Tailored anterior temporal lobectomy. Relation between extent of resection of mesial structures and postsurgical seizure outcome.

OBJECTIVE: The purpose of this study was to assess the relationship between the extent of resection of mesial temporal structures and postsurgical seizure outcome in a group of patients who had undergone a tailored anterior temporal lobectomy. METHODS: Twenty-four patients with unilateral interictal and ictal foci restricted to anterior/mesial temporal regions underwent resection of mesial and temporal lateral structures, the extent of which was tailored by intraoperative electrocorticographic findings and functional mapping of eloquent cortex. The extent of resection was determined with postoperative magnetic resonance imaging scans, using a semiquantitative method, based on a 20-compartment model of the temporal lobe. The magnetic resonance imaging scans were rated by three investigators blinded to seizure outcome. Follow-up period ranged between 18 months and 5 years. RESULTS: Amygdala and hippocampus were spared in six patients; nine patients had a partial to total resection of amygdala, eight patients had a resection of amygdala and the anterior third of the hippocampus, and one patient underwent resection of amygdala and anterior two thirds of hippocampus. Twenty-one of the 24 patients were seizure free (Engel's class I) and three had rare seizures (Engel's class II). Among these three patients, one had a resection of amygdala; one had resection of amygdala and anterior third of hippocampus; while in the third patient, mesial structures were spared. CONCLUSION: These data suggest that in patients with an anterotemporal seizure focus, the sparing or limited resection of amygdala and/or hippocampus is not necessarily associated with a poor seizure outcome, as had been previously suggested, provided that the decision not to resect is based on the absence of epileptiform activity during intraoperative electrocorticography or during recordings with depth electrodes.

Psychiatric and neurologic predictors of psychogenic pseudoseizure outcome.

OBJECTIVE: To investigate the patterns of occurrence of psychogenic pseudoseizures (PPS) of 45 consecutive patients during a 6-month period after diagnosis, and to determine whether psychiatric and neurologic variables identified previously in PPS patient series can predict their recurrence after diagnosis, and whether any of these variables are associated with a particular outcome pattern. METHOD: Postdiagnosis PPS recurrence was assessed twice: during the first month and during a period ranging from the second to the sixth month. Outcome was categorized as follows: class I, complete cessation of PPS; class II, PPS only during one of the two observation periods; and class III, persistent PPS during the two observation periods. The authors used a logistic regression model to identify predictors of PPS recurrence (versus no PPS) among four neurologic and nine psychiatric variables, and compared their frequency among the three outcome classes. RESULTS: Class I, n = 13 (29%); class II, n = 12 (27%); and class III, n = 20 (44%). The presence of an abnormal MR image predicted PPS recurrence during the second observation period with a 75% accuracy. The presence of all nine psychiatric variables predicted PPS recurrence during both the first and second observation periods with a 93% and an 89% accuracy respectively. Patients with a class III outcome had a markedly higher frequency of recurrent major depression, dissociative and personality disorders, and a history of chronic abuse. Patients with a class II outcome displayed a notably higher frequency of denial of stressors and psychosocial problems, refusal of treatment recommendations, and new somatic symptoms after disclosure of diagnosis. Conversely, one episode of major depression was the one common diagnosis in patients with a class I outcome. CONCLUSIONS: PPS outcome after disclosure of diagnosis can be predicted by the presence of certain psychiatric characteristics. More than one psychopathogenic mechanism appears to operate in PPS.

Deficits in delayed memory following cerebral malaria: a case study.

Cerebral malaria is a common disease, but there have not been any reports or investigations of long-term neurological or neuropsychological outcome. We present a case in which severe deficits in delayed memory and naming ability are observed 10 years after the patient contracted cerebral malaria. Neuropsychological testing and medical imaging are both consistent with temporal lobe/hippocampal dysfunction, which corroborates earlier animal research that cerebral malaria is particularly likely to lead to interrupted blood circulation in this area.

Invasive adenoviral infections in T-cell-depleted allogeneic hematopoietic stem cell transplantation: high mortality in the era of cidofovir.

BACKGROUND: Adenovirus (ADV) infection occurs in 5-21% of allogeneic hematopoietic stem cell transplants (HSCT). Symptomatic enteritis and hemorrhagic cystitis may be encountered but are seldom fatal. In contrast, mortality rates of up to 75% are reported for adenoviral pneumonia or hepatitis. Cidofovir is currently being increasingly used for treatment of adenoviral infections after HSCT. The efficacy of cidofovir in patients with invasive adenoviral infection is not established. FINDINGS: We reviewed 687 adult and pediatric patients who received allogeneic HSCT at our institution from 1998 through June 2005. ADV was isolated from 64 (9.3%) patients. Eleven patients received cidofovir for invasive disease occurring at median 39 days (range 3-145) post HSCT. The median age was 40 (range 6-61) years. Seventy-three percent received a T-cell-depleted graft and 18% had grade 3-4 graft-versus-host disease (GVHD) of the gut. Three out of 3 (100%) patients with adenoviral pneumonia died. One patient with hepatitis, cholecysitis, and viremia cleared the infection after 3 months. Two out of 7 (28.6%) patients with hemorrhagic colitis or cystitis died of ADV (1 with extensive GVHD). CONCLUSION: Mortality rates of ADV pneumonitis after allogeneic HSCT remain high in the era of cidofovir. Clinical trials are needed to evaluate management strategies for this life-threatening infection.

Epileptiform activity in chronically isolated cerebral cortex in humans.

The ability of neuronally isolated human cerebral cortex to sustain epileptiform rhythms over long time intervals is unknown. We report here two patients after functional hemispherectomy for infantile hemiplegia and infantile meningoencephalitis. Both patients had intractable seizures. EEG performed early and up to 3 years after surgery showed persistent epileptiform activity in the isolated frontal cortex in both cases. This indicates that human isolated cortex retains its epileptogenic potential for years, independently of subcortical influences. Previous related animal and human studies are briefly reviewed.

