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• Twenty-three patients with complex partial seizures were evaluated with 18 F-2-deoxyglucose positron emission tomography and with the Beck Depression Inventory. Five of 10 patients with left and zero of eight with right temporal electroencephalographic foci had depressive symptoms; one of five patients with poorly localized electroencephalographic foci also scored in the depressed range. Temporal, frontal, caudate, and thalamic normalized glucose metabolic rates among five patients with depressive symptoms and well-localized left temporal epileptogenic regions were compared with five patients without depressive symptoms but with similar electroencephalographic characteristics. Multifactorial analysis of variance yielded a significant nonlateralized mood by region interaction. Of nine individual regions compared, only inferior frontal cortex showed a significant difference in normalized regional metabolic rate between depressed and nondepressed patients. Metabolism in this region also distinguished patients with depressive symptoms from normal control subjects. Depressive symptoms in patients with complex partial seizures are associated with a bilateral reduction in inferior frontal glucose metabolism, compared with patients without depressive symptoms and normal control subjects. The frontal lobe hypometabolism observed in patients with depressions associated with epilepsy, Parkinson's disease, and primary affective disorder suggests that similar frontal lobe metabolic disturbances could underlie these conditions.

Objective: To examine the time course of alterations in glucose metabolism in relation to the interval from the last seizure, focus laterality, seizure frequency, and seizure type. Design: Metabolic study with the use of positron emission tomography with fludeoxyglucose F 18. Blinded scan evaluation with use of a standard template. Multivariate regression analysis of positron emission tomographic data. Setting: National Institutes of Health Clinical Center, Bethesda, Md. Patients: Thirty-two adults with intractable partial epilepsy and lateralized seizure onset documented by video-electroencephalographic monitoring. Main Outcome Measure: Normalized metabolic rate for glucose ipsilateral and contralateral to the epileptic focus. Results: The most dramatic changes occurred in inferior temporal regions; the midtemporal region was affected as well. Effects lasting 48 hours were found after both simple and complex partial seizures. The time course was different for the two types of seizures. The inferior temporal metabolic rate ipsilateral to the focus increased compared with the interictal rate during the 24-hour period following simple partial seizures; a nadir occurred in the second 24 hours. The rate then rose to an intermediate level after 48 hours. The relative regional increase in ipsilateral metabolism following complex partial seizures persisted for 48 hours before falling. Conclusion: The brain may take longer than 24 hours after a partial seizure to return to its baseline state.

Background A Korean family had distinctive clinical and neuroimaging features and carried the same genetic mutation that was found in a previously described Japanese kindred with autosomal dominant nocturnal frontal lobe epilepsy. Objective To describe the first Korean family with autosomal dominant nocturnal frontal lobe epilepsy. Methods Members of a large family, including 9 affected individuals from 3 generations, underwent a comprehensive genetic, clinical, electroencephalographic, neuropsychological, and neuroimaging evaluation. Affected members were tested for possible mutations in transmembrane regions 1 through 3 of the neuronal nicotinic acetylcholine receptor α4 subunit (CHRNA4) by direct sequencing and subsequent restriction analysis. Results Seizures began in childhood, presenting as nocturnal episodes of staring, confusion, shouting, perioral movements, unintelligible speech, and hand waving. Some patients had ictal or interictal epileptiform activity in the temporal and/or frontocentral areas. Neurological examination and brain magnetic resonance imaging results showed no abnormalities, except that all patients available for testing had mild to moderate mental retardation. Fluorodeoxyglucose F 18 with positron emission tomography showed mild decreased glucose uptake in the superior and middle frontal regions, more so on the left than on the right. Patient response to carbamazepine was poor. All affected members were heterozygous for theCHRNA4Ser252Leu mutation. Conclusions Disorders associated with mutations in the transmembrane region 2 ofCHRNA4are genetically and phenotypically heterogeneous. Distinctive features of this kindred include (1) mental retardation in all affected members available for testing, (2) abnormal brain findings on fluorodeoxyglucose F 18 with positron emission tomography, (3) poor response to carbamazepine, and (4) full penetrance.

Context Febrile seizures may lead to later epilepsy. They have been associated with hippocampal atrophy but their effect on total cerebral volume is unknown. Objective To compare total cerebral volume in patients with mesial temporal lobe epilepsy with and without a history of complex febrile seizures (CFS). Design Survey. Setting Epilepsy monitoring center. Subjects Forty patients with localization-related epilepsy and temporal lobe onset determined by video electroencephalogram and 20 controls. Intervention Magnetic resonance imaging measurement of cerebral volume. Main Outcome Measure Total cerebral volume. Results Patients with a history of CFS had significantly reduced total cerebral volume compared with patients without CFS. In addition, male patients with CFS had significantly lower total cerebral volume than male normal controls. There was no significant difference between patients without CFS, or all patients, and controls. Conclusion Complex febrile seizures may have a global effect on brain development.

