Temporomandibular joint disc position and shape in patients submitted to two protocols of rapid maxillary expansion and face mask therapy: A randomized clinical trial.

OBJECTIVE: The objective of this prospective study was to assess possible changes in the position and shape of the temporomandibular joint (TMJ) articular disc in patients treated with two protocols of rapid maxillary expansion (RME) and face mask (FM) therapy. METHODS: A sample of 88 patients with Class III or Class III subdivision malocclusions, aged between 6 and 13 years, were consecutively selected and divided into three groups (G): G1-34 patients were treated with RME, followed by FM therapy; G2-34 patients were treated using RME according to modified alternate rapid maxillary expansion and constriction (ALT-RAMEC) protocol, followed by FM therapy. These treated groups were randomly (1:1 allocation ratio) distributed according to the two treatment protocols. G3 - Control Group - 20 untreated patients were followed. Magnetic resonance imaging (MRI) TMJs were obtained before (T1) and after (T2) a treatment period or follow-up. McNemar test, Fisher's exact test and intra- and inter-observer concordance (K) were performed (p ≤ .05). RESULTS: There were no statistically significant differences in the baseline cephalometric variables at T1 between the groups. There were statistically significant differences between the groups (p < .001) in relation to the disc shape in T1, since G1 (8 TMJs -11.76%) presented higher occurrences of altered forms in comparison with G2 (no changes). No significant differences were observed in disc position CM and OM (G1 - p > .999; G2 - p = .063; G3 - p = .500) and shape (G1 - p > 0.999; G2 - p = .250; G3 - not calculable), between T1 × T2, in any of the groups studied. CONCLUSION: The two treatment protocols did not have adverse effects on the position and shape of the TMJ disc, in a short-term evaluation.

Temporomandibular joint articular disc position and shape in skeletal Class III.

OBJECTIVE: To compare the position and shape of the temporomandibular joint (TMJ) articular disc among the sagittal and vertical skeletal patterns in Angle Class III, Class III subdivision malocclusion and normal occlusion. The null hypothesis was that there was no difference in disc position and shape in different (1) malocclusions and (2) skeletal patterns. METHODS: This cross-sectional observational study evaluated 105 patients divided into 3 groups: Class III (33, 9.39 ± 1.96 years), Class III subdivision (45, 9.51 ± 1.59 years) and a normal occlusion (27, 10.24 ± 0.87 years) was included as healthy control. Severity of the maxilla-mandibular anteroposterior discrepancy and vertical facial pattern were determined using 2D cephalometry, and the position and shape of the articular discs were evaluated in magnetic resonance images. Statistical parametric and non-parametric tests and Kappa analysis for intra-observer and inter-observer assessment were used (p ≤ .05). RESULTS: Significant between-group differences were found in articular disc position. In the normal occlusion group, all the articular discs were well positioned. In Class III and Class III subdivision, the discs were displaced in 30.3% and 12.2% of the TMJs, respectively. Sagittal and vertical skeletal patterns did not affect the findings significantly. The Class III subdivision malocclusion group is probably different from the other groups, showing 97.7% of biconcave discs in both TMJs. CONCLUSION: The longitudinal follow-up of this sample becomes relevant as the two groups with malocclusion in the pre-peak phase of pubertal growth showed differences in the prevalence of displacement and form of the articular disc, with no association with their vertical facial characteristics.

Personality traits in juvenile myoclonic epilepsy: evidence of cortical abnormalities from a surface morphometry study.

Cluster B personality disorders (PD), characterized as emotional instability, immaturity, lack of discipline, and rapid mood changes, have been observed among patients with juvenile myoclonic epilepsy (JME) and have been associated with a worse seizure outcome. Proper understanding of the neurobiology of PD associated with JME could contribute to understanding the basis for earlier and more effective interventions. In the present study, volumetric and geometric features of cortical structure were assessed through an automated cortical surface reconstruction method aiming to verify possible structural cortical alterations among patients with JME. Twenty-two patients with JME with cluster B PD, 44 patients with JME without psychiatric disorders, and 23 healthy controls were submitted to a psychiatric evaluation through SCID I and SCID II and to an MRI scan. Significant cortical alterations in mesiofrontal and frontobasal regions, as well as in other limbic and paralimbic regions, were observed mainly in patients with JME with PD. The present study adds evidence to the hypothesis of frontal and limbic involvement in the pathophysiology of cluster B PD in JME, regions linked to mood and affective regulation, as well as to impulsivity and social behavior. Moreover, a multidimensional pattern of frontal, limbic, and paralimbic changes was observed through a method of structural analysis which offers different and simultaneous geometric features, allowing the elaboration of important pathophysiologic insights about cluster B PD in JME.

