Outcomes of Bilateral Lateral Rectus Tucking in Patients with Divergence Insufficiency

Purpose@#Divergence insufficiency is characterized by esotropia at far distance with symptomatic diplopia, minimal or no deviation at near distance, and full ocular duction and version. We analyzed the results of bilateral lateral rectus (BLR) tucking in patients with divergence insufficiency. @*Methods@#Surgery was performed on patients with persistent distance diplopia with esotropia for at least 6 months after diplopia onset. The surgical results were evaluated after BLR tucking based on the maximum angle of deviation at distance among all the angles of deviation measured repeatedly, including the results of the prism adaptation test (PAT). @*Results@#24 patients were included. The average follow-up period was 14 months (1-48 months). The maximum deviations measured by alternate prism and cover test before surgery were 24.79 ± 8.15 prism diopter (PD) at far distance and 15.45 ± 9.30 PD at near distance. The PAT revealed that, the far distance deviation increased to 28.50 ± 7.77 PD and that at near distance to 25.88 ± 8.07 PD, but the difference between the two values fell to less than 3 PD on average. In 14 patients (58%), followed-up for up to 1 year, we noted no recurrence of diplopia or esotropia, or near distance overcorrection, with the exception of one patient who developed diplopia recurrence at far distance. @*Conclusions@#BLR tucking guided by the maximum distance deviation of the 1 hour PAT affords stable results in patients with divergence insufficiency without overcorrection at near distance or undercorrection at far distance.

Neurologists' Awareness and Preparedness on Prion Diseases in Korea

BACKGROUND: Creutzfeldt-Jakob disease (CJD) is very rare human prion disease. But, neurologists take a key role in diagnosis, surveillance and management of the cases because of its complexity and difficulty in diagnosis of the disease. The aim of this study is to investigate the level of awareness and preparedness of Korean neurologists on this rare disease. METHODS: Survey sheets of self-administered questionnaire were given to Korean neurologists who participated in the 31st Annual Meeting of the Koran Neurological Association. Data from 133 respondents were conducted by descriptive analysis. RESULTS: Their answers were as follows: About 62% of neurologists have experienced patients of CJD. Forty-four percent of the patients were confirmed by brain biopsy. Most of neurologists (44%) were not confident to diagnose CJD and the reason why they felt hard to diagnose was due to the variable initial clinical manifestations (45.1%) and the lack of clinical experience (51.9%). Heidenheim variant CJD, proteinase sensitive prionopathy, molecular subtypes of sporadic CJD, diagnostic criteria was not familiar term to Korean neurologists (76.7%, 53.4%, 58.6%, and 62.4% respectively). Opinion for the most useful diagnostic tool was brain MRI (45.1%), CSF 14-3-3 protein (30.1%), typical EEG finding (36.8%) and gene (PRNP) test (42.9%). And they consider none of them are specific for the diagnosis of CJD (89.5%, 73.7%, 83.5%, 91.7%, respectively). Most of the neurologist in this survey answered that the opportunity for education of CJD should be increased (67.7%). CONCLUSIONS: Most of neurologists have encountered CJD patients although it is very rare disease. Some of the important and fundamental concepts of CJD were not correctly recognized to Korean neurologists, necessitating a persistent support for updating knowledge and information.

Three Cases of Moraxella osloensis Meningitis: A Difficult Experience in Species Identification and Determination of Clinical Significance

We had three cases of Moraxella osloensis meningitis. The species identification was impossible by conventional and commercial phenotypic tests. However, we could identify the species using the 16S rRNA gene sequencing. Determination of clinical significance was difficult in one patient. All three patients recovered by appropriate antimicrobial therapy.

