Comparison of minimally invasive to standard temporal lobectomy approaches to epilepsy surgery: Seizure relief and visual confrontation naming outcomes.

The purpose of this study was to systematically examine three different surgical approaches in treating left medial temporal lobe epilepsy (mTLE) (viz., subtemporal selective amygdalohippocampectomy [subSAH], stereotactic laser amygdalohippocampotomy [SLAH], and anterior temporal lobectomy [ATL]), to determine which procedures are most favorable in terms of visual confrontation naming and seizure relief outcome. This was a retrospective study of 33 adults with intractable mTLE who underwent left temporal lobe surgery at three different epilepsy surgery centers who also underwent pre-, and at least 6-month post-surgical neuropsychological testing. Measures included the Boston Naming Test (BNT) and the Engel Epilepsy Surgery Outcome Scale. Fisher's exact tests revealed a statistically significant decline in naming in ATLs compared to SLAHs, but no other significant group differences. 82% of ATL and 36% of subSAH patients showed a significant naming decline whereas no SLAH patient (0%) had a significant naming decline. Significant postoperative naming improvement was seen in 36% of SLAH patients in contrast to 9% improvement in subSAH patients and 0% improvement in ATLs. Finally, there were no statistically significant differences between surgical approaches with regard to seizure freedom outcome, although there was a trend towards better seizure relief outcome among the ATL patients. Results support a possible benefit of SLAH in preserving visual confrontation naming after left TLE surgery. While result interpretation is limited by the small sample size, findings suggest outcome is likely to differ by surgical approach, and that further research on cognitive and seizure freedom outcomes is needed to inform patients and providers of potential risks and benefits with each.

Comparing the North American Adult Reading Test (NAART) and the Test of Premorbid Functioning (TOPF) to estimate premorbid Wechsler Adult Intelligence Scale - 4th edition FSIQ in a clinical sample with epilepsy.

Estimating premorbid general cognitive functioning is an essential component to the neuropsychological evaluation process. The North American Adult Reading Test (NAART) is a method to predict premorbid general cognitive functioning based on word reading skills developed using the Wechsler Adult Intelligence Scale-Revised (WAIS-R), which is currently in its fourth edition (WAIS-IV). The Test of Premorbid Function (TOPF) was developed using the WAIS-IV, based on the same method as the NAART, to estimate premorbid intellectual ability. There is a paucity of research comparing estimates of premorbid general intellectual ability between the NAART and TOPF. This study evaluated the clinical utility of premorbid estimates of FSIQ derived from the NAART and TOPF in a sample of 101 patients with temporal lobe epilepsy (TLE). Differences between NAART-derived premorbid FSIQs and TOPF simple demographic predicted FSIQs were significant (p < .001) with large effect sizes. NAART estimated premorbid FSIQ (M = 104.04, SD = 8.42) was significantly greater than TOPF premorbid estimates (M = 99.83, SD = 9.26). Results suggested NAART-derived estimates of premorbid FSIQ may be more accurate than TOPF-based estimates, which likely underestimated premorbid FSIQ in this sample of patients with epilepsy. Limitations and future directions are discussed.

Surgical disconnection of epilepsy network correlates with improved outcomes.

PURPOSE: A novel software algorithm combining non-invasive EEG and resting state functional MRI data to map networks of cortex correlated to epileptogenic tissue was used to map an epilepsy network non-invasively. The relationship between epilepsy network connectivity and outcomes after surgery was investigated using this non-invasive and non-concurrent modeling algorithm. METHOD: Scalp EEG and resting state functional MRI were acquired for nineteen patients with temporal lobe epilepsy. The hypothetical irritative zone was mapped, and resting state functional MRI data was used to model regions functionally correlated with the irritative zone. Epilepsy network connectivity was measured in patient with temporal lobe epilepsy (n = 19) both pre- and post-operatively. Temporal networks were also mapped in healthy control participants (n = 6). RESULTS: Thirteen of nineteen patients (68 %) were seizure free after 20.3 ± 4.8 months. Epilepsy network connectivity within the temporal lobe was significantly higher among patients with temporal lobe epilepsy compared to the healthy control patients (p < 0.05). Disconnection of the epilepsy network was significantly higher in patients who were seizure free. Using spearman rho analyses, neuropsychological function after surgery was found to be relatively better in patients with higher degree of epilepsy network disconnection. CONCLUSIONS: The magnitude of network disconnection after surgery was strongly associated with increased rates of seizure freedom and relatively better neuropsychological measures of memory and naming function. It was shown that seizure-free outcomes and relatively improved neuropsychological function correlated with surgical disconnection of a highly synchronous epilepsy network.

