Hippocampal GABA transporter distribution in patients with temporal lobe epilepsy and hippocampal sclerosis.

PURPOSE: To determine hippocampal expression of neuronal GABA-transporter (GAT-1) and glial GABA-transporter (GAT-3) in patients with temporal lobe epilepsy (TLE) and hippocampal sclerosis (HS). METHODS: Hippocampal sections were immunohistochemically stained for GABA-transporter 1 and GABA-transporter-3, followed by quantification of the immunoreactivity in the hilus by optical density measurements. GABA-transporter 3 positive hilar cells were counted and GABA-transporter protein expression in sections that included all hippocampal subfields was quantified by Western blot. RESULTS: The hilar GABA-transporter 1 expression of patients with severe hippocampal sclerosis was about 7% lower compared to that in the mild hippocampal sclerosis/control group (p<0.001). The hilar GABA-transporter 3 expression was about 5% lower in the severe hippocampal sclerosis group than in the mild hippocampal sclerosis/control group (non-significant). Also, severe hippocampal sclerosis samples contained 34% less (non-significant) GABA-transporter 3 positive cells compared to that of controls. Protein expression as assessed by Western blot showed that GABA-transporter 1 was equally expressed in mild and severe hippocampal sclerosis samples, whereas GABA-transporter 3 was reduced by about 62% in severe hippocampal sclerosis samples (p<0.0001). CONCLUSION: These data confirm that GABA-transporter expression is spatially and isoform-specific reduced and GABA-transporter 3 positive cell numbers are unchanged in hippocampal sclerosis. Implications for the use of GABAergic antiepileptic therapies in hippocampal sclerosis vs non-hippocampal sclerosis patients remain to be studied.

Effects of an inpatient rehabilitation program after temporal lobe epilepsy surgery and other factors on employment 2 years after epilepsy surgery.

OBJECTIVE: To evaluate the effects of a postsurgical rehabilitation program on employment status 2 years after temporal lobe epilepsy surgery in relation to other predictors. METHODS: Employment outcome 2 years after temporal lobe resection in a group of 232 adult patients with the offer of a 3-week inpatient rehabilitation program immediately after surgery ("Reha group") was compared to a group of 119 patients who had surgery before such a rehabilitation program existed. One hundred thirty-nine (59.9%) of the Reha group patients attended the rehabilitation program. Further predictors for employment outcome were analyzed using multivariate logistic regression analysis. RESULTS: Preoperatively, the groups did not differ significantly in variables relevant for employment, including employment rate. Two years after surgery, the rate of those not being employed had decreased in the Reha group from 38.4% to 27.6% (p < 0.001, McNemar test), and slightly increased in the control group (37.8-42.0%; n.s.), resulting in a difference of 14.4% in favor of the Reha group (p = 0.008). General unemployment rates during the two observation periods were similar. In addition to the offer of rehabilitation support ("Reha group") and preoperative employment, the following other variables were shown as significant predictors of employment post surgery in multivariate regression analysis: seizure outcome, diagnosis of a personality disorder preoperatively, and age at surgery (all, p < 0.01; Nagelkerkes R(2) = 0.59). SIGNIFICANCE: Independently from other factors, a 3-week inpatient rehabilitation program after temporal lobe epilepsy surgery seems to improve employment status 2 years after surgery.

Sturge-Weber syndrome: clinical and radiological correlates in 86 patients.

