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Temporal lobe resections in children.

Often, seizures in childhood are intractable to medical therapy. Intractable seizures and prolonged anticonvulsant medication can adversely affect intellectual development and psychosocial maturation in children. Temporal lobe resections for complex partial seizures and focal epilepsy in children can be performed with minimal morbidity. The higher morbidity lies with prolonged observation of these children with intractable seizures. The final result of surgical treatment shows that children can significantly benefit from an early developmental period without anticonvulsant medication or intractable seizures with improvements in both IQ and behavioral interactions. With improvements in neuroimaging techniques and evaluation procedures, more children can be identified who might benefit from a resective procedure. It is thus advocated that early evaluation and surgical intervention be performed to gain improvement in seizure control and psychosocial development.

Adolescent↗

Epilepsy surgery in children and adults.

Epilepsy surgery is now accepted as a treatment modality for medically intractable epilepsy. A careful and detailed evaluation of patients is required by a trained epilepsy team which includes neurosurgeons, neurologists, neuroradiologists, psychologists and psychiatrists. For intractable complex partial seizures of temporal lobe origin, epilepsy surgery offers an 80% success rate.

Adult↗

Simultaneous intracranial and extracranial recording of interictal epileptiform activity in patients with drug resistant partial epilepsy: patterns of conduction and results from dipole reconstructions.

Ten patients with complex partial epileptic seizures undergoing invasive video/EEG-monitoring were recorded with a combination of 10 subdural strip electrode contacts (subtemporal + lateral temporal), and 22 extracranial recording sites. In each patient several spikes with different intracranial distributions were identified, and spikes with similar distributions were averaged together with their extracranial activity. Dipole analysis of the extracranial activity was performed with the BESA program (Scherg, Garching Instrumente, München). In the horizontal plane subtemporal spikes gave oblique posterior, and lateral temporal spikes straight lateral or oblique anterior dipole orientations. In the coronal plane all spikes had an elevated orientation, most pronounced for medial subtemporal spikes. Dipole locations did not separate as well as dipole orientations. In our opinion our results would be difficult to explain without postulating a substantial degree of volume conduction from deep temporal areas to the surface. We conclude that dipole analysis of the interictal epileptiform activity does provide substantial information about which parts of the temporal lobe are involved in the epileptogenic process, making the method a useful tool in the preoperative investigation of patients with drug resistant partial epilepsy.

Adult↗

Tiagabine.

Tiagabine (TGB), a specific gamma-aminobutyric acid (GABA)-uptake inhibitor, is a potential new antiepileptic drug with a novel mechanism of action. In animal models of epilepsy as well as in a placebo-controlled trial in patients with complex partial seizures, TGB showed significant anticonvulsant effects. TGB was well tolerated by most patients.

Acoustic Stimulation↗

Vigabatrin in complex partial seizures: a long-term study.

The efficacy and safety of oral vigabatrin (VGB) as add-on therapy in the long-term treatment of poorly controlled epilepsy were evaluated in 19 patients with complex partial seizures, either with or without secondary generalization. The study was run with a single-blind, placebo-controlled, crossover design, and included 2 months of placebo and 13-15 months of treatment with VGB, at doses ranging from 1 to 4 g/day. Of the 14 patients who completed the trial, 2 were seizure free, in 5 seizure frequency dropped by more than 75% and in another 5 by more than 50% with respect to baseline. The decrease in seizure frequency in the group as a whole was significant at all observation points of the trial. Three patients were not entered into the long-term phase due to lack of improvement (an increase in seizure frequency was observed in one of them), and 2 were excluded later because improvement disappeared leading to unauthorized changes in comedication. Side effects were mild and never caused discontinuation of treatment. In conclusion, VGB showed a remarkable efficacy and safety in the long-term treatment of complex partial seizures.

Administration, Oral↗

Gamma-vinyl GABA (vigabatrin) in epilepsy: clinical, neurochemical, and neurophysiologic monitoring in epileptic patients.