Seizure Freedom After Epilepsy Surgery and Higher Baseline Cognition May Be Associated With a Negatively Correlated Epilepsy Network in Temporal Lobe Epilepsy.

Background: Brain regions positively correlated with the epileptogenic zone in patients with temporal lobe epilepsy vary in spread across the brain and in the degree of correlation to the temporal lobes, thalamus, and limbic structures, and these parameters have been associated with pre-operative cognitive impairment and seizure freedom after epilepsy surgery, but negatively correlated regions have not been as well studied. We hypothesize that connectivity within a negatively correlated epilepsy network may predict which patients with temporal lobe epilepsy will respond best to surgery. Methods: Scalp EEG and resting state functional MRI (rsfMRI) were collected from 19 patients with temporal lobe epilepsy and used to estimate the irritative zone. Using patients' rsfMRI, the negatively correlated epilepsy network was mapped by determining all the brain voxels that were negatively correlated with the voxels in the epileptogenic zone and the spread and average connectivity within the network was determined. Results: Pre-operatively, connectivity within the negatively correlated network was inversely related to the spread (diffuseness) of that network and positively associated with higher baseline verbal and logical memory. Pre-operative connectivity within the negatively correlated network was also significantly higher in patients who would go on to be seizure free. Conclusion: Patients with higher connectivity within brain regions negatively correlated with the epilepsy network had higher baseline memory function, narrower network spread, and were more likely to be seizure free after surgery.

Network connectivity separate from the hypothesized irritative zone correlates with impaired cognition and higher rates of seizure recurrence.

INTRODUCTION: Surgery remains an essential option for the treatment of medically intractable temporal lobe epilepsy (TLE). However, only 66% of patients achieve postoperative seizure freedom, perhaps attributable to an incomplete understanding of brain network alterations in surgical candidates. Here, we applied a novel network modeling algorithm and measured key characteristics of epileptic networks correlated with surgical outcomes and objective measures of cognition. METHODS: Twenty-two patients were prospectively included, and relevant demographic information was attained. Resting state functional magnetic resonance imaging (rsfMRI) and electroencephalography (EEG) data were recorded and preprocessed. Using our novel algorithm, patient-specific epileptic networks were mapped preoperatively, and geographic spread was quantified. Global functional connectivity was also determined using a volumetric functional atlas. Neuropsychological pre- and postsurgical raw and standardized scores obtained blinded to epileptic network status. Key demographic data and features of epileptic networks were then correlated with surgical outcome using Pearson's product-moment correlation. RESULTS: At an average follow-up of 18.4 months, 15/22 (68%) patients were seizure-free. Connectivity was measured globally using a functional 3D atlas. Higher mean global connectivity correlated with worse scores in preoperative neuropsychological testing of executive functioning (Ruff Figural Fluency Test [RFFT]-ER; R = 0.943, p = 0.005). A higher ratio of highly correlated connections between regions of interest (ROIs) in the hemisphere contralateral to the seizure onset correlated with impairment in executive functioning (RFFT-ER; R = 0.943, p = 0.005). Higher numbers of highly correlated connections between ROIs in the contralateral hemisphere correlated with impairment in both short- and long-term measures of verbal memory (Rey Auditory Verbal Learning Test Trials 6, 7 [RAVLT6, RAVLT7]; R = -0.650, p = 0.020, R = -0.676, p = 0.030). Epilepsy networks were modeled in each patient, and localization of the epilepsy network in the bitemporal lobes correlated with lower scores in neuropsychological tests measuring verbal learning and short-term memory (RAVLT6; R = -0.671, p = 0.024). Higher rates of seizure recurrence correlated with localization of the epilepsy network bitemporally (R = -0.542, p = 0.014), with the stronger correlation found with localization to the contralateral temporal lobe from side of surgery (R = - 0.530, p = 0.016). CONCLUSION: Increased connectivity contralateral to seizure onset and epilepsy network spread in the bitemporal lobes correlated with lower measures of executive functioning and verbal memory. Epilepsy network localization to the bitemporal lobes, in particular, the contralateral temporal lobe, is associated with higher rates of seizure recurrence. These findings may reflect network-level disruption that has infiltrated the contralateral hemisphere and the bitemporal lobes contributing to impaired cognition and relatively worse surgical outcomes. Further identification of network parameters that predict patient outcomes may aid in patient selection, resection planning, and ultimately the efficacy of epilepsy surgery.