BACKGROUNDS AND PURPOSE: To correlate the extent of the leptomeningeal angiomatosis with clinical features in Sturge-Weber syndrome (SWS). METHODS: The study group consisted of 86 consecutive patients aged two months to 56 (mean 7.9 +/- 10.3) years with SWS and epilepsy. Clinical and MRI data were analyzed. RESULTS: Based on the extent of leptomeningeal angiomatosis, patients were divided into two subgroups: 43 patients had hemispheric angiomatosis and atrophy, whereas, another 43 had focal involvement. Nine of the 43 hemispherial patients (10%) showed bilateral involvement: all of these bilateral cases demonstrated dominance in a single side with hemispheric leptomeningeal angiomatosis and contralateral focal extension. Hemispheric and focal subgroups were clinically different. Patients with hemispheric SWS were younger at the age of epilepsy onset (p < 0.001) and age at MRI examination (p < 0.05). Neither gender, lateralization, duration of epilepsy, appearance of secondarily generalized seizures, nor seizure frequency revealed a significant difference between subgroups. CONCLUSION: Bilateral involvement is frequent and occurs in cases with a hemisperic involvement on one side. The age of epilepsy onset is related to the extent of leptomeningeal angiomatosis. Patients with hemispheric form of SWS presented with earlier age of seizure onset. Focal pial angiomatoses do not tend to progress (a longer duration is not associated with more frequent hemispheric involvement). Other variables including seizure frequency and secondary generalized tonic-clonic seizures are not associated with the extent of angiomatosis.

Epileptic monocular nystagmus and ictal diplopia as cortical and subcortical dysfunction.

We present the case of a patient with ictal monocular nystagmus and ictal diplopia who became seizure-free after resection of a right frontal focal cortical dysplasia (FCD), type 2B. Interictal neuroophthalmological examination showed several beats of a monocular nystagmus and a spasm of the contralateral eye. An exclusively ictal monocular epileptic nystagmus could be an argument for an exclusively cortical involvement in monocular eye movement control. The interictal findings in our patient, however, argue for an irregular ictal activation of both the cortical frontal eye field and the brainstem.

Determinants of quality of life in patients with refractory focal epilepsy who were not eligible for surgery or who rejected surgery.

UNLABELLED: The aim of the study was to assess the determinants of quality of life (QOL) in adult patients with refractory focal epilepsy who were not eligible for surgery or who rejected surgery after presurgical evaluation. The QOLIE-31, the Hospital Anxiety and Depression Scale and PESOS questionnaire were mailed in 2009 to all adult patients who had been evaluated for suitability for epilepsy surgery between 2001 and 2007 in the Bethel Epilepsy Center and had been deemed not eligible for surgery or had decided against surgery. Questionnaires were sent by post to 359 patients: 172 (47.9%) replied, and of these, 125 patients were eligible for this study. The remaining 47 patients were excluded mainly because they did not fulfill the criteria of refractory epilepsy. Out of the included 125 patients, 106 were considered to be poor surgical candidates for medical reasons, and 19 had decided against surgery. The mean follow-up was 4.1±2.1 years. In the past 6 months, 13.9% of the patients were seizure free, 12 of them (9.6%) were seizure free for one year, 10.7% had 1-2 seizures, 11.5% had 3-5 seizures, 27.0% had one or more seizures a month, 23.0% had one or more seizures a week, and 13.9% had one or more seizures a day. Patient-perceived changes in their seizures since presurgical evaluation were rated by 15.6% of the patients as 'improved significantly', by 28.7% as 'improved', by 46.7% as 'no change', by 6.6% as 'deteriorated' and by 2.5% as 'significantly deteriorated'. Quality of life in patients with refractory epilepsy was much lower compared to operated patients from our center. Multivariate analysis of QOL showed that depression and anxiety are strong predictors but not exclusively. Furthermore, tolerability and efficacy of AEDs are significant predictors of most QOLIE-31 subscales. Employment, seizure frequency, patient-perceived change in their seizures, number of AEDs and the degree of comorbidity appeared as predictors for some aspects of QOL as well. When excluding anxiety and depression, the most important predictors of QOL were tolerability of AEDs and employment. For other aspects of QOL, efficacy of AEDs, gender, number of AEDs, degree of comorbidity and a certificate of disability were additional predictors. The results of the multivariate analysis did not essentially change when seizure-free patients were excluded. CONCLUSION: Quality of life in non-operated patients with refractory epilepsy is significantly lower than in operated patients from the same center. Besides depression and anxiety, patient-rated tolerability and efficacy of AEDs, seizure frequency and employment are the main determinants of QOL.

Unilateral autoscopic phenomena as a lateralizing sign in focal epilepsy.

