Testing an Adapted Auditory Verbal Learning Test Paradigm for fMRI to Lateralize Verbal Memory in Patients with Epilepsy.

BACKGROUND AND PURPOSE: fMRI is a noninvasive tool for predicting postsurgical deficits in candidates with pharmacoresistant temporal lobe epilepsy. We aimed to test an adapted paradigm of the Rey Auditory Verbal Learning Test to evaluate differences in memory laterality indexes between patients and healthy controls and its association with neuropsychological scores. MATERIALS AND METHODS: We performed a prospective study of 50 patients with temporal lobe epilepsy and 22 healthy controls. Participants underwent a block design language and memory fMRI. Laterality indexes and the hippocampal anterior-posterior index were calculated. Language and memory lateralization was organized into typical and atypical on the basis of laterality indexes. A neuropsychological assessment was performed with a median time from fMRI of 8 months and was compared with fMRI performance. RESULTS: We studied 40 patients with left temporal lobe epilepsy and 10 with right temporal lobe epilepsy. Typical language occurred in 65.3% of patients and 90.9% of healthy controls (P = .04). The memory fMRI laterality index was obtained in all healthy controls and 92% of patients. The verbal memory laterality index was bilateral (24.3%) more frequently than the language laterality index (7.69%) in patients with left temporal lobe epilepsy. Atypical verbal memory was greater in patients with left temporal lobe epilepsy (56.8%) than in healthy controls (36.4%), and the proportion of bilateral laterality indexes (53.3%) was larger than right laterality indexes (46.7%). Atypical verbal memory might be associated with higher cognitive scores in patients. No relevant differences were seen in the hippocampal anterior-posterior index according to memory impairment. CONCLUSIONS: The adapted Rey Auditory Verbal Learning Test paradigm fMRI might support verbal memory lateralization. Temporal lobe epilepsy laterality influences hippocampal memory laterality indexes. Left temporal lobe epilepsy has shown a higher proportion of atypical verbal memory compared with language, potentially to memory functional reorganization.

Intraoperative warming and post-operative cognitive dysfunction after total knee replacement.

BACKGROUND: Post-operative cognitive dysfunction (POCD) can affect 30% of orthopedic surgery patients. We hypothesized that perioperative temperature has an impact on POCD. METHODS: We included 150 patients over 65 years of age scheduled for total knee replacement under spinal anesthesia. They were randomized to receive standard care (sheet cover) or active warming. Neurocognitive assessment (11 subtests) was performed pre-operatively and at day 4 (three subtests) and 3 months (10 subtests). A control group of 55 nonsurgical patients took the same tests at equivalent times. POCD was defined as an individual score decrease of more than 2 standard deviations (SDs) below the baseline on at least two subtests or 2 SDs in the combined z-score, in both cases using control-adjusted changes. RESULTS: Tympanic temperature declined below 35 °C in 88% of standard-care patients; 25.3% of warmed patients had a temperature ≥36 °C. On day 4, 3.2% of standard-care patients and 19.4% of warmed patients had POCD (P=0.0058). At 3 months, there were no between-group differences (standard care, 14.3%; warmed, 6.5%) (P=0.2440). CONCLUSIONS: Perioperative warming was associated with a higher incidence of cognitive dysfunction at 4 days after total knee replacement in patients >65 years of age.

PET/MRI and PET/MRI/SISCOM coregistration in the presurgical evaluation of refractory focal epilepsy.

We aimed to investigate the usefulness of coregistration of positron emission tomography (PET) and magnetic resonance imaging (MRI) findings (PET/MRI) and of coregistration of PET/MRI with subtraction ictal single-photon emission computed tomography (SPECT) coregistered to MRI (SISCOM) (PET/MRI/SISCOM) in localizing the potential epileptogenic zone in patients with drug-resistant epilepsy. We prospectively included 35 consecutive patients with refractory focal epilepsy whose presurgical evaluation included a PET study. Separately acquired PET and structural MRI images were coregistered for each patient. When possible, ictal SPECT and SISCOM were obtained and coregistered with PET/MRI. The potential location of the epileptogenic zone determined by neuroimaging was compared with the seizure onset zone determined by long-term video-EEG monitoring and with invasive EEG studies in patients who were implanted. Structural MRI showed no lesions in 15 patients. In these patients, PET/MRI coregistration showed a hypometabolic area in 12 (80%) patients that was concordant with seizure onset zone on EEG in 9. In 7 patients without MRI lesions, PET/MRI detected a hypometabolism that was undetected on PET alone. SISCOM, obtained in 25 patients, showed an area of hyperperfusion concordant with the seizure onset zone on EEG in 7 (58%) of the 12 of these patients who had normal MRI findings. SISCOM hyperperfusion was less extensive than PET hypometabolism. A total of 19 patients underwent surgery; 11 of these underwent invasive-EEG monitoring and the seizure onset zone was concordant with PET/MRI in all cases. PET/MRI/SISCOM coregistration, performed in 4 of these patients, was concordant in 3 (75%). After epilepsy surgery, 13 (68%) patients are seizure-free after a mean follow-up of 4.5 years. PET/MRI and PET/MRI/SISCOM coregistration are useful for determining the potential epileptogenic zone and thus for planning invasive EEG studies and surgery more precisely, especially in patients without lesions on MRI.