Wada asymmetry in patients with drug-resistant mesial temporal lobe epilepsy: Implications for postoperative neuropsychological outcomes.

OBJECTIVE: This study reports neuropsychological outcomes based on preoperative Wada testing in patients with drug-resistant mesial temporal lobe epilepsy (mTLE). METHODS: Patient records were retrospectively reviewed as part of a larger database. Patients with a diagnosis of TLE based on seizure semiology and long-term surface video-electroencephalography (EEG) were identified. These patients underwent preoperative and postoperative testing including advanced imaging (magnetic resonance imaging [MRI]), Wada testing, and neuropsychological assessment. Decrements in neuropsychological function were noted in comparison of pre- and postoperative studies. Patients had regular follow-up in the multidisciplinary epilepsy clinic to assess seizure outcomes. All participants had Engel class I/II outcome following selective amygdalohippocampectomy (AH) via the inferior temporal gyrus (ITG) approach. RESULTS: Forty-eight patients with electrographic and clinical semiology consistent with unilateral mTLE were identified. Left mTLE was identified in 28 patients (58.3%), whereas 20 patients (41.7%) had right mTLE. Language-dominant hemisphere resections were performed on 23 patients (47.9%) (all left-sided surgery), whereas 25 (52.1%) had language nondominant resection (all right-sided and five left-sided surgery). Twenty-two participants (45.8%) showed no Wada memory asymmetry (No-WMA), whereas 26 (54.2%) exhibited Wada memory asymmetry (WMA). Postoperatively, analysis of variance (ANOVA) found that the No-WMA group exhibited a decline in verbal memory, but average scores on measures of nonverbal reasoning, general intelligence, and mood improved. Alternatively, patients with WMA did not show declines in memory postoperatively, and also exhibited improved nonverbal reasoning and general intelligence. Neither group exhibited reliable decline in verbal fluency or visual confrontation naming. SIGNIFICANCE: Wada procedures for predicting surgical outcome from elective temporal surgery have been criticized and remain an area of active debate. However, decades of data across multiple epilepsy centers have demonstrated the value of Wada for reducing unanticipated neuropsychological adverse effects of surgical treatment. These data show that no Wada memory asymmetry increases the risk for neuropsychological decline following ITG approach for selective AH for drug-resistant mTLE.

Deciding to adopt revised and new psychological and neuropsychological tests: an inter-organizational position paper.

OBJECTIVE: Neuropsychological tests undergo periodic revision intended to improve psychometric properties, normative data, relevance of stimuli, and ease of administration. In addition, new tests are developed to evaluate psychological and neuropsychological constructs, often purporting to improve evaluation effectiveness. However, there is limited professional guidance to neuropsychologists concerning the decision to adopt a revised version of a test and/or replace an older test with a new test purporting to measure the same or overlapping constructs. This paper describes ethical and professional issues related to the selection and use of older versus newer psychological and neuropsychological tests, with the goal of promoting appropriate test selection and evidence-based decision making. METHOD: Ethical and professional issues were reviewed and considered. CONCLUSIONS: The availability of a newer version of a test does not necessarily render obsolete prior versions of the test for purposes that are empirically supported, nor should continued empirically supported use of a prior version of a test be considered unethical practice. Until a revised or new test has published evidence of improved ability to help clinicians to make diagnostic determinations, facilitate treatment, and/or assess change over time, the choice to delay adoption of revised or new tests may be viewed as reasonable and appropriate. Recommendations are offered to facilitate decisions about the adoption of revised and new tests. Ultimately, it is the responsibility of individual neuropsychologists to determine which tests best meet their patients' needs, and to be able to support their decisions with empirical evidence and sound clinical judgment.

Quantitative Measurement of Communication Ability in Children with Angelman Syndrome.

