High b-value diffusion tractography: Abnormal axonal network organization associated with medication-refractory epilepsy.

Diffusion magnetic resonance imaging (dMRI) tractography has played a critical role in characterizing patterns of aberrant brain network reorganization among patients with epilepsy. However, the accuracy of dMRI tractography is hampered by the complex biophysical properties of white matter tissue. High b-value diffusion imaging overcomes this limitation by better isolating axonal pathways. In this study, we introduce tractography derived from fiber ball imaging (FBI), a high b-value approach which excludes non-axonal signals, to identify atypical neuronal networks in patients with epilepsy. Specifically, we compared network properties obtained from multiple diffusion tractography approaches (diffusion tensor imaging, diffusion kurtosis imaging, FBI) in order to assess the pathophysiological relevance of network rearrangement in medication-responsive vs. medication-refractory adults with focal epilepsy. We show that drug-resistant epilepsy is associated with increased global network segregation detected by FBI-based tractography. We propose exploring FBI as a clinically feasible alternative to quantify topological changes that could be used to track disease progression and inform on clinical outcomes.

Cortical disconnection in temporal lobe epilepsy.

A critical concept in neurology is cortical disconnection, in which seemingly normal gray matter can have reduced function due to loss of white matter (WM) connections. White matter damage has been extensively described in temporal lobe epilepsy (TLE), but the anatomical distribution of cortical disconnection in TLE is not fully characterized. Here, we studied 221 participants (64 left-TLE, 55 right-TLE, 102 controls) from three different epilepsy treatment centers. We employed a group connectometry diffusion imaging tractography approach to identify WM fibers with reduced integrity in TLE. We then assessed the anatomical distribution of the gray matter endpoint projections of abnormal fibers to map the anatomical pattern of disconnections. As expected, left- and right-TLE were associated with multiple WM pathways with reduced integrity, which were associated with extensive cortical disconnection involving predominantly limbic structures. Controlling for medial temporal gray matter atrophy, cortical disconnection of the left cingulum and the thalamus as well as disconnection of the bilateral putamen and the amygdala was associated with lower verbal memory immediate recall. In conclusion, our results support that cortical disconnection is an underappreciated but pervasive phenomenon in TLE, and cortical disconnection of limbic structures beyond the medial temporal regions is related to verbal memory performance.

Patterns of seizure spread in temporal lobe epilepsy are associated with distinct white matter tracts.

OBJECTIVE: It is commonly hypothesized that seizure spread patterns in patients with focal epilepsy are associated with structural brain pathways. However, this relationship is poorly understood and has not been fully demonstrated in patients with temporal lobe epilepsy. Here, we sought to determine whether directionality of seizure spread (DSS) is associated with specific cerebral white matter tracts in patients with temporal lobe epilepsy. METHODS: Thirty-three adult patients with temporal lobe epilepsy who underwent stereoelectroencephalography (sEEG) and magnetic resonance diffusion tensor imaging (MR-DTI) as part of their standard-of-care clinical evaluation were included in the study. DSS was defined as anterior-posterior (AP) or medial-lateral (ML) spread based upon sEEG evaluation by two independent specialists who demonstrated excellent inter-rater agreement (Cohen's kappa = .92). DTI connectometry was used to assess differences between seizure spread pattern groups along major fiber pathways regarding fractional anisotropy (FA). RESULTS: Twenty-four participants showed seizures with AP spread and nine participants showed seizures with ML spread. There were no significant differences between the groups on their demographic and clinical profile. Patients with ML seizures had higher FA along the corpus callosum and, to a lesser degree, some portions of the bilateral cingulate tracts. In contrast, patients with AP seizures had higher FA along several anterior-posterior white matter projections bundles, including the cingulate fasciculus and the inferior longitudinal, with significantly less involvement of the corpus callosum compared with ML seizures. SIGNIFICANCE: This study confirms the hypothesis that the anatomical pattern of electrophysiological ictal propagation is associated with the structural reinforcement of supporting pathways in temporal lobe epilepsy. This observation can help elucidate mechanisms of ictal propagation and may guide future translational approaches to curtail seizure spread.

Implementation of psychological clinical trials in epilepsy: Review and guide.

The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.

Prediction of specific depressive symptom clusters in youth with epilepsy: The NDDI-E-Y versus Neuro-QOL SF.

