), perampanel (n=30), eslicarbazepine (n=29), and retigabine (n=14). Changes resulted in freedom from seizures in 20 (13.9%) patients and in ≥50% decrease in frequency in 55 (38.2%). The drugs most commonly associated with significant improvement (freedom from seizures or ≥50% reduction) were lacosamide (39.3%), clobazam (11.2%), and levetiracetam (11.2%). CONCLUSIONS: In patients with drug-resistant epilepsy, sequential changes increase the possibility of seizure control, and newer anti-epileptic drugs offer additional options for effective changes. Best combinations must be chosen taking into account drug, epilepsy and patient features.

[Results of vagal nerve stimulation in patients with pharmacoresistant epilepsy in a national epilepsy referral centre]. / Resultados de la estimulacion del nervio vago en pacientes con epilepsia farmacorresistente en un centro de referencia nacional de epilepsia.

AIM: To describe clinical results and complications derived from vagal nerve stimulation therapy in drug resistant epileptic patients unsuitable for other surgical treatments, since the first implant in an epilepsy national referral centre. PATIENTS AND METHODS: A retrospective analysis of the patients implanted in our centre was held. Data related to baseline characteristics of their epilepsy and therapy complications was collected. RESULTS: 32 new implants in 31 patients are included, mean age of 34 years, 29.3 years of disease evolution, three anti-epileptic drugs at surgery and a postoperative follow-up of 4.03 years. Complex partial seizures types (71.9%) and cryptogenic aetiology (59.4%) were the most frequent. 75% of patients hadn't history of previous epilepsy surgery. 43.8% of patients had a seizure frequency improvement above 50%, with a better response in patients with complex partial seizures (p = 0.22) and cryptogenic aetiology. None statistical significance was found between antiepileptic drugs and seizure frequency. Dysphonia, hoarseness and dysphagia, mostly transient, were the side effects registered. There was an asystole during surgery, completely recovered. One device was replaced due to hardware rupture after a seizure related trauma, one had to be adjusted due to a previous vocal cord paresis, and one dysfunctioning device was removed. In 84.4% the tolerance was excellent. CONCLUSIONS: Vagal nerve stimulation is an effective treatment for significant seizure frequency improvement of resistant patients untreatable with other medical or surgical treatments. Further studies are needed to predict the individual response of each patient to therapy and optimizing indications, therefore contributing to cost/benefit optimization.

TITLE: Resultados de la estimulacion del nervio vago en pacientes con epilepsia farmacorresistente en un centro de referencia nacional de epilepsia.Objetivos. Describir los resultados clinicos y complicaciones derivados de la estimulacion vagal en pacientes con epilepsia farmacorresistente no tributaria de otras modalidades de tratamiento quirurgico, desde el primer implante en un centro de referencia nacional. Pacientes y metodos. Se realizo un analisis retrospectivo de los pacientes implantados en nuestro centro y se extrajeron datos relativos a las caracteristicas basales de su epilepsia y complicaciones derivadas. Resultados. Se incluyeron 32 nuevos implantes en 31 pacientes, con una edad media de 34 años, evolucion de enfermedad de 29,3 años, tres farmacos antiepilepticos prequirurgicos y 4,03 años de seguimiento. Las crisis parciales complejas (71,9%) y criptogenicas (59,4%) fueron el tipo y la etiologia de crisis mas frecuentes. El 75% no tenia antecedentes quirurgicos de epilepsia. Un 43,8% presento mejoria igual o superior al 50%, mayor en las epilepsias parciales complejas (p = 0,22) y la etiologia criptogenica. No se hallo asociacion estadistica entre ajustes de medicacion y frecuencia de las crisis. Los efectos secundarios encontrados fueron disfonia, ronquera y disfagia transitorias, y una asistolia intraoperatoria recuperada. Se realizo un recambio por ruptura de hardware postraumatica. Un paciente con paresia preexistente de cuerda vocal presento estridor laringeo que requirio ajuste de intensidad, y se produjo una retirada del sistema por disfuncion. En el 84,4%, la tolerancia fue excelente. Conclusiones. Constituye un tratamiento efectivo para mejorar significativamente la frecuencia de crisis de los pacientes farmacorresistentes y con contraindicacion para otras modalidades de tratamiento quirurgico. Se precisan futuros estudios para predecir la respuesta individual de cada paciente, optimizar las indicaciones y mejorar la relacion coste/beneficio.

Accuracy of arterial spin labeling magnetic resonance imaging (MRI) perfusion in detecting the epileptogenic zone in patients with drug-resistant neocortical epilepsy: comparison with electrophysiological data, structural MRI, SISCOM and FDG-PET.