Auras in temporal lobe epilepsy with hippocampal sclerosis: relation to seizure focus laterality and post surgical outcome.

We examined the relationship between presence and frequency of different types of auras and side of lesion and post surgical outcomes in 205 patients with medically intractable mesial temporal lobe epilepsy (MTLE) with unilateral hippocampal sclerosis (HS). With respect to the number of auras, multiple auras were not associated with side of lesion (p=0.551). The side of HS was not associated with the type of auras reported. One hundred fifty-seven patients were operated. The occurrence of multiple auras was not associated with post-surgical outcome (p=0.740). The presence of extratemporal auras was significantly higher in patients with poor outcome. In conclusion, this study suggests that the presence of extratemporal auras in patients with MTLE-HS possibly reflects extratemporal epileptogenicity in these patients, who otherwise showed features suggestive of TLE. Therefore, TLE-HS patients undergoing pre-surgical evaluation and presenting clinical symptoms suggestive of extratemporal involvement should be more extensively evaluated to avoid incomplete resection of the epileptogenic zone.

Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

A pioneering FreeSurfer volumetric study of a series of patients with mesial temporal lobe epilepsy and hippocampal sclerosis with comorbid depression.

Depression is the most frequent psychiatric comorbidity in patients with mesial temporal lobe epilepsy (MTLE) and hippocampal sclerosis (HS). This study aimed to confirm whether patients with comorbid depression have different volumetric patterns on magnetic resonance imaging, analysing the influence of HS sides. Psychiatrists conducted semi-structured interviews with 75 patients, who were divided into non-depression group (NDG, n = 52) and depression group (DG, n = 23), and compared with 98 controls. The FreeSurfer software was used in the volumetric analysis of the estimated total intracranial volume (eTIV), bilateral cortical and subcortical regions of interest (ROIs), and for presence of left (L-, n = 41) or right (R-, n = 34) MTLE-HS. Twenty-three (30.7%) patients had depression, of whom 14 (34.1%) had l-MTLE-HS and 9 (26.5%) had R-MTLE-HS. No difference was observed between DG and NDG vs. controls in terms of eTIV and cortical ROIs, regardless of the severity of depression. In patients with l-MTLE-HS, the eTIV in the DG was reduced in comparison with that in the NDG and control group, with a small effect size. Hippocampal reduction occurred ipsilateral to HS in the l-MTLE-HS and R-MTLE-HS subgroups when DG and NDG were compared with controls, as expected according to Enhancing Neuro Imaging Genetics through Meta-Analysis (2018).

Personality traits related to juvenile myoclonic epilepsy: MRI reveals prefrontal abnormalities through a voxel-based morphometry study.

Studies involving juvenile myoclonic epilepsy (JME) patients have demonstrated an elevated prevalence of cluster B personality disorders (PD) characterized as emotional instability, immaturity, unsteadiness, lack of discipline, and rapid mood changes. We aimed to verify a possible correlation between structural brain abnormalities in magnetic resonance image (MRI) and the PD in JME using voxel-based morphometry (VBM). Sixteen JME patients with cluster B PD, 38 JME patients without psychiatric disorders, and 30 healthy controls were submitted to a psychiatric evaluation through SCID I and II and to a MRI scan. Significant reduction in thalami and increase in mesiofrontal and frontobasal regions' volumes were observed mainly in JME patients with PD. Structural alterations of the orbitofrontal cortex (OFC), involved in regulation of mood reactivity, impulsivity, and social behavior, were also observed. This study supports the hypothesis of frontobasal involvement in the pathophysiology of cluster B PD related to JME.

Blinking and eyelid myoclonia: Characteristics and correlations of eyelid movements.