OBJECTIVE: Proper assessment and early identification of depressive symptoms are essential to initiate treatment and minimize the risk for poor outcomes in youth with epilepsy (YWE). The current study examined the predictive utility of the Neurological Disorders Depression Inventory-Epilepsy for Youth (NDDI-E-Y) and the Neuro-QOL Depression Short Form (Neuro-QOL SF) in explaining variance in overall depressive symptoms and specific symptom clusters on the gold standard Children's Depression Inventory-2 (CDI-2). METHODS: Cross-sectional study examining 99 YWE (female 68, mean age 14.7 years) during a routine epilepsy visit, who completed self-report measures of depressive symptoms, including the NDDI-E-Y, CDI-2, and the Neuro-QOL SF. Caregivers completed a measure of seizure severity. All sociodemographic and medical information was evaluated through electronic medical record review. RESULTS: After accounting for seizure and demographic variables, the NDDI-E-Y accounted for 45% of the variance in the CDI-2 Total score and the CDI-2 Ineffectiveness subscale. Furthermore, the NDDI-E-Y predicted CDI-2 Total scores and subscales similarly, with the exception of explaining significantly more variance in the CDI-2 Ineffectiveness subscale compared to the Negative Mood subscale. The NDDI-E-Y explained greater variance compared to Neuro-QOL SF across the Total (48% vs. 37%) and all CDI-2 subscale scores; however, the NDDI-E-Y emerged as a stronger predictor of only CDI-2 Ineffectiveness. Both the NDDI-E-Y and Neuro-QOL SF accounted for the lowest amount of variance in CDI-2 Negative Mood. Sensitivity was poor for the Neuro-QOL SF in predicting high versus low CDI-2 scores. SIGNIFICANCE: The NDDI-E-Y has strong psychometrics and can be easily integrated into routine epilepsy care for quick, brief screening of depressive symptoms in YWE.

Mapping the neuropsychological profile of temporal lobe epilepsy using cognitive network topology and graph theory.

OBJECTIVE: Normal cognitive function is defined by harmonious interaction among multiple neuropsychological domains. Epilepsy has a disruptive effect on cognition, but how diverse cognitive abilities differentially interact with one another compared with healthy controls (HC) is unclear. This study used graph theory to analyze the community structure of cognitive networks in adults with temporal lobe epilepsy (TLE) compared with that in HC. METHODS: Neuropsychological assessment was performed in 100 patients with TLE and 82 HC. For each group, an adjacency matrix was constructed representing pair-wise correlation coefficients between raw scores obtained in each possible test combination. For each cognitive network, each node corresponded to a cognitive test; each link corresponded to the correlation coefficient between tests. Global network structure, community structure, and node-wise graph theory properties were qualitatively assessed. RESULTS: The community structure in patients with TLE was composed of fewer, larger, more mixed modules, characterizing three main modules representing close relationships between the following: 1) aspects of executive function (EF), verbal and visual memory, 2) speed and fluency, and 3) speed, EF, perception, language, intelligence, and nonverbal memory. Conversely, controls exhibited a relative division between cognitive functions, segregating into more numerous, smaller modules consisting of the following: 1) verbal memory, 2) language, perception, and intelligence, 3) speed and fluency, and 4) visual memory and EF. Overall node-wise clustering coefficient and efficiency were increased in TLE. SIGNIFICANCE: Adults with TLE demonstrate a less clear and poorly structured segregation between multiple cognitive domains. This panorama suggests a higher degree of interdependency across multiple cognitive domains in TLE, possibly indicating compensatory mechanisms to overcome functional impairments.

Surgical Management of Pediatric Epilepsy: Decision-Making and Outcomes.

First-line treatment for epilepsy is antiepileptic drug and requires an interdisciplinary approach and enduring commitment and adherence from the patient and family for successful outcome. Despite adherence to antiepileptic drugs, refractory epilepsy occurs in approximately 30% of children with epilepsy, and surgical treatment is an important intervention to consider. Surgical management of pediatric epilepsy is highly effective in selected patients with refractory epilepsy; however, an evidence-based protocol, including best methods of presurgical imaging assessments, and neurodevelopmental and/or behavioral health assessments, is not currently available for clinicians. Surgical treatment of epilepsy can be critical to avoid negative outcomes in functional, cognitive, and behavioral health status. Furthermore, it is often the only method to achieve seizure freedom in refractory epilepsy. Although a large literature base can be found for adults with refractory epilepsy undergoing surgical treatment, less is known about how surgical management affects outcomes in children with epilepsy. The purpose of the review was fourfold: (1) to evaluate the available literature regarding presurgical assessment and postsurgical outcomes in children with medically refractory epilepsy, (2) to identify gaps in our knowledge of surgical treatment and its outcomes in children with epilepsy, (3) to pose questions for further research, and (4) to advocate for a more unified presurgical evaluation protocol including earlier referral for surgical candidacy of pediatric patients with refractory epilepsy. Despite its effectiveness, epilepsy surgery remains an underutilized but evidence-based approach that could lead to positive short- and long-term outcomes for children with refractory epilepsy.

