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Item does not contain fulltext PURPOSE: To determine hippocampal expression of neuronal GABA-transporter (GAT-1) and glial GABA-transporter (GAT-3) in patients with temporal lobe epilepsy (TLE) and hippocampal sclerosis (HS). METHODS: Hippocampal sections were immunohistochemically stained for GABA-transporter 1 and GABA-transporter-3, followed by quantification of the immunoreactivity in the hilus by optical density measurements. GABA-transporter 3 positive hilar cells were counted and GABA-transporter protein expression in sections that included all hippocampal subfields was quantified by Western blot. RESULTS: The hilar GABA-transporter 1 expression of patients with severe hippocampal sclerosis was about 7% lower compared to that in the mild hippocampal sclerosis/control group (p more...

Summary Objective To evaluate the effects of a postsurgical rehabilitation program on employment status 2 years after temporal lobe epilepsy surgery in relation to other predictors. Methods Employment outcome 2 years after temporal lobe resection in a group of 232 adult patients with the offer of a 3-week inpatient rehabilitation program immediately after surgery (“Reha group”) was compared to a group of 119 patients who had surgery before such a rehabilitation program existed. One hundred thirty-nine (59.9%) of the Reha group patients attended the rehabilitation program. Further predictors for employment outcome were analyzed using multivariate logistic regression analysis. Results Preoperatively, the groups did not differ significantly in variables relevant for employment, including employment rate. Two years after surgery, the rate of those not being employed had decreased in the Reha group from 38.4% to 27.6% (p more...

Background and purpose In the epilepsy community, there is talk that the number of classical patients with early onset temporal lobe epilepsy (TLE) and Ammon's horn sclerosis (AHS) is decreasing. This is counterintuitive, considering the success story of epilepsy surgery, improved diagnostic methods and the current recommendation of early admission to surgery. In order to recognize trends, the development of temporal lobe surgery over 20 years in three major German epilepsy centers was reviewed. Methods Age at surgery and duration of epilepsy, which was differentiated according to histopathology (AHS, developmental, tumor, vascular), year of surgery and center, were evaluated in a cohort of 2812 patients from three German epilepsy centers who underwent temporal lobe surgery between 1988 and 2008. The analysis was carried out for the pooled cohort as well as for each center separately. Results Of all patients, 52% showed AHS. Compared with other pathologies, the AHS group had the earliest epilepsy onset and the longest duration of epilepsy. Across five time epochs, the diagnosis of AHS increased in the first epoch, remaining constant thereafter. Contrary to the trends in other pathologies, in the AHS group the mean age of patients at surgery increased by 7 years and the duration of epilepsy until surgery increased by 5 years. This trend could be replicated in all three centers. As initially hypothesized for all groups, age and duration of epilepsy in other pathology groups remained constant or indicated earlier submission to surgery. Conclusions During the first few years studied, most probably due to progress in brain imaging, the proportion of patients with AHS increased. However, despite stable numbers over time, and contrary to the trends in other pathology groups, age and duration of epilepsy in mesial TLE with AHS (mTLE + AHS) increased over time. This supports the hypothesis of a decreasing incidence of AHS. This trend is discussed with respect to disease-modifying factors which have changed the incidence of classical mTLE + AHS or, alternatively, to recent developments in antiepileptic drug treatment, the appraisal of surgery and economic incentives for treatment options other than surgery. more...

Background The arrhythmogenic potential of short QT intervals has recently been highlighted in patients with a short QT syndrome. Drug-induced QT-interval prolongation is a known risk factor for ventricular tachyarrhythmias. However, reports on drug-induced QT-interval shortening are rare and proarrhythmic effects remain unclear. Objective Recently, rufinamide, a new antiepileptic drug for the add-on treatment of Lennox-Gastaut syndrome, was approved in the European Union and the United States. Initial trials showed drug-induced QT-interval shortening. The aim of our study was to evaluate the effects of rufinamide on QT intervals in patients with difficult-to-treat epilepsies. Methods Nineteen consecutive patients with Lennox-Gastaut syndrome and other epilepsy syndromes were included (n = 12 men; mean age 41 ± 12 years). QRS, QT, and Tpeak-Tend intervals were analyzed before and during rufinamide treatment. Results The mean QT interval shortened significantly following rufinamide administration (QT interval 349 ± 23 ms vs 327 ± 17 ms; corrected QT interval 402 ± 22 ms vs 382 ± 16 ms; P = .002). Tpeak-Tend intervals were 79 ± 17 ms before and 70 ± 20 ms on treatment (P = .07). The mean reduction of the corrected QT interval was 20 ± 18 ms. During follow-up (3.04 ± 1.09 years), no adverse events including symptomatic cardiac arrhythmias or sudden cardiac deaths were observed. Conclusion QTc-interval shortening following oral rufinamide administration in a small patient group was not associated with significant clinical adverse effects. These observations nothwithstanding, the ability of rufinamide to significantly shorten the QT interval portends a potential arrhythmogenic risk that may best be guarded against by periodic electrocardiographic recordings. more...

Summary Purpose: Secondarily generalized tonic–clonic seizure (SGTCS) may occur rarely in temporal lobe epilepsy (TLE), but SGTCS is the major risk factor for sudden death and for seizure-related fatal injuries. Our aim was to investigate clinical factors associated with the occurrence of SGTCS in TLE by addressing two questions: (1) What clinical features differentiate patients with TLE who regularly had SGTCS from those who did not? (2) Is there an association of secondarily generalized seizures with preceding seizure elements and clinical data? Methods: We included 171 patients with TLE (mean age 34.4 ± 10) who participated in our presurgical evaluation program, which included continuous video–electroencephalography (EEG) and magnetic resonance imaging (MRI). Patients had a temporal lobectomy as a result of mesial or neocortical TLE. To reevaluate the archived seizures, we selected the consecutively recorded seizures of each patient. If the patient had more than three recorded seizures, then we reevaluated only the first three. Altogether video-recorded seizures of 402 patients were reanalyzed. Key Findings: A positive association between the presence of hippocampal sclerosis on the MRI and SGTCS in the patient history was found, whereas ictal speech and pedal automatism showed a negative association with a SGTCS history. The age of patients showed a positive association, whereas patient’s reactivity before and during the seizure, oral/pedal automatisms, and vocalizations showed a negative association with secondary generalization of a focal-onset seizure during video-EEG monitoring. Significance: Clinical features associated with SGTCS may help clinicians during presurgical monitoring identify high-risk patients for SGTCS. Our study may help in understanding the pathophysiology of secondary generalization. more...

