Acute postoperative seizures and long-term seizure outcome after surgery for hippocampal sclerosis.

PURPOSE: To assess the incidence and the prognostic value of acute postoperative seizures (APOS) in patients surgically treated for drug-resistant temporal lobe epilepsy due to hippocampal sclerosis (TLE-HS). METHODS: We studied 139 consecutive patients with TLE-HS who underwent epilepsy surgery and were followed up for at least 5 years (mean duration of follow-up 9.1 years, range 5-15). Medical charts were reviewed to identify APOS, defined as ictal events with the exception of auras occurring within the first 7 days after surgery. Seizure outcome was determined at annual intervals. Patients who were in Engel Class Ia at the last contact were classified as having a favorable outcome. RESULTS: Seizure outcome was favorable in 99 patients (71%). Six patients (4%) experienced APOS and in all cases their clinical manifestations were similar to the habitual preoperative seizures. All patients with APOS had unfavorable long-term outcome, as compared with 35 (26%) of 133 in whom APOS did not occur (p<0.001). CONCLUSIONS: Our study suggests that APOS, despite being relatively uncommon in patients undergoing resective surgery for TLE-HS, are associated with a worse long-term seizure outcome. Given some study limitations, our findings should be regarded as preliminary and need confirmation from future larger, prospective, multicenter studies.

Serial postoperative awake and sleep EEG and long-term seizure outcome after anterior temporal lobectomy for hippocampal sclerosis.

OBJECTIVE: To test if postoperative prolonged awake and sleep EEG monitoring predict long-term seizure outcome in patients operated for drug-resistant temporal lobe epilepsy due to hippocampal sclerosis (TLE-HS). METHODS: This longitudinal study includes 107 patients with MTLE-HS who underwent anterior temporal lobectomy (ATL), were followed for at least 5 years (mean 8.3, range 5-12), had postoperative EEG after 2 months and at least one prolonged video-EEG monitoring during both wakefulness and sleep after 12 and 24 months. At each follow-up visit, the presence of interictal epileptiform discharges (IED) was determined, and seizure outcome was evaluated. RESULTS: Sixty-six patients (62%) remained free from auras and seizures throughout the follow-up period. Twenty-six (24%), 22 (21%), and 16 (16%) patients had IED at the 2-month, 12-month, and 24-month follow-up, respectively. The presence of IED at each time point was found to be associated with seizure or aura recurrence. Sleep recording contributed to the identification of patients with IED, as half of patients with IED displayed anomalies in sleep EEG only. In multivariate analysis, the presence of IED 2 months after surgery was found to be associated with seizure or aura recurrence independent of pre-operative factors consistently reported as outcome predictors in the literature. CONCLUSIONS: The presence of IED in serial postoperative EEG including sleep recording may predict long-term seizure outcome after ATL for TLE-HS. Serial postoperative EEGs may contribute to outcome prediction and help making decision about medication withdrawal in patients operated for TLE-HS.

Prognostic significance of acute postoperative seizures in extra-temporal lobe epilepsy surgery.

OBJECTIVE: This study aims to assess the prognostic value of acute postoperative seizures (APOS) in patients surgically treated for drug-resistant extra-temporal lobe (ET) epilepsy. METHODS: We studied 77 consecutive patients with ET epilepsy who underwent epilepsy surgery and were followed up for at least 2 years (mean duration of follow-up 6.2 years, range 2-14). Medical charts were reviewed to identify APOS, defined as ictal events with the exception of auras occurring within the first 7 days after surgery. Seizure outcome was determined at annual intervals. Patients who were in Engel Class I at the last contact were classified as having a favourable outcome. RESULTS: Seizure outcome was favourable in 47 patients (61%). The occurrence of APOS and incompleteness of resection were found to be independently associated with unfavourable outcome in a multiple regression model including all preoperative factors identified as outcome predictors in univariate analysis. Duration of illness was the only independent preoperative predictor of APOS. CONCLUSIONS: Our study suggests that APOS may predict long-term outcome in patients undergoing resective surgery for ET epilepsy. Given some study limitations, our findings should be regarded as preliminary and need confirmation from future larger, prospective, multicentre studies. SIGNIFICANCE: Caution may be required in the clinical management of patients experiencing APOS.