Graph theory and cognition: A complementary avenue for examining neuropsychological status in epilepsy.

The recent revision of the classification of the epilepsies released by the ILAE Commission on Classification and Terminology (2005-2009) has been a major development in the field. Papers in this section of the special issue explore the relevance of other techniques to examine, categorize, and classify cognitive and behavioral comorbidities in epilepsy. In this review, we investigate the applicability of graph theory to understand the impact of epilepsy on cognition compared with controls and, then, the patterns of cognitive development in normally developing children which would set the stage for prospective comparisons of children with epilepsy and controls. The overall goal is to examine the potential utility of this analytic tool and approach to conceptualize the cognitive comorbidities in epilepsy. Given that the major cognitive domains representing cognitive function are interdependent, the associations between neuropsychological abilities underlying these domains can be referred to as a cognitive network. Therefore, the architecture of this cognitive network can be quantified and assessed using graph theory methods, rendering a novel approach to the characterization of cognitive status. We first provide fundamental information about graph theory procedures, followed by application of these techniques to cross-sectional analysis of neuropsychological data in children with epilepsy compared with that of controls, concluding with prospective analysis of neuropsychological development in younger and older healthy controls. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".

Determining patient needs: A partnership with South Carolina Advocates for Epilepsy (SAFE).

PURPOSE: The purpose of this study was to collaborate with a community partner to administer a current needs assessment of persons with epilepsy (PWE) and determine the types of resources that PWE would like to access through the community partner. METHODS: A self-report needs assessment survey was administered to caregivers and PWE across the state of South Carolina during a community partner educational workshop (n=20) and via secure software distributed through an email link (n=54). KEY FINDINGS: The most frequently reported challenges (>50%) were concerns about finding time to participate in epilepsy community activities, the personal safety of the PWE, finding social connections or social support, finding mental or behavioral health services, and work concerns. However, top ranked concerns centered on personal safety (27.8%), lack of insurance/not enough money to pay for epilepsy treatment (15.3%), and difficulty with daily management of epilepsy (13.9%). Participants reported likely engagement with the epilepsy community partner via in-person meetings, over the phone, and through social media contacts; however, there were differences between PWE and caregivers regarding preferences for communication. Almost 60% endorsed that they would likely participate in a brief program to learn skills to manage their epilepsy daily. SIGNIFICANCE: Persons with epilepsy in South Carolina continue to have many unmet needs and would access resources, if available, from a state-wide epilepsy community partner via various modes of communication.

Mapping the landscape of cognitive development in children with epilepsy.

OBJECTIVE: Normal childhood development is defined by age-dependent improvement across cognitive abilities, including language, memory, psychomotor speed and executive function. Epilepsy is often associated with a global disruption in cognitive development, however, it is still largely unknown how epilepsy affects the overall organization of overlapping cognitive domains. The aim of the study was to evaluate how childhood epilepsy affects the developmental interrelationships between cognitive domains. METHODS: We performed a comprehensive assessment of neuropsychological function in 127 children with new onset epilepsy and 80 typically developing children matched for age, gender, and socio-demographic status. A cross-correlation matrix between the performances across multiple cognitive tests was used to assess the interrelationship between cognitive modalities for each group (patients and controls). A weighted network composed by the cognitive domains as nodes, and pair-wise domain correlation as links, was assessed using graph theory analyses, with focus on global network structure, network hubs and community structure. RESULTS: Normally developing children exhibited a cognitive network with well-defined modules, with verbal intelligence, reading and spelling skills occupying a central position in the developing network. Conversely, children with epilepsy demonstrated a less well-organized network with less clear separation between modules, and relative isolation of measures of attention and executive function. CONCLUSION: Our findings demonstrate that childhood-onset epilepsy, even within its early course, is associated with an extensive disruption of cognitive neurodevelopmental organization. The approach used in this study may be useful to assess the effectiveness of future interventions aimed at mitigating the cognitive consequences of epilepsy.

Shifted neuronal balance during stimulus-response integration in schizophrenia: an fMRI study.