Positive autoscopic phenomena - autoscopy, heautoscopy and out-of-body experience - may occur in a variety of diseases and also in physiological conditions. They are a rare but probably underreported phenomenon in focal epilepsies. Here, we investigate whether ictal lateralized autoscopic phenomena give lateralizing information about the underlying epileptic focus. We present the cases of seven patients from our center who experienced ictal lateralized autoscopic phenomena and analyzed their focus lateralization and localization of the underlying brain lesion. In addition, we reviewed seven cases published in German and English language literature. In the total group of 14 patients with ictal lateralized autoscopic phenomena, 12 (85.7%) of them had a well-defined epileptic focus contralateral to the side of the autoscopic appearance. Therefore, the data point to an association between ictal lateralized autoscopy and contralateral epileptic focus. (C) 2012 Elsevier Inc. All rights reserved. more...

Summary Purpose: Ictal asystole (IA) and ictal bradycardia (IB) are rare autonomic symptoms during epileptic seizures and may be potentially life-threatening. Guidelines for the care of these patients are missing. The aim of this multicenter study was to evaluate the management and long-term outcome in patients with IA and IB. Patients and Methods: All patients with IA and IB were included from four epilepsy centers (Bielefeld, Kork, Marburg, and Zurich) from 2002 until 2009. Using a standardized assessment form, clinical data, treatment decisions, and outcomes were extracted from patient charts and simultaneous electroencephalography/electrocardiography (EEG/ECG) recordings. Key Findings: Seizures with IA or IB were identified in 16 patients. In all patients an associated temporal seizure pattern was recorded and in 15 patients, sudden falls, fainting, or trauma was previously reported or recorded during the monitoring. In three patients (18.8%) diagnosis of focal epilepsy was newly established and anticonvulsive treatment was initiated. Two patients with refractory epilepsy underwent epilepsy surgery. In seven patients (43.8%) a cardiac pacemaker was implanted. In 14 of 16 treated patients, seizure freedom (n = 5) or absence of sudden falls, fainting, or trauma (n = 9) could be achieved. Two patients denied epilepsy surgery as well as a pacemaker and continue to have frequent falls and trauma. Significance: Our study demonstrates that epilepsy surgery and antiepileptic drugs may lead to sustained freedom of seizures as well as ictal syncope. In drug-resistant patients not suitable for epilepsy surgery, implantation of a cardiac pacemaker may prevent sudden falls as well as trauma. Based on our results and previously reported cases we propose a treatment algorithm. more...

We analysed the association of presurgical language fMRI activations and postsurgical verbal memory changes in 16 left-sided mesial temporal lobe epilepsy patients with initially intact memory. Patients with severe verbal memory decline after surgery (n=9) had stronger presurgical fMRI activations within the left posterior temporal lobe, compared to those with no decline (n=7). Language fMRI activation may predict verbal memory outcome, even in patients with a high risk of postsurgical memory deterioration. (C) 2010 Elsevier B.V. All rights reserved. more...

Rationale and Objectives Focal epilepsies potentially can be cured by neurosurgery; other treatment options usually remain symptomatic. High-resolution magnetic resonance (MR) imaging is the central imaging strategy in the evaluation of focal epilepsy. The most common substrate of temporal epilepsies is hippocampal sclerosis (HS), which cannot always be sufficiently characterized with current MR field strengths. Therefore, the purpose of our study was to demonstrate the feasibility of high-resolution MR imaging at 7 Tesla in patients with focal epilepsy resulting from a HS and to improve image resolution at 7 Tesla in patients with HS. Materials and Methods Six patients with known HS were investigated with T1-, T2-, T2 ∗ -, and fluid-attenuated inversion recovery–weighted sequences at 7 Tesla with an eight-channel transmit-receive head coil. Total imaging time did not exceed 90 minutes per patient. Results High-resolution imaging at 7 Tesla is feasible and reveals high resolution of intrahippocampal structures in vivo. HS was confirmed in all patients. The maximum non-interpolated in-plane resolution reached 0.2 × 0.2 mm 2 in T2 ∗ -weighted images. The increased susceptibility effects at 7 Tesla revealed identification of intrahippocampal structures in more detail than at 1.5 Tesla, but otherwise led to stronger artifacts. Imaging revealed regional differences in hippocampal atrophy between patients. The scan volume was limited because of specific absorption rate restrictions, scanning time was reasonable. Conclusions High-resolution imaging at 7 Tesla is promising in presurgical epilepsy imaging. “New” contrasts may further improve detection of even very small intrahippocampal structural changes. Therefore, further investigations will be necessary to demonstrate the potential benefit for presurgical selection of patients with various lesion patterns in mesial temporal epilepsies resulting from a unilateral HS. more...

Background: One of the possible pathomechanisms of sudden death in epilepsy (SUDEP) is a postictal dysregulation of autonomic nervous system. We performed a heart rate variability (HRV) analysis of the periictal state to analyze whether a cardiac autonomic disturbance exists after an epileptic seizure. Methods: We included 31 periictal video–EEG–ECG recordings of 31 patients with epilepsy who had consecutively undergone pre-surgical evaluation. Nine generalized tonic-clonic (GTCS), 15 complex partial, and seven simple motor seizures were included. HRV was evaluated by analyzing 5-min-long ECG epochs, sampling from baseline, direct preictal, early-postictal ( more...