Reliability and clinical usefulness of the short-forms of the Wechsler memory scale (revised) in patients with epilepsy.

PURPOSE: The Wechsler Memory Scale-R (WMS-R) is often used for the evaluation of patients with epilepsy, but is time consuming. Two shortened forms of the WMS-R have been published in an effort to reduce the time involved in the test. The purpose of this study is to cross-validate these abbreviated forms in patients with epilepsy. METHODS: We assessed 103 consecutive patients with drug-resistant partial epilepsy being treated in our epilepsy unit. The WMS-R was administered to all patients. The reliability of two shortened versions of the WMS-R were evaluated. The appraisal was performed taking into account the side of the epileptogenic region. The statistical analyses were carried out with the Pearson's correlation and with the intraclass correlation coefficient. RESULTS: Both shortened formulas showed good reliability coefficients for predicting the General Memory and Delayed Recall Indices. In the overall accuracy of the predictions by both short forms no significant differences were found among the three study. groups (right, left or bilateral). However, when considering the predictive error only the three-subtest formulas comprising logical memory, verbal paired associates and visual reproduction efficiently predicted performance, regardless of the side of the epileptogenic region. Of the predicted scores in the overall sample, 92 and 97% fell below the standard error of measurement for general and delayed memory index, respectively. Both short forms correctly classified 89-94% of the performances at the average or impaired level. CONCLUSIONS: The short form of the M-MS-R using three subtests (logical memory, verbal paired associates and visual reproduction) is reliable and time-efficient for estimating the General and Delayed Recall Memory indexes in patients with drug-resistant partial epilepsy.

Brain perfusion and neuropsychological changes in schizophrenic patients after cognitive rehabilitation.

The role of cognitive variables was compared in two single cases of schizophrenia hypofrontality. SPECT procedures and neuropsychological tests were used to study frontal brain function. After cognitive rehabilitation, neuropsychological performance were enhanced in both patients, but only one of them showed enhanced the frontal blood flow. The brain perfusion changes after cognitive rehabilitation could be associated with the cognitive-dependent hypofrontality.

[Neuropsychological pattern of cognitive impairment in Alzheimer type dementia and vascular dementia]. / Patrón de déficit neuropsicológico en la demencia tipo Alzheimer y en la demencia vascular.

BACKGROUND: Cummings et al, 1987, hypothesized that Alzheimer dementia type (ADT) patients would present poorer performances than vascular dementia (VD) patients on the neuropsychological tests that mainly involve cortical neurological structures, and that VD would perform worse on tests that mainly involve subcortical structures. The main purpose of the research was to identify a cognitive impairment pattern that discriminates the type of dementia in the initial stages. METHOD: Two groups of patients, one affected by mild ADT (n = 30) and the other by multi-infarct dementia (VD, n = 30) were given a neuropsychological battery. The battery was composed by Temporal Orientation (Benton et al.); Vocabulary, Similarities, Digits, Coding and Kohs (WAIS) of Wechsler; the Colour-Form Test of Weigh; the Trail Making Test (A and B) (Halstead-Reitan Neuropsychological Battery); Tapping (McQuarrie); Logical Memory, Visual Memory and Paired Association (Wechsler Memory Scale) of Wechsler; Delayed Memory (Russell). The two groups were similar in age and socio-cultural features. The z-score and its statistical significance on the Mann-Whitney test were made and we performed an exploratory discriminant analysis to the classification. RESULTS: In general, results were poorer in the ADT group. But we detected no significant differences in the tests, although some test (Immediate Visual Memory and Kohs' Blocks) almost reached significance. The discriminant analysis reached a classification of the 67% of the subjects into the ADT group and the 70% of the subjects into the VD group. CONCLUSIONS: In the initial stages of dementia it is difficult to differentiate between a cortical pattern of cognitive impairment in ADT and a subcortical pattern in VD, a distinction that the other researchers have reported. When complex tests were used the performance depended on the coordination of multiple related systems. These findings are in agreement with the holistic models of higher mental functions.

