Effects of lateralisation and gender on temporal lobe ictal behaviour associated with hippocampal sclerosis.
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INTRODUCTION: Information derived from animal models and neuroradiological studies in humans indicates that males and females exhibit differences in the functional and anatomical organisation of the brain. This study aimed to evaluate the effect of gender in ictal behaviour considering lateralisation in a group with homogeneous pathology. METHODS: Patients with hippocampal seizures who underwent temporal lobectomy and who were seizure-free during one year of follow-up were selected. Surgery was performed on the right side in 27 patients and on the left side in 21. Videotape recordings of the patients were reviewed in order to investigate ictal behaviour. There were 42 seizure episodes in 20 males and 40 in 21 females. For auras, 48 patients' data were reviewed. Ictal behaviour was evaluated taking into consideration the lateralisation of seizures and gender differences. RESULTS: Ictal vocalisation was significantly higher in females with right temporal lobe epilepsy (RTLE) (P < 0.05). Forced head deviation was significantly higher in males with left temporal lobe epilepsy (LTLE) (P < 0.03) and in females with RTLE (P < 0.0001). Unforced head deviation was significantly higher in males with RTLE (P < 0.002). Ipsilateral eye deviation was significantly higher in RTLE, with no differences between males and females. Postictal coughing was significantly higher in RTLE, again with no differences between males and females (P < 0.03). With regard to automatisms, posturing and nose wiping, there was no difference between right and left temporal lobe seizures or between genders. CONCLUSIONS: To the best of our knowledge, this study is the first demonstrating differences in ictal behaviour between females and males, thus showing that gender is related to different functional and anatomical organisations of the human brain. (+info)
Early antiepileptic drug reduction following anterior temporal lobectomy for medically intractable complex partial epilepsy.
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PURPOSE: To determine the safety, in our practice, of allowing patient preference to influence the timing of antiepileptic drug (AED) reduction, once they became seizure-free after anterior temporal lobectomy (ATL). METHODS: Thirty patients underwent anterior temporal lobectomy for medically intractable complex partial epilepsy at Loma Linda University Medical Center between December 1st 1991 and November 30th 2001. Timing of AED reduction in seizure-free patients was based on patient request. A review of patient records noted seizure status, duration from surgery to AED reduction, AED side effects, seizure recurrence and whether control was regained. RESULTS: Twenty-four (80%) of the 30 patients became seizure-free on their preoperative AEDs after initial ATL; three additional patients after a second operation. AEDs were not reduced in the reoperated patients, the three patients who did not become seizure-free, and in two patients who asked to increase AEDs to control auras. Thus, AEDs were reduced in 22 of the 27 seizure-free patients. Patients were followed an average of 3.4 +/- 2.7 (mean +/- standard deviation) years. AED reduction was initiated 4.6 +/- 7.2 months (range 0-27 months) after surgery. Polytherapy use decreased from 54% preoperatively to 18% at last follow up. Seizures recurred in six patients (27% of 22); three became seizure-free after AED adjustments. CONCLUSIONS: In our practice, using an individualized approach to AED reduction following successful epilepsy surgery resulted in early reduction in AEDs. Our data suggest that early AED reduction can be performed safely and without undue risk of seizure recurrence. (+info)
Orgasmic aura--a report of seven cases.
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We report on seven patients who experienced an orgasmic aura at the start of their seizures. The patients (five women, two men) were aged 36-58. Three of seven patients described the exact nature of their auras only many years after their appearance, when the epilepsy diagnostic procedure became more intensive due to drug resistance. Moreover, one patient even refused any new therapeutical options due to the reportedly positive role of the orgasmic aura in her life. All of our patients had temporal lobe epilepsy. The clinical picture, EEG, MRI or SPECT findings suggested a right temporal epileptic focus in six patients, while in one patient the epileptogenic region was localised in the left temporal lobe. In the latter case, the left hemisphere was speech-dominant, while in the other cases no Wada tests were done. Our results confirm that orgasmic aura could be considered as an ictal lateralising sign to the right hemisphere, however, it has no 100% lateralising value. (+info)
Nonverbal memory functioning following right anterior temporal lobectomy: a meta-analytic review.