Prognostic significance of serial postoperative EEG in extratemporal lobe epilepsy surgery.

OBJECTIVE: To assess the prognostic value of postoperative EEG in patients surgically treated for drug-resistant extra-temporal lobe (ET) epilepsy. METHODS: We studied 63 consecutive patients with ET epilepsy who underwent epilepsy surgery and were followed up for at least 2 years (mean duration of follow-up 6.2 ± 2.3 years, range 2-12). Follow-up evaluations were performed 2, 12, and 24 months after surgery, and included standard EEG (at 2 months) and long-term video-EEG monitoring during both wakefulness and sleep (at 12 and 24 months). Seizure outcome was determined at each follow-up evaluation, and then at yearly intervals. Patients who were in Engel Class I at the last contact were classified as having a good outcome. RESULTS: Seizure outcome was good in 39 patients (62%). The presence of interictal epileptiform discharges (IED) in postoperative EEG at each time point was found to be associated with poor outcome. The strength of this association was greater for awake plus sleep recording as compared with awake recording alone. In a multiple regression model including all pre- and post-operative factors identified as predictors of outcome in univariate analysis, the presence of early (2 months after surgery) EEG epileptiform abnormalities was found to be independently associated with poor seizure outcome. CONCLUSIONS: Postoperative IED may predict long-term outcome in patients undergoing resective surgery for ET epilepsy. SIGNIFICANCE: The increase in risk of unfavourable outcome associated with EEG epileptiform abnormalities detected as early as two months after surgery may have substantial practical importance. Serial postoperative EEGs including sleep recording may add further predictive power and help making decision about antiepileptic drug discontinuation.

Seizure clusters and adverse events during pre-surgical video-EEG monitoring with a slow anti-epileptic drug (AED) taper.

OBJECTIVE: To evaluate the efficiency and safety of pre-surgical video-EEG monitoring with a slow anti-epileptic drug (AED) taper and a rescue benzodiazepine protocol. METHODS: Fifty-four consecutive patients with refractory focal epilepsy who underwent pre-surgical video-electroencephalography (EEG) monitoring during the year 2010 were included in the study. Time to first seizure, duration of monitoring, incidence of 4-h and 24-h seizure clustering, secondarily generalised tonic-clonic seizures (sGTCS), status epilepticus, falls and cardiac asystole were evaluated. RESULTS: A total of 190 seizures were recorded. Six (11%) patients had 4-h clusters and 21 (39%) patients had 24-h clusters. While 15 sGTCS were recorded in 14 patients (26%), status epilepticus did not occur and no seizure was complicated with cardiac asystole. Epileptic falls with no significant injuries occurred in three patients. The mean time to first seizure was 3.3days and the time to conclude video-EEG monitoring averaged 6days. CONCLUSION: Seizure clustering was common during pre-surgical video-EEG monitoring, although serious adverse events were rare with a slow AED tapering and a rescue benzodiazepine protocol. SIGNIFICANCE: Slow AED taper pre-surgical video-EEG monitoring is fairly safe when performed in a highly specialised and supervised hospital setting.

Memory outcome 2 years after anterior temporal lobectomy in patients with drug-resistant epilepsy.