I read with interest the valuable study by Ney et al 1 on cerebellar atrophy in patients with complex partial seizures who were taking phenytoin. Sixteen of their 36 patients had no history of generalized tonicclonic seizures. Among these 16 patients, was there a higher incidence of atrophy than that expected in the control population? In a study using positron emission tomography with 18 F-deoxyglucose, we found that cerebellar glucose metabolism was reduced in patients with complex partial seizures compared with control subjects. 2 In our study, the effects of phenytoin were weak. I agree with Ney et al that phenytoin may have some influence on the development of cerebellar atrophy in patients with epilepsy, but I do not think that the effect is likely to be of clinical importance. Lindvall et al 3 described a patient with acute subarachnoid hemorrhage who never had seizures, but who developed ataxia and

Objective: To examine postictal behaviors after temporal lobe complex partial seizures (CPSs) and to correlate these behavioral phenomena with side of origin and ictal spread pattern. Design: Review language and other behavioral phenomena after seizures defined by subdural electroencephalography. Setting: A surgical epilepsy center. Patients: We studied postictal behavior following 65 CPSs in 18 patients with left hemisphere language dominance using subdural electrode recordings. Intervention: Subdural electrodes. Main Outcome Measures: Language function, affect, orientation, and postictal automatisms. Results: Following the CPS ictal discharge, the mean interval for initial nonreflexive response to an environmental stimulus was 43 seconds (left foci, 57 seconds; right foci, 29 seconds; not significant) and for first correct verbal response was 219 seconds (left foci, 275 seconds; right foci, 167 seconds; not significant). Impaired comprehension with fluent but unintelligible speech, as well as anomia, occurred after seizures arising from either temporal lobe. All nine seizures followed by global or nonfluent aphasia originated on the left side. Paraphasic errors were significantly more common after left temporal CPSs. Prolonged disorientation for place and flat affect were significantly more common after right temporal CPS. Postictal automatisms were frequent and included rubbing of the face, fumbling and picking hand movements, and repetitive oral movements. Conclusions: Postictal paraphasias, disorientation for place, and flat affect most likely reflect the functions of the area from which seizures arise but not the areas involved by spread.

• The association between anxiety, depression, and lateralization of an epileptogenic focus was explored in 18 adult patients with a left temporal lobe focus, 21 with a right focus, 20 with bilateral temporal foci, and 16 individuals with absence seizures. No significant difference in the level of anxiety was found among the groups. However, patients with left-sided temporal lobe epilepsy scored significantly higher than other groups on selfratings for depression. This could not be accounted for by factors such as duration of epilepsy, employment status, education, age at seizure onset, or medication status. The left temporal lobe epilepsy group had a nonsignificantly larger number of males and left-handed subjects. The possible interactions between gender, handedness, seizure focus, and vulnerability to depression are described.

• We evaluated the relationship between findings from EEG, transmission computed tomography (CT), and positron emission tomography in 23 adults with gliomas. The cortical metabolic rate was suppressed in patients with and without focal slowing. Focal delta activity was not related to involvement of gray or white matter. Rhythmic delta activity and focal attenuation of background amplitude on EEG, however, were correlated with involvement of the thalamus.

• We compared metabolic patterns on 18F-2-deoxyglucose positron emission tomography (PET) with closed circuit television and simultaneous electroencephalographic ictal recordings of complex partial seizures in 48 patients. Closed circuit television and electroencephalographic data and PET scans were scored by "blinded" raters. Of the 48 patients, 26 had unilateral temporal; three, frontal; ten, ipsilateral frontotemporal; one, frontoparietal; and five, temporoparietal hypometabolism; and three had widespread hypometabolism affecting frontal, temporal, and parietal lobes. Patients with frontal hypometabolism alone had shorter ictal and postictal durations, but involvement of multiple regions was associated with prolonged seizures. Auras were more likely to be present in patients with temporal hypometabolism alone, but an initial motionless stare did not distinguish this group. However, other metabolic patterns did not predict specific ictal clinical features. Vocalizations (formed or unformed) were not more closely associated with frontal involvement. When hypometabolism is multilobar, it may be difficult to use PET to distinguish between complex partial seizures of frontal and temporal origin.

We report the cases of 3 patients with medically intractable seizures in whom withdrawal of treatment with a long-acting benzodiazepine (clorazepate dipotassium, 2 patients; clonazepam, 1 patient) was followed by delirium with catatoniclike features. While an increase in seizure frequency occurred during withdrawal and prior to the onset of behavioral changes, electroencephalograms did not show epileptiform activity during the delirium. We compared these 3 patients with 10 others with intractable seizures in whom antiepileptic therapy was withdrawn without subsequent behavior changes. High-dose benzodiazepine therapy and a history of viral encephalitis may be risk factors for withdrawal delirium.