Schizophrenia is characterized by marked deficits in executive and psychomotor functions, as demonstrated for goal-directed actions in the antisaccade task. Recent studies, however, suggest that this deficit represents only one manifestation of a general deficit in stimulus-response integration and volitional initiation of motor responses. We here used functional magnetic resonance imaging to investigate brain activation patterns during a manual stimulus-response compatibility task in 18 schizophrenic patients and 18 controls. We found that across groups incongruent vs. congruent responses recruited a bilateral network consisting of dorsal fronto-parietal circuits as well as bilateral anterior insula, dorsolateral prefrontal cortex (DLPFC) and the presupplementary motor area (preSMA). When testing for the main-effect across all conditions, patients showed significantly lower activation of the right DLPFC and, in turn, increased activation in a left hemispheric network including parietal and premotor areas as well as the preSMA. For incongruent responses patients showed significantly increased activation in a similar left hemispheric network, as well as additional activation in parietal and premotor regions in the right hemisphere. The present study reveals that hypoactivity in the right DLPFC in schizophrenic patients is accompanied by hyperactivity in several fronto-parietal regions associated with task execution. Impaired top-down control due to a dysfunctional DLPFC might thus be partly compensated by an up-regulation of task-relevant regions in schizophrenic patients.

Crossmodal emotional integration in major depression.

Major depression goes along with affective and social-cognitive deficits. Most research on affective deficits in depression has, however, only focused on unimodal emotion processing, whereas in daily life, emotional perception is often highly dependent on the evaluation of multimodal inputs. We thus investigated emotional audiovisual integration in patients with depression and healthy subjects. Subjects rated the expression of happy, neutral and fearful faces while concurrently being exposed to emotional or neutral sounds. Results demonstrated group differences in left inferior frontal gyrus and inferior parietal cortex when comparing incongruent to congruent happy facial conditions, mainly due to a failure of patients to deactivate these regions in response to congruent stimulus pairs. Moreover, healthy subjects decreased activation in right posterior superior temporal gyrus/sulcus and midcingulate cortex when an emotional stimulus was paired with a neutral rather than another emotional one. In contrast, patients did not show such deactivation when neutral stimuli were integrated. These results demonstrate aberrant neural response in audiovisual processing in depression, indicated by failure to deactivate regions involved in inhibition and salience processing when congruent and neutral audiovisual stimuli pairs are integrated, providing a possible mechanism of constant arousal and readiness to act in this patient group.

Translating working memory into action: behavioral and neural evidence for using motor representations in encoding visuo-spatial sequences.

The neurobiological organization of action-oriented working memory is not well understood. To elucidate the neural correlates of translating visuo-spatial stimulus sequences into delayed (memory-guided) sequential actions, we measured brain activity using functional magnetic resonance imaging while participants encoded sequences of four to seven dots appearing on fingers of a left or right schematic hand. After variable delays, sequences were to be reproduced with the corresponding fingers. Recall became less accurate with longer sequences and was initiated faster after long delays. Across both hands, encoding and recall activated bilateral prefrontal, premotor, superior and inferior parietal regions as well as the basal ganglia, whereas hand-specific activity was found (albeit to a lesser degree during encoding) in contralateral premotor, sensorimotor, and superior parietal cortex. Activation differences after long versus short delays were restricted to motor-related regions, indicating that rehearsal during long delays might have facilitated the conversion of the memorandum into concrete motor programs at recall. Furthermore, basal ganglia activity during encoding selectively predicted correct recall. Taken together, the results suggest that to-be-reproduced visuo-spatial sequences are encoded as prospective action representations (motor intentions), possibly in addition to retrospective sensory codes. Overall, our study supports and extends multi-component models of working memory, highlighting the notion that sensory input can be coded in multiple ways depending on what the memorandum is to be used for.

Modulation of affective face processing deficits in Schizophrenia by congruent emotional sounds.

Schizophrenia is a psychiatric disorder resulting in prominent impairments in social functioning. Thus, clinical research has focused on underlying deficits of emotion processing and their linkage to specific symptoms and neurobiological dysfunctions. Although there is substantial research investigating impairments in unimodal affect recognition, studies in schizophrenia exploring crossmodal emotion processing are rare. Therefore, event-related potentials were measured in 15 patients with schizophrenia and 15 healthy controls while rating the expression of happy, fearful and neutral faces and concurrently being distracted by emotional or neutral sounds. Compared with controls, patients with schizophrenia revealed significantly decreased P1 and increased P2 amplitudes in response to all faces, independent of emotion or concurrent sound. Analyzing these effects with regard to audiovisual (in)congruence revealed that P1 amplitudes in patients were only reduced in response to emotionally incongruent stimulus pairs, whereas similar amplitudes between groups could be observed for congruent conditions. Correlation analyses revealed a significant negative correlation between general symptom severity (Brief Psychiatric Rating Scale-V4) and P1 amplitudes in response to congruent audiovisual stimulus pairs. These results indicate that early visual processing deficits in schizophrenia are apparent during emotion processing but, depending on symptom severity, these deficits can be restored by presenting concurrent emotionally congruent sounds.