BACKGROUND AND PURPOSE: Locating the epileptogenic zone (EZ) in patients with neocortical epilepsy presents major challenges. Our aim was to assess the accuracy of arterial spin labeling (ASL), an emerging non-invasive magnetic resonance imaging (MRI) perfusion technique, to locate the EZ in patients with drug-resistant neocortical epilepsy. METHODS: Twenty-five consecutive patients with neocortical epilepsy referred to our epilepsy unit for pre-surgical evaluation underwent a standardized assessment including video-electroencephalography (EEG) monitoring, structural MRI, subtraction ictal single-photon emission computed tomography co-registered to MRI (SISCOM) and fluorodeoxyglucose positron emission tomography (FDG-PET) studies. An ASL sequence was included in the MRI studies. Areas of hypoperfusion or hyperperfusion on ASL were classified into 15 anatomic-functional cortical regions; these regional cerebral blood flow maps were compared with the EZ determined by the other tests and the strength of concordance was assessed with the kappa coefficient. RESULTS: Of the 25 patients [16 (64%) women; mean age 32.4 (±13.8) years], 18 (72%) had lesions on structural MRI. ASL abnormalities were seen in 15 (60%) patients (nine hypoperfusion, six hyperperfusion). ASL had a very good concordance with FDG-PET (k = 0.84), a good concordance with structural MRI (k = 0.76), a moderate concordance with video-EEG monitoring (k = 0.53) and a fair concordance with SISCOM (k = 0.28). CONCLUSION: Arterial spin labeling might help to confirm the location and extent of the EZ in the pre-surgical workup of patients with drug-resistant neocortical epilepsy.

PET/MRI and PET/MRI/SISCOM coregistration in the presurgical evaluation of refractory focal epilepsy.

We aimed to investigate the usefulness of coregistration of positron emission tomography (PET) and magnetic resonance imaging (MRI) findings (PET/MRI) and of coregistration of PET/MRI with subtraction ictal single-photon emission computed tomography (SPECT) coregistered to MRI (SISCOM) (PET/MRI/SISCOM) in localizing the potential epileptogenic zone in patients with drug-resistant epilepsy. We prospectively included 35 consecutive patients with refractory focal epilepsy whose presurgical evaluation included a PET study. Separately acquired PET and structural MRI images were coregistered for each patient. When possible, ictal SPECT and SISCOM were obtained and coregistered with PET/MRI. The potential location of the epileptogenic zone determined by neuroimaging was compared with the seizure onset zone determined by long-term video-EEG monitoring and with invasive EEG studies in patients who were implanted. Structural MRI showed no lesions in 15 patients. In these patients, PET/MRI coregistration showed a hypometabolic area in 12 (80%) patients that was concordant with seizure onset zone on EEG in 9. In 7 patients without MRI lesions, PET/MRI detected a hypometabolism that was undetected on PET alone. SISCOM, obtained in 25 patients, showed an area of hyperperfusion concordant with the seizure onset zone on EEG in 7 (58%) of the 12 of these patients who had normal MRI findings. SISCOM hyperperfusion was less extensive than PET hypometabolism. A total of 19 patients underwent surgery; 11 of these underwent invasive-EEG monitoring and the seizure onset zone was concordant with PET/MRI in all cases. PET/MRI/SISCOM coregistration, performed in 4 of these patients, was concordant in 3 (75%). After epilepsy surgery, 13 (68%) patients are seizure-free after a mean follow-up of 4.5 years. PET/MRI and PET/MRI/SISCOM coregistration are useful for determining the potential epileptogenic zone and thus for planning invasive EEG studies and surgery more precisely, especially in patients without lesions on MRI.

Successful outcome of episodes of status epilepticus after vagus nerve stimulation: a multicenter study.

