A 6-Year-Old With Episodes of Hand-Waving and Loss of Attention.

A 6-year-old girl was referred to pediatric neurology because of concerns about her behavior. Her mother had noticed episodes in which the girl would wave her hand in front of her face and lose awareness of her surroundings several times per day. These episodes usually occurred when she was outdoors and had caused the child to walk into objects and stop in traffic. The patient otherwise had no neurological deficits or cognitive impairment, and there was no family history of neuropsychiatric disorders. Although the patient was aware of her behavior, she could not explain why she performed these hand-waving motions. A neurological workup revealed that these behaviors were not complex stereotypies but rather a rare and unusual disorder. This case highlights the role of neurology in assessing complex motor behaviors and offers insight into when a practicing pediatrician should consider a neurological workup for complex stereotypies. [Pediatr Ann. 2023;52(8):e309-e312.].

Psychiatric changes after stereotactic laser amygdalohippocampotomy for medial temporal lobe epilepsy.

PURPOSE: Stereotactic laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for drug-resistant temporal lobe epilepsy (TLE) that has comparable rates of seizure freedom to traditional open resective TLE surgery. The objective of this study was to determine psychiatric outcome (i.e., depression and anxiety changes, psychosis) after SLAH, to explore possible contributory factors to these changes, and to determine the prevalence of de novo psychopathology. METHODS: We explored mood and anxiety in 37 adult patients with TLE undergoing SLAH using the Beck psychiatric symptoms scales (i.e., Beck Depression Inventory-II [BDI-II] and Beck Anxiety Inventory [BAI]) preoperatively and 6 months following surgery. Multivariable regression analysis was conducted to identify predictors of worse depression or anxiety symptoms following SLAH. The prevalence of de novo psychopathology following SLAH was also determined. RESULTS: We found a significant decrease in BDI-II (mean decline from 16.3 to 10.9, p = 0.004) and BAI (mean decline from 13.3 to 9.0, p = 0.045) scores following SLAH at the group level. While the rate of resolution of depression (from 62% to 49%) did not achieve statistical significance (p = 0.13, McNemar's), the rate of resolution of anxiety (from 57% to 35%) was statistically significant (p = 0.03, McNemar's). The de novo rate of psychopathology (i.e., new onset depression or anxiety) following SLAH was 1 of 7 (14%). Using a metric of meaningful change rather than complete symptom resolution, 16 of 37 (43%) patients experienced improvement in depression and 6 of 37 (16%) experienced worsening. For anxiety, 14 of 37 (38%) experienced meaningful improvement and 8 of 37 (22%) experienced worsening. Baseline performance on the Beck Scales was the only factor contributing to outcome status. DISCUSSION: In one of the first studies to evaluate psychiatric outcomes after SLAH, we found promising overall trends toward stability or significant improvement in symptom burden at the group level for both depression and anxiety. There was also a significant improvement in clinical anxiety, though the decrease in clinical depression was not significant, likely owing to the limitations of sample size. SLAH may improve overall psychiatric symptoms, similarly to traditional resective TLE surgery, but de novo psychopathology and postoperative psychiatric morbidity remain significant issues, and larger samples are necessary to determine causal contributory factors.

Withdrawal of antiseizure medications after MRI-Guided laser interstitial thermal therapy in extra-temporal lobe epilepsy.

PURPOSE: This study investigated the success rate of antiseizure medications (ASMs) withdrawal following MRI Guided Laser Interstitial Thermal Therapy (MRg-LITT) for extra-temporal lobe epilepsy (ETLE), and identified predictors of seizure recurrence. METHODS: We retrospectively assessed 27 patients who underwent MRg-LITT for ETLE. Patients' demographics, disease characteristics, and post-surgical outcomes were evaluated for their potential to predict seizure recurrence associated with ASMs withdrawal. RESULTS: The median period of observation post MRg-LITT was 3 years (range 18 - 96 months) and the median period to initial ASMs reduction was 0.5 years (range 1-36 months). ASMs reduction was attempted in 17 patients (63%), 5 (29%) of whom had seizure recurrence after initial reduction. Nearly all patient who relapsed regained seizure control after reinstitution of their ASMs regimen. Pre-operative seizure frequency (p = 0.002) and occurrence of acute post-operative seizures (p = 0.01) were associated with increased risk for seizure recurrence post ASMs reduction. At the end of the observation period, 11% of patients were seizure free without drugs, 52% were seizure free with drugs and 37% still experienced seizures despite ASMs. Compared with pre-operative status, the number of ASMs was reduced in 41% of patients, unchanged in 55% of them and increased in only 4% of them. CONCLUSIONS: Successful MRg-LITT for ETLE allows for ASMs reduction in a significant portion of patients and complete ASMs withdrawal in a subset of them. Patients with higher pre-operative seizure frequency or occurrence of acute post operative seizures exhibit higher chances relapse post ASMs reduction.

Stereoelectroencephalography-guided radiofrequency ablation of the epileptogenic zone as a treatment and predictor of future success of further surgical intervention.

OBJECTIVE: Stereoelectroencephalography (SEEG)-guided radiofrequency ablation (RFA) is increasingly being used as a treatment for drug-resistant localization-related epilepsy. The aim of this study is to analyze the successes and failures using RFA and how response correlates with surgical epilepsy treatment outcomes. METHODS: We retrospectively reviewed 62 patients who underwent RFA via SEEG electrodes. After excluding five, the remaining 57 were classified into subgroups based on procedures and outcomes. Forty patients (70%) underwent a secondary surgical procedure, of whom 32 were delayed: 26 laser interstitial thermal therapy (LITT), five resection, one neuromodulation. We determined the predictive value of RFA outcome upon subsequent surgical outcome by categorizing the delayed secondary surgery outcome as success (Engel I/II) versus failure (Engel III/IV). Demographic information, epilepsy characteristics, and the transient time of seizure freedom after RFA were calculated for each patient. RESULTS: Twelve of 49 patients (24.5%) who had RFA alone and delayed follow-up achieved Engel class I. Of the 32 patients who underwent a delayed secondary surgical procedure, 15 achieved Engel class I and nine Engel class II (24 successes), and eight were considered failures (Engel class III/IV). The transient time of seizure freedom after RFA was significantly longer in the success group (4 months, SD = 2.6) as compared to the failure group (.75 months, SD = 1.16; p < .001). Additionally, there was a higher portion of preoperative lesional findings in patients in the RFA alone and delayed surgical success group (p = .03) and a longer time to seizure recurrence in the presence of lesions (p < .05). Side effects occurred in 1% of patients. SIGNIFICANCE: In this series, RFA provided a treatment during SEEG-guided intracranial monitoring that led to seizure freedom in ~25% of patients. Of the 70% who underwent delayed surgery, longer transient time of seizure freedom after RFA was predictive of the results of the secondary surgeries, 74% of which were LITT.