BACKGROUND: Angelman syndrome is a rare disorder in which most individuals do not develop speech. Testing of communication ability using traditional neuropsychological measures reveals a performance level at or near the floor of the instrument resulting in an inability to detect change when experimental therapeutics are applied. METHODS: Nine individuals, with molecularly confirmed AS, ranging in age from 34 to 126 months, and a single healthy control child (age 16 months) were audio and video-recorded while interacting with a licensed speech-language pathologist in an attempt to elicit vocalization and non-verbal communication. Thirty-minute audio recordings were transcribed and categorized per the Stark Assessment of Early Vocal Development-Revised and a phonetic inventory was created. Using video recordings, gestures were classified by function, either behavioral regulation or social interaction and further categorized as deictic or representational (i.e., behavioral regulation) and joint attention or shared engagement (i.e., social interaction). RESULTS: The range of vocalizations produced by the children with AS was characteristic of children between 0-6 months and none of the children with AS used advanced forms of vocalizations. The mean frequency of reflexive vocalizations, control of phonation and expansion far exceeded the number of uses of canonical syllables, consistant with the characteristics of children around 12 months of age. Most vocalizations were either laughter or isolated vowels, only three children with AS produced consonant-vowel combinations. Children with AS tended to use central and low vowels with few producing high vowels, suggesting the presence of childhood apraxia of speech. CONCLUSION: Our results show the utilization of video-recorded behavioral observations provides a feasible and reliable alternative for quantification of communication ability in this patient population and may be employed during future clinical studies of potential therapeutics.

Physician Preferences to Communicate Neuropsychological Results: Comparison of Qualitative Descriptors and a Proposal to Reduce Communication Errors.

OBJECTIVE: Errors in communication are a leading cause of medical errors. A potential source of error in communicating neuropsychological results is confusion in the qualitative descriptors used to describe standardized neuropsychological data. This study sought to evaluate the extent to which medical consumers of neuropsychological assessments believed that results/findings were not clearly communicated. In addition, preference data for a variety of qualitative descriptors commonly used to communicate normative neuropsychological test scores were obtained. METHODS: Preference data were obtained for five qualitative descriptor systems as part of a larger 36-item internet-based survey of physician satisfaction with neuropsychological services. A new qualitative descriptor system termed the Simplified Qualitative Classification System (Q-Simple) was proposed to reduce the potential for communication errors using seven terms: very superior, superior, high average, average, low average, borderline, and abnormal/impaired. A non-random convenience sample of 605 clinicians identified from four United States academic medical centers from January 1, 2015 through January 7, 2016 were invited to participate. RESULTS: A total of 182 surveys were completed. A minority of clinicians (12.5%) indicated that neuropsychological study results were not clearly communicated. When communicating neuropsychological standardized scores, the two most preferred qualitative descriptor systems were by Heaton and colleagues (26%) and a newly proposed Q-simple system (22%). Comprehensive norms for an extended Halstead-Reitan battery: Demographic corrections, research findings, and clinical applications. Odessa, TX: Psychological Assessment Resources) (26%) and the newly proposed Q-Simple system (22%). DISCUSSION: Initial findings highlight the need to improve and standardize communication of neuropsychological results. These data offer initial guidance for preferred terms to communicate test results and form a foundation for more standardized practice among neuropsychologists.

Neuropsychology Outcomes Following Trephine Epilepsy Surgery: The Inferior Temporal Gyrus Approach for Amygdalohippocampectomy in Medically Refractory Mesial Temporal Lobe Epilepsy.

BACKGROUND: Surgery is indicated in cases of mesial temporal lobe epilepsy(MTLE) that are refractory to medical management. The inferior temporal gyrus (ITG) approach provides access to the mesial temporal lobe (MTL) structures with minimal tissue disruption. Reported neuropsychology outcomes following this approach are limited. OBJECTIVE: To report neuropsychological outcomes using an ITG approach to amygdalohippocampectomy (AH) in patients with medically refractory MTLE based on a prospective design. METHODS: Fifty-four participants had Engel class I/II outcome following resection of MTL using the ITG approach. All participants had localization-related epilepsy confirmed by long-term surface video-electroencephalography and completed pre/postsurgical evaluations that included magnetic resonance imaging (MRI), Wada test or functional MRI, and neuropsychology assessment. RESULTS: Clinical semiology/video-electroencephalography indicated that of the 54 patients, 28 (52%) had left MTLE and 26 (48%) had right MTLE. Dominant hemisphere resections were performed on 23 patients (43%), nondominant on 31(57%). Twenty-nine (29) had pathology-confirmed mesial temporal sclerosis (MTS). Group level analyses found declines in verbal memory for patients with language-dominant resections (P < .05). No significant decline in neuropsychological measures occurred for patients with MTS. Participants without MTS who underwent a language-dominant lobe resection exhibited a significant decline in verbal and visual memory (P < .05). Nondominant resection participants did not exhibit significant change in neuropsychology scores (P > .05). CONCLUSION: Neuropsychology outcomes of an ITG approach for selective mesial temporal resection are comparable to other selective AH techniques showing minimal adverse cognitive effects. These data lend support to the ITG approach for selective AH as an option for MTLE.