Simple fMRI postprocessing suffices for normal clinical practice.

BACKGROUND AND PURPOSE: Whereas fMRI postprocessing tools used in research are accurate but unwieldy, those used for clinical practice are user-friendly but are less accurate. We aimed to determine whether commercial software for fMRI postprocessing is accurate enough for clinical practice. METHODS: Ten volunteers underwent fMRI while performing motor and language tasks (hand, foot, and orolingual movements; verbal fluency; semantic judgment; and oral comprehension). We compared visual concordance, image quality (noise), voxel size, and radiologist preference for the activation maps obtained by using Neuro3D software (provided with our MR imaging scanner) and by using the SPM program commonly used in research. RESULTS: Maps obtained with the 2 methods were classified as "partially overlapping" for 70% for motor and 72% for language paradigm experiments and as "overlapping" in 30% of motor and in 15% of language paradigm experiments. CONCLUSIONS: fMRI is a helpful and robust tool in clinical practice for planning neurosurgery. Widely available commercial fMRI software can provide reliable information for therapeutic management, so sophisticated, less widely available software is unnecessary in most cases.

Does gender matter in glioblastoma?

BACKGROUND The clinical outcome of glioblastoma (GBM) patients who receive radiotherapy alone or with chemotherapy is well established. However, little is known about how many patients do not receive this treatment. We consider it is important to investigate why a proportion of operated patients do not receive further treatment after surgery. METHODS We reviewed all consecutive GBM patients operated on in our hospital between January 2000 and December 2008. RESULTS A total of 216 patients with GBM were identified. Fifty-five (25%) did not receive any treatment after surgery. Univariate analysis showed that factors associated with no further treatment after surgery were older than 60 years (p=0.002), of female gender (p=0.03), had a KPS<70 (p<0.001) and had had a biopsy (p<0.001). Multivariate analysis indicated that age =60 years and KPS <70 were independent predictors of no further treatment after surgery. Gender was not an independent variable. However, women in the whole series were older than 60 years (p=0.01), and they had a worse KPS (p=0.02) and more biopsies (p=0.04) than men. In the whole group, median survival time was 10.4 months for men (n=125) vs. 7.2 months for women (n=91), log rank p<0.04. This difference was not observed in the group that was treated after surgery. CONCLUSIONS One out of four patients could not be treated after surgery. Independent predictors were older age and low KPS. These poor risk variables were more frequent in women and their survival was therefore lower than men in our series.

[Successful functional hemispherectomy in adult patients with refractory epilepsy]. / La hemisferectomía funcional también es eficaz en pacientes adultos con epilepsia catastrófica.

INTRODUCTION: Functional hemispherectomy is a surgical technique used to treat refractory epilepsies in the setting of extensive unilateral hemispheric lesions. Most series of hemispherectomies include mainly pediatric patients. METHODS: We report our series of four adult patients that have undergone functional hemispherectomy for their refractory epilepsy. Each one had a complete presurgical evaluation including video EEG, neuropsychological testing and anatomical and functional neuroimaging. In three of them, the epilepsy was secondary to a middle cerebral artery infarction. One patient had Rasmussen encephalitis. RESULTS: After surgery, three patents have become completely seizure free (follow up 13-26 months). The fourth patient has had more than 75% reduction in seizure frequency. All of them have had significant improvement in their quality of life. Early complications included an isolated tonic-clonic generalized seizure (one patient), and status epilepticus in another patients related to infection and use of meropenem. Only one patient has presented hemianopia as a permanent neurological deficit after surgery. CONCLUSIONS: Functional hemispherectomy is a good surgical option in the setting of large unilateral hemispheric lesions causing hemiparesis and intractable seizures, even in adult patients.

Parry Romberg syndrome and linear scleroderma in coup de sabre mimicking Rasmussen encephalitis.

We present one patient with Parry Romberg syndrome and another with linear scleroderma in coup de sabre, with focal neurologic deficits and intractable seizures arising from the hemisphere ipsilateral to the cutaneous lesion. Brain MRI showed progressive hemispheric atrophy. Pathology after functional hemispherectomy showed chronic inflammatory features suggestive of Rasmussen encephalitis.

[Gender differences in cognitive functions and influence of sex hormones]. / Diferencias de género en las funciones cognitivas e influencia de las hormonas sexuales.