Die Wirksamkeit von Levetiracetam (LEV) bei postoperativ nichtanfallsfreien Patienten ist in fruheren Studien nachgewiesen worden. Im Folgenden wird uber Ergebnisse der erneuten Anwendung von LEV bei 10 Patienten berichtet, die nach dem epilepsiechirurgischen Eingriff nicht anfallsfrei wurden und vor der Operation bereits erfolglos mit LEV behandelt worden waren. Sieben von 10 Patienten wurden trotz niedrigerer als der praoperativen LEV-Dosierung anfallsfrei. (Funf von 7 Patienten wurden komplett auren- und anfallsfrei; 2 Patienten behielten lediglich Auren.) Zwei weitere Patienten erfuhren eine Verbesserung der Anfallssituation um >50%. Nur in einem Fall konnte keine positive Veranderung beobachtet werden. Levetiracetam sollte postoperativ auch dann bei Patienten mit Anfallsrezidiven eingesetzt werden, wenn die Anfalle zuvor gegen LEV resistent waren. more...

Summary Purpose: We systematically analyzed the video-recorded and patient-reported, as well as positive and negative ictal affective symptoms (IAS) in temporal lobe epilepsy (TLE). Our aim was to assess (1) frequency, (2) gender effect, (3) lateralizing significance, (4) localizing value, and (5) prognostic significance in epilepsy surgery of IAS in patients with video-registered seizures. Methods: We reviewed ictal video recordings of 184 patients (99 women, aged 16–63). All patients had surgery for intractable TLE with video-recorded complex partial seizures (CPS) due to temporal lobe lesions visualized by high-resolution magnetic resonance imaging (MRI). Affective auras (AAs) were categorized into two groups: positive or negative. Results: We registered AAs in 18% of patients: positive in 3%, negative in 15%. We saw ictal affective behavior (IAB) in 22% of patients; 10% had positive, whereas 14% had negative IAB. Two patients had both positive and negative IAB. AAs showed an association with IAB in case of fear expression versus fear auras (p = 0.018). IAB, especially negative IAB, occurred more often in women than in men. Patients with negative IAB were younger than others. We could not demonstrate an association between IAS and the localization, lateralization, or hemispheric dominance. Surgical outcome did not associate with IAS. Discussion: Patient-reported and video-recorded negative—but not positive—affective signs are related to each other. Video-recorded negative AAs occur more often in women and young patients. more...

We report the case of a 21-year-old man with idiopathic generalized epilepsy who ingested about 8,000 mg of topiramate (TPM) in a suicide attempt. On admission to the hospital he had a nonconvulsive status epilepticus and received 4 mg lorazepam i.v. He recovered rapidly despite an initial TPM concentration of 144.6 microg/ml. To our knowledge, this is the first report of a patient who survived such a high TPM concentration. The case indicates that nonconvulsive status epilepticus could be a manifestation of TPM intoxication. Language: en more...

Objectives Pregabalin (PGB) is a newer antiepileptic drug (AED) licensed as add-on treatment for partial epilepsy in adults. Efficacy and safety have been proven in several controlled clinical studies. These trials, however, only partially reflect clinical practice. Retention rate has been established as a marker for efficacy and safety of AEDs in long-term follow-up studies. Methods We evaluated the data of the first 105 patients treated with PGB at Bethel Epilepsy Centre, a tertiary referral centre for epilepsy. The patients were interviewed after 3, 6 and 12 months. Results 105 adult patients (aged 38±13 years) were treated with PGB, on average in combination with 2.1 AEDs (mean observation period 232 days). 76.2% had focal epilepsy, 19.0 multifocal epilepsy, and 3.8% epilepsy with both focal and generalised seizures. 40% continued PGB with the following outcome: 5.7% seizure-free for at least 1 month (4.8% for at least 3 months, 2.4% for at least 6 months; one of the seizure-free patients, however, had had epilepsy surgery during the observational period), 17.1% responders (≥50% reduction of seizure frequency but not seizure-free), 13.3% with unchanged or increased seizure frequency. Reasons for withdrawal were lack of efficacy (47.6%) or side-effects (12.7%). Conclusions PGB is a new therapeutic option as add-on therapy for patients with highly refractory focal epilepsies although the therapeutic success that can be expected in this group of patients is limited. more...

Object The aim of this study was to evaluate the long-term efficacy of temporal lobe epilepsy (TLE) surgery and potential risk factors for seizure recurrence after surgery. Methods This retrospective study included 434 consecutive adult patients who underwent TLE surgery at Bethel Epilepsy Centre between 1991 and 2002. Results Hippocampal sclerosis was found in 62% of patients, gliosis in 17.3%, tumors in 20%, and focal cortical dysplasia (FCD) in 6.9%. Based on a Kaplan-Meier analysis, the probability of Engel Class I outcome for the patients overall was 76.2% (95% CI 71–81%) at 6 months, 72.3% (95% CI 68–76%) at 2 years, 71.1% (95% CI 67–75%) at 5 years, 70.8% (95% CI 65–75%) at 10 years, and 69.4% (95% CI 64–74%) at 16 years postoperatively. The likelihood of remaining seizure free after 2 years of freedom from seizures was 90% (95% CI 82–98%) for 16 years. Seizure relapse occurred in all subgroups. Patients with FCD had the highest risk of recurrence (hazard ratio 2.15, 95% CI 0.849–5.545). Predictors of remission were the presence of hippocampal atrophy on preoperative MR imaging and a family history of epilepsy. Predictors of relapse were the presence of bilateral interictal sharp waves and versive seizures. Six-month follow-up electroencephalography predicted relapse in patients with FCD. Short epilepsy duration was predictive of seizure remission in patients with tumors and gliosis; 28.1% of patients were able to discontinue antiepileptic medications without an increased risk of seizure recurrence (hazard ratio 1.05, 95% CI 0.933–1.20). Conclusions These findings highlight the role of etiology in prediction of long-term outcome after TLE surgery. more...