Towards reporting standards for neuropsychological study results: A proposal to minimize communication errors with standardized qualitative descriptors for normalized test scores.

OBJECTIVE: Rapid, clear and efficient communication of neuropsychological results is essential to benefit patient care. Errors in communication are a lead cause of medical errors; nevertheless, there remains a lack of consistency in how neuropsychological scores are communicated. A major limitation in the communication of neuropsychological results is the inconsistent use of qualitative descriptors for standardized test scores and the use of vague terminology. PATIENTS AND METHODS: PubMed search from 1 Jan 2007 to 1 Aug 2016 to identify guidelines or consensus statements for the description and reporting of qualitative terms to communicate neuropsychological test scores was conducted. The review found the use of confusing and overlapping terms to describe various ranges of percentile standardized test scores. RESULTS: In response, we propose a simplified set of qualitative descriptors for normalized test scores (Q-Simple) as a means to reduce errors in communicating test results. The Q-Simple qualitative terms are: 'very superior', 'superior', 'high average', 'average', 'low average', 'borderline' and 'abnormal/impaired'. A case example illustrates the proposed Q-Simple qualitative classification system to communicate neuropsychological results for neurosurgical planning. CONCLUSIONS: The Q-Simple qualitative descriptor system is aimed as a means to improve and standardize communication of standardized neuropsychological test scores. Research are needed to further evaluate neuropsychological communication errors. Conveying the clinical implications of neuropsychological results in a manner that minimizes risk for communication errors is a quintessential component of evidence-based practice.

A randomized, double-blind, placebo-controlled crossover study of the effects of levetiracetam on cognition, mood, and balance in healthy older adults.

OBJECTIVE: The cognitive and mood effects of levetiracetam (LEV) in older adults are not known. This study compared the cognitive and mood effects of LEV to placebo in healthy older adults. METHODS: Cognitive, mood, and balance variables were compared between LEV and placebo using a randomized, double-blind, placebo-controlled crossover study with two 5-week treatment periods. Healthy volunteers (n = 20) aged 65-80 (mean age 72.4) received either LEV or placebo in which the LEV target dose was 1,000 mg/day. Volunteers, aged 65-80, were without epilepsy to limit potentially confounding the impact of seizures and/or underlying neuropathology on outcomes. LEV was initiated at 250 mg twice a day for 2 weeks, then increased to 500 mg twice a day for 2 weeks, and then tapered to 250 mg twice a day for 1 week. This was randomized with placebo for the two treatment arms. Measures included standardized neuropsychological, mood, and balance tests yielding 32 variables. Balance was assessed using subjective report (e.g., A-B neurotoxicity scale) and objective data (e.g., Berg Balance Scale). RESULTS: Average LEV serum concentration was 16.9 (standard deviation [SD} 7.7). Repeated-measures analysis of variance (ANOVA) found no differences between LEV and placebo phases for 29 (90.6%) of 32 variables including no change in balance. Performance on LEV was better than placebo on a visual memory (MCG Complex Figure Recall; p = 0.007) and two attention tests (Trail Making Test, Part A, p = 0.009; Stroop Interference, p = 0.004). There was a trend for greater irritability and fatigue (POMS Anger and Fatigue) during the LEV phase (p = 0.029, p = 0.035). Effect-size changes were generally small (Cohen d < 0.5). SIGNIFICANCE: LEV was well tolerated in this elderly population in terms of cognition, mood, and balance. When anticonvulsant medication is indicated for older adults, LEV has pharmacokinetic advantages, and these data indicate no adverse impact on cognition or balance.