BACKGROUND AND PURPOSE: Vagus nerve stimulation (VNS) has been reported to be a safe and effective treatment for drug-resistant epilepsy. The aim of this study is to describe the effect of VNS in patients with a history of repeated episodes of status epilepticus (SE) before implantation. METHODS: From a total of 83 adult patients with drug-resistant epilepsy who had VNS implanted in four tertiary centers in Spain between 2000 and 2010, eight had a previous history of repeated episodes of SE. We performed a retrospective observational study analyzing the outcome of seizures and episodes of SE after implantation. Stimulation was started at the usual settings, and intensity increased according to clinical response and tolerability. RESULTS: Regarding the eight patients with a history of SE, the mean age at time of VNS implantation was 25.1 [14-40] years. Duration of epilepsy until the implantation was 21.7 [7-39.5] years, and they had been treated with a mean of 12 antiepileptic drugs [10-16]. Mean follow-up since implantation was 4.15 [2-7.5] years. Average seizure frequency decreased from 46 to 8.2 per month. Interestingly, four of the eight patients remained free of new episodes of SE after implantation, and in two additional patients, the frequency decreased by >75%. Adverse effects were mild or moderate in intensity and included mainly coughing and dysphonia. CONCLUSION: In those patients with refractory epilepsy and history of SE who are not surgical candidates, VNS is a safe and effective method to reduce seizure frequency and episodes of SE.

[Predictive variables for mental retardation in a Pediatric Epilepsy Monitoring Unit. Neuropsychological assessment]. / Variables predictoras de retraso mental en una unidad de monitorización videoelectroencefalográfica pediátrica. Evaluación neuropsicológica.

AIM: We sought to describe the epidemiological and clinical data from our patients in the Pediatric Epilepsy Monitoring Unit (PEMU) of the Sant Joan de Deu Hospital of Barcelona, and determine the variables of risk for mental retardation. PATIENTS AND METHODS: A retrospective review of PEMU reports and hospital discharge summaries from March 2005 to December 2008 was conducted. The data from patients with intelligence quotient (IQ) estimated, older than 3 years of age and with epileptic electroencephalography (EEG) activity was analyzed in 158 patients (8.8 +/- 5.2 years; 55.1% boys). Of those pediatric patients, 63 had IQ less than 70 and 47 an IQ greater than or equal to 70. Intractable epilepsy was present in all of them. RESULTS: The percentage of the patients with mental retardation is significantly higher in patients with onset of epilepsy before 24 months (68.3%) than patients with later onset (27.7%). Onset of seizures, EEG findings and epilepsy etiology are significant risk factors for mental retardation. CONCLUSIONS: Early age at seizure, multifocal epilepsy and cryptogenic etiology are factors of worse prognosis to normal development of cognitive functions in pediatric intractable epilepsy.

Fístula peritoneocutánea por cálculos biliares: una complicación tardía de la colecistectomía laparoscópica / Peritoneocutaneous fistula caused by abandoned biliary stones during laparoscopic cholecystectomy

Gallbladder perforation may occur during laparoscopic cholecystectomy. The leakage of bile and stones to the peritoneal cavity is less common and the real incidence of abandoned stones is hard to ascertain. The possible complications of these abandoned stones are not well known. We report five patients (four females) aged 49 to 78 years, with a peritoneo-cutaneous fistula caused by biliary stones abandoned in the peritoneal cavity during laparoscopic cholecystectomy performed between 1.5 and 10 years before. We conclude that abandoned stones in the peritoneal cavity can be associated to important complications and those that leak to the peritoneal cavity during laparoscopic cholecystectomy, should be removed during the surgical procedure and the gallbladder should be excised in a bag. The conversion to open surgery for an exhaustive peritoneal lavage is apparently not indicated.

La perforación de la vesícula biliar ocurre con alguna frecuencia durante la colecistectomía laparoscópica (CL). El derrame de bilis y cálculos en la cavidad peritoneal es menos frecuente y la verdadera incidencia de cálculos abandonados en ésta cavidad es difícil de determinar. Éstos no son considerados un peligro; sin embargo, la exacta biología natural de estos cálculos extraviados no está bien dilucidada y parece ser que no son tan inocuos como se creía, ya que con frecuencia se están reportando variadas complicaciones tardías de esta condición. Presentamos 5 pacientes atendidos en nuestro servicio por fístula peritoneocutánea secundaria a litiasis biliar abandonada en la cavidad abdominal durante la CL practicada entre 1,5 y 10 años atrás. Concluimos que, si bien es cierto que las complicaciones secundarias a cálculos biliares abandonados en la cavidad peritoneal son poco frecuentes (0,08 -0,3 por ciento), cuando ocurren se traducen en alta morbilidad, por lo que debe evitarse esta condición retirando todos los cálculos derramados al ocurrir una rotura vesicular, e idealmente exteriorizarla en una bolsa. La conversión a cirugía abierta para aseo peritoneal exhaustivo pareciera no estar indicada, pero si la necesidad de entregar clara información al paciente acerca de las potenciales complicaciones tardías que la situación puede conllevar, evitando así problemas médico legales futuros.