PURPOSE: Memory decline is often observed after anterior temporal lobectomy (ATL), particularly in patients with dominant hemisphere resections. However, the follow-up length has been 1 year or less in most studies. Our aims were to examine postoperative memory changes over a longer period and to identify baseline demographic and clinical predictors of memory outcome. METHODS: We administered material-specific memory tests at baseline, and 1 and 2 years after surgery to 82 consecutive right-handed patients (52% males) who underwent ATL for drug-resistant temporal lobe epilepsy (TLE) (35 left, 47 right) after a non-invasive presurgical protocol. Repeated measures multivariate analysis of variance (RM-MANOVA) was used to examine the relationship between changes in memory tests scores over time and side of TLE and pathology. Also, standardized residual change scores were calculated for each memory test and entered in multiple linear regression models aimed at identifying baseline predictors of better memory outcome. RESULTS: RM-MANOVA revealed a significant change in memory test scores over time, with an interaction between time and side of surgery, as 2 years after surgery patients with RTLE were improved while patients with LTLE were not worse as compared with baseline. Pathology was not associated with changes in memory scores. In multiple regression analysis, significant associations were found between right TLE and greater improvement in verbal memory, younger age and greater improvement in visuospatial memory, and male gender and greater improvement in both verbal and visuospatial memory. CONCLUSIONS: Our results suggest that the long-term memory outcome of TLE patients undergoing ATL without invasive presurgical assessment may be good in most cases not only for right-sided but also for left-sided resections.

Partial seizures due to sclerosis of the right amygdala presenting as panic disorder. On the importance of psychopathological assessment in differential diagnosis.

The differential diagnosis between panic disorder and focal epilepsy may sometimes pose a serious challenge. We report the case of a 32-year-old woman who complained of paroxysmal episodes of acute anxiety that evaded diagnosis for 8 years. Standard EEGs and brain CT scan showed no clear pathologic findings. Antidepressants, support psychotherapy and several courses of antiepileptic drugs were not beneficial. She was referred to our centre for a comprehensive diagnostic assessment. Clinical and standardized personality assessment did not reveal the personality organization typically associated with proneness to develop phobic anxiety disorders. Also, agoraphobic avoidance was absent, and the patient's main worries during the episodes involved negative social judgments rather than health. A brain MRI revealed a slightly increased signal at FLAIR images in the right amygdala. Video-EEG monitoring was decisive in establishing the diagnosis of drug-resistant right mesial temporal lobe epilepsy. Anteromesial temporal lobectomy was offered and successfully performed. Pathological examination of removed brain tissue revealed amygdalar sclerosis and mild hippocampal neuronal loss. At a 6-month follow-up visit, the paroxysmal episodes had completely disappeared. Depression, anxiety and quality of life were markedly improved. This case suggests that focal epilepsy should be considered in patients with paroxysmal episodes of anxiety, especially if dissociative symptoms and atypical clinical features for panic disorder are present, and if there is no satisfactory response to adequate trials of medication and psychotherapy within one year. A careful psychopathological analysis rather than a descriptive enumeration of symptoms is needed to bring these features to light. In such cases, even if routine EEGs or MRI are inconclusive and there is no response to antiepileptic drugs, it would be advisable to perform video-EEG monitoring to rule out partial seizures.

Factors associated with generic and disease-specific quality of life in temporal lobe epilepsy.

PURPOSE: We aimed at further elucidating the association between quality of life (QOL) and sociodemographic factors, clinical seizure factors, depression and anxiety in drug-resistant temporal lobe epilepsy (TLE). METHODS: We studied 106 consecutive adult right-handed patients (mean age 35.4 +/- 9.7; 50% males; IQ> or = 70) with drug-resistant unilateral (59% right) TLE (70% hippocampal sclerosis, 30% tumors or other lesions), who underwent a comprehensive non-invasive pre-surgical protocol. They completed the Beck Depression Inventory (BDI) and the State Form of the Spielberger State-Trait Anxiety Inventory (STAI). To measure QOL, we used both a generic instrument, the WHOQOL-100, and a disease-specific instrument, the 31-item quality of life in epilepsy (QOLIE-31). Multiple linear regression analysis was used to examine the relationship between each QOL domain and age, gender, education, side of TLE, duration of epilepsy, seizure frequency, and level of depression and anxiety. RESULTS: Severity of depressive symptoms was significantly associated with lower scores across most QOL domains. Depression was consistently the strongest predictor of lower scores on almost all QOL domains. Also, severity of anxiety symptoms was significantly associated with lower scores across many QOL domains. Independent significant relationships between QOL and sociodemographic or clinical epilepsy variables were limited in number and strength. CONCLUSIONS: Our findings suggest that QOL in TLE might be substantially affected by the presence and severity of depressive symptoms and, to a lesser degree, of anxiety symptoms. While clinical seizure variables had a weaker association with QOL, the absence of seizure-free patients might have obscured a relation between seizure frequency and QOL. Healthcare professionals should be aware of the significance of patients' emotional state and of the role it plays for their QOL. Adopting a biopsychosocial approach might be useful to address patients' needs.