Reversal of changes in lipoprotein A and lipoprotein B cholesterol during and for a year after a detoxication treatment program in chronic alcoholism.

We studied the individual and occasional changes in lipid metabolism induced by chronic alcohol abuse. In addition, the influence of a detoxication treatment program on the evolutionary changes in some serum lipidic components was studied for a one-year period. Before this program, total cholesterol was above normal, with high values for LP-A cholesterol, whereas for some patients LP-B cholesterol was increased. After the program, there was an increase in total cholesterol, LP-B cholesterol, and apolipoprotein B, with a decrease in LP-A cholesterol. These evolutionary changes continued during the one-year period after the end of the inpatient program.

Neurologic complications of critical medical illnesses.

OBJECTIVES: To identify the neurologic complications of critical medical illnesses, and to assess their effect on mortality rates and on medical ICU and hospital lengths of stay. DESIGN: Prospective clinical evaluation of all medical ICU admissions for 2 yrs. SETTING: A 14-bed, general medical intensive and coronary care unit in a large university hospital. PATIENTS: Patients (n = 1,850) admitted to the hospital, of whom 92 were admitted for primarily neurologic problems. Of the remaining 1,758 patients, 217 (12.3%) experienced a neurologic complication. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients developing a neurologic complication while in the medical ICU demonstrated an increased risk of inhospital mortality when compared with patients who did not suffer such problems (45.7% vs. 26.6%; p < .00001). Patients with neurologic complications experienced 2.5-fold longer medical ICU stay times (p < .001) and almost two-fold longer hospital stay times (p < .001). Metabolic encephalopathy, seizures, hypoxic-ischemic encephalopathy, and stroke were the most common complications. Sepsis was the most frequent cause of encephalopathy, and cerebrovascular lesions were the most common cause of seizures. Formal neurologic consultations were requested in only 36% of these patients. CONCLUSIONS: Neurologic complications are associated with increased mortality rates and longer medical ICU and hospital lengths of stay. These conditions are probably underrecognized at present. ICUs have the potential to serve as environments for neurologic teaching and research.

Significance of unilateral ear extinction on the dichotic listening test.

The association between unilateral ear extinction on the dichotic listening test and the lateralization of epileptogenic foci was examined in a sample of 49 seizure patients undergoing preoperative evaluation for epilepsy surgery. Results from patients who were left hemisphere dominant for speech indicated that right ear impairment was always predictive of a unilateral left hemisphere focus, but left ear extinction was associated with unilateral lesions of either hemisphere. In this patient sample, dichotic listening performance reflected an interaction of both lateralized foci and hemispheric preference of language processing. Implications concerning clinical use of the dichotic listening test are discussed.

Infection with GB virus C/hepatitis G virus among blood donors and hemophiliacs in Martinique, a Caribbean island.

GB virus C/hepatitis G virus (GBV-C/HGV) RNA was detected by reverse transcription-polymer- ase chain reaction with primers derived from the nonstructural region 3 (NS3) in 9 (4.1%) of 221 blood donors and 2 of 20 (10%) hemophilia patients in Martinique, French West Indies. Anti-E2 antibodies were found in sera from 33 (14.9%) of the blood donors and 5 (25%) of the hemophiliacs. None of the subjects was positive for both GBV-C/HGV RNA and anti-E2. Among the 20 hemophiliacs, 12 (60%) had anti-HCV antibodies and 7 (35%) were positive for HCV RNA by PCR. All patients positive for HCV markers belonged to the group of 13 patients exposed previously to blood factor concentrates that were not activated virally. Nucleotide sequences of the 5'-untranslated region (5'UTR) of the GBV-C/HGV genome were obtained for the 10 NS3 PCR positive samples. Phylogenetic comparison of these isolates with reference isolates published previously showed a strong homology with European and American GBV-C/HGV strains, 8 isolates belonging to the genotype 2a and 1 isolate to the type 2b. The isolate from 1 blood donor was identified as subtype 1a, indicating the presence of West African type strains.

Study of HLA antigens in systemic lupus erythematosus in the French West Indies.

As incidence of SLE is high in Blacks, we studied HLA and SLE associations in the French West Indies, whose population is racially mixed. Forty-seven coloured SLE patients have been typed in HLA A,B,C and DR. We observed B8 association in nearly all of the studies. B15 association, more frequent in Caucasians, was found, also B53 association, a Black variant of B5 more frequent in Blacks. We did not find any class II association.

Landau-Kleffner syndrome. Treatment with subpial intracortical transection.

Landau-Kleffner syndrome (LKS) is an acquired epileptic aphasia occurring in childhood and associated with a generally poor prognosis for recovery of speech. It is thought to be the result of an epileptogenic lesion arising in speech cortex during a critical period of development. Utilizing a new surgical technique designed to eliminate the capacity of cortical tissue to generate seizures while preserving the normal cortical physiological function, we have treated 14 children with aphasia, seizures and a severely abnormal EEG by multiple subpial transection of the epileptogenic cortex. Seven of the 14 patients (50%) have recovered age-appropriate speech, are in regular classes in school and no longer require speech therapy. Four of the 14 (29%) have shown marked improvement, are speaking and understanding verbal instruction but are still receiving speech therapy. Thus, 11 of the 14 (79%), none of whom had used language to communicate for at least 2 years, are now speaking--a rate of sustained improvement considered unusual in this disorder. This study documents the value of a treatment modality not previously used in LKS. Success depends on selection of cases having severe epileptogenic abnormality that can be demonstrated to be unilateral in origin despite a bilateral electrographic manifestation.