Our aim is to investigate seizure outcome and prognostic factors after pure frontal lobe epilepsy (FLE) surgery. We retrospectively studied the operative outcome in 97 consecutive adult patients who underwent resective surgery for intractable partial epilepsy between 1991 and 2005. Based on Kaplan-Meier, the probability of an Engel Class I outcome was found to be 54.6% (95% CI 44-64) at 6 months, 49.5% (95% CI 39.3-59.6) at 2 years, 47% (CI 34-59) at 5 years and 41.9% (CI 23.5-60.3) at 10 years. If the patient was seizure free at 2-year follow-up, the probability of remaining seizure free up to 10 years was 86% (95% CI 76-98). For 13.6% of the patients a running down of seizures could be shown. Factors predictive of poor long-term outcome were incomplete resection, using of subdural grids, IED in follow-up EEG, tonic seizures and an unspecific aura or a postoperative aura. Factors predictive of good long-term outcome were the presence of a well-circumscribed lesion in preoperative MRI, ipsilateral IED in preoperative EEG, surgery before age of 30 and short epilepsy duration prior to surgery. In the multivariate analysis, preoperative well-circumscribed lesion in MRI predicts seizure remission whereas persistent postoperative auras predict seizure relapse. FLE surgery should depend on restrictive patient selection to assure favorable outcome. more...

Background: Gelastic epilepsy due to hypothalamic hamartomas is usually a severe condition encompassing both epileptic seizures and an epileptic encephalopathy associated with behavioral and cognitive impairments. Here we report the effects of interstitial radiosurgery in the treatment of this generally pharmacoresistant epilepsy syndrome. Methods: Twenty-four consecutive patients (3–46 years of age, 7 women, mean age 21.9 years, mean duration of epilepsy 17.6 years) with gelastic epilepsy due to MR-ascertained hypothalamic hamartoma and a minimum follow-up period of 1 year were included in this evaluation. Treatment was performed by interstitial radiosurgery using stereotactically implanted 125 I seeds. Effects of treatment on seizure frequency and possible side effects were assessed prospectively. Factors influencing outcome and side effects were analyzed statistically. Results: After a mean 24-month follow-up period following the last radiosurgical treatment, 11/24 patients were seizure free or had seizure reduction of at least 90% (Engel class I and II), in some cases only after repeated treatment. The duration of epilepsy prior to radiosurgery negatively influenced outcome. Treatment was well tolerated in most patients. Headache, fatigue, and lethargy were transient side effects associated with the development of brain edema extending from the implantation site in five patients. Four patients had a weight gain of more than 5 kg which was severe in two patients. The majority of those patients whose cognitive functions initially deteriorated showed subsequent recovery of cognitive functions, but episodic memory in two patients showed persistent decline at 1 year follow-up. Longer disease duration increased the risk for cognitive side effects, and larger hamartoma size and eccentric seed positioning increased the risk for radiogenic brain edema. Neither perioperative mortality nor neurologic impairments, visual field defects, or endocrinologic disturbances were encountered following treatment. Conclusion: Interstitial radiosurgery was efficacious in significantly improving gelastic epilepsy in about half of the patients treated in this series. Weight gain may occur as a side effect, whereas other severe side effects reported following microsurgical removal of the hamartoma were absent. The study results strongly suggest early causal treatment, as chances for seizure control are higher and the risk for cognitive side effects is lower in patients with shorter disease duration. more...

Electrical stimulation of the human epileptic brain is used mainly for identification of eloquent cortical regions such as motor and speech areas. Other stimulation responses include the patient's epileptic auras and seizures. In addition, experiential phenomena may be elicited. Here we describe the reproducible initiation of a structured complex visual hallucination on stimulation of the left lateral occipital cortex (superior part of Brodmann area 19, close to the angular gyrus of the parietal lobe). Our findings illustrate that stimulation of the left temporo-parieto-occipital junction may activate networks of visual perception (color, pattern, movement, rotation, shape, and memory) independent of the cortical hierarchy from elementary to complex information. more...

Zusammenfassung Seit seiner Entwicklung durch Berger Anfang des 20sten Jahrhunderts kommt dem Oberflachen-EEG eine entscheidende Rolle bei der Diagnose und Therapie von Epilepsie zu. Bis heute ist es die einfachste, sicherste und kostengunstigste diagnostische Methode, die pathophysiologischen Basismechanismen des Gehirns zu registrieren, die den Epilepsien zugrunde liegen. Die Spezifizitat und Sensitivitat so genannter epilepsietypischer Potentiale wie Spitzen, scharfe Wellen und Spitze-Wellen-Komplexe liegen bei ungefahr 90%, so dass ihr interiktales Auftreten im Oberflachen-EEG die Diagnose Epilepsie nahe legt, eine Ableitung wahrend eines Ereignisses, die ein Anfallsmuster zeigt, dessen epileptische Natur sogar beweist. Masnahmen wie Hyperventilation, intermittierende Photostimulation, Schlafableitung, wiederholte oder langere Registrierungen erhohen die Sensitivitat, wahrend von Seiten des Befunders die Kenntnis epilepsieahnlicher Potentiale -die so genannten benignen Varianten- die Spezifizitat erhoht. Dies berucksichtigt, ist die Analyse epilepsietypischer Aktivitat im Oberflachen-EEG hinsichtlich Lokalisation, Verhalten und Morphologie auserst hilfreich bei der Diagnosesicherung Epilepsie und daruber hinaus bei der Bestimmung des Epilepsiesyndroms. more...

We investigated peri-ictal vegetative symptoms (PIVS) in 141 patients with adult temporal lobe epilepsy (TLE) and assessed frequency, gender effect, and lateralizing value of peri-ictal autonomic signs. We recorded abdominal auras in 62%, goosebumps in 3%, hypersalivation in 12%, spitting in 1%, cold shivering in 3%, urinary urge in 3%, water drinking in 7%, postictal nose wiping (PNW) in 44%, and postictal coughing in 16%. At least one vegetative sign appeared in 86% of the patients. The presence of PIVS did not have a significant lateralizing value. PNW occurred in 52% of women and in 33% of men, whereas any PIVS was present in 93% of women and 77% of men. In summary, contradictory to previous studies, the presence of PIVS has no lateralizing value, which may be linked to a low frequency of occurrence of PIVS. PIVS, especially PNW, occurred more frequently in women, supporting the gender differences in epilepsy. more...