[Successful functional hemispherectomy in adult patients with refractory epilepsy]. / La hemisferectomía funcional también es eficaz en pacientes adultos con epilepsia catastrófica.

INTRODUCTION: Functional hemispherectomy is a surgical technique used to treat refractory epilepsies in the setting of extensive unilateral hemispheric lesions. Most series of hemispherectomies include mainly pediatric patients. METHODS: We report our series of four adult patients that have undergone functional hemispherectomy for their refractory epilepsy. Each one had a complete presurgical evaluation including video EEG, neuropsychological testing and anatomical and functional neuroimaging. In three of them, the epilepsy was secondary to a middle cerebral artery infarction. One patient had Rasmussen encephalitis. RESULTS: After surgery, three patents have become completely seizure free (follow up 13-26 months). The fourth patient has had more than 75% reduction in seizure frequency. All of them have had significant improvement in their quality of life. Early complications included an isolated tonic-clonic generalized seizure (one patient), and status epilepticus in another patients related to infection and use of meropenem. Only one patient has presented hemianopia as a permanent neurological deficit after surgery. CONCLUSIONS: Functional hemispherectomy is a good surgical option in the setting of large unilateral hemispheric lesions causing hemiparesis and intractable seizures, even in adult patients.

[Non-convulsive status with hemianopsia and ictal headaches: an uncommon manifestation of parieto-occipital epilepsy]. / Estatus no convulsivo con hemianopsia y cefalea ictales: una manifestación poco habitual de epilepsia parieto-occipital.

INTRODUCTION: Parieto-occipital epilepsy is uncommon disease that usually occurs with positive symptoms such as illusions, visual hallucinations. The pericital headache, with or without migraine-type characteristics, is common symptoms (amaurosis, hemianopsia) are rare. CLINICAL CASE: A 21 year-old woman with a previous medical history of Rendu-Osler disease was admitted to the hospital because of migraine-type headache. Examination revealed homonymous hemianopsia which had not been previously observed. During admission, brief episodes of ocular and cephalic deviation to the left were observed. An electroecephalogram showed frequent seizures arising from the right parieto-occipital region. Symptoms disappeared with antiepileptic drug treatment. CONCLUSION: We report a case of parieto-occipital epilepsy with headache and hemianopsia as ictal symptoms. Differential diagnosis must be done basically with migraine attacks. This type of epilepsy may be underdiagnosed.

Parry Romberg syndrome and linear scleroderma in coup de sabre mimicking Rasmussen encephalitis.

We present one patient with Parry Romberg syndrome and another with linear scleroderma in coup de sabre, with focal neurologic deficits and intractable seizures arising from the hemisphere ipsilateral to the cutaneous lesion. Brain MRI showed progressive hemispheric atrophy. Pathology after functional hemispherectomy showed chronic inflammatory features suggestive of Rasmussen encephalitis.

[The utility of interictal SPECT in temporal lobe epilepsy]. / ¿Es útil la SPECT interictal en la epilepsia del lóbulo temporal?

INTRODUCTION: Interictal brain single photon emission computed tomography (SPECT) is used in the presurgical evaluation of patients with complex partial epilepsy. The aim of the present study was to compare interictal SPECT, MRI and video-electroencephalography (EEG) for seizure focus localization in patients with temporal lobe epilepsy, one year after temporal lobectomy, in order to determine the utility of interictal brain SPECT. PATIENTS AND METHODS: Thirty four consecutive patients with refractory temporal epilepsy were evaluated with video-EEG, MRI and interictal SPECT for seizure focus localization before surgery. Seizure focus was confirmed with the clinical follow-up one year after temporal lobectomy in all patients. MRI and SPECT analysis was performed visually. RESULTS: 31/34 patients were seizure free one year after surgery and the remaining 3 patients remain with seizures occasionally. Video-EEG results coincided with postsurgical seizure focus localization in 31 (91%) patients. MRI localized seizure focus correctly in 30 (88%) patients and was normal in 3 cases. Interictal brain SPECT was normal in 10 patients and showed temporal hypoperfusion consistent with postsurgical seizure focus in 23 (68%) patients. In all patients with abnormalities in the interictal SPECT, seizure focus was identified with video-EEG or MRI. CONCLUSIONS: When MRI and video-EEG localize seizure focus in the same temporal lobe, interictal brain SPECT does not offer any additional information for surgical decision making.

Cortical laminar necrosis related to prolonged focal status epilepticus.