Addressing potential role of magnesium dyshomeostasis to improve treatment efficacy for epilepsy: A reexamination of the literature.

Magnesium (Mg(2+) ) is an abundant mineral in the body serving many biochemical functions. Magnesium supplementation has been shown to raise seizure threshold in animal and human studies, but the etiological contribution of magnesium deficiency to the onset and maintenance of epilepsy, as well as the degree to which it impacts antiepileptic drug efficacy, remains poorly understood. This may be due, at least in part, to the inherent limitations of commonly used serum levels as a measure of functional magnesium status, as well as insufficient data regarding relative bioavailabilities of various magnesium salts and chelates for use with humans. To date, 1 randomized clinical trial has been conducted assessing Mg(2+) supplementation in epilepsy, and findings yielded promising results. Yet a notable dearth in the literature remains, and more studies are needed. To better understand the potential role of magnesium deficiency as a causal factor in epilepsy, more convenient and accurate measurement methods should to be developed and employed in randomized, controlled trials of oral magnesium supplementation in epilepsy. Findings from such studies have the potential to facilitate far-reaching clinical and economic improvements in epilepsy treatment standards.

Utility of Green's Word Memory Test Free Recall Subtest as a Measure of Verbal Memory: Initial Evidence from a Temporal Lobe Epilepsy Clinical Sample.

This study investigated the Word Memory Test (WMT) Free Recall (FR) subtest as a conventional memory measure. Nineteen participants with pharmacoresistant left temporal lobe epilepsy (LTLE) and 16 with right temporal lobe epilepsy (RTLE) completed the WMT, Rey Auditory Verbal Learning Test (RAVLT), and Wechsler Memory Scale-Fourth Edition Logical Memory (LM) subtest during presurgical evaluation. LTLE participants performed significantly worse on FR subtest (p < .05, [Formula: see text]) and RAVLT Trial 7 (p < .01, [Formula: see text]), but not on LM subtest. Age was a significant covariate for FR (p < .01, [Formula: see text]). Logistic regression revealed FR plus age and RAVLT age-adjusted T-scores both yielded 77.1% classification accuracy and respective diagnostic odds ratios of 11.36 and 11.84. Receiver operating characteristic curves to classify seizure laterality found that RAVLT and FR were significant (area under the curve [AUC] = 0.82 and 0.74), whereas LM was nonsignificant (AUC = 0.67). Cut scores and positive/negative predictive values were established for improved clinical classification.

Predictors of surgical outcome in medically-resistant temporal lobe epilepsy with bilateral features on pre-operative evaluation.

OBJECTIVE: This study identifies potential prognostic factors for favorable anterior mesial temporal lobe (AMTL) resection outcomes in patients with medically refractory temporal lobe epilepsy (TLE) with bilateral features on pre-operative examination. METHODS: Thirty-one patients demonstrated bilateral features defined as: bilateral independent temporal or bitemporal ictal onsets on surface or intracranial EEG, or bitemporal interictal epileptiform abnormalities on surface EEG with bilateral radiographic mesial temporal sclerosis. Surgical outcomes were classified according to reduction in seizure frequency: I (100% reduction), II (≥75% reduction), III (50-74% reduction), IV (<50% reduction). RESULTS: Of 31 patients, 14 (45%) improved to class I and 9 (29%) had a class II outcome at an average of 4 years after surgery. Eight (26%) patients did not exhibit good surgical outcome (class III, class IV). We found that neuropsychological and Wada memory scores were significantly correlated (p<0.05) with surgical outcome, and logistic regression found neuropsychological evaluation significantly predicted better surgical outcome (p<0.05). CONCLUSIONS: When bilateral features are present on pre-operative evaluation, neuropsychological and Wada test results can provide unique data to better identify those patients more likely to achieve substantial seizure reduction.

Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes.

OBJECTIVE: Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit. METHODS: A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy. RESULTS: Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p = 0.018). There was no difference in seizure control based on disease duration or location (p > 0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology. CONCLUSIONS: Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.

Laser ablation therapy: An alternative treatment for medically resistant mesial temporal lobe epilepsy after age 50.