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PURPOSE: Studies investigating nonverbal memory functioning following right anterior temporal lobectomy (RATL) in patients with intractable temporal lobe epilepsy have resulted in conflicting findings, as nonverbal memory deficits have been reported for some, but not all patients. To examine the association between nonverbal memory deficits and RATL, the present study employed meta-analytic principles in a quantitative review of the literature. METHODS: Thirteen studies, reporting pre- and postoperative nonverbal memory performance for a total of 324 RATL patients, were identified. Effect sizes were calculated to measure the extent of nonverbal memory deficit in patients following RATL. Additionally, effect sizes for primary studies comprising a common dependent variable were combined using standard meta-analytic procedures. RESULTS: Of the 22 dependent variables utilized to assess nonverbal memory, 14 indicated postoperative declines in functioning while 8 demonstrated postoperative improvements in performance. All resultant effect sizes were relatively small. Mean effect sizes calculated for dependent variables used in multiple studies identified the Warrington Recognition Memory Test for Faces as the only nonverbal memory measure which produced consistent results. CONCLUSIONS: Overall, the collective findings demonstrate the inability of the current research to provide any consistent evidence as to the nature of nonverbal memory outcome following RATL. Problems with nonverbal memory measures are discussed and suggestions for future research are proposed. (+info)
Postoperative interictal spikes during sleep contralateral to the operated side is associated with unfavourable surgical outcome in patients with preoperative bitemporal spikes.
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PURPOSE: To correlate the persistence of contralateral spikes during sleep after unilateral surgery with seizure outcome in a temporal lobe epilepsy (TLE) population and to test the existing hypotheses about the origin of the contralateral spikes in temporal lobe epilepsy. METHODS: In the 19 patients selected for this study unilateral temporal lobe surgery was performed. To investigate the course of bilateral interictal epileptiform discharges observed before surgery in awake or sleep over the temporal lobe contralateral to surgery, 24 h mobile 12 channel EEG recording was performed at minimum two, in average 4.6 (2-10) years after the surgery. RESULTS: The association of postoperative contralateral spikes and non-seizure free outcome was highly significant. The existence of unilateral pathology before surgery was highly predictive for good outcome and disappearance of contralateral spikes. The association between good seizure outcome, disappearance of contralateral spikes and the existence of unilateral pathology before surgery was also significant. Our data partially satisfies the expectations of both the "seizure induced" and mirror type secondary epileptogenesis hypotheses concerning origin of contralateral spikes, but were not completely congruent with either of them. CONCLUSIONS: Unfavourable surgical outcome in a temporal lobe epilepsy group with preoperative independent bilateral interictal spikes was associated with the persistence of postoperative contralateral spikes and lack of unilateral pathology. Compared with seizure outcome the presence/absence and distribution of postoperative interictal spikes in NREM sleep not entirely fit to the predictions of existing secondary epileptogenesis hypotheses. (+info)
Functional MRI predicts post-surgical memory following temporal lobectomy.