Clinical Characteristics of Bleeding Peptic Ulcer in Elderly Patients: Experience at a Single Secondary Referral Center / 대한소화기내시경학회지

BACKGROUND/AIMS: Bleeding peptic ulcer in elderly patients is believed to differ from that found in younger patients. The purpose of this study was to evaluate the characteristics of bleeding peptic ulcer in elderly Korean patients. METHODS: We retrospectively evaluated 113 patients who were admitted to an emergency room for peptic ulcer bleeding from January 2006 to August 2008. For each patient, we investigated the clinical manifestations, the treatments and the hospital course. RESULTS: Peptic ulcer bleeding was more prevalent in elderly patients (n=63) than in younger patients (n=50). The elderly group had a higher incidence of comorbidities such as hypertension, stroke and ischemic heart disease, which might have be attributable to higher usage of aspirin and antiplatelet agents. There were no differences in the chief complaints or laboratory findings. The rate of Helicobacter pylori infection was lower in the elderly patients than that in the younger patients (41.3% vs. 62.0%, respectively, p=0.029). Four elderly patients and one younger patient died while in hospital, with one patient in each group dying due to bleeding. CONCLUSIONS: Peptic ulcer bleeding in elderly patients was associated with higher usage of aspirin and antiplatelet agents. There were no significant differences between the elderly and younger patients for the initial clinical presentation, the hospital course or the mortality due to bleeding.

Cryptococcal Meningitis Presenting with Isolated Sixth Cranial Nerve Palsy in a Patient with Systemic Lupus Erythematosus

Cryptococcal meningitis is a rare complication of systemic lupus erythematosus (SLE). The nonspecific neurologic findings associated with this infection delays accurate diagnosis because initial neuropsychiatric manifestations of SLE are in instances indistinguishable from that of crytococcal meningitis. We report a case of cryptococcal meningitis presenting with unilateral sixth cranial nerve palsy in a male patient with SLE, which was successfully treated with antifungal agents.

Epidemiological Analysis and Study of Social Welfare of Low Vision Patients

PURPOSE: To analysis the epidemiology, distribution of age, and social welfare statue of low vision patients. METHODS: A retrospective analysis of age, visual acuity, underlying ocular disease, and optical aids of 102 patients who visited our clinic from March 2004 to March 2006. We had an interview with patients about their educational background, jobs and registration of legal blindness. RESULTS: The mean age was 40.87+/-22.72 years old and the patients in their forties were most common. The most frequent cause of low vision included optic atrophy (16.7%), macular degeneration (15.7%), retinitis pigmentosa (11.8%), congenital cataract (10.8%), glaucoma (6.9%), amblyopia (6.9%). 42 patients had already got the registration for legal blindness but, 41 patients were newly registered during this study. Under 20 years old, there were 17 general school students, 4 special school students, and 1 preschool child. Over 20 years old, there were only 14 patients who got regular job and all patients have educational attainment under high school graduate except 10 patients. CONCLUSIONS: The epidemiology of low vision has been changed to the aging society. And the registration of legal blindness criteria and understanding of low vision need to be changed. Moreover, understanding how low vision impacts lives is important to be able to provide better social services in the future.

Adjustable Strabismus Surgery under Intravenous Anesthesia with Propofol and Fentanyl

PURPOSE: To evaluate the clinical usefulness of intravenous propofol and fentanyl anesthesia during adjustable strabismus surgery, to investigate the effectiveness and safety of adjustable strabismus surgery, and assess the degree of patient satisfaction. METHODS: Patients over 15 years of age who underwent strabismus surgery using propofol and fentanyl sedation from January 2003 to December 2004 were included in this study. At the beginning of the operation, the patients received an intravenous bolus of fentanyl 1 to 1.5 mg/kg. Propofol was injected into a vein continuously during the operation to keep the blood concentration within 1.2-1.5 ug/mL. Intraoperative adjustment was then made. We evaluated, via questionnaire, patient satisfaction with the operation and the adjustment. RESULTS: In all 44 patients, the adjustment was completed successfully. The rate of intraoperative side effects was low (11.4%). The satisfaction degree regarding the anesthesia was very high (95.5%), and the success rate at the three-month postoperative visit was 88.6%. CONCLUSIONS: Intravenous anesthesia using propofol combined with fentanyl provides a sufficient level of sedation and rapid awakening that enables a surgeon to perform adjustable strabismus surgery conveniently. It also allows the patient to feel comfortable and safe throughout the surgery.

