Predictors of meaningful improvement in quality of life after temporal lobe epilepsy surgery: A prospective study.

OBJECTIVES: To investigate prospectively the independent predictors of a minimum clinically important change (MCIC) in quality of life (QOL) after anterior temporal lobectomy (ATL) for drug-resistant mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) in Brazilian patients. METHODS: Multiple binary logistic regression analysis was performed to identify the clinical, demographic, radiologic, and electrophysiologic variables independently associated with MCIC in the Quality of Life in Epilepsy-31 Inventory (QOLIE-31) overall score 1 year after ATL in 77 consecutive patients with unilateral MTLE-HS. RESULTS: The overall QOLIE-31 score and all its subscale scores increased significantly (p < 0.0001) 1 year after ATL. In the final logistic regression model, absence of presurgical diagnosis of depression (adjusted odds ratio [OR] 4.4, 95% confidence interval [CI] 1.1-16.1, p = 0.02) and a complete postoperative seizure control (adjusted OR 4.1, 95% CI 1.2-14.5, p = 0.03) were independently associated with improvement equal to or greater than the MCIC in QOL after ATL. The overall model accuracy for MCIC improvement in the QOL was 85.6%, with a 95.2% of sensitivity and 46.7% of specificity. SIGNIFICANCE: These results in Brazilian patients reinforce the external validation of previous findings in Canadian patients showing that presurgical depression and complete seizure control after surgery are independent predictors for meaningful improvement in QOL after ATL, and have implications for the surgical management of MTLE patients.

Decline in word-finding: The objective cognitive finding most relevant to patients after mesial temporal lobe epilepsy surgery.

PURPOSE: The purpose of this study was to investigate the following: i) the objective impairment in neuropsychological tests that were associated with the subjective perception of cognitive function decline in Brazilian patients who underwent mesial temporal lobe epilepsy (MTLE) surgery and ii) the predictive variables for those impaired objective neuropsychological tests. METHODS: Forty-eight adults with MTLE (27 right HS and 23 male) were divided according to their perception of changes (Decline or No-decline) of cognitive function domain of the QOLIE-31 questionnaire applied before and 1year after the ATL. The mean (SD) of changes in the raw score difference of the neuropsychological tests before and after the ATL was compared between Decline and No-decline groups. Receiver Operating Characteristic curves, sensitivity, specificity, and predictive values were used to assess the optimum cutoff points of neuropsychological test score changes to predict patient-reported subjective cognitive decline. KEY FINDINGS: Six (12.5%) patients reported a perception of cognitive function decline after ATL. Among the 25 cognitive tests analyzed, only changes in the Boston Naming Test (BNT) were associated with subjective cognitive decline reported by patients. A reduction of ≥8 points in the raw score of BNT after surgery had 91% of sensitivity and 45% specificity for predicting subjective perception of cognitive function decline by the patient. Left side surgery and age older than 40years were more associated with an important BNT reduction with overall accuracy of 91.7%, 95% predictive ability for no impairment, and 75% for impairment of cognitive function. SIGNIFICANCE: Impairment in word-finding seems to be the objective cognitive finding most relevant to Brazilian patients after mesial temporal lobe epilepsy surgery. Similar to American patients, the side of surgery and age are good predictors for no decline in the BNT, but shows a lower accuracy to predict its decline. If replicated in other populations, the results may have wider implications for the surgical management of patients with drug-resistant MTLE.

Dissociation of decisions in ambiguous and risky situations in obsessive-compulsive disorder.

Patients with obsessive-compulsive disorder (OCD) often show deficits in everyday decision-making, a phenomenon which is leading to a growing research interest in neuropsychological aspects of decision-making in OCD. Previous investigations of OCD patients demonstrated deficits in the Iowa Gambling Task (IGT), a decision-making task with implicit rules. Results were interpreted as reflecting orbitofrontal cortex dysfunctions observed in OCD. The aim of the present study is to investigate OCD patients' performance on the Game of Dice Task (GDT), a decision-making task with explicit and stable rules. For this purpose, 23 patients with OCD and 22 healthy comparison subjects were examined with the GDT and the IGT as well as with tests of executive functioning. While patients performed worse than comparison subjects on the IGT, they were unimpaired on the GDT and executive functioning tasks. Results further emphasize dysfunctions of the orbitofrontal cortex, but indicate intact functioning of the dorsolateral prefrontal cortex in patients with OCD.

Skin conductance responses during decisions in ambiguous and risky situations in obsessive-compulsive disorder.