A right shoulder electrode (RS) has been used as a non-cephalic reference in addition to 10-20, 10-10 and sphenoidal or mandibular electrode placements for scalp EEG-recording in more than 2000 patients at the Bethel Epilepsy Center. The RS is placed on the acromion of the right shoulder and therefore allows us to record from a considerably larger distance from cortical brain activity. Analysis of epileptiform discharges in reference to the RS shows many temporal sharp waves with negativity over the sphenoidal region having an additional widespread positive maximum over midline and contralateral electrodes. This vertical dipole becomes easily evident in reference to RS whereas commonly used cephalic reference montages (e.g., to PZ, CZ) normally do not unmask it. Such a vertically oriented dipolar field was found in 83% of all temporal epileptiform discharges, 75% of which had a mesiobasal origin, and only 25% had a lateral temporal origin. None of the extratemporal discharges showed a similar dipole field. Therefore, analysis of epileptiform discharges on scalp EEG with the RS as a non-cephalic reference offers an additional possibility to differentiate between spikes of mesiobasal, latero-temporal and extratemporal origin. The finding of temporal discharges characterized by a vertical dipole was correlated with ipsilateral mesial sclerosis on cranial MRI and a good surgical outcome after temporal lobectomy. more...

Eine wichtige Voraussetzung fur die erfolgreiche epilepsiechirurgische Behandlung ist der Nachweis kongruenter Befunde der praoperativen Abklarung. Anfallsfreiheit wird in der Regel nur dann erwartet, wenn es gelingt, eine als epileptogen definierte Lasion komplett zu entfernen. In diesem Fallbericht wird der unerwartet gute postoperative Verlauf nach inkompletter Resektion einer ausgedehnten kortikalen Entwicklungsstorung beschrieben. more...

We assessed cognitive functions before and 3 months after interstitial radiotherapy in 14 patients with gelastic seizures caused by hypothalamic hamartoma. Cognitive functioning was assessed before temporary implantation of (125)I-seed and 3 months after seed explantation. Performance was compared with that of a selected control group of conservatively treated patients with symptomatic focal epilepsy tested before add-on treatment with a new antiepileptic drug and after reaching steady state. No short-term negative side effects of the interstitial radiosurgery could be observed for the domains of attention and executive functions and verbal and figural memory performance. Cognitive development of the patients treated with seeds was comparable to that of the control group at both assessments. Thus, the stereotactic implantation of (125)I-seeds in this patient group with gelastic seizures caused by hypothalamic hamartoma provides a well-tolerated minimally invasive method in the treatment of this severe epileptic syndrome without negative cognitive side effects. more...

Summary Objectives To analyse the lateralising value of unilateral manual automatism (UMA), its relation to contralateral dystonia and the hand by which the UMA was performed. Methods In this retrospective study, we reviewed video recordings of 141 patients (mean age 34.1±10) who had consecutively undergone presurgical evaluations with ictal video-EEG recordings and high-resolution MRI, had had epilepsy surgery due to intractable medial temporal lobe epilepsy with complex partial seizures due to unilateral medial temporal lobe lesions. The video recordings were prospectively reviewed by one of the authors blinded to patient's clinical data except the diagnosis of medial temporal lobe epilepsy. Altogether 310 archived seizures were analysed. Results Hand automatisms occurred in 86.5% of patients. UMA occurred in 53% of patients. If UMA was accompanied by contralateral hand dystonia, it had a high lateralising value to the ipsilateral epileptic focus (EF), it was ipsilateral in 85% of patients. Conversely, if UMA occurred without contralateral dystonia, it had only a limited lateralising value because it was ipsilateral to the EF in only 63% of patients. However, we found that left-sided UMA without dystonia had a high lateralising value to the left hemisphere (ipsilateral to the EF in 82%), while right-sided UMA without dystonia has practically no lateralising value. Conclusions UMA with contralateral dystonia has a high lateralising value to the ipsilateral hemisphere. Left-sided UMA without contralateral dystonia has a lateralising value to the left hemisphere. Right-sided UMA without contralateral dystonia has no lateralising value. more...

Der kurzlich erschienene Vorschlag der ILAE-Taskforce zur Epilepsieklassifikation ist ein multiaxialer, syndromorientierter Ansatz. Hierbei werden die Patienten unterschiedlichen und oftmals unzureichend definierten Kriterien zugeordnet. Die resultierenden Syndrome haben haufig keine atiologische oder pathophysiologische Relevanz, uberlappen und wechseln je nach Alter des Patienten. Wir schlagen einen 5-dimensionalen, patientenorientierten Ansatz zur Klassifikation der Epilepsien vor. Dieser Ansatz wendet sich von der Orientierung an Syndromen ab und basiert stattdessen auf dem methodologischen Ansatz der allgemeinen Neurologie, in dem einerseits das klinische Bild des einzelnen Patienten im Mittelpunkt steht und andererseits in jeder Dimension voneinander unabhangige und moglichst operationalisierbare Kriterien angewandt und schlieslich zusammengefuhrt werden. Die Dimension dieser Klassifikation sind: (1) Lokalisation der epileptogenen Zone, (2) Semiologie der epileptischen Anfalle, (3) Atiologie, (4) Anfallshaufigkeit und (5) sonstige relevante medizinische Faktoren. Diese Dimensionen enthalten alle fur das Management eines Patienten notwendige Information und sind voneinander unabhangige Parameter. Alle Patienten konnen selbst beim initialen Patientenkontakt sinnvoll in das System eingeordnet werden, auch wenn noch keine apparativen Untersuchungen durchgefuhrt wurden. Die Information aller Untersuchungen (z. B. MRT, EEG) fliest zum jeweiligen Zeitpunkt der Klassifikation in die Zuordnung des Patienten ein und erlaubt mit jeder neu verfugbaren Information eine Zunahme der Prazision und Validitat der Klassifikation. more...