Task- and resting-state functional connectivity of brain regions related to affection and susceptible to concurrent cognitive demand.

A recent fMRI-study revealed neural responses for affective processing of stimuli for which overt attention irrespective of stimulus valence was required in the orbitofrontal cortex (OFC) and bilateral amygdala (AMY): activation decreased with increasing cognitive demand. To further characterize the network putatively related to this attenuation, we here characterized these regions with respect to their functional properties and connectivity patterns in task-dependent and task-independent states. All experiments of the BrainMap database activating the seed regions OFC and bilateral AMY were identified. Their functional characteristics were quantitatively inferred using the behavioral meta-data of the retrieved experiments. Task-dependent functional connectivity was characterized by meta-analytic connectivity modeling (MACM) of significant co-activations with these seed regions. Task-independent resting-state functional connectivity analysis in a sample of 100 healthy subjects complemented these analyses. All three seed regions co-activated with subgenual cingulum (SGC), precuneus (PCu) and nucleus accumbens (NAcc) in the task-dependent MACM analysis. Task-independent resting-state connectivity revealed significant coupling of the seeds only with the SGC, but not the PCu and the NAcc. The former region (SGC) moreover was shown to feature significant resting-state connectivity with all other regions implicated in the network connected to regions where emotional processing may be modulated by a cognitive distractor. Based on its functional profile and connectivity pattern, we suggest that the SGC might serve as a key hub in the identified network, as such linking autobiographic information [PCu], reward [NAcc], (reinforce) values [OFC] and emotional significance [AMY]. Such a role, in turn, may allow the SGC to influence the OFC and AMY to modulate affective processing.

Is there "one" DLPFC in cognitive action control? Evidence for heterogeneity from co-activation-based parcellation.

The dorsolateral prefrontal cortex (DLPFC) has consistently been implicated in cognitive control of motor behavior. There is, however, considerable variability in the exact location and extension of these activations across functional magnetic resonance imaging (fMRI) experiments. This poses the question of whether this variability reflects sampling error and spatial uncertainty in fMRI experiments or structural and functional heterogeneity of this region. This study shows that the right DLPFC as observed in 4 different experiments tapping executive action control may be subdivided into 2 distinct subregions-an anterior-ventral and a posterior-dorsal one -based on their whole-brain co-activation patterns across neuroimaging studies. Investigation of task-dependent and task-independent connectivity revealed both clusters to be involved in distinct neural networks. The posterior subregion showed increased connectivity with bilateral intraparietal sulci, whereas the anterior subregion showed increased connectivity with the anterior cingulate cortex. Functional characterization with quantitative forward and reverse inferences revealed the anterior network to be more strongly associated with attention and action inhibition processes, whereas the posterior network was more strongly related to action execution and working memory. The present data provide evidence that cognitive action control in the right DLPFC may rely on differentiable neural networks and cognitive functions.

Modulating the processing of emotional stimuli by cognitive demand.

Emotional processing is influenced by cognitive processes and vice versa, indicating a profound interaction of these domains. The investigation of the neural mechanisms underlying this interaction is not only highly relevant for understanding the organization of human brain function. Rather, it may also help in understanding dysregulated emotions in affective disorders and in elucidating the neurobiology of cognitive behavioural therapy (e.g. in borderline personality disorder), which aims at modulating dysfunctional emotion processes by cognitive techniques, such as restructuring. In the majority of earlier studies investigating the interaction of emotions and cognition, the main focus has been on the investigation of the effects of emotional stimuli or, more general, emotional processing, e.g. instituted by emotional material that needed to be processed, on cognitive performance and neural activation patterns. Here we pursued the opposite approach and investigated the modulation of implicit processing of emotional stimuli by cognitive demands using an event-related functional magnetic resonance imaging--study on a motor short-term memory paradigm with emotional interferences. Subjects were visually presented a finger-sequence consisting either of four (easy condition) or six (difficult condition) items, which they had to memorize. After a short pause positive, negative or neutral International affective picture system pictures or a green dot (as control condition) were presented. Subjects were instructed to reproduce the memorized sequence manually as soon as the picture disappeared. Analysis showed that with increasing cognitive demand (long relative to short sequences), neural responses to emotional pictures were significantly reduced in amygdala and orbitofrontal cortex. In contrast, the more difficult task evoked stronger activation in a widespread frontoparietal network. As stimuli were task-relevant go-cues and hence had to be processed perceptually, we would interpret this as a specific attenuation of affective responses by concurrent cognitive processing--potentially reflecting a relocation of resources mediated by the frontoparietal network.