Comparison of IOL Formulas in Pediatric Intraocular Lens Implantation

PURPOSE: To evaluate the refractive outcomes using 5 different IOL power calculation formulas (SRK II, Holladay I, Hoffer Q, SRK T, Binkhorst II) in pediatric cataract patients. METHODS: A retrospective analysis of biometric and refractive data was performed on 63 eyes of 44 pediatric patients, who successfully underwent primary and secondary IOL implantation. For analysis, the eyes were divided into three groups: those with axial length or =22 mm but or =24.5 (group L). And also divided into another three groups: those with mean keratomery value or =42.5D but or =44.5D (group III). The postoperative refractive outcome was taken as a spherical equivalent of the refraction at 1 week and 2 to 3 months after surgery. The 'predictive error' was defined as absolute error between the target and actual postoperative refraction. RESULTS: SRK II had a best predictive error but there was no statically significant in short eye group and medium eye group at 1 week and 2 to 3 months after the surgery. And SRK II also had a best predictive error but there was no statically significant in group I, II, and III at 1 week and 2 to 3 months. CONCLUSIONS: In our study, theoretical formulas did not outperform the regression formula in pediatric IOL implantation. This may be related to the variability of the relationship between axial length and corneal curvature in pediatric eyes and to dependent variables inherited in the formulas.

Stereoacuity of Normal Subjects Assessed by Frisby Davis Distance Stereotest

PURPOSE: The Frisby Davis Distance (FD2) Stereotest has been introduced to measure distance stereoacuity. The purpose of this study is to establish the range of normal distance stereoacuity responses on the FD2 Stereotest in a normal population. METHODS: This study comprised 65 subjects. All had best corrected vision of 20/25 or better in each eye at distance, 1.0 diopters or less of anisometropia, 8 prism diopters or less of phoria on alternate cover test at both distance and near, binocular fusion on the Worth four dot test and stereopsis on Titmus test. Distance stereoacuity was measured using the FD2 stereotest. RESULTS: The mean age of the subjects was 18.6 years (range, 3 to 59). The mean stereoacuity for distance was 15.61+/-10.41 sec (seconds of arc), and the mean stereoaucity of the subject over 10 years old was 12.98+/-6.86 sec. Results of the test-retest variability as well as of different test distances revealed no statistically significant differences. Of 60 subject with one eye closed, 11 (18.3%) of them detected the disparity of 200 sec but none could detect smaller disparity except one. CONCLUSIONS: The FD2 Stereotest is reliable test without test distance variance. The results of this study can be used as a normative data of distance stereoacuity by FD2.

A Study of Patients with Spasm of the Near Reflex

PURPOSE: To determine changes in the degree of pseudomyopia and convergence in patients with spasm of the near reflex. METHODS: In 5 patients with spasm of the near reflex, we checked following: UCVA/BCVA, the degree of pseudomyopia revealed through manifest and cycloplegic refraction tests, pupil size, limitation of EOM, the amount of convergence defined by the alternate prism cover test, and slit lamp and funduscopic exams. RESULTS: Of the 5 patients with spasm of near reflex, 3 had accommodative spasm alone and 2 had accommodative spasm, convergence spasm and miosis. The patients' degrees of pseudomyopia and convergence were -8.0D and 14PD on the average. which disappeared after an average of 10.8 months but recurred in 1 of the 3 patients with accommodative spasm. As for spasm of the near reflex, 1 patient showed improvement in convergence but worsening pseudomyopia during the follow-up period, and another patient showed recurrence. CONCLUSIONS: The most common clinical feature of spasm of the near reflex is accommodative spasm. Patients with accommodative spasm alone showed better prognosis among all patients with spasm of the near reflex in terms of recurrence and the disease course.

Changes in Refraction following Pediatric Cataract Surgery

PURPOSE: To evaluate the factors influencing the refractive changes and to predict the ideal intraocular lens powers in children who had undergone cataract surgery. METHODS: The medical records of the pediatric patients with aphakia or pseudophakia who were followed for more than 5 years postoperatively were reviewed retrospectively. They were grouped according to the age at surgery and were followed-up every six months postoperatively. The myopic changes and the factors associated with these changes among the groups were evaluated and compared. RESULTS: The follow-up time was 5 years. In the age-matched subset of patients, no statistically significant difference in the refractive change were found between the aphakic and pseudophakic eyes as well as between the unilateral and bilateral cataracts. Children operated on at 1 month to 1 year of age had a mean myopic shift of -5.58D (range -1.88 to -12.85) and children operated on at 1 to 3 years of age had a shift of -4.25D (range -1.78 to -8.71). The mean myopic shift decreased as the age at operation increased. Children operated on at 10 to 15 years of age had a shift of -1.46D (range 0 to -5.28). CONCLUSIONS: During the first 5 years after surgery, no statistically significant difference in refractive change was observed between the aphakic eyes and pseudophakic eyes as well as between the unilateral and bilateral cataracts. The increasing difficulty in deciding the ideal IOL-power is expected in young children as the refractive change becomes more unpredictable when surgery is performed on younger patients.