We report long-term clinical, neurochemical, and electrophysiologic data of gamma-vinyl GABA (GVG, vigabatrin) in three groups of patients. GVG was started as add-on therapy for 75 patients with refractory complex partial seizures (group A) and for 36 mentally handicapped patients with severe epilepsy (group B). The third group (C) consisted of 20 patients with carbamazepine (CBZ) monotherapy, in half of whom GVG monotherapy was substituted. After 3 months, 55% of patients in group A and 42% in group B were responders (reduction in seizure frequency greater than 50%). After 6 (group A) and 3 years (group B) of follow-up, 27 and 33% of the patients, respectively, still had good response to GVG. Neurochemical measurements showed a twofold increase in CSF GABA concentrations and minimal or no changes in other neurotransmitter-related parameters. In group C, substitution of GVG as medication tended to normalize the lengthened latencies in somatosensory evoked potentials (SEPs) observed during CBZ treatment.

Adult↗

Heautoscopy, epilepsy, and suicide.

Heautoscopy (the doppelgänger experience), epilepsy, and suicide is a triad primarily known from literary accounts. This paper reports a patient with complex partial seizures who tried to commit suicide during the experience of heautoscopy.

Adult↗

HMPAO SPECT in non-epileptic seizures: preliminary results.

The diagnosis of non-epileptic seizures (NES) is problematic. Although diagnosis can be achieved by videotelemetry, these facilities are expensive and not widely available. HMPAO SPECT studies show focal hypoperfusion interictally in focal epilepsy. SPECT has not been studied in any detail in NES previously. Two groups (10 patients each) were studied, one with NES and one with complex partial seizures and localisation related epilepsy. SPECT scans were normal in 7 of 10 (70%) NES patients, while showing clear focal hypoperfusion in 8 of 10 patients (80%) with epilepsy. In the NES group, 1 patient showed hypoperfusion indistinguishable from that seen in epilepsy, while 2 patients in the epilepsy group showed only equivocal focal hypoperfusion. The remaining 2 patients in the NES group showed bifrontal and equivocal focal hypoperfusion. A normal HMPAO SPECT study supports the diagnosis of NES in patients with seizures of uncertain aetiology.

Adolescent↗

CT, MRI and SPECT neuroimaging in status epilepticus with simple partial and complex partial seizures: case report.

A 35-year-old female patient suffering from epilepsy was examined during status epilepticus with simple partial and complex partial seizures by means of EEG, CT, MRI and ictal SPECT. All these examinations showed focal abnormalities with identical location due to oedema and hypervascularisation; these were, however, absent during examinations carried out before and after status epilepticus.

Adult↗

Effect of frontal and temporal seizure foci on P50 auditory evoked potentials.

Event-related potentials have been occasionally investigated in epilepsy. We recorded P50 auditory evoked potentials in 25 patients with complex partial seizures of frontal and temporal lobe origin. P50 was significantly reduced in amplitude and prolonged in latency in temporal lobe seizure patients as compared to controls. Patients with complex partial seizures originating in the frontal lobes did not differ from controls in P50 amplitude. P50 attenuation differences may be related to interictal behavioral or cognitive changes, but could also reflect medication effects. Event-related potentials may be helpful in differentiating frontal and temporal seizure foci.

Adolescent↗

Characterization of phenytoin-resistant kindled rats, a new model of drug-resistant partial epilepsy: comparison of inbred strains.

PURPOSE: Previous work from our laboratory showed that amygdala-kindled Wistar outbred rats can be selected according to the increase of afterdischarge threshold (ADT) after phenytoin application. Animals that consistently do not respond to phenytoin (PHT) with an ADT increase (non-responders) are the first animal model of pharmacoresistant complex partial seizures. In this study, we determined the ability to respond to PHT in male kindled rats of different inbred strains. METHODS: The experiments were performed in fully kindled rats of five different inbred strains, Wistar-Kyoto, Lewis, Fischer 344, ACI, and Brown Norway. The response type of each rat was revealed by four consecutive PHT applications (75 mg/kg, i.p.) in fully kindled rats. RESULTS: PHT application resulted in plasma concentrations ranging from some 16 microg/ml in Lewis rats to 35 microg/ml in Fischer 344 rats, and in slight ataxia, most strongly in Fischer 344 rats. The rats of each strain did not show a homogeneous response to PHT. A significant increase of ADT was found after 86-97% of applications in Lewis, Wistar-Kyoto, and Fischer 344 rats. In contrast, Brown Norway rats responded in only 34% of experiments. This led to a considerable number of responders (i.e., consistent ADT increase by >20%) in Fischer 344, Wistar-Kyoto, and Lewis rats. The only strain revealing nonresponders (i.e., consistent lack of ADT increase by >20% with PHT treatment) was Brown Norway. CONCLUSIONS: Inbred strains, although genetically more homogenous than outbred strains, differ in their response to PHT. Brown Norway rats can offer advantages for further detailed investigation of the resistance to PHT in the kindling model of complex partial seizures.

