Presurgical evaluation in refractory epilepsy secondary to meningitis or encephalitis: bilateral memory deficits often preclude surgery.

We investigated the clinical features and surgical outcome of 17 patients with refractory epilepsy secondary to CNS infection who were referred to a tertiary center for presurgical evaluation. Six patients had a history of meningitis and 11 patients had a history of encephalitis. Median age at infection was three years (40 days-40 years). Time to seizure onset was shorter in the encephalitis group (median of 0.9 years versus 5.9 years in the meningitis group). MRI showed unilateral mesial temporal sclerosis (MTS) in all but one patient with meningitis (5/6). MRI in the encephalitis group showed unilateral MTS (four patients), bilateral MTS (three), porencephalic cysts (one) or no significant findings (three). Seizure semiology, following analysis of 127 seizures, included automotor seizures, complex motor/hypermotor seizures, dialeptic seizures and bilateral asymmetric tonic seizures. Neuropsychological assessment in patients with MTS frequently showed bilateral memory impairment (7 out of 12 MTS-patients), even in 4 patients with unilateral MTS, precluding epilepsy surgery. Six patients (two meningitis and four encephalitis patients) underwent a temporal lobe resection. All patients are either seizure-free (Class 1a) or are having only auras after surgery. One patient from the meningitis group underwent functional hemispherectomy and he is also seizure-free. In our series, MTS was the most common finding in refractory epilepsy after CNS infections. Bilateral memory deficits were often encountered in patients with MTS, even when unilateral, these deficits being a limiting factor for surgery. Good surgical outcome can be expected in selected patients with unilateral MTS and congruent memory deficits.

Psychiatric disorders in temporal lobe epilepsy patients over the first year after surgical treatment.

OBJECTIVE: To evaluate the psychiatric disorders over a 1-year period in a group of TLE patients who underwent surgery. METHODS: Prospective, open study in a sample of 70 TLE patients. Psychiatric disorders' assessment was made before surgery, and at 1, 6 and 12 months after surgery, with the structured clinical diagnostic interview for DSM-IV axis I diagnoses (SCID). Presurgical psychiatric and neurological variables were compared with the outcomes of surgery and the course of psychiatric pathology over the follow-up through parametric and non-parametric tests. RESULTS: Depression decreased from 17.2% before surgery to 4.3% at 12 months after surgery (chi(2)=5.41, d.f.=1, p=0.071), anxiety disorders decreased from 21.5% before surgery to 14.2% at 12 months after surgery (chi(2)=10.309, d.f.=1, p<0.005). Patients with no presurgical psychiatric condition had lower postsurgical rate of psychiatric disorders than those with psychiatric history (X(2)=9.87, gl=1, p< or =0.001), with psychiatric disorders in the presurgical evaluation (X(2)=12.02, gl=1, p< or =0.001), or with both conditions (chi(2)=15.28, d.f.=1, p<0.001). No association was found between psychiatric disorders and the outcomes after surgery. No association was found between the course of psychiatric disorders before and after surgery and neurological or neurosurgical variables. CONCLUSIONS: Surgery in TLE patients does not worsen the global psychopathological status. Presurgical psychiatric morbidity was found to be related to the presence of psychiatric disorders after surgery. Specific psychiatric assessment should be made before and after surgery.

Neuropsychological tests with lateralizing value in patients with temporal lobe epilepsy: reconsidering material-specific theory.

PURPOSE: To assess the ability of neuropsychological tests to determine the side of seizure onset for preoperative assessment in patients with drug-resistant temporal lobe epilepsy. METHODS: Twenty-nine consecutive patients diagnosed with temporal lobe epilepsy (TLE), in whom the epileptogenic focus was clearly identified and localized to either the right or left hemisphere. Patients underwent a full neuropsychological assessment as part of their pre-surgical investigation, including the Boston Naming Test (BNT) and a variety of Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) and Wechsler Memory Scale-Third Edition (WMS-III) subtests. Two multivariate analyses of variance were carried out to assess differences on memory and language measures between groups according to side of epileptogenic focus. Binary logistic regression analysis was performed to find the sets of tests that best predicted the side of seizure onset (determined by EEG and MRI). RESULTS: Memory multivariate analysis of variance failed to show significant differences between the right- and left-sided groups. Among language measures, only the BNT revealed significant differences between the groups. The neuropsychological measures that best predicted the side of seizure onset were the BNT and Visual Reproduction II. CONCLUSIONS: Language measures predict the side of seizure focus better than memory measures. The results of this study in a sample of drug-resistant temporal lobe epilepsy patients challenge the memory material-specific theory for the side of seizure focus.

Presurgical evaluation and cognitive functional reorganization in Fishman syndrome.

Fishman syndrome, also known as encephalocraniocutaneous lipomatosis (ECCL), is a rare, congenital neurocutaneous syndrome characterized by unilateral skin, eye, and brain abnormalities. Epileptic seizures and developmental delay are usually present. We report the clinical, radiological, and, for the first time, neurophysiological findings in a 24-year-old woman diagnosed with ECCL who was evaluated for epilepsy surgery. Functional magnetic resonance imaging revealed transfer of memory and language functions to the nonaffected hemisphere, providing evidence that functional reorganization and restoration of cognitive functions may occur in the context of extensive malformations, such as neurocutaneous syndromes.