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Purpose: The aim of this study was to evaluate the effects of vagus nerve stimulation (VNS) on heart rate variability (HRV) in children with epilepsy., Methods: The subgroups of HRV, namely time domain (Standard deviation of NN interval (SDNN), SDNN index, Standard deviation of the averages of NN intervals (SDANN), Root mean square of successive differences (RMMSD), Adjacent NN intervals differing by more than 50 ms in the entire recording divided by the total number of all NN intervals (PNN50), triangular index) and frequency domain (Low-frequency (LF), High-frequency (HF), LF/HF), were investigated in 20 pediatric patients before and after 6 and 12months of VNS treatment during day and night by comparing their data with those of 20 control subjects. In addition, subgroups of age, epilepsy duration and localization, and antiepileptic drugs (AEDs) were also evaluated if they had further effects on basal HRV levels., Results: Increased heart rates (HRs); decreased SDNN, SDANN, RMMSD, and PNN50; and increased LF/HF ratios were identified before VNS therapy (p<0.05). Even though remarkable improvement was seen after 6months of VNS treatment (p<0.05), no further changes were observed in 12-month compared with 6-month levels (p>0.05) in all parameters, still even significantly lower than those of controls (p<0.05). Longer duration of epilepsy and localization of epileptic focus, such as in the temporal lobe, were also found to further contribute to diminished basal HRV levels (p<0.05)., Conclusion: The cardiovascular system is under deep sympathetic influence in children with epilepsy. Although VNS seems to provide a substantial improvement by achieving increased parasympathetic effects in short-term therapy, the levels were still lower than those of healthy children after either short- or long-term therapy. Therefore, impaired cardiovascular autonomic regulation may be associated with the epileptic process itself as well as with the contribution of some additional factors. Overall, different aspects such as age, epilepsy duration, epileptic focus, seizure frequency, and AEDs should also be considered for their further possible effects on HRV during VNS therapy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate the efficacy of resective surgery in children with focal lesional epilepsy by evaluating the predictive value of pre- and postsurgical factors in terms of seizure freedom., Methods: This study included 61 children aged between 2 and 18years who were admitted to the pediatric video-EEG unit for presurgical workup. Each patient was evaluated with a detailed history, video-EEG, neuroimaging, and postsurgical outcomes according to Engel classification to predict postsurgical seizure freedom. All the possible factors including history, etiology, presurgical evaluation, surgical procedures, and postsurgical results were analyzed for their predictive value for postoperative seizure freedom., Results: Of the 61 patients, 75% were diagnosed as having temporal lobe epilepsy (TLE), and 25% were diagnosed with extra-TLE. Two years after the surgery, 78.6% were seizure-free, of which 89% had TLE, and 50% had extra-TLE (p<0.05). Patients were more likely to have a favorable outcome for seizure freedom if they had rare seizure frequency, focal EEG findings, and focal seizures; had a temporal epileptogenic zone; or had TLE and hippocampal sclerosis. On the other hand, patients were more likely to have unfavorable results for seizure freedom if they had younger age of seizure onset, frequent seizures before the surgery, a frontal or multilobar epileptogenic zone, secondarily generalized seizures, extra-TLE with frontal lobe surgery, or focal cortical dysplasia., Significance: Resective surgery is one of the most effective treatment methods in children with intractable epilepsy. A history of young age of seizure onset, frequent seizures before surgery, secondarily generalized seizures, a multilobar epileptogenic zone, frontal lobe surgery, and focal cortical dysplasia (FCD) are the most important predictive factors indicating that a patient would continue having seizures after surgery. On the other hand, focal seizure semiologies, temporal lobe localization, and hippocampal sclerosis indicate that a patient would have better results in terms of seizure freedom., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Resective epilepsy surgery has been accepted as an effective treatment for patients with medically intractable temporal lobe epilepsy (TLE) to control the seizures and to limit cognitive dysfunction. Complete resection of the epileptic zone, and therefore the success of the surgery, depends on the identification of the seizure focus. Reliable lateralizing semiologic signs, together with other presurgical assessments, are of great importance for an accurate identification of the seizure focus. In this respect, this study evaluated the frequency of semiologic signs in medically intractable temporal lobe epilepsy (TLE) together with the lateralizing values and variations according to the age and gender groups. Two hundred seventy-three seizures of 55 patients of the Adult Epilepsy Monitoring Unit of Gazi University Faculty of Medicine with the diagnosis of medically intractable TLE, whose epileptic foci were detected through noninvasive presurgical procedures and seizures were controlled successfully after anterior temporal lobectomy (ATL), were analyzed retrospectively. Seizure semiologies of the patients were evaluated in terms of lateralizing values, and it was inquired whether age/gender causes any variation. Versive head rotation, unilateral dystonic limb posturing, asymmetric tonic limb posturing, and the combination of unilateral hand automatisms and dystonic posturing were determined as the semiologic signs with the highest lateralizing values (90-100%). While hand automatisms were observed frequently in the group with early seizure-onset age (onset age ≤ 2), asymmetric tonic limb posturing was detected as more frequent in the group with later seizure-onset age (onset age > 2; p < .005). In addition to this, semiologic signs were noted to be different between male and female groups; psychic and autonomic auras and ictal emotional signs were associated with women (p < .005)., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Despite the explanations of many lateralization findings, body turning in focal epilepsy has been rarely investigated. One of the aims of this study was to evaluate the role of ictal body turning in the lateralization of focal epilepsies. The records of 263 patients with focal epilepsy (temporal lobe epilepsy (TLE), n=178; extratemporal lobe epilepsy (ETLE), n=85) who underwent prolonged video-EEG monitoring during presurgical epilepsy evaluation were reviewed. Preoperative findings (TLE, n=16; ETLE, n=6) and postoperative outcomes (TLE, n=7) of patients with focal epilepsy with ictal body turning were assessed. For the evaluation of ictal body turning, two definitions were proposed. Nonversive body turning (NVBT) was used to denote at least a 90° nonforced (without tonic or clonic component) rotation of the upper (shoulder) and lower (hip) parts of the body around the body axis for a minimum of 3s. Versive body turning (VBT) was used to denote at least a 90° forced (with tonic or clonic component) rotation of the upper (shoulder) and lower (hip) parts of the body around the body axis for a minimum of 3s. Nonversive body turning was observed in 6% (n=11) of patients with TLE and 2% (n=2) of patients with ETLE. For VBT, these ratios were 5% (n=8) and 7% (n=6) for patients with TLE and ETLE, respectively. Nonversive body turning was frequently oriented to the same side as the epileptogenic zone (EZ) in TLE and ETLE seizures (76% and 80%, respectively). If the amount of NVBT was greater than 180°, then it was 80% to the same side in TLE seizures. Versive body turning was observed in 86% of the TLE seizures, and 55% of the ETLE seizures were found to be contralateral to the EZ. When present with head turning, NVBT ipsilateral to the EZ and VBT contralateral to the EZ were more valuable for lateralization. In TLE seizures, a significant correlation was found between the head turning and body turning onsets and durations. Our study demonstrated that ictal body turning is a rarely observed but reliable lateralization finding in TLE and ETLE seizures, which also probably has the same pathophysiological mechanism as head turning in TLE seizures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Ictal behavioral characteristics may provide clues in determining the nature of the epileptic focus. We defined ictal behavioral characteristics in patients with intractable temporal lobe epilepsy (TLE) who underwent anterior temporal lobectomy (ATL) and lived seizure-free for 2 years of follow-up. Video/EEG data on 282 seizures observed in 48 patients who suffered from TLE and underwent ATL were analyzed. All patients were seizure-free after surgery. We divided the patients into two groups on the basis of the pathological examination. Two hundred and two seizures in 35 patients with hippocampal sclerosis (Group 1) and eighty seizures in 13 patients with other pathological findings, such as tumors, cavernoma, and hamartoma (Group 2), were analyzed. Ictal behavior characteristics were evaluated for each of the seizures recorded in the two groups. Behavioral arrest, bilateral hand automatisms, oral and leg automatisms, and ictal aggression were significantly more frequent in Group 2 (P<0.05), whereas contralateral dystonia of the upper extremity (P<0.05), ipsilateral hand automatisms (P<0.05), ipsilateral hand automatisms in the presence of contralateral dystonia of the upper extremity (P<0.001), contralateral forced head deviation (P<0.05), and secondary generalization (P<0.05) were more significant in Group 1. There was no significant difference in vocalization and ipsilateral nonforced head deviation between the two groups (P>0.05). The number of seizures observed during ictal speech, crying, and postictal nose wiping was not large enough, so differences could not be analyzed. It was concluded that although ictal behavioral characteristics differed between the two groups, certain behavioral patterns may be helpful in differentiating between hippocampal sclerosis and other pathology.

Neurologists have been analyzing the clinical behaviors that occur during seizures for many years. Several ictal behaviors have been defined in temporal lobe epilepsy (TLE). Ictal behaviors are especially important in the evaluation of epilepsy surgery candidates. We propose a new lateralizing sign in TLE originating from the nondominant hemisphere-the "hush" sign. Our patients were 30- and 21-year old women (Cases 1 and 2, respectively). Their epileptogenic foci were localized to the right mesial temporal region after noninvasive presurgical investigations. Case 1 had no cranial MRI abnormality, whereas cranial MRI revealed right hippocampal atrophy in Case 2. These women repeatedly moved their right index fingers to their mouth while puckering their lips during complex partial seizures. We have named this ictal behavior the "hush" sign. Anterior temporal lobectomy with amygdalohippocampectomy was performed in both patients, and pathological examinations revealed hippocampal sclerosis. The "hush" sign no longer occurred after seizures were controlled. They were seizure free as of 30 and 31 months of follow-up, respectively. We believe that the "hush" sign may be supportive of a diagnosis of TLE originating from the nondominant hemisphere. This sign may occur as a result of ictal activation of a specific brain region in this hemisphere.