PURPOSE: Eyelid myoclonia (EM) is considered a seizure type and has been described in several epileptic conditions. Previous studies reported that EM are precipitated only by slow eye closure, but little is known about the characteristics of blinking in patients with EM seizures and differences in precipitation of EM by different kinds of eye closure. We analyzed by video-EEG the characteristics of blinking and eye closure in these patients. METHOD: Twenty patients with EM had a video-EEG protocol with eyelid sensors. Semiology and rate of blinking and EM were analyzed. Statistical analysis was performed and p-values <0.05 were considered significant. RESULTS: Seventeen cases (mean age 20.7, range 3-35) were women, 10 had EM as the main seizure type and between the others, all, but one, had criteria to Juvenile Myoclonic Epilepsy. All patients presented EM, 18 spontaneously during awake, 10 on eye closure and one only during intermittent photic stimulation. EM assumed the form of flicker, flutter or jerk, accompanied by generalized discharges, spiky posterior alpha, theta rhythm or absence of any EEG abnormality. Analysis of the characteristics of blinking had no statistics differences between patients and healthy subjects. The rate of blinks and EM increased during speech and decreased during reading. EM never occurred during blinking or in the dark. CONCLUSIONS: Despite normal physiology of blinking, EM can manifest as jerk, flicker or flutter, with or without EEG abnormalities and independently of IPS, suggesting that eye closure sensitivity seems to include both, a motor and a visual component.

Hemispheric surgery for refractory epilepsy in children and adolescents: outcome regarding seizures, motor skills and adaptive function.

PURPOSE: The aim of the study was to report the seizure outcome, motor skills and adaptive motor functions in a series of children and adolescents who underwent hemispheric surgery, analysing the risk-benefits of surgery. METHODS: The clinical course, seizure and motor function outcomes of 15 patients who underwent hemispheric surgery were reviewed. RESULTS: The mean age at surgery was 9.5, with 1-9 years follow-up. The underlying pathologies were Rasmussen encephalitis, vascular disorders, and hemimegalencephaly. All the patients presented with severe epilepsy and different degrees of hemiparesis, although motor functionality was preserved in 80% of the patients. At last follow-up, 67% were seizure free, and 20% rarely experienced seizures. Antiepileptic drugs were reduced in 60%, and complete withdrawal from such drugs was successful in 20% of the patients. The motor outcome following the surgery varied between the patients. Despite the motor deficit after surgery, the post-operative motor function showed unchanged for gross motor function in most (60%), while 27% improved. Similar results were obtained for the ability to handle objects in daily life activities. Sixty percent of the children were capable of handling objects, with somewhat reduced coordination and/or motor speed. CONCLUSION: Pre-surgical motor function continues to play a role in the pre-surgical evaluation process in order to provide a baseline for outcome. Hemispheric surgery, once regarded as a radical intervention and last treatment resource, may become routinely indicated for refractory hemispheric epilepsy in children and adolescents, with oftentime favourable motor outcomes.

Intracranial depth electrodes implantation in the era of image-guided surgery.

The advent of modern image-guided surgery has revolutionized depth electrode implantation techniques. Stereoelectroencephalography (SEEG), introduced by Talairach in the 1950s, is an invasive method for three-dimensional analysis on the epileptogenic zone based on the technique of intracranial implantation of depth electrodes. The aim of this article is to discuss the principles of SEEG and their evolution from the Talairach era to the image-guided surgery of today, along with future prospects. Although the general principles of SEEG have remained intact over the years, the implantation of depth electrodes, i.e. the surgical technique that enables this method, has undergone tremendous evolution over the last three decades, due the advent of modern imaging techniques, computer systems and new stereotactic techniques. The use of robotic systems, the constant evolution of imaging and computing techniques and the use of depth electrodes together with microdialysis probes will open up enormous prospects for applying depth electrodes and SEEG both for investigative use and for therapeutic use. Brain stimulation of deep targets and the construction of "smart" electrodes may, in the near future, increase the need to use this method.

The integrity of corpus callosum and cluster B personality disorders: a quantitative MRI study in juvenile myoclonic epilepsy.

Evidence suggests increased prevalence of cluster B personality disorders (PD) among patients with juvenile myoclonic epilepsy (JME), which has been associated with worse seizure control and more psychosocial dysfunctions. A preliminary voxel-based morphometry study demonstrated corpus callosum (CC) volume reduction in patients with JME and cluster B PD, particularly in the posterior midbody and isthmus. In this study we aimed to follow up these results with region of interest analysis. Sixteen JME patients with cluster B PD, 38 JME patients without any psychiatric disorder, and 30 demographically matched healthy controls submitted to a psychiatric evaluation and a magnetic resonance imaging scan. The total and regional callosal areas were obtained from the midsagittal slice using a semi-automated program. Psychiatric evaluation was performed through SCID-I and -II. Significant reductions in the posterior region of the CC were observed in the JME with PD group relative to the other groups. These data support previous findings of callosal reductions in cluster B PD, as well as a possible involvement of CC in patients with JME and such personality characteristics.