Long-term Follow-up Results of Hyperopic Refractive Change

PURPOSE: To investigate the trend of refractive change in hyperopic patients according to increases in age. METHODS: Eighty-eight children who had hyperopia of more than +1.50 diopters (D) and could be followed up for at least 5 years were included in this study. We divided the patients into two groups according to the level of initial hyperopia and retrospectively analyzed hyperopic refractive changes over a 5-year period according to age at initial diagnosis, presence of esotropia, amblyopia, astigmatism and anisometropia. RESULTS: We gained the following formula about the aspect of hyperopic reduction in 88 patients over a period of 5 years: Diopter (D)=7.99-2.14 Ln (age). The presence of anisometropia and amblyopia did not affect hyperopic reduction. Hyperopic reduction amounts in the group with a hyperopic eye of more than +5D at initial diagnosis were greater than in the group with a hyperopic eye less than +5D, and greater in the group with an astigmatic eye of more than 1D. The presence of esotropia and the age at initial diagnosis did not affect hyperopic reduction. CONCLUSIONS: We show that emmetropization in hyperopic children occurs according to the following formula: Diopter (D)=7.99-2.14 Ln (age). Both the initial level of hyperopia and the concurrent presence of astigmatism affected hyperopic reduction. However, the presence of anisometropia, amblyopia, esotropia and the age at initial diagnosis did not significantly affect hyperopic reduction.

The Clinical Consideration of Sensory Strabismus

PURPOSE: To evaluate the factors influencing the direction of sensory strabismus and the consequent surgical outcomes. METHODS: We retrospectively reviewed the medical records of 150 sensory strabismus patients who had undergone surgery. Consisting of 38 esotropes and 112 exotropes. Parameters considered were the cause of vision loss, the age at vision loss, the refractive error of the sound eye, the interorbital distance in the posteroanterior view of the orbit, the deviation angle at postoperative 6 months and 1 year. Patients were excluded if the cause of vision loss was strabismic amblyopia. RESULTS: The major causative factors of sensory strabismus were corneal opacity (26.7%) followed in frequency by cataract (22.7%), and optic nerve disorder (15.3%). The age at vision loss, the refractive error of the sound eye, and the inner and outer interorbital distance were statistically significant among the considered factors in determining the direction of sensory strabismus. At postoperative 6 months, 69.3% of the patients maintained the alignment within 10 PD of orthotropia and 70.4% at 1 year. CONCLUSIONS: We considered that the age at vision loss, the refractive error of the sound eye, and the inner and outer interorbital distance could play a role in determining the direction of sensory strabismus. In spite of the deficit of sensory fusion, the surgical outcomes of sensory strabismus remained favorable at 1 year after surgery.

Serial Follow-up of Neuroimaging Findings in a Progression-free Survival Case with Progressive Multifocal Leukoencephalopathy in Nonimmunocompromised Child

Progressive multifocal leukoencephalopathy (PML) is a demyelination disease caused by opportunistic infection of the ubiquitous, usually nonpathogenic neurotropic papovavirus (JC virus). The virus infects and destroys myelin-producing oligodendrocytes, thereby causing patchy areas of demyelination in the cerebral white matter. It is exclusively a disease of immunosuppressed individuals. We report a case of an immunocompetent child patient with pathologically-proven PML and with a survival over 3 years after diagnosis. Serial follow up of neuroimaging study including brain MRI, MRS, SPECT and PET was obtained.