Summary: Purpose: By using speech-activated functional MRI (fMRI), we investigated whether the frequency of left-sided interictal epileptic activity (IED: spikes or sharp waves on the EEG) is associated with atypical speech lateralization. Methods: We investigated 28 patients (13 men, aged 17–59 years) with left-sided mesial temporal lobe epilepsy (MTLE) and 11 patients with right-sided MTLE as a control population. Only patients with unilateral hippocampal sclerosis with unilateral IED were included. For fMRI of individual patients, we contrasted images sampled during covert word generation with a low-level rest condition. With SPM99, an individual comparison for the contrast “word generation versus resting inactivity” was conducted. To characterize speech lateralization in individual patients, we calculated asymmetry indexes (AIs): the difference between activated left-sided and right-sided voxels was divided by all activated voxels. Analyzing long-term EEG, the first 2 min of each hour were evaluated for the frequency of IED. Univariate associations with AIs were assessed by Pearson's correlation and by t test. When testing the independent associations, multivariate linear regression was performed. Results: The AIs in patients with left-sided MTLE were 0.40 ± 0.53 on average (range, −0.83 to +1.0), whereas in right-sided MTLE, they were 0.78 ± 0.15 (p = 0.029). For the further investigations, we included left-sided MTLE patients only. The median frequency of IED was six per hour (range, 0–240). Higher IED frequency was correlated with left-right shift of lateralization of speech fMRI activity (p = 0.002). Conclusions: Higher left-sided spike frequency in MTLE was associated with a left–right shift of speech representation, suggesting that chronic frequent interictal activity may induce a reorganization of speech lateralization. more...

Summary: Purpose: The mechanisms of drug resistance in epilepsy are only incompletely understood. According to a current concept, overexpression of drug efflux transporters at the blood‐brain barrier may reduce levels of antiepileptic drugs (AEDs) in epileptogenic brain tissue. Increased expression of drug efflux transporters such as P-glycoprotein has been found in brain tissue surgically resected from patients with medically intractable epilepsy, but it is not known whether this leads to decreased extracellular (interstitial) AED concentrations in affected brain regions. This prompted us to measure concentrations of AEDs in the extracellular space of human neocortical tissue by using intraoperative microdialysis (IOMD) in those parts of the brain that had to be removed for therapeutic reasons. For comparison, AED levels were determined in brain tissue, subarachnoid CSF, and serum. Methods: Concentrations of carbamazepine (CBZ), 10-hydroxy-carbazepine (10-OH-CZ, metabolite of oxcarbazepine), lamotrigine (LTG), levetiracetam (LEV), topiramate, or phenytoin were determined by using one to four catheters during IOMD in the medial temporal gyrus. Furthermore, to calculate the individual recovery of every catheter, an in vitro microdialysis was performed with ultrafiltrate of serum concurrently obtained from the respective patient. In addition, AED levels were determined in the resected brain tissue, CSF, and serum of the same patients. Altogether 22 pharmacoresistant epilepsy patients (nine male, 13 female patients; age 15‐54 years) with complex partial seizures or secondarily generalized seizures were involved. In a first series, IOMD samples 40 min after beginning of the microdialysis (flow rate, 1 μl/min), and in a second series, continuous measurements 25, 30, 35, and 40 min from the beginning were evaluated (flow rate, 2 μl/min). With in vitro recovery data of the individual catheters, the concentration in the extracellular space (ECS) was estimated. Results: AED concentrations in the ECS of the cortex measured by catheters located at a distance of 0.6 cm differed markedly in some patients, whereas concentrations in the ultrafiltrate of the serum of the respective patients measured with the same catheters varied only slightly. Furthermore, ECS concentrations related to the ultrafiltrate of serum showed considerable interindividual variations. The high intra- and interindividual variation of ECS concentrations is demonstrated by the low correlation between concentrations in ECS and the ultrafiltrate of serum (CBZ, r = 0.41; 10-OH-CZ, r = 0.42; LTG, r = 0.27) in contrast to the high correlation between brain tissue concentration and the ultrafiltrate of serum (CBZ, r = 0.97; 10OH-CZ, r = 0.88; LTG, r = 0.98) in the same group of patients. When comparing AED concentrations in the ECS with those in the CSF, ECS concentrations were significantly lower for CBZ, 10-OH-CZ, LTG, and LEV. Conclusions: The data demonstrate that AED concentrations show a considerable intraindividual and interindividual variation in the ECS of cortical regions. Furthermore, the ECS concentration of several AEDs is significantly lower than their CSF concentration in patients with intractable epilepsy. However, in the absence of data from nonepileptic tissues, it is not possible to judge whether the present findings relate to overexpression of multidrug transporters in the brain. Instead, the present study illustrates the methodologic difficulties involved in performing IOMD studies in patients and may thus be helpful for future approaches aimed at elucidating the role of multidrug transporters in epilepsy. Key Words: Antiepileptic drugs— Neocortex—Temporal lobe—Drug resistance—Intraoperative microdialysis. more...

SummaryObjectivesIn the current classification of epilepsies two forms of temporal lobe epilepsy (TLE) were included: mesial and lateral (neocortical) TLE. We aimed at identifying prognostic factors for the surgical outcome of lesional neocortical TLE.MethodsWe included consecutive patients who had undergone presurgical evaluation including ictal video-EEG and high-resolution MRI, who had TLE due to neocortical lateral epileptogenic lesions, who had a lesionectomy and who had >2-year follow-up.ResultsThere were 29 patients who met the inclusion criteria. Twenty of them became postoperatively seizure-free. Patients’ mean age was 34.8±9 years (range 18–52). The age at epilepsy onset was 20.1±8 years. We found that left-sided surgery (p=0.048) and focal cortical dysplasia (FCD) on MRI (p=0.005) were associated with non-seizure-free outcome, while lateralized/localized EEG seizure pattern (p=0.032), tumors on the MRI (p=0.013), and a favorable seizure situation at the 6-month postoperative evaluation were associated with 2-year postoperative seizure-freedom (p more...