Selective anterior mesial temporal lobe (AMTL) resection is considered a safe and effective treatment for medically refractory mesial temporal lobe epilepsy (MTLE). However, as with any open surgical procedure, older patients (aged 50+) face greater risks. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has shown recent potential as an alternative treatment for MTLE. As a less invasive procedure, MRgLITT could be particularly beneficial to older patients. To our knowledge, no study has evaluated the safety and efficacy of MRgLITT in this population. Seven consecutive patients (aged 50+) undergoing MRgLITT for MTLE were followed prospectively to assess surgical time, complications, postoperative pain control, length of stay (LOS), operating room (OR) charges, total hospitalization charges, and seizure outcome. Five of these patients were assessed at the 1-year follow-up for seizure outcome. These data were compared with data taken from 7 consecutive patients (aged 50+) undergoing AMTL resection. Both groups were of comparable age (mean: 60.7 (MRgLITT) vs. 53 (AMTL)). One AMTL resection patient had a complication of aseptic meningitis. One MRgLITT patient experienced an early postoperative seizure, and two MRgLITT patients had a partial visual field deficit. Seizure-freedom rates were comparable (80% (MRgLITT) and 100% (AMTL) (p>0.05)) beyond 1year postsurgery (mean follow-up: 1.0years (MRgLITT) vs. 1.8years (AMTL)). Mean LOS was shorter in the MRgLITT group (1.3days vs. 2.6days (p<0.05)). Neuropsychological outcomes were comparable. Short-term follow-up suggests that MRgLITT is safe and provides outcomes comparable to AMTL resection in this population. It also decreases pain medication requirement and reduces LOS. Further studies are necessary to assess the long-term efficacy of the procedure.

Sex differences in lateralization of semantic verbal fluency in temporal lobe epilepsy.

When differences exist, women tend to outperform men on measures of verbal fluency, possibly due to greater bilateral language representation. Patients with temporal lobe epilepsy (TLE) have a higher rate of atypical cortical language representation than the general population, making them a population of interest for the study of language. For the current study, 78 TLE patients (51% male, 51% left temporal focus) underwent pre-surgical neuropsychological evaluations. Retrospective data analyses investigated the impact of seizure laterality and sex on letter and semantic verbal fluency. Results indicated an interaction between sex and laterality for semantic, but not letter, verbal fluency. Males with left TLE exhibited significantly worse semantic fluency than males with right TLE, whereas females' semantic fluency did not differ by seizure focus. These data indicate that females with TLE may indeed engage in more bilateral hemispheric processing of semantic verbal fluency, whereas males may be more reliant on left temporal cortical function for this task.

Five-months-postoperative neuropsychological outcome from a pilot prospective randomized clinical trial of thalamic deep brain stimulation for Tourette syndrome.

OBJECTIVE: Tourette syndrome (TS) is a neuropsychiatric disorder presenting with motor and/or sonic tics associated with frontostriatal dysfunction. This study provided pilot data of the neuropsychological safety of bilateral thalamic deep brain stimulation (DBS) to treat medication-refractory TS in adults. METHOD: This study used a repeated-measures design with pretest and 3-month follow-up from start of continuous bilateral DBS. Five male patients underwent DBS surgery for medically refractory TS. Repeated-measures ANOVA was used to evaluate for any change in neuropsychological test scores, employing a false discovery rate. Outcome measures included 14 neuropsychological tests assessing psychomotor speed, attention, memory, language, visuoconstructional, and executive functions, as well as subjective mood ratings of depression and anxiety. RESULTS: Average age was 28.2 years (SD = 7.5) with 12-17 years of education. Participants were disabled by tics, with a tic frequency of 50-80 per minute before surgery. At baseline, subjects' cognitive function was generally average, although mild deficits in sequencing and verbal fluency were present, as were clinically mild obsessive-compulsive symptoms. At 3 months of continuous DBS (5 months after implantation), 3 of 5 participants had clinical reductions in motor and sonic tics. Cognitive scores generally remained stable, but declines of moderate to large effect size (Cohen's d > 0.6) in verbal fluency, visual immediate memory, and reaction time were observed. Fewer symptoms of depression and anxiety, as well as fewer obsessions and compulsions, were reported after 3 months of continuous high-frequency DBS. CONCLUSIONS: Bilateral centromedian-parafascicular thalamic DBS for medically refractory TS shows promise for treatment of medically refractory TS without marked neuropsychological morbidity. Symptoms of depression and anxiety improved.