Ictal Scalp EEG in Mesial Temporal Lobe Epilepsy Patients with Unilateral versus Bilateral Interictal Epileptiform Discharges

BACKGROUND: Interictal and ictal scalp EEG is the most often used and relied-on method of noninvasive presurgical evaluation in temporal lobe epilepsy. We attempted to compare unitemporal interictal epileptiform discharges (UIED) with bitemporal interictal epileptiform discharges (BIED) groups for lateralizing value and propagation patterns of ictal scalp EEGs. METHODS: We investigated ictal scalp EEGs in 48 patients who had undergone anterior temporal lobectomies. We divided them into UIED and BIED groups by cut-off value of 90% in the laterality of IED. RESULTS: We analyzed ictal EEG patterns in 201 seizures of 32 patients with UIED and 86 seizures of 16 patients with BIED. Ictal scalp EEG was correctly lateralized significantly more often in the UIED group compared with the BIED group; 93.5% versus 57.0% in seizures and 93.8% versus 62.5% in patients, respectively. Bilateral independent onset was seen more frequently in the BIED group whereas the maintenance of ictal discharges in the unilateral temporal or hemisphere occurred more frequently in the UIED group. Lateralization by a later significant pattern (LSP) presents additional value of correct lateralization rather than pattern at onset (PAO) only. CONCLUSIONS: Interpretation of ictal scalp EEGs must be considered more cautiously in patients with BIED because BIED may be correlated with bitemporal excitability.

Bilateral Lateral Rectus Resection in Patients with Residual Esotropia

Unilateral or bilateral lateral rectus resection1-5 is commonly performed for the correction of residual esotropia, but few results have been reported. Twenty-eight patients with residual esotropia underwent bilateral lateral rectus (BLR) resection. Six months after operation (n = 25), there were 17 (68%) successful cases, 7 (28%) cases of undercorrection, and 1 (4%) case of overcorrection. The success rate at the 24th postoperative month (n = 11) was 72.7%. The success rate for cases of infantile esotropia (n = 18) was higher than that for acquired esotropia (n = 7) at the 6th postoperative month (p = 0.156). The results were not significantly affected by the presence of other deviations (p = 0.387), the performance of other surgery (p = 0.393), the presence of amblyopia (p = 1.00), or the amount of residual esotropia (p = 0.604). Performance of BLR resection in patients with residual esotropia after bilateral medial rectus (BMR) recession is considered appropriate due to its high success rate and provision of a stable alignment during two-year follow up.

Three Patients with Nondominant Temporal Lobe Epilepsy Showing Ictal Spitting / 대한간질학회지

Spitting as an ictal phenomenon has rarely been reported. It is considered to indicate a seizure onset in the nondominant temporal lobe. Three cases with ictal spitting were found in 81 consecutive patients who underwent temporal lobe resections due to intractable temporal lobe epilepsy. Two had evidence of the right temporal ictal onset. One had the left temporal ictal onset, but the Wada test demonstrated language dominance in the right hemisphere. Three all had mesial temporal sclerosis. One had recollection of her episodes of spitting with a gustatory aura, whereas the other patients had no awareness of this symptom. These cases support previous studies suggesting that spitting is a lateralizing sign to nondominant temporal lobe epilepsy.

Surgical Treatment of Post-Traumatic Kyphosis with Neurologic Compromised Osteoporotic Fracture: Comparison between Anterior-Posterior Surgery versus Posterior Egg-Shell Procedure / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the surgical results between anterior-posterior surgery and posterior eggshell procedures in post-traumatic kyphosis with neurologic compromised osteoporotic fracture. SUMMARY OF LITERATURE REVIEW: Combined anterior-posterior surgery is usually recommended in cases of kyphotic deformities with neurologic deficit secondary to osteoporosis. However, it is associated with significant morbidity in elderly patients. MATERIALS AND METHODS: Twenty-six post-traumatic kyphosis with neurologic compromised osteoporotic fracture patients subjected to either anterior-posterior surgery (n=11) or posterior egg-shell procedure (n=15) were analyzed. The average age at the operation was 62.6 years (range: 50-82), male : female ratio was 12 : 14, and the average follow up was 2.9 years (range:2.0-4.9). Preoperative interval from injury to operation was 15.4 months (range: 1-36). Thoracolumbar (T12-L1) fracture was in 20 and lumbar fracture was in 6. RESULTS: There was no significant difference in age, sex, preoperative and postoperative Frankel grade, and preoperative vertebral collapse between two groups(p<0.05). In anterior-posterior group, the mean operation time was 351 minutes with a mean blood loss of 2892 ml, and preoperative kyphosis of 22 degrees was corrected to 11 degrees at latest follow-up with 7 cases of neurologic improvement. In the eggshell group, the mean operative time was 215 minutes with blood loss of 1930 ml, and preoperative kyphosis of 34 degrees was corrected to 8 degrees at latest follow-up with 11 cases of neurologic improvement. Egg-shell group showed significantly less operation time and blood loss with beter kyphosis correction. In anterior-posterior group, postoperative pneumonia was developed in 2 and superficial infection in 1. Distal screw loosening was detected in 4, 2 in anterior-posterior group and 2 in posterior eggshell group. One of them was treated by revision and others were treated by brace more than 6 months. CONCLUSIONS: Posterior eggshell procedure showed a better kyphosis correction with significantly less operation time and blood loss. It is a preferable alternative to anterior-posterior surgery in post-traumatic kyphosis with neurologic compromised osteoporotic fracture.