Pre-surgical evaluation and surgical treatment in children with extratemporal epilepsy.

INTRODUCTION: This review summarizes some patterns of pre-surgical evaluation and surgical treatment of extratemporal epilepsy in pediatric patients with medically refractory seizures, whose ictal behavior is variable. The most effective treatment for intractable partial epilepsy is a focal cortical resection with excision of the epileptogenic zone (the area of ictal onset and initial seizure propagation). This might be risky, though, in the case of a widespread lesion, sometimes encroaching one or more lobes, given the risk to the functional cerebral cortex. An anterior temporal lobectomy might prove more effective then in preventing seizures with fewer potential complications. If partial extratemporal epilepsy is associated with pharmaco-resistant seizures, the preoperative evaluation and operative strategy are determined according to the epileptogenic zone and to the relationship between a substrate-directed disorder and eloquent areas. The pediatric treatment of extratemporal epilepsy is aimed at controlling the seizures, avoiding morbidity, and improving the patient's quality of life through psychosocial integration. Since the immature brain is more plastic than when mature, the recovery of functions after surgery is greater in children than in adults. RECOMMENDATION: Early surgery is recommended for children with intractable epilepsy, and is now accepted as an important therapeutic modality also for children with chronic epilepsy. CONCLUSION: Technological advances in the last two decades, mainly in neuroimaging, have led many medical centers to consider surgical treatment of epilepsy, accuracy being granted by MRI-based neuronavigation systems-an interface between the lesion seen in the preoperative magnetic resonance imaging (MRI) and the operative field, often invisible to the surgeon.

Intracranial depth electrodes implantation in the era of image-guided surgery / A implantação de eletrodos de profundidade na era da cirurgia guiada por imagem

The advent of modern image-guided surgery has revolutionized depth electrode implantation techniques. Stereoelectroencephalography (SEEG), introduced by Talairach in the 1950s, is an invasive method for three-dimensional analysis on the epileptogenic zone based on the technique of intracranial implantation of depth electrodes. The aim of this article is to discuss the principles of SEEG and their evolution from the Talairach era to the image-guided surgery of today, along with future prospects. Although the general principles of SEEG have remained intact over the years, the implantation of depth electrodes, i.e. the surgical technique that enables this method, has undergone tremendous evolution over the last three decades, due the advent of modern imaging techniques, computer systems and new stereotactic techniques. The use of robotic systems, the constant evolution of imaging and computing techniques and the use of depth electrodes together with microdialysis probes will open up enormous prospects for applying depth electrodes and SEEG both for investigative use and for therapeutic use. Brain stimulation of deep targets and the construction of "smart" electrodes may, in the near future, increase the need to use this method.

O advento das modernas técnicas de cirurgia guiadas por imagem revolucionaram a técnica de implantação dos eletrodos de profundidade (EP). A estereoeletroencefalografia (E-EEG), conforme introduzida na década de 50 por Talairach, é um método invasivo de análise tridimensional da zona epilpeptogênica, baseado na técnica de implantação intracraniana de EP. O objetivo deste artigo é discutir os princípios da E-EEG e sua evolução, desde a era Talairach até a era atual, da cirurgia guiada por imagem, e suas perspectivas futuras. Embora os princípios gerais da E-EEG tenham permanecidos intactos ao longo dos anos, a implantação de EP, que é a técnica cirúrgica que viabiliza este método, sofreu grande evolução ao longo das últimas três décadas devido ao advento das modernas técnicas de imagem, de sistemas de computação e das novas técnicas estereotáxicas. O uso de sistemas robotizados, a evolução constante das técnicas de imagem e computação e a utilização de EP com sondas para micro diálise associados a si, abre no futuro uma enorme perspectiva para a aplicação dos EP e da E-EEG, tanto para uso investigativo como terapêutico. A estimulação cerebral de alvos profundos e a fabricação de eletrodos "inteligentes", poderão incrementar, num futuro próximo, a necessidade do uso deste método.