Animals↗

Effect of YM928, a novel AMPA receptor antagonist, on seizures in EL mice and kainate-induced seizures in rats.

Kainate-induced seizures and seizures induced by tossing stimulation in epilepsy-prone EL mice are considered as models of complex partial seizures. We used these models to evaluate the anticonvulsive effects of 2-[ N-(4-chlorophenyl)- N-methylamino]-4 H-pyrido[3.2-e]-1,3-thiazin-4-one (YM928), a novel alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist. In the kainate-induced seizure test in rats, wet-dog shakes (WDS) were reduced by oral administration of YM928 at doses of 7.5 mg/kg and 30 mg/kg. YM928 (15 mg/kg) reduced the number of WDS within the first 80 min, but then prolonged the time of occurrence compared with the other groups. Significant reduction in kainate-induced motor seizure was observed with 4-30 mg/kg. YM928 did not induce apparently abnormal behaviour at doses of 2-15 mg/kg but did induce sedation at 30 mg/kg. Carbamazepine (40 or 80 mg/kg), valproate (600 mg/kg), diazepam (2.5 mg/kg), and phenobarbital (20 or 40 mg/kg) exerted anticonvulsant effects against motor seizures, but only valproate, at a dose that also caused sedation, suppressed WDS. Phenytoin and ethosuximide did not show significant anti-kainate effects. In the tossing stimulation test in EL mice, i.p. injection of YM928 at 5 mg/kg or 10 mg/kg significantly increased the number of stimulations required to elicit generalized seizure. Carbamazepine (4 or 8 mg/kg), phenytoin (8 or 16 mg/kg), valproate (100-400 mg/kg), diazepam (0.5 mg/kg), phenobarbital (1.3 or 2.5 mg/kg) and ethosuximide (75-300 mg/kg) exerted significant anticonvulsant effects against these seizures. These results indicate that YM928 has anticonvulsant effects on seizure models that are characteristic of partial onset seizures in humans. YM928 is expected to have beneficial effects against human complex partial seizure with secondary generalization or temporal lobe epilepsy.

Animals↗

Prolonged post-ictal confusion as a manifestation of continuous complex partial status epilepticus: a depth EEG study.

We report a peculiar depth-EEG recording of prolonged post-ictal confusion which proved to be continuous complex partial status epilepticus. A 33 year old male with intractable medial temporal lobe epilepsy exhibited this ictal EEG recording. After repetitive habitual complex partial seizures, and an ensuing short lucid interval with intact memory and full communicability, the patient became more and more unresponsive and, finally, even cataleptic. Concurrent with this change in responsiveness, an EEG revealed a gradual and steady increase of ictal EEG activity. Immediately after intravenous diazepam infusion, this ictal EEG activity was suppressed and the patient began to move. This case confirms that a paradoxical excitation can occur after clustered complex partial seizures, instead of the well-known neuronal exhaustion.

Adult↗

[Prognostic factors in temporal lobe epilepsy surgery].