Positive autoscopic phenomena - autoscopy, heautoscopy and out-of-body experience - may occur in a variety of diseases and also in physiological conditions. They are a rare but probably underreported phenomenon in focal epilepsies. Here, we investigate whether ictal lateralized autoscopic phenomena give lateralizing information about the underlying epileptic focus. We present the cases of seven patients from our center who experienced ictal lateralized autoscopic phenomena and analyzed their focus lateralization and localization of the underlying brain lesion. In addition, we reviewed seven cases published in German and English language literature. In the total group of 14 patients with ictal lateralized autoscopic phenomena, 12 (85.7%) of them had a well-defined epileptic focus contralateral to the side of the autoscopic appearance. Therefore, the data point to an association between ictal lateralized autoscopy and contralateral epileptic focus.

Secondarily generalized seizures in temporal lobe epilepsy.

PURPOSE: Secondarily generalized tonic-clonic seizure (SGTCS) may occur rarely in temporal lobe epilepsy (TLE), but SGTCS is the major risk factor for sudden death and for seizure-related fatal injuries. Our aim was to investigate clinical factors associated with the occurrence of SGTCS in TLE by addressing two questions: (1) What clinical features differentiate patients with TLE who regularly had SGTCS from those who did not? (2) Is there an association of secondarily generalized seizures with preceding seizure elements and clinical data? METHODS: We included 171 patients with TLE (mean age 34.4 ± 10) who participated in our presurgical evaluation program, which included continuous video-electroencephalography (EEG) and magnetic resonance imaging (MRI). Patients had a temporal lobectomy as a result of mesial or neocortical TLE. To reevaluate the archived seizures, we selected the consecutively recorded seizures of each patient. If the patient had more than three recorded seizures, then we reevaluated only the first three. Altogether video-recorded seizures of 402 patients were reanalyzed. KEY FINDINGS: A positive association between the presence of hippocampal sclerosis on the MRI and SGTCS in the patient history was found, whereas ictal speech and pedal automatism showed a negative association with a SGTCS history. The age of patients showed a positive association, whereas patient's reactivity before and during the seizure, oral/pedal automatisms, and vocalizations showed a negative association with secondary generalization of a focal-onset seizure during video-EEG monitoring. SIGNIFICANCE: Clinical features associated with SGTCS may help clinicians during presurgical monitoring identify high-risk patients for SGTCS. Our study may help in understanding the pathophysiology of secondary generalization.

Drug-induced QT-interval shortening following antiepileptic treatment with oral rufinamide.

BACKGROUND: The arrhythmogenic potential of short QT intervals has recently been highlighted in patients with a short QT syndrome. Drug-induced QT-interval prolongation is a known risk factor for ventricular tachyarrhythmias. However, reports on drug-induced QT-interval shortening are rare and proarrhythmic effects remain unclear. OBJECTIVE: Recently, rufinamide, a new antiepileptic drug for the add-on treatment of Lennox-Gastaut syndrome, was approved in the European Union and the United States. Initial trials showed drug-induced QT-interval shortening. The aim of our study was to evaluate the effects of rufinamide on QT intervals in patients with difficult-to-treat epilepsies. METHODS: Nineteen consecutive patients with Lennox-Gastaut syndrome and other epilepsy syndromes were included (n = 12 men; mean age 41 ± 12 years). QRS, QT, and T(peak)-T(end) intervals were analyzed before and during rufinamide treatment. RESULTS: The mean QT interval shortened significantly following rufinamide administration (QT interval 349 ± 23 ms vs 327 ± 17 ms; corrected QT interval 402 ± 22 ms vs 382 ± 16 ms; P = .002). T(peak)-T(end) intervals were 79 ± 17 ms before and 70 ± 20 ms on treatment (P = .07). The mean reduction of the corrected QT interval was 20 ± 18 ms. During follow-up (3.04 ± 1.09 years), no adverse events including symptomatic cardiac arrhythmias or sudden cardiac deaths were observed. CONCLUSION: QTc-interval shortening following oral rufinamide administration in a small patient group was not associated with significant clinical adverse effects. These observations notwithstanding, the ability of rufinamide to significantly shorten the QT interval portends a potential arrhythmogenic risk that may best be guarded against by periodic electrocardiographic recordings.