Cortical laminar necrosis (CLN) is radiologically defined as high intensity cortical lesions on T1 weighted MRI images following a gyral distribution. Histopathologically, CLN is characterised by pannecrosis of the cortex involving neurones, glial cells, and blood vessels. It has been reported to be associated with hypoxia, metabolic disturbances, drugs, and infections. We present two patients who developed CLN and permanent neurological deficits after prolonged and repeated focal status epilepticus. The possible mechanisms leading to CLN in these patients are discussed, together with the implications of prompt and aggressive treatment in similar cases.

Complex motor behaviors in temporal lobe epilepsy.

Complex motor behaviors differing from typical automatisms were found in 12 of 502 patients with temporal lobe epilepsy. Movements involved proximal limb segments (6) or body axis (6) and were often preceded by auras and followed by automatisms. Seven of 12 patients are seizure free after surgery. The other 5 patients declined surgery.

[Topographic disorientation associated with infarction in the territory of the right posterior cerebral artery]. / Desorientación topográfica asociada al infarto en el territorio de la arteria cerebral posterior derecha.

INTRODUCTION: Topographic disorientation is defined as the difficulty to find one s way in familiar surroundings. It can be due to an amnesic or agnostic like defect, which is known as topographic amnesia or agnosia. This disorder can give rise to disability in the life of the patient and may well go undetected unless a suitable neuropsychological study is conducted. CASE REPORTS: We report the cases of two patients with infarction in the territory of the right posterior cerebral artery who began with hemianopsia and topographic disorientation. One of the cases was due to a disorder affecting spatial memory and the other was caused by errors in visuospatial perception. The battery of tests for studying visuospatial perception VOSP was administered. CONCLUSIONS: Occipital lesions are often associated with topographic disorientation, especially when it is the right hemisphere that is injured. It is important to detect this alteration, which makes the patient totally dependent on others even in his or her own home. The appearance of an amnesic or agnostic type disorientation can be related with a disorder affecting one of the two systems that play a part in the processing of visual data. A guided neuropsychological study can provide us with a great deal of information about the type of disorder presented by the patient.

Paramagnetism-based versus classical constraints: an analysis of the solution structure of Ca Ln calbindin D9k.

The relative importance of paramagnetism-based constraints (i.e. pseudocontact shifts, residual dipolar couplings and nuclear relaxation enhancements) with respect to classical constraints in solution structure determinations of paramagnetic metalloproteins has been addressed. The protein selected for the study is a calcium binding protein, calbindin D9k, in which one of the two calcium ions is substituted with cerium(III). From 1823 NOEs, 191 dihedral angles, 15 hydrogen bonds, 769 pseudocontact shifts, 64 orientational constraints, 26 longitudinal relaxation rates, plus 969 pseudocontact shifts from other lanthanides, a final family with backbone r.m.s.d. from the average of 0.25 A was obtained. Then, several families of structures were generated either by removing subsets of paramagnetism-based constraints or by removing increasing numbers of NOEs. The results show the relative importance of the various paramagnetism-based constraints and their good complementarity with the diamagnetic ones. Although a resolved structure cannot be obtained with paramagnetism-based constraints only, it is shown that a reasonably well resolved backbone fold can be safely obtained by retaining as few as 29 randomly chosen long-range NOEs using the standard version of the program PSEUDYANA.

[Progressive primary aphasia associated with corticobasal degeneration]. / Afasia primaria progresiva asociada a degeneración corticobasal.

INTRODUCTION: Progressive primary aphasia generally progresses to global cognitive deterioration of Alzheimer type, although occasionally it remains unchanged. The neuropathological findings are varied: Alzheimer, spongiform etc. The case we describe followed a very unusual course. Initially there was a clinical picture of progressive primary aphasia with which that of corticobasal degeneration was later associated. CASE REPORT: The patient, who had no relevant previous clinical history apart from chronic obstructive pulmonary disease presented with gradually deteriorating oral expression, with no loss of memory and maintenance of autonomy in everyday activities. This condition was later associated with slowing of voluntary movements, hypertonia of the right limbs, difficulty in manipulation with the right hand and myoclonic jerks. Neuro imaging on cranial CT showed global cerebral atrophy, most marked on the right and cerebral SPECT showed reduced fronto temporal uptake. No other significant alterations were found in the investigations done. On neuropsychological examination there was alteration of language in the form of mutism and reduction in denomination, repetition, fluency and comprehension (except for simple orders). However, copies of drawings were done correctly with absence of apraxia of ideas or ideomotor initiation. Handwriting was also normal. CONCLUSION: . The unusual aspect of our case was the simultaneous presentation of an aphasic disorder and corticobasal degeneration.