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Temporal lobectomy is an effective therapy for medically refractory temporal lobe epilepsy (TLE), but may be complicated by amnestic syndromes. Therefore, pre-surgical evaluation to assess the risk/benefit ratio for surgery is required. Intracarotid amobarbital testing (IAT) is currently the most widely used method for assessing pre-surgical memory lateralization, but is relatively invasive. Over the past decade functional MRI (fMRI) has been shown to correlate with IAT for language lateralization, and also for memory lateralization in a small number of patients. This study was carried out to compare fMRI during memory encoding with IAT testing for memory lateralization, and to assess the predictive value of fMRI during memory encoding for post-surgical memory outcome. Thirty-five patients with refractory TLE undergoing pre-surgical evaluation for temporal lobectomy and 30 normal subjects performed a complex visual scene-encoding task during fMRI scanning at 1.5 T using a 10-min protocol. Encoding performance was evaluated with subsequent recognition testing. Twenty-three patients also completed the same task again outside the scanner, an average of 6.9 months following surgery. A region of interest (ROI) analysis was used to quantify activation within hippocampal and a larger mesial temporal lobe ROI consisting of hippocampus, parahippocampus and fusiform gyrus (HPF) as defined by a published template. Normal subjects showed almost symmetrical activation within these ROI. TLE patients showed greater asymmetry. Asymmetry ratios (ARs) from the HPF ROI correlated significantly with memory lateralization by intracarotid amobarbital testing. HPF ARs also correlated significantly with memory outcome, as determined by a change in scene recognition between pre-surgical and post-surgical trials. When absolute activation within the HPF ROI was considered, a significant inverse correlation between activation ipsilateral to temporal lobectomy and memory outcome was observed, with no significant correlation in the contralateral HPF ROI. Although further technical improvements and prospective clinical validation are required, these results suggest that mesial temporal memory activation detected by fMRI during complex visual scene encoding correlates with post-surgical memory outcome and supports the notion that this approach will ultimately contribute to patient management. (+info)
Pre-operative verbal memory fMRI predicts post-operative memory decline after left temporal lobe resection.
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Functional MRI (fMRI) of cognitive tasks depends on technology widely available in the clinical sphere, but has yet to show a role in the investigation of patients. We report here the first demonstration of a clinically valuable role for cognitive fMRI. Temporal lobe epilepsy (TLE) is commonly caused by hippocampal sclerosis and is frequently resistant to drug treatment. Surgical resection of the left hippocampus in this setting can cure seizures, but may produce significant verbal memory decline, which is hard to predict. We report 10 right-handed TLE patients with left hippocampal sclerosis who underwent left hippocampal resection. We compared currently used data for the prediction of post-operative verbal memory decline in such patients with a novel fMRI assessment of verbal memory encoding. Multiple regression analyses showed that fMRI provided the strongest independent predictor of memory outcome after surgery. At the individual subject level, the fMRI data had high positive predictive value for memory decline. (+info)
Lesional mesial temporal lobe epilepsy and limited resections: prognostic factors and outcome.
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OBJECTIVES: To evaluate the influence of clinical, investigational, surgical, and histopathological factors on postoperative seizure relief in patients with mesial temporal lobe epilepsy (MTLE) due to lesions other than ammonshornsclerosis (AHS). METHODS: Of 738 patients operated for TLE, 78 patients underwent limited resections for lesional MTLE (1990-2000). Seventy four patients with a follow up of more than one year were included. The preoperative clinical, neuropsychological, electroencephalogram, and neuroimaging characteristics were prospectively collected in a database. The histopathological material was re-examined. RESULTS: The mean follow up was 49 months. Fifty eight patients were classified as seizure free (78.4% Class I), and six as almost seizure free (8.1% Class II), grouped together as satisfactory seizure control (64 patients, 86.5%). Five patients (6.8%) were categorised in Classes III and IV, respectively. These were grouped as unsatisfactory seizure control (10 patients, 13.5%). Surgical procedures were: 32 amygdalohippocampectomies (AH), 17 partial anterior AH, 15 AH plus polar resection, seven AH plus basal resection, and three AH plus extended temporal lesionectomy. There was no mortality and 2.7% mild permanent morbidity. Seizure relief did neither differ significantly with these approaches, nor with different classes of pathological findings (43 developmental tumours, 12 glial tumours, 10 dysplasias, and nine others). Even operation of dysplasias resulted in 80% satisfactory seizure control. Seizure onset during childhood proved to be a negative predictor for seizure relief (p = 0.020). MRI revealed 73 suspected lesions (98.6%), one dysembryoplastic neuroepithelial tumour was missed, in four cases no structural abnormalities could be confirmed with histopathological exam. Additionally, multifactorial regression revealed the factors "seizure onset after 10 years of age", "presence of complex partial seizures", "absence of a neurological deficit", and a "correlating neuropsychological deficit" as predictive for satisfactory seizure control. CONCLUSIONS: "Preoperative tailoring" resulting in limit resections has proven to be safe and to provide a very good chance for satisfactory seizure relief in patients with lesional MTLE. (+info)