Determination of Distal Fusion Level with Segmental Pedicle Screw Fixation in Single Thoracic Idiopathic Scoliosis / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine the exact distal fusion level in the treatment of single thoracic idiopathic scoliosis (King III and IV) with segmental pedicle screw fixation and rod rotation. SUMMARY OF LITERATURE REVIEW: Pedicle screw fixation effectively shortens the distal fusion extent by improved 3-D deformity correction. However, the selection of distal fusion extent remains controversial in single thoracic idiopathic scoliosis. MATERIAL AND METHODS: Forty-two single thoracic adolescent idiopathic scoliosis patients subject to segmental pedicle screw fixation and rod rotation with minimum follow-up of 2 years (2-6 years) were analyzed. The patients were grouped according to the distal fusion level with reference to the standing neutral vertebra (NV) for comparison of deformity correction, radiological and clinical spinal balance using standing radiographs. Distal fusion down to NV +1 was in 9 patients, NV in 5, NV-1 in 9, NV-2 in 12 and NV-3 in 7 patients respectively. RESULTS: Preoperative 50+/-11 degrees of thoracic deformity was corrected to 13+/-5 degrees showing 74% of curve correction. Preoperative 23+/-7 degrees of lumbar deformity was corrected to 2+/-8 degrees showing 93% of curve correction. Postoperative adding on deformity was obtained in 14 patients. Significant difference was found not by King classification but by distal fusion level: significantly higher chance of unsatisfactory results from not going to the NV-1 (p=0.001). CONCLUSIONS: In correction of single thoracic idiopathic scoliosis with segmental pedicle screw fixation, the curve should be fused to NV-1 saving one or more motion segments when compared to the fusion to the stable vertebra.

Thalamic Damage in Temporal Lobe Epilepsy with Mesial Temporal Sclerosis / 대한간질학회지

PURPOSE: To investigate the frequency of the thalamic damage and its relationship with clinical data in patients with temporal lobe epilepsy and mesial temporal sclerosis (MTS). METHODS: We evaluated 45 patients with temporal lobe epilepsy showing unequivocal changes of unilateral MTS by the visual inspection of magnetic resonance imaging (MRI) compared to 20 controls. We presumed the inferior margin of the lateral ventricle (IMLV) posterior to the foramen of Monro reflects the volume of the thalamus, and investigated the thalamic damage by comparing bilateral IMLVs on oblique coronal T2 MR images posterior to the foramen of Monro. The relationships between clinical data and the presence of asymmetry of IMLV were evaluated. RESULTS: None of the control group had asymmetry of the hippocampus or IMLV. Asymmetry of IMLV was observed in 42% (19 of 45) of the patient group;IMLV was downward on the ipsilateral side in 40% (18), and on the contralateral side of MTS in one of the four patients having a larger lateral ventricle on the contralateral side of MTS. An asymmetric small fornix and mamillary body was found in 42% and 29% of the patients, respectively, in all ipsilateral to the side of MTS. A history of status epilepticus (SE) was more frequent in patients with downward IMLV ipsilateral to the side of MTS than in patients with symmetry of IMLV (five of 18 versus one of 26, p=0.011). CONCLUSIONS: This study suggests that the thalamic damage may be more frequently associated with MTS, when compared with previous studies, which applied more strict methods in evaluating the thalamic damage. There is a significant correlation between the presence of asymmetrical IMLV and history of SE, and our study suggests that excessive and prolonged seizure activity related to SE, can provoke thalamic injury in patients with temporal lobe epilepsy and MTS.