INTRODUCTION: Patients with obsessive-compulsive disorder (OCD) often have difficulties in everyday decision making. In addition, recent research suggests that patients have reduced performance on the Iowa Gambling Task, a laboratory decision-making task with implicit rules that taps emotional feedback processing. Disadvantageous decision making is accompanied by reduced skin conductance responses (SCRs) generated during task performance. METHODS: The current study investigates behavioural and SCR data during the Iowa Gambling Task (IGT) and additionally the Game of Dice Task (GDT), a decision-making task with explicit and stable rules. We examined 14 patients with OCD and 15 comparison subjects performing the two decision-making tasks while recording accompanying SCR. RESULTS: Patients showed difficulties on the Iowa Gambling Task but not the Game of Dice Task. This was also confirmed by the SCR results. In the Iowa Gambling Task differences in SCR patterns for patients and comparison subjects were observed, whereas SCRs during the Game of Dice Task did not differ between groups. CONCLUSIONS: Behavioural and SCR data indicate that patients with OCD have difficulties in decisions under implicit but not under explicit risk conditions.

Neuropsychological functioning and brain energetics of drug resistant mesial temporal lobe epilepsy patients.

Interictal hypometabolism is commonly measured by 18-fluoro-deoxyglucose Positron Emission Tomography (FDG-PET) in the temporal lobe of patients with mesial temporal lobe epilepsy (MTLE-HS). Left temporal lobe interictal FDG-PET hypometabolism has been associated with verbal memory impairment, while right temporal lobe FDG-PET hypometabolism is associated with nonverbal memory impairment. The biochemical mechanisms involved in these findings remain unknown. In comparison to healthy controls (n=21), surgically treated patients with MTLE-HS (n=32, left side=17) had significant lower scores in the Rey Auditory Verbal Learning Test (RAVLT retention and delayed), Logical Memory II (LMII), Boston Naming test (BNT), Letter Fluency and Category Fluency. We investigated whether enzymatic activities of the mitochondrial enzymes Complex I (C I), Complex II (C II), Complex IV (C IV) and Succinate Dehydrogenase (SDH) from the resected samples of the middle temporal neocortex (mTCx), amygdala (AMY) and hippocampus (HIP) were associated with performance in the RAVLT, LMII, BNT and fluency tests of our patients. After controlling for the side of hippocampus sclerosis, years of education, disease duration, antiepileptic treatment and seizure outcome after surgery, no independent associations were observed between the cognitive test scores and the analyzed mitochondrial enzymatic activities (p>0.37). Results indicate that memory and language impairment observed in MTLE-HS patients are not strongly associated with the levels of mitochondrial CI, CII, SDH and C IV enzymatic activities in the temporal lobe structures ipsilateral to the HS lesion.

Deficits in visual functions and neuropsychological inconsistency in Borderline Personality Disorder.

For Borderline Personality Disorder (BPD) cognitive and perceptual impairments were reported in some but not all studies. The aim of the present study was to analyze the neuropsychological performance of BPD patients in different domains. Predominant impairments of visual functions and an increased intra-individual variation of test performances within neuropsychological domains were expected. We investigated 22 patients with BPD and a matched sample of 22 healthy control subjects. A comprehensive clinical and neuropsychological test battery was administered. Effect sizes indicate primarily deficits of visual functions such as visual memory (Wechsler Memory Scale-Revised, WMS-R: Visual pair associates and visual reproduction, Complex Figure Test: Recall) and visuo-spatial abilities (Leistungspruefsystem, LPS 9 and 10: Spatial imagination and embedded figures), but also of executive functions (Tower of Hanoi, Trail Making Test-B, semantic and figural fluency, LPS 4: Reasoning). In addition, the intra-individual ranges of neuropsychological test results in BPD patients were increased compared to those of healthy subjects. This finding might be due to a high degree of temporary stress that interferes with effective cognitive processing. Further research is needed to confirm the present results and to control for stress during the test procedure.

Neuroimaging-guided rTMS of the left inferior frontal gyrus interferes with repetition priming.

Neuroimaging studies of right-handed normal volunteers under semantic word generation tasks have consistently reported left lateralized activation of the anterior inferior frontal gyrus (ifg) which decreased during task repetition. This repetition-related activation decrease has been interpreted as the neurophysiological correlate of repetition priming, a mechanism of implicit memory for initial semantic processing. We interfered with left lateralized ifg activation, as identified by O-15-water PET activation, using repetitive transcranial magnetic stimulation (rTMS) in five right-handed male normal subjects, once using new (unprimed) nouns and once using known (primed) nouns for the procedure. All five subjects exhibited clear left lateralized activations of the triangular part of the left ifg in the PET studies. In all subjects, reaction time latencies were significantly longer during rTMS over the activation sites in the left ifg as compared to latencies off stimulation. Latencies were not affected during stimulation of the right ifg or over the vertex. These effects were observed within the group and in each individual, only if lists of primed nouns were used in the verb-generation task. In conclusion, these results demonstrate that the anterior part of the left ifg is not only involved in semantic processing, but is also essential for repetition priming on semantic tasks since successful interference with rTMS was only observed if lists of primed words were used for the generation task.