Radiofrequency lesioning for epileptogenic periventricular nodular heterotopia: a rational approach.

Periventricular nodular heterotopias (PNHs) are frequently associated with pharmacoresistant epilepsy. They are considered part of a dysfunctional network, connected to the overlying cortex. Therefore, removal of the PNHs and additional cortectomy or lobectomy seem to be essential for significant and long-lasting seizure reduction. These procedures, however, can have considerable limitations, especially in patients with functional eloquent cortex adjacent to the PNH. Alternatively, stereotactic neurosurgery can reduce the surgical trauma. Presented is a 56-year-old man who became seizure-free after stereotactically guided radiofrequency lesioning of a solitary PNH.

Long term outcome in patients not initially seizure free after resective epilepsy surgery.

PURPOSE: To assess the long-term seizure outcome and find predictors of outcome for patients who were not initially seizure free 6 months after epilepsy surgery. METHODS: We retrospectively reviewed all adult patients who underwent epilepsy surgery at the Epilepsy Center Bethel, between 1992 and 2003. There were 266 patients included in this analysis. RESULTS: Of the 266 patients who were included in this study, the probability of becoming seizure free was 12% (95%CI 8-16%) after 2 years, 19.5% (95%CI 15-24%) after 5 years and 34.7% (95%CI 28-41%) after 10 years. In patients who had auras only, the probability of being seizure free was 18.2% after 2 years, 25.5% after 5 years, and 39.1% after 10 years. In the multiregression analysis, the EEG carried out 2 years after surgery, a psychic aura, the frequency of postoperative focal seizures and hypermotor seizures predicted seizure remission in the long-term outcome. CONCLUSIONS: The frequency and type of postoperative seizures are critical determinants for long-term outcome. Seizure semiology may be the clue to a precise diagnosis and long-term prognosis of epilepsy.

Management and long-term outcome in patients presenting with ictal asystole or bradycardia.

PURPOSE: Ictal asystole (IA) and ictal bradycardia (IB) are rare autonomic symptoms during epileptic seizures and may be potentially life-threatening. Guidelines for the care of these patients are missing. The aim of this multicenter study was to evaluate the management and long-term outcome in patients with IA and IB. PATIENTS AND METHODS: All patients with IA and IB were included from four epilepsy centers (Bielefeld, Kork, Marburg, and Zürich) from 2002 until 2009. Using a standardized assessment form, clinical data, treatment decisions, and outcomes were extracted from patient charts and simultaneous electroencephalography/electrocardiography (EEG/ECG) recordings. KEY FINDINGS: Seizures with IA or IB were identified in 16 patients. In all patients an associated temporal seizure pattern was recorded and in 15 patients, sudden falls, fainting, or trauma was previously reported or recorded during the monitoring. In three patients (18.8%) diagnosis of focal epilepsy was newly established and anticonvulsive treatment was initiated. Two patients with refractory epilepsy underwent epilepsy surgery. In seven patients (43.8%) a cardiac pacemaker was implanted. In 14 of 16 treated patients, seizure freedom (n = 5) or absence of sudden falls, fainting, or trauma (n = 9) could be achieved. Two patients denied epilepsy surgery as well as a pacemaker and continue to have frequent falls and trauma. SIGNIFICANCE: Our study demonstrates that epilepsy surgery and antiepileptic drugs may lead to sustained freedom of seizures as well as ictal syncope. In drug-resistant patients not suitable for epilepsy surgery, implantation of a cardiac pacemaker may prevent sudden falls as well as trauma. Based on our results and previously reported cases we propose a treatment algorithm.

Analysis of reoperation in mesial temporal lobe epilepsy with hippocampal sclerosis.