In diesem Fallbericht wird eine erfolgreich epilepsiechirurgisch behandelte Patientin vorgestellt, die in der Kernspintomographie drei Lasionen aufwies: zwei Cavernome, eines links posterior temporal, eines rechts mesial temporal sowie zusatzlich eine Hippokampussklerose linksseitig. Diagnoseentscheidend war ein zwar subtiler, aber konsistenter iktaler EEG-Befund im Oberflachen-EEG mit einem Anfallsmuster uber der links posterior temporalen Region. Eine erweiterte Lasionektomie des links temporal posterior gelegenen Cavernoms fuhrte zu bislang 2-jahriger Anfallsfreiheit. Die bilateral mesial temporal gelegenen Lasionen sind offensichtlich nicht epileptisch aktiv. more...

Objective: To test pathophysiologic hypotheses regarding the occurrence of a splenial lesion in patients with epilepsy. Methods: The authors studied 16 patients with a splenial lesion and 32 control patients, all of whom had MRI examination immediately after presurgical EEG long-term monitoring (LTM). The authors compared the number of generalized tonic-clonic and partial seizures during LTM, antiepileptic drug (AED) withdrawal, and laboratory results. Results: All of the patients with a splenial lesion had their AEDs stopped completely, vs 47% of the controls ( p = 0.001). Patients with SCC lesion had a longer duration of complete withdrawal (median 3.5 vs 2 days, p = 0.03). There was no correlation with seizure frequency or the introduction of new AEDs. Conclusion: A lesion of the splenium of the corpus callosum in patients with epilepsy is not associated with toxic drug effects or high seizure frequency, but might be induced by a rapid and relatively long-lasting reduction of antiepileptic drugs. Its frequency might be underestimated as MRI after long-term monitoring is rarely done. more...

SummaryWe investigated the correlation of interictal epileptiform discharges (IED) in routine EEG 6 and 24 months after epilepsy surgery with regard to long-term seizure outcome. In 148 patients (74% temporal lobe epilepsy (TLE), 26% extratemporal epilepsy) EEG results (IED present or absent) were correlated with the postoperative outcome using the Engel classification 6 and 24 months after resection (PO6m and PO2y, respectively). Self-evaluation was conducted 3 and 5 years after resection (PO3y and PO5y, respectively). Ninety-one patients (62%) were seizure-free 5 years after resection; 88% of them showed no IED in PO6m. Twenty-eight patients (19%) displayed IED in routine EEG 6 months after resection; 61% of them had recurrent seizures at PO5y, whereas of 120 patients without IED only 33% had recurrent seizures at PO5y; p=0.01.Absence of IED in PO6m and PO2y correlated with good outcome: 71% without IED remained seizure-free, whereas only 25% with IED at PO6m and PO2y remained seizure-free; p=0.001.Seizure-free patients (Engel 1) and patients with less favourable outcome (Engel 3–4) at PO6m and PO2y rarely changed categories of outcome during the following years (p more...

To analyze systematically hyperorality associated with epileptic seizures and its relation to the localization of epileptic activity.To identify patients with periictal hyperorality, we reviewed video-recordings of 269 patients (aged 6-59 years) who had consecutively undergone presurgical evaluations including ictal video-EEG recordings and high-resolution magnetic resonance imaging (MRI) and had had epilepsy surgery because of intractable frontal (FLE) or temporal lobe epilepsy (TLE). Periictal hyperorality was defined if patients put or unambiguously intended to put nonfood items into their mouths during or after at least one of the reviewed seizures. For the further analysis, we included only patients with periictal hyperorality. We reviewed their medical records and reexamined their ictal video-EEG recordings.We identified eight patients (six women) aged 8-59 years who had hyperorality during or after seizures. Seven patients had TLE, and one patient had frontal lobe epilepsy (FLE). Three of these patients underwent right-sided surgery, whereas five patients had surgery on the left. Three patients exhibited ictal and five showed postictal hyperorality. Interictal EEG suggested bilateral interictal epileptiform discharges (IEDs) in three patients; in two other patients, no IEDs were detected. Ictal EEG suggested bilateral involvement in six cases. Patients with unilateral epileptiform activity had left TLE.Periictal hyperorality is a rare phenomenon occurring in 3% of the investigated epilepsy population. We suggest that periictal hyperorality is an ictal-postictal mental disturbance, an incomplete Klüver-Bucy syndrome. In most patients, bilateral seizure activity plays an important role in the pathomechanism, but it would appear that left-sided epileptic activity without contralateral involvement also can cause periictal hyperorality. more...

Although studies of epileptic human hippocampus suggest changes of synaptic and intrinsic excitability, few changes, save the appearance of spontaneous field/synaptic potentials, are known in epileptic neocortical tissue. However, invasive EEG and histological studies suggest that neocortical tissue, even in mesial temporal lobe epilepsy, can play an important role as an irritative zone or extrahippocampal focus. We hypothesized that intrinsic neuronal and synaptic excitability, as well as short-term plasticity, are altered in neocortical areas, particularly with elevated K+ levels as occur during seizures. We analyzed neuronal firing properties, synaptic responses, and paired-pulse plasticity in human neocortical slices from tissue resected during epilepsy surgery, both under normal and under pathological conditions, i.e., after elevating K+ (4/8 mM), with rat neocortical slices as controls. Neuronal firing properties were not different. We did find, however, alterations of synaptic responsiveness in epileptic tissue, i.e., an elevated network excitability with K+ elevations, and reduction of paired-pulse depression. more...

In dieser Kasuistik wird der Verlauf einer operativ behandelten fokalen Epilepsie eines Patienten beschrieben, der im ersten Lebensjahr eine rechtshemispharische perforierende Hirnverletzung erlitt. Bis zum Alter von 21 Jahren traten selten sensomotorische Anfalle der linken Korperseite auf. Im weiteren Verlauf losten durch epigastrische Auren eingeleitete psychomotorische Anfalle letztere ab. Die nichtinvasive praoperative Abklarung ergab die Diagnose einer mesialen Temporallappenepilepsie rechts bei Hippokampussklerose. Aufgrund der Ergebnisse der invasiven Untersuchung mit Subduralelektroden wurde eine nach posterior erweiterte Temprallappenresektion durchgefuhrt. Nach dreijahriger postoperativer Anfallsfreiheit traten erneut Anfalle mit jetzt tonisch-hypermotorischer Symptomatik auf. Diese Fallbeschreibung zeigt die Dynamik einer fokalen epileptischen Erkrankung und die Probleme der praoperativen Diagnostik bei Vorliegen einer dualen Pathologie auf. more...