OBJECTIVE: To review scientific evidence on gender differences in cognitive functions and influence of sex hormones on cognitive performance. METHOD: Systematical search of related studies identified in Medline. RESULTS: Women outperform men on verbal fluency, perceptual speed tasks, fine motor skills, verbal memory and verbal learning. Men outperform women on visuospatial ability, mathematical problem solving and visual memory. No gender differences on attention and working memory are found. Researchers distinguish four methods to investigate hormonal influence on cognitive performance: a) patient with hormonal disorders; b) neuroimaging in individuals during hormone administration; c) in women during different phases of menstrual cycle, and d) in patients receiving hormonal treatment (idiopathic hypogonadotropic hypogonadism, postmenopausal women and transsexuals). The findings mostly suggest an influence of sex hormones on some cognitive functions, but they are not conclusive because of limitations and scarcity of the studies. CONCLUSIONS: There are gender differences on cognitive functions. Sex hormones seem to influence cognitive performance.

Cortical laminar necrosis related to prolonged focal status epilepticus.

Cortical laminar necrosis (CLN) is radiologically defined as high intensity cortical lesions on T1 weighted MRI images following a gyral distribution. Histopathologically, CLN is characterised by pannecrosis of the cortex involving neurones, glial cells, and blood vessels. It has been reported to be associated with hypoxia, metabolic disturbances, drugs, and infections. We present two patients who developed CLN and permanent neurological deficits after prolonged and repeated focal status epilepticus. The possible mechanisms leading to CLN in these patients are discussed, together with the implications of prompt and aggressive treatment in similar cases.

Complex motor behaviors in temporal lobe epilepsy.

Complex motor behaviors differing from typical automatisms were found in 12 of 502 patients with temporal lobe epilepsy. Movements involved proximal limb segments (6) or body axis (6) and were often preceded by auras and followed by automatisms. Seven of 12 patients are seizure free after surgery. The other 5 patients declined surgery.

Neuropsychological and psychiatric complications in endoscopic third ventriculostomy: a clinical case report.

The clinical case report of a patient who underwent an endoscopic third ventriculostomy for the treatment of a slit ventricle syndrome is presented. After surgery the patient developed a severe complication consisting of an organic personality disorder, characterised by impulsiveness, physical heteroaggressiveness, binge eating, hypersomnia and impairment of memory, and frontal-executive functions.A frontal lobe lesion may explain some of the symptoms presented, such as the uncontrolled impulses, the aggressive behaviour, and even the binge eating. However, a longitudinal neuropsychological evaluation showed a severe deficit in immediate memory and difficulties in planning and consolidation of newly learned information, which may be best related to damage in the frontal basal structures of the brain: the fornix and its connection to the hippocampus and the mamillary bodies. Postoperative MR images confirmed the clinical hypothesis. The emergence of such a severe organic personality disorder and cognitive disturbances as a psychiatric complication of an endoscopic third ventriculostomy has not, it seems, been previously reported elsewhere. Clinicians should take these possible complications into account when recommending this so-called minimally invasive neuroendoscopic procedure.

[Neuropsychological changes in schizophrenia and its modification]. / Alteraciones neuropsicológicas en la esquizofrenia y su modificación.

The main experimental works about neuropsychological impairments of schizophrenia are reviewed. The underlying mechanisms of the cognitive deficits are set in a framework of the limited capacity model. In second point, the current status of the modificability of the cognitive deficits and the clinical and psychosocial consequences of this deficits are presented. At least, neuropsychological rehabilitation programs are reviewed from a clinical point of view.

Does neuroticism influence cognitive self-assessment after epilepsy surgery?

PURPOSE: To examine how cognitive, personality, and seizure outcome variables influence the subjective cognitive functioning of patients with refractory temporal lobe seizures after epilepsy surgery. METHODS: Thirty-three consecutive patients with drug-resistant partial epilepsy who underwent surgical treatment at a tertiary referral university epilepsy center were tested before surgery and 1 year after surgery. Objective cognitive and subjective cognitive functioning tests were used, and personality was assessed. Seizure control was operationalized as a dichotomous variable. RESULTS: A significant inverse relationship was found between neuroticism and subjective cognitive functioning. None of the other pre- and postoperative cognitive and surgery outcome variables were significant predictors of subjective cognitive functioning, even after controlling for the effect of neuroticism. CONCLUSIONS: Subjective and objective memory functioning are independent in patients with epilepsy after surgical treatment. Subjective memory functioning appears to be related not to seizure relief but to neuroticism. These data suggest that psychological factors such as personality traits predisposing to emotional distress should be taken into consideration in the clinical management and counseling of patients undergoing epilepsy surgery.