INTRODUCTION: Temporal lobe epilepsy surgery represents the majority of surgical interventions in patients with refractory epilepsy. In consequence, knowledge of prognostic factors in this type of epilepsy surgery is of major importance. The objective of this study is to study series of prognostic factors in a group of patients who underwent temporal lobe epilepsy surgery and to correlate Engel's Classification of Postoperative Outcome, now used in most epilepsy centers, and the Proposal for New Classification in regards to Epileptic Seizures Following Epilepsy Surgery of the International League Against Epilepsy (ILAE). METHODS: We analyzed 41 consecutive patients who underwent temporal lobe epilepsy surgery in the Epilepsy Surgery Program of the Epilepsy Unit in the Fundación Jiménez Díaz. The following prognostic factors were analyzed: age at surgery, time since the first seizure (excluding febrile seizures), risk factors for the development of epilepsy, presence of simple partial seizures, presurgical complex partial seizure frequency, findings in brain magnetic resonance imaging, interictal and ictal electroencephalogram, neuropsychological assessment, Wada test and neuropathological study of the surgical specimen. Two outcome classifications were used: Engel's classification of postoperative outcome and the proposal for a new classification of outcome in regards to epileptic seizures following epilepsy surgery of the ILAE. Statistical analysis was performed using non-parametric tests. RESULTS: The presence of temporal unilateral interictal epileptiform activity and the presence of less than 20 seizures complex partial seizures per month before surgery were associated with a better prognosis using both classifications. The electronencephalographic unilateral temporal ictal onset recording was associated with a better prognosis using Engel's classification but not ILAE's outcome classification. The presence of febrile seizures was associated with a better prognosis in regards to ILAE's outcome classification but not in regards to Engel's classification. The remaining factors were not associated with outcome. CONCLUSIONS: The following factors were associated with a good prognosis: presence of unilateral temporal interictal epileptiform activity, presurgery seizure frequency below 20 complex partial seizures per month, unilateral temporal ictal onset, and presence of febrile seizures. A good correlation was found between both outcome classifications in regards to most of the analyzed prognostic factors.

Adult↗

[Total or partial withdrawal of antiepileptic drugs].

Total withdrawal of antiepileptic drugs leads to a mean relapse rate of approximately 50 p. 100 in adults and 25 p. 100 in children. The relapse rates are lowest in patients with benign epilepsies of childhood and epilepsies with absence seizures only and those with a short duration of epilepsy. Relapse rates are higher in patients with complex partial seizures, absences with generalized tonic-clonic seizures, juvenile myoclonic epilepsy, patients with several types of seizures, high seizure frequency prior to control, in patients with neurological, psychiatric or social handicaps and in those with emotional ambivalence towards the reduction. Guidelines for slow and safe withdrawal are given. Reduction should be actively encouraged only in patients with absence seizures or benign focal epilepsy and those with epilepsy of short duration. Slow partial withdrawal is recommended in uncontrolled epilepsy because in 80 p. 100 of the patients it results in a decrease in seizure frequency and side effects or both.

Anticonvulsants↗

[Clinical and electroencephalographic analysis of epilepsy in children with hydrocephalus].

Clinical and electroencephalographic features of epilepsy and the prognosis of intelligence were investigated in 156 children with hydrocephalus. Of these 53 (34.0%) had epilepsy. The incidence and outcome of epilepsy were determined by the etiology of hydrocephalus. The incidence was high in children with hydrocephalus caused by intra-cranial infection and dysgenetic hydrocephalus without dysraphism. Furthermore, it was difficult to control the epileptic seizures in these patients. In contrast, children with dysgenetic hydrocephalus caused by dysraphism and simple hydrocephalus had lower incidence of epilepsy and epileptic seizures had been well controlled in these cases. In hydrocephalic children, localization-related epilepsy was the most common. Complex partial seizures and focal motor seizures were frequently observed. Common electroencephalographic findings were focal spikes or multi-focal spikes. The intelligence quotient was significantly lower in children with epilepsy than in those without epilepsy. All these findings suggest that the incidence of epilepsy may be a crucial prognostic factor in children with hydrocephalus.

Adolescent↗

Cerebral neurocytoma: an unusual cause of refractory epilepsy. Case report and review of the literature.

We report a patient with medically refractory complex partial seizures (CPS) caused by a cerebral neurocytoma located near the amygdala. Neurocytoma represents an important addition to the differential diagnosis and, in particular, must be differentiated from oligodendroglioma and dysembryoplastic neuroepithelial tumor. Accurate pathological differential has therapeutic and prognostic implications.

Adult↗

[Bradycardia: an unrecognized complication of some epileptic crises].

A 36-year-old man, treated for epilepsy since early childhood, was hospitalized for nocturnal paroxysmal disorders. The EEG-EKG-video monitoring revealed complex partial seizures with bradycardia secondary to a sino-auricular block. The occurrence of autonomic disturbances during seizures is well known, mostly described in temporal epilepsy. Ictal bradycardia, with asystole, has been unfrequently reported, while tachycardia appears more common. A systematic investigation of cardiac data synchronized with EEG recordings, especially in case of aspecific fainting, could give a more accurate diagnosis and treatment, and so reducing sudden unexplained death in epileptic patients.

Adult↗