BACKGROUND: Most patients do well after epilepsy surgery for mesial temporal lobe sclerosis, and in only 8 to 12% of all operations, the outcome is classified as not improved. OBJECTIVE: To analyze the outcome of reoperation in cases of incomplete resection of mesial temporal lobe structures in patients with mesial temporal lobe sclerosis in temporal lobe epilepsy. METHODS: We analyzed 22 consecutive patients who underwent reoperation for mesial temporal lobe sclerosis (follow-up, 23-112 months; mean, 43.18 months) by evaluating noninvasive electroencephalographic/video monitoring before the first and second surgeries (semiology, interictal epileptiform discharges, ictal electroencephalography with special attention to the secondary contralateral evolution of the electroencephalographic seizure pattern after the initial regionalization), and magnetic resonance imaging (resection indices after the first and second surgeries on the amygdala, hippocampus, lateral temporal lobe). In 18 of 22 patients T2 relaxometry of the contralateral hippocampus was performed. RESULTS: Nine of 22 patients became seizure free; another 4 patients had a decrease in seizures and eventually became seizure free (range, 16-51 months; mean, 30.3). Recurrence of seizures is associated with (1) ictal electroencephalography with later evolution of an independent pattern over the contralateral temporal lobe (0 of 5 patients seizure free vs 5 of 7 patients non-seizure free; P = .046) and (2) a smaller amount of lateral temporal lobe resection in the second surgery (1.06 ± 0.59 cm vs 2.18 ± 1.37 cm; P = .019). No significant correlation with outcome was found for lateralization of interictal epileptiform discharges, change in semiology, other resection indices, T2 relaxometry, onset and duration of epilepsy, duration of follow-up, and side of surgery. CONCLUSION: Patients have a less favorable outcome with a reoperation if they show ictal scalp electroencephalography with secondary contralateral propagation and if only a small second resection of the lateral temporal lobe is performed.

Apical temporal lobe resection; "tailored" hippocampus-sparing resection based on presurgical evaluation data.

BACKGROUND: It is the aim of epilepsy surgery in patients with lesional epilepsy for the surgeon to not only remove the lesion itself, but also the epileptogenic zone. Here, we report our experience with a modified temporal resection technique confined to the apical temporal lobe, i.e., sparing the hippocampal formation in patients with epileptogenic lesions in the anterior part of the temporal lobe. This apical temporal lobe resection (aTLR) includes tailored lesionectomy, amygdalectomy, and resection of the mesial structures only in the apex of the temporal lobe. This paper presents our surgical technical details and the outcome of aTLR. METHODS: Between 2001 and 2008, aTLR was performed in 61 patients. All patients underwent comprehensive presurgical evaluation including video-EEG monitoring, magnetic resonance imaging (MRI), and neuropsychological testing. All patients had a lesion in the apex of the temporal lobe and a normal hippocampus as seen in MRI, as well as intact memory functions in neuropsychological examination. There were 33 males (54.1%) and 28 females (45.9%). The mean age in years at epilepsy onset was 20.2 ± 13.4, the mean age at epilepsy surgery was 32.1 ± 11.9, the mean preoperative epilepsy duration was 11.8 ± 8.8 years and the mean duration of follow-up was 2.1 ± 1.3 years (range 0.5-6 years). RESULTS: Fifty-four (88.5%) of 61 patients were in Engel Class 1 at 6 months, 38 (80.9%) of 47 at 2 years and nine (81.8%) of 11 at the 5 year follow-up. Histopathological examination showed tumors in 31 patients, FCD in ten patients, amygdala sclerosis in seven patients, cavernomas in six patients, unspecific reactions in eight patients, and gliosis in one patient. Surgical complications occurred in four patients: one had a permanent and three had transient complications which could be successfully treated. Fifty (82%) resections were considered to be complete resections as evaluated by serial postoperative MRI, seven patients (11.5%) had incomplete resection of the preoperative MRI lesion and in four patients (6.6%) it remained unclear. Fifteen patients (29.4%) were withdrawn from antiepileptic drugs for more than 2 years without relapse. Postoperative neuropsychological examination revealed worsening of memory performance in two patients (3.2%) and improved or no changes in the rest of the patients. CONCLUSIONS: Apical temporal resection sparing the mesial temporal structures is an effective procedure with good long-term seizure outcome in patients with refractory epilepsy due to lesions confined to the apex of the temporal lobe.