Genital and sexual manifestations in drug-resistant partial epilepsy.

Genital and sexual manifestations represent rare clinical phenomena during or after focal seizures. The semiology of these types of automatisms is controversial. In particular, it is unclear whether temporal or frontal structures are involved in their generation and whether these clinical manifestations have a potential lateralizing value. In this view, from a population of 212 consecutive patients with drug resistant focal epilepsy referred to us for presurgical assessment, we retrospectively identified 24 patients with genital ictal manifestations. We evaluated the incidence of these behaviours, the clinical semiology, the associated symptoms/signs with the corresponding ictal EEG findings and their potential role in lateralizing the epileptogenic zone. Our results indicate that ictal genital automatisms are possible in seizures originating from temporal lobe and they cannot be attributed exclusively to frontal lobe seizures. In particular, the most frequent genital automatisms consist in subtle phenomena while hypermotoric behaviour, such as pelvic rhythmic movements are quite rare. No lateralizing value for genital automatisms was disclosed.

Ictal heart rate increase precedes EEG discharge in drug-resistant mesial temporal lobe seizures.

OBJECTIVE: Heart rate (HR) changes, mainly tachycardia, are often observed during seizures originating from the temporal lobe. The aim of this study was to analyze the role of ictal HR changes in localizing both mesial and lateral temporal lobe epilepsy (TLE) in a group of 68 patients. The influence of the gender and the side of epilepsy on HR modulation was also evaluated. METHODS: Ictal HR was recorded during prolonged Video-EEG monitoring performed in 68 patients affected by drug-resistant TLE during a non-invasive pre-surgical protocol. According to the electro-clinical correlation, obtained by video-EEG monitoring, one hundred-thirteen seizures (n=113) and one hundred-forty-four auras (n=144) were identified and included in the study. Furthermore, the electro-clinical correlation allowed the classification of all the epileptic events (seizures and auras) as having mesial or lateral origin, based on the temporal lobe seizure onset zone. Ictal HR was calculated with respect to the R-R waves, and assessed from 15 sec (s) before (T(- 15)) to 15 s after (T(+15)) the time of EEG seizure onset (T(0)). RESULTS: We observed a high incidence (92%) of ictal HR increase in TLE seizures. When the ictal EEG indicated a seizure onset from the mesial temporal structures, the onset of ictal HR increase preceded by about 5 s the EEG ictal onset (SD+/-18.4), whereas the onset of HR increase coincided with the onset of EEG discharges (SD+/-14.8) when the ictal EEG indicated the onset of seizures from the lateral temporal structures. No significant differences were found between male and female patients; and between right and left TLE. CONCLUSIONS: Our findings show that ictal HR increase, preceding the onset of the EEG discharge, is associated with ictal EEG seizure pattern defining temporal lobe seizures originating from the mesial temporal lobe structures; this association suggests that the HR changes may be coupled to the functional impairment of neural circuits involved in sympathetic cardiovascular regulation, in the mesial temporal lobe structures. Further studies investigating the relationship between intracranial EEG monitoring and ECG recording are worthwhile, to confirm our results and to give further indications on the pathogenesis of ictal HR abnormalities.