Wir untersuchten die Anfallssemiologie und EEG-Befunde von elf Patienten mit insularen Epilepsien. Alle Patienten hatten Auren, funf hatten epigastrische Auren, vier „Kribbeln im ganzen Korper“, drei psychische, zwei somatosensible und einer komplex visuelle Auren. Die auf die Auren folgende Anfallssemiologie zeigte unterschiedliche Anfallsformen, es traten sieben psychomotorische, funf hypermotorische, zwei autonome Anfalle sowie drei fokal tonisch klonische Anfalle des kontralateralen Arms auf. Im interiktalen EEG fanden sich epilepsietypische Potentiale ipsilateral frontal bei vier, temporal mesial und lateral bei je zwei, zentroparietal und parietal bei je einem Patienten. Vier Patienten hatten keine epilepsietypische Aktivitat interiktal. Iktale Aktivitat trat ebenfalls ausschlieslich ipsilateral zur Lasion auf, temporal bei drei, frontotemporal und frontal bei je zwei, parietal, zentroparietal und diffus bei je einem Patienten. Acht von zehn Patienten zeigten wahrend der Auren keine Anfallsmuster. more...

Bei Patienten mit anfallsartigen Symptomen kann sich die Differenzialdiagnose zwischen Epilepsie und Narkolepsie ergeben. Wir beschreiben vier Patienten mit einem gemeinsamen Auftreten beider Erkrankungen. Die Epilepsiediagnose ging der Diagnose der Narkolepsie einige Jahre voraus. Verschiedene Hypothesen uber mogliche Ursachen eines gemeinsamen Auftretens dieser beiden Krankheiten (Einflusse der antiepileptischen Medikation, Verursachung der einen Krankheit durch die andere, genetische Disposition, exogene Faktoren) werden erortert. Die Analyse der Patientenvorgeschichten legt nahe, dass bei vermutlich vielen Patienten mit Epilepsie das zusatzliche Vorliegen einer Narkolepsie undiagnostiziert bleibt, sodass im Hinblick auf die spezifischen Behandlungsmoglichkeiten das parallele Vorliegen beider Erkrankungen haufiger als bisher bedacht werden sollte. more...

Objective: To identify clinical factors contributing to the lateralization of mesiotemporal memory functions in epilepsy by using memory-activated fMRI. Methods: Sixty patients aged 16 to 63 years with mesial temporal lobe epilepsy (MTLE) and 20 patients aged 16 to 60 years with extratemporal epilepsy (ETE) due to circumscribed epileptogenic lesions who consecutively underwent presurgical evaluation including continuous video-EEG monitoring and structural MRI examinations were examined. During memory fMRI, the activation condition consisted of retrieval from long-term memory induced by self-paced performance of an imaginative walk through the patient’s hometown. On the basis of a previous study, memory lateralization was defined as typical if larger fMRI activation was in the mesiotemporal structures contralateral to the epileptic focus. Results: There were 45 patients with MTLE who had typical memory lateralization (75%), whereas only 9 patients (45%) with ETE exhibited typical memory lateralization ( p = 0.013). In MTLE patients, bilateral independent epileptiform discharges occurred more often in the atypical group than in patients with typical memory lateralization ( p = 0.015). Conclusions: The fMRI lateralization of mesiotemporal visuospatial memory functions in patients with mesiotemporal lobe epilepsy (MTLE) is asymmetric: The larger activation usually appears contralateral to the side of the epileptogenic region. These findings occur more often in MTLE; in patients with extratemporal epilepsy, such type of asymmetry is not characteristic. In MTLE patients with bilateral independent epileptiform discharges, this type of asymmetry is also less frequent. more...

We investigated the nature of preictal subjective phenomena and whether they had any effect on the seizure frequency in 95 adult patients with medial temporal lobe epilepsy. Seventy-three (77%) patients indicated that they experienced seizure-provoking factors. Ten patients (11%) had prodromas independent of auras, while auras occurred in 89%. Forty-four patients (46%) reported that that they had tried to stop their seizures in the presence of prodroma or aura and this action had resulted in success at least once. Twenty-one patients (22%) regularly tried to stop their seizures because this effort was often successful according to their interpretation. Patients who reported that they could frequently inhibit their seizures had 1.8±1.6 seizures/month, a significantly lower mean seizure frequency than those 74 patients who did not do it regularly (4.6±4.8 seizures/month, P more...

A-type currents powerfully modulate discharge behavior and have been described in a large number of different species and cell types. However, data on A-type currents in human brain tissue are scarce. Here we have examined the properties of a fast transient outward current in acutely dissociated human neocortical neurons from the temporal lobe of epilepsy patients by using the whole-cell voltage-clamp technique. The A-type current was isolated with a subtraction protocol. In addition, delayed potassium currents were reduced pharmacologically with 10 mM tetraethylammonium chloride. The current displayed an activation threshold of about -70 mV. The voltage-dependent activation was fitted with a Boltzmann function, with a half-maximal conductance at -14.8 +/- 1.8 mV (n = 5) and a slope factor of 17.0 +/- 0.5 mV (n = 5). The voltage of half-maximal steady-state inactivation was -98.9 +/- 8.3 mV (n = 5), with a slope factor of -6.6 +/- 1.9 mV (n = 5). Recovery from inactivation could be fitted monoexponentially with a time constant of 18.2 +/- 7.5 msec (n = 5). At a command potential of +30 mV, application of 5 mM 4-aminopyridine or 100 microM flecainide resulted in a reduction of A-type current amplitude by 35% or 22%, respectively. In addition, flecainide markedly accelerated inactivation. Current amplitude was reduced by 31% with application of 500 microM cadmium. All drug effects were reversible. In conclusion, neocortical neurons from epilepsy patients express an A-type current with properties similar to those described for animal tissues. more...

Es sollten klinische, MRT- und EEG-Befunde von chirurgisch behandelten Patienten mit NMS mit denen von Patienten mit HTU und HS verglichen werden