Presurgical language fMRI activation correlates with postsurgical verbal memory decline in left-sided temporal lobe epilepsy.

We analysed the association of presurgical language fMRI activations and postsurgical verbal memory changes in 16 left-sided mesial temporal lobe epilepsy patients with initially intact memory. Patients with severe verbal memory decline after surgery (n = 9) had stronger presurgical fMRI activations within the left posterior temporal lobe, compared to those with no decline (n = 7). Language fMRI activation may predict verbal memory outcome, even in patients with a high risk of postsurgical memory deterioration.

Absolute spike frequency and etiology predict the surgical outcome in epilepsy due to amygdala lesions.

PURPOSE: To identify surgical prognostic factors for temporal lobe epilepsy (TLE) due to amygdala lesions. METHODS: We included 42 patients (mean age: 31.4 ± 11) who underwent presurgical evaluation including long-term video-EEG and in whom the high-resolution MRI showed amygdala lesions without hippocampal abnormalities. All patients had apical temporal lobe resection without hippocampectomy. We distinguished patients with frequent spikes (spike frequency ≥ 60/h) and with non-frequent spikes (< 60 spikes/h). RESULTS: At the 2-year postoperative evaluation, 30 patients (71%) were seizure-free. The presence of infrequent spikes (p = 0.013), tumor on the MRI (p = 0.027), and no epilepsy history in the family (p = 0.027) were independently associated with 2-year seizure-free outcome. Of 33 patients with infrequent spikes, 79% became seizure-free, while of 9 patients with frequent spikes only 4 had a favorable surgical outcome (44%). CONCLUSION: In TLE patients due to amygdala lesions, high spike frequency and family history of epilepsy predicted an unfavorable, while tumoral etiology a favorable outcome after apical temporal lobe resection without hippocampectomy. Seventy-one percent of patients with amygdalar epilepsy who underwent this novel type of epilepsy surgery became seizure-free. This is comparable with results of "classical" anterior temporal lobe resections where hippocampus is NOT spared. Moreover, the surgical outcome may be predictable.

Alterations of decision making and underlying neural correlates after resection of a mediofrontal cortical dysplasia: A single case study.

We investigated the impact of a congenital prefrontal lesion and its resection on decision making under risk and under ambiguity in a patient with right mediofrontal cortical dysplasia. Both kinds of decision making are normally associated with the medial prefrontal cortex. We additionally studied pre- and postsurgical fMRI activations when processing information relevant for risky decision making. Results indicate selective impairments of ambiguous decision making pre- and postsurgically. Decision making under risk was intact. In contrast to healthy subjects the patient exhibited no activation within the dysplastic anterior cingulate cortex but left-sided orbitofrontal activation on the fMRI task suggesting early reorganization processes.

Vagus nerve stimulation: outcome and predictors of seizure freedom in long-term follow-up.

OBJECTIVES: To present long-term outcome and to identify predictors of seizure freedom after vagus nerve stimulation (VNS). METHODS: All patients who had undergone VNS implantation in the Epilepsy Centre Bethel were retrospectively reviewed. There were 144 patients who had undergone complete presurgical evaluation, including detailed clinical history, magnetic resonance imaging, and long-term video-EEG with ictal and interictal recordings. After implantation, all patients were examined at regular intervals of 4 weeks for 6-9 months. During this period the antiepileptic medication remained constant. All patients included in this study were followed up for a minimum of 2 years. RESULT: Ten patients remained seizure-free for more than 1 year after VNS implantation (6.9%). Seizures improved in 89 patients (61.8%) but no changes were observed in 45 patients (31.3%). The following factors were significant in the univariate analysis: age at implantation, multifocal interictal epileptiform discharges, unilateral interictal epileptiform discharge, cortical dysgenesis, and psychomotor seizure. Stepwise multivariate analysis showed that unilateral interictal epileptiform discharges (IEDs), P=0.014, HR=0.112 (95% CIs, 0.019-0.642), cortical dysgenesis P=0.007, HR=0.065 (95% CIs, 0.009-0.481) and younger age at implantation P=0.026, HR=7.533 (95% CIs 1.28-44.50) were independent predictors of seizure freedom in the long-term follow-up. CONCLUSION: VNS implantation may render patients with some forms of cortical dysgenesis (parietooccipital polymicrogyria, macrogyria) seizure-free. Patients with unilateral IEDs and earlier implantation achieved the most benefit from VNS.

