Psychiatric outcome of surgery for temporal lobe epilepsy and presurgical considerations.

In recent years, surgery has become a treatment option for some patients with intractable epilepsy, particularly those with temporal lobe epilepsy. Psychiatric disturbances may complicate the postsurgical outcome in some patients and de novo psychiatric symptoms have been reported. In many but not all epilepsy surgical centres, a psychiatric assessment is included as part of the presurgical evaluation of potential candidates for surgery. This review indicates that affective disorders, namely, depression and anxiety, and psychosis are the most frequently reported postsurgical psychiatric disturbances. Whilst there are no absolute psychiatric contraindications to surgery, certain pre-existing psychiatric conditions may need careful consideration as there may be a risk of postsurgical psychiatric complications. Routine pre- and postsurgical psychiatric evaluations in patients undergoing epilepsy surgery are recommended. Clinicians involved in the care of surgical candidates should be aware of the possible psychiatric complications following surgery and ensure that the psychiatric risks are discussed with the patient and family.

Increased sensitivity to pathological brain changes using co-registration of magnetic resonance imaging scans.

PURPOSE: To compare automatic software-based co-registration of serial magnetic resonance imaging (MRI) scans with conventional visual comparison, by expert neuroradiologists. MATERIAL AND METHODS: Sixty-four patients who were referred to our epilepsy MRI unit for cerebral imaging were identified as having potentially, non-, or slow-growing lesions or cerebral atrophy and followed with sequential scans over a period of up to 8 years, resulting in a total of 92 pairs of scans. Scans were categorized as showing either lesions or atrophy. Each pair of scans was reviewed twice for the presence of change, with and without co-registration, performed using automated software. RESULTS: Co-registration and visual reporting without co-registration were discordant in the lesions group in nine out of 69 datasets (13%), and in 16 out of 23 pairs of scans in the atrophy group (69%). The most common cause of discordance was visual reporting not detecting changes apparent by co-registration. In three cases, changes detected visually were not detected following co-registration. CONCLUSION: In the group of patients studied, co-registration was more sensitive for detecting changes than visual comparison, particularly with respect to atrophic changes of the brain. With the increasing availability of sophisticated independent consoles attached to MRI scanners that may be used for image co-registration, we propose that serial T1-weighted volumetric MRI brain co-registration should be considered for integration into routine clinical practice to assess patients with suspected progressive disease.

Autonomic involvement in tick-borne encephalitis (TBE): report of five cases.

BACKGROUND: Tick-borne encephalitis (TBE) is a viral infection of the CNS with significant acute and long-term morbidity. Dysfunction of the autonomic nervous system may be a potentially harmful complication of TBE. MATERIAL AND METHODS: In a retrospective case series, 5 patients with acute TBE were evaluated for clinical signs of autonomic dysfunction and subject to autonomic testing. Heart rate variability (HRV) with 6 per minute deep breathing was performed between day 9 to 31 after onset of meningitis. Follow-up data were available in three cases. RESULTS: All patients showed clinical signs of autonomic dysfunction, including upper and lower gastrointestinal tract symptoms, orthostatic hypotension, and urinary retention. A reduced HRV was observed in 4 patients, with sustained sinus tachycardia in 2 of them. The minimum of the HRV was reached 9 to 20 days after onset of meningitis. In one patient, normalization of the HRV occurred within 3 months. CONCLUSION: Acute TBE can be associated with autonomic dysfunction including reduced HRV and tachycardia. Prospective studies are needed to analyze the incidence of autonomic dysfunction in TBE, and to clarify which patients have the highest risk for autonomic failure.

Oxygen: modulator of physiological and pathophysiological processes in the liver.

Oxygen has important functions as substrate for biochemical reactions and as modulator of gene expression. In the liver, the physiologically occurring oxygen gradient is a major effector of metabolic zonation. In addition, cross-talks between the O2 signaling and nutrient signaling chains initiate a dynamic zonation pattern. Under pathological situations, hypoxia appears to be a major determinant for liver diseases and cancer. Thereby transcription factors of the HIF family are activated whereas USF proteins have the potential to counteract HIFs. In addition, feedback mechanisms between hypoxia, HIF and the IGF axes appear to exist. Thus, the knowledge of these mechanisms may help to initiate new therapies in diseases with disturbed O2 availability.

Selective activation of ectopic grey matter during motor task.

The role of ectopic grey matter in neuronal migration disorders is still a matter of debate. Using fMRI we studied the activation pattern of ectopic and regular cortical neurons in a female patient with subcortical bilateral laminar heterotopia (double cortex syndrome) performing a simple motor task. We demonstrate a synchronous activation pattern of the motor cortex and the adjacent subcortical ectopic grey matter layer during finger-tapping. We also observed activation in the cerebellum ipsilaterally and in the basal ganglia contralaterally. The present findings are consistent with the hypothesis that ectopic neurons may be functionally integrated in motor circuits during repetitive voluntary movements.

Reproductive dysfunction in women with epilepsy: recommendations for evaluation and management.

BACKGROUND: Epilepsy is commonly associated with reproductive endocrine disorders. These include polycystic ovary syndrome (PCOS), isolated components of this syndrome such as polycystic ovaries, hyperandrogenaemia, hypothalamic amenorrhoea, and functional hyperprolactinaemia. OBJECTIVE: To summarise the currently known relations between epilepsy and reproductive endocrine disorders. METHODS: A review of clinical experience and published reports. RESULTS: The most likely explanations for endocrine disorders related to epilepsy or antiepileptic drugs are: (1) a direct influence of the epileptogenic lesion, epilepsy, or antiepileptic drugs on the endocrine control centres in the brain; (2) the effects of antiepileptic drugs on peripheral endocrine glands; (3) the effects of antiepileptic drugs on the metabolism of hormones and binding proteins; and (4) secondary endocrine complications of antiepileptic drug related weight changes or changes of insulin sensitivity. Regular monitoring of reproductive function at visits is recommended, including questioning about menstrual disorders, fertility, weight, hirsutism, and galactorrhoea. Particular attention should be paid to patients on valproate and obese patients or those experiencing significant weight gain. Single abnormal laboratory or imaging findings without symptoms may not constitute a clinically relevant endocrine disorder. However, patients with these kinds of abnormalities should be monitored to detect the possible development of a symptomatic disorder associated with, for example, menstrual disorders or fertility problems. CONCLUSIONS: If a reproductive endocrine disorder is found, antiepileptic drug treatment should be reviewed to ensure that it is correct for the particular seizure type and that it is not contributing to the endocrine problem. The possible benefits of a change in treatment must be balanced against seizure control and the cumulative side effect of alternative agents.

Serum androgens return to normal after temporal lobe epilepsy surgery in men.

BACKGROUND: Epileptic discharges from the temporal lobe may influence the release of hormones from the hypothalamic-pituitary axis. If epilepsy surgery influences the underlying epileptic disorder one might expect serum hormone concentrations to return to normal following surgery. PATIENTS: Twenty-two men with epilepsy aged 25 to 48 years (mean, 34.9 years) were investigated before surgery and at 3, 6, and 12 months after surgery. Medication (all patients received carbamazepine) was maintained following surgery. METHODS: Hormone measurements included luteinizing hormone, follicle stimulating hormone, estradiol, testosterone, free testosterone, androstenedione, prolactin, dehydroepiandrosterone sulfate, cortisol, growth hormone, and sex hormone-binding globulin. These hormone levels were compared with those of 105 healthy men (mean age, 33.9 years). RESULTS: Fourteen of the 22 patients (63.6%) achieved total seizure control following epilepsy surgery. The 14 patients with successful seizure control entered further analysis. Before surgery these patients' free testosterone and androstenedione concentrations were significantly lower compared with healthy men. In seven of the 14 patients a significant increase of hormone serum concentrations could be demonstrated for testosterone, free testosterone, and androstenedione. Laterality of epileptic focus, enzyme-inducing medication, stress, and the decreasing number of patients during the follow-up did not correlate with the finding of a normalization of serum androgens. PATIENTS without complete seizure control did not show an increase in serum androgen concentrations. CONCLUSION: Successful temporal lobe epilepsy surgery may lead to a normalization of serum androgen concentrations in men with epilepsy.

The impact of epilepsy surgery on sex hormones and the menstrual cycle in female patients.

We investigated the impact of temporal lobe epilepsy surgery on sex hormones and menstrual cycles. Sixteen female patients with temporal lobe epilepsy were investigated prior to surgery and 3, 6, and 12 months after surgery. The patients received carbamazepine (CBZ) as monotherapy (10 patients) or in combination with other antiepileptic drugs (six patients). Antiepileptic drugs were maintained after surgery. During the 1-year follow-up after surgery eight patients (50%) remained completely free of seizures. In another four patients (25%) only rare disabling seizures occurred. There were no significant differences between pre-surgical and post-surgical serum concentrations of testosterone, free testosterone, prolactin, dehydroepiandrosterone sulfate, growth hormone, cortisol and sex hormone binding globulin. There was, however, a significant increase in serum androstenedione concentration 6 months post-surgically (P < 0.02). Documentation of menstrual cycles in addition to laboratory parameters revealed individual post-surgical changes of the menstrual cycle in eight patients. Four patients had a change in menstrual periodicity: two patients with complete seizure control had regular cycles instead of oligomenorrhoea and two patients with incomplete seizure control had oligomenorrhoea instead of regular cycles. These data indicate that at least in some patients with temporal lobe epilepsy surgical treatment influences menstrual periodicity.

Serum sex hormones are altered in patients with chronic temporal lobe epilepsy receiving anticonvulsant medication.

PURPOSE: To evaluate the changes in serum sex hormones of gonadal or adrenal origin, the gonadotropic hormones, and sex hormone-binding globulin (SHBG) in men and women with chronic temporal lobe epilepsy (TLE), who are undergoing monotherapy with carbamazepine or receiving carbamazepine in combination with other anticonvulsant drugs. METHODS: Gonadal hormones (estradiol, testosterone, free testosterone, and inhibin B), adrenal hormones [cortisol, dehydroepiandrosterone sulfate (DHEAS), androstenedione, and 17alpha-hydroxyprogesterone], and gonadotropic hormones (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) were measured in 22 women and 26 men with TLE. The study also measured prolactin; human growth hormone and its major mediator, insulin-like growth factor-I; thyroid hormones (free thyroxine and free triiodothyronine); thyroid-stimulating hormone (TSH); and SHBG. The results were compared with those obtained from 60 healthy women and 106 healthy men. RESULTS: In the female patients, TSH, DHEAS, follicular-phase LH, and luteal-phase estradiol were significantly lower than in the control groups, with prolactin and SHBG significantly higher. In the male patients, DHEAS, 17alpha-hydroxyprogesterone, free testosterone, inhibin B, and the testosterone/LH ratio were significantly lower than in the control group, with LH, FSH, and SHBG significantly higher. Increased FSH in 31% of the men indicates an impairment of spermatogenesis; lowered inhibin B in 12% indicates an impaired Sertoli's cell function; and the decreased testosterone/LH ratio in 50% indicates an impaired Leydig's cell function. CONCLUSIONS: The case patients had endocrine disorders, mainly concerning the gonadotropic and gonadal functions in both sexes; the adrenal function, with lowered DHEAS levels in both sexes; and lowered 17alpha-hydroxyprogesterone levels in the men. SHBG levels were increased in patients taking anticonvulsant medications.

[Epilepsy in the very old]. / Epilepsien im höheren Lebensalter.

Epilepsy ist the third most common neurological disease of the elderly. In the elderly the incidence is higher than in childhood and adolescence. Cerebrovascular diseases are in 50% of the cases the most common cause for a seizure beyond the age of sixty. The importance of neoplasias is often overestimated. The risk for a renewed seizure after a first seizure is higher in the senium than in youth. Furthermore, the incidence of seizure-related injuries is increased in the elderly and therefore, anticonvulsive therapy must be started early with guaranteed compliance. With regard to therapy, the altered pharmacokinetics in senium must be considered. The drug of first choice is carbamazepine. If a monotherapy with carbamazepine, phenytoin or valproate does not control the seizures a combination with one of the new antiepileptic drugs must be initiated. Due to their pharmacokinetic characteristics, the new drugs-such as vigabatrin, gabapentin and lamotrigine-are specially suitable in the therapy of elderly patients. In case of undesirable side effects, monotherapy with one of the new anti-convulsants ought to be considered.

The effect of a synthetic GnRH analogue on catamenial epilepsy: a study in ten patients.

Ten female patients suffering from catamenial epilepsy were treated with a synthetic analogue of the gonadotrophin releasing hormone (GnRH) in addition to antiepileptic drugs. Three of the patients became seizure free, in four patients seizure frequency decreased and in one patient seizures were of shorter duration. In only two of the patients was there no therapeutic effect. Adverse effects, including hot flushes, headache and increase in weight, were noticed in eight patients. These results support the hypothesis that treatment with a synthetic GnRH analogue might be helpful in patients with intractable catamenial epilepsies.

[Etiology, follow-up and therapy of seizure clusters in temporal lobe epilepsy and catamenial epileptic seizures]. / Ursachen, Verlauf und Therapie von Anfallsclustern bei Temporallappenepilepsien und katamenialen epileptischen Anfällen.

The phenomenon of seizure clustering is still poorly understood. We therefore investigated 192 patients with temporal lobe epilepsies among whom 60 showed clustering of seizures. The percentage of women was significantly higher in the cluster than in the non-cluster group, the history of epilepsy lasted longer and the excess of complex partial seizures over tonic clonic seizures was more prominent in the cluster group. In 46 out of the 60 patients the clustering did not occur initially but developed in the course of the disease. In a particular subgroup the development initiated with isolated tonic clonic seizures, in a later phase complex partial seizures appeared and finally only complex partial seizures remained. This type of history was found significantly more frequent in the cluster than in the non-cluster group (27% versus 7%). It is conjectured that endogenous, as well as exogenous factors, both of them not completely revealed, cause the occurrence of clusters; anticonvulsant drug therapy might even enlarge this trend. Patients with seizure clustering tend to be pharmacoresistant. Chronic therapy with antiepileptic drugs besides intermittent therapy with benzodiazepines may help. A particular type of seizure clustering is observed in catamenial epilepsies where seizures appear in the perimenstrual and/or periovulatory phase of the menstrual hormonal cycle of females. This type of seizure incidence is obviously influenced by hormonal rhythms. Ten patients suffering from catamenial epileptic seizures were therefore treated with a synthetic analogue of GnRH in order to suppress the menstrual hormonal rhythm. As a result 3 patients became seizure free and in 5 patients seizure frequency decreased.

The influence of stimulus type on the magnetic excitation of nerve structures.

The voltage measured was that induced in a measuring coil from 3 different commercially available magnetic stimulators. The strongest stimulus was from the Cadwell, followed by Novametrix and then Digitimer. The Digitimer and Novametrix produced a monophasic pulse, whilst the Cadwell stimulator produced a polyphasic pulse, all measured by an induction coil. This is thought to be the reason why reversed coil polarity does not influence the position of peripheral nerve excitation with a Cadwell stimulator; this is, however, the case with the two other magnetic stimulators. Nevertheless, electrical stimulation was found to be the most useful method for exciting peripheral nerves. The lack of influence of Cadwell coil polarity on the excitation of spinal roots and motor cortex is also thought to be due to the bipolar stimulus effect mentioned above. The stimuli induced by Digitimer and Novametrix are monophasic, exciting one hemisphere first, depending on the direction of the current impulse. The stimulus generated by Cadwell excites both hemispheres by reversal of current direction.

[The study of the central motor conduction time to the leg: normal findings and methodologic observations]. / Die Untersuchung der zentralen motorischen Leitungszeit zur unteren Extremität, Normalbefunde und methodische Anmerkungen.

Central motor conduction time (CMCT) is calculated by subtracting latencies from each other measured to a target muscle after transcranial brain stimulation and after stimulation of lumbar spinal nerve roots. Transcranial magnetoelectrical stimulation of the motor cortex has proved to be the most useful method. However this is not true for transcutaneous stimulation of lumbar roots. In healthy subjects electrical root stimuli given at T12/L1 produced compound muscle responses in Tibialis anterior muscles in all 18 trials. However, magnetoelectrical stimulation (100% stimulus strength) evoked responses in only 8 (Novametrix) and 12 out of 18 trials (Cadwell). Stimulation with the Digitimer D190 was less effective. Additionally compound responses after electrical root excitation were more consistent and they had a higher amplitude compared with magnetoelectrical stimulation. Regarding to these results electrical lumbar root stimulation is thought to be the advantageous method despite it is slightly more uncomfortable. Therefore normal results of CMCT to Tibialis anterior (shown in Table 1) are measured after magnetoelectrical transcranial (Digitimer D190) and transcutaneous electrical stimulation of spinal nerve roots. If the peripheral motor conduction is delayed normal values have to be adapted since CMCT is thought to involve a proximal anterior root segment. An intraspinal motor conduction time can be calculated from CMCT to upper and lower extremities.