Prevalence of anxiety disorders in patients with refractory focal epilepsy--a prospective clinic based survey.

Comorbid anxiety disorders severely affect daily living and quality of life in patients with epilepsy. We evaluated 97 consecutive outpatients (41.2% male, mean age=42.3+/-13.2 years, mean epilepsy duration=26.9+/-14.2 years) with refractory focal epilepsy using the German version of the anxiety section of the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Nineteen patients (19.6%) were diagnosed with an anxiety disorder (social phobia, 7.2%; specific phobia, 6.2%; panic disorder, 5.1%; generalized anxiety disorder, 3.1%; anxiety disorder not further specified, 2.1%; obsessive-compulsive disorder, 1.0%; posttraumatic stress disorder, 1.0%). Four-week prevalence rates reported elsewhere for the general population in Germany are 1.24% for social phobia, 4.8% for specific phobia, 1.1% for panic disorder, 1.2% for generalized anxiety disorder, 1.3% for anxiety disorder not further specified, and 0.4% for obsessive-compulsive disorder. A trend for people with shorter epilepsy duration (P=0.084) and younger age (P=0.078) being more likely to have a diagnosis of anxiety disorder was revealed. No gender differences were found; however, this may be due to the small sample size. In conclusion, anxiety disorders are frequent in patients with refractory focal epilepsy, and clinicians should carefully examine their patients with this important comorbidity in mind.

Ictal affective symptoms in temporal lobe epilepsy are related to gender and age.

PURPOSE: We systematically analyzed the video-recorded and patient-reported, as well as positive and negative ictal affective symptoms (IAS) in temporal lobe epilepsy (TLE). Our aim was to assess (1) frequency, (2) gender effect, (3) lateralizing significance, (4) localizing value, and (5) prognostic significance in epilepsy surgery of IAS in patients with video-registered seizures. METHODS: We reviewed ictal video recordings of 184 patients (99 women, aged 16-63). All patients had surgery for intractable TLE with video-recorded complex partial seizures (CPS) due to temporal lobe lesions visualized by high-resolution magnetic resonance imaging (MRI). Affective auras (AAs) were categorized into two groups: positive or negative. RESULTS: We registered AAs in 18% of patients: positive in 3%, negative in 15%. We saw ictal affective behavior (IAB) in 22% of patients; 10% had positive, whereas 14% had negative IAB. Two patients had both positive and negative IAB. AAs showed an association with IAB in case of fear expression versus fear auras (p = 0.018). IAB, especially negative IAB, occurred more often in women than in men. Patients with negative IAB were younger than others. We could not demonstrate an association between IAS and the localization, lateralization, or hemispheric dominance. Surgical outcome did not associate with IAS. DISCUSSION: Patient-reported and video-recorded negative-but not positive-affective signs are related to each other. Video-recorded negative AAs occur more often in women and young patients.

Topiramate overdose: a case report of a patient with extremely high topiramate serum concentrations and nonconvulsive status epilepticus.

We report the case of a 21-year-old man with idiopathic generalized epilepsy who ingested about 8,000 mg of topiramate (TPM) in a suicide attempt. On admission to the hospital he had a nonconvulsive status epilepticus and received 4 mg lorazepam i.v. He recovered rapidly despite an initial TPM concentration of 144.6 microg/ml. To our knowledge, this is the first report of a patient who survived such a high TPM concentration. The case indicates that nonconvulsive status epilepticus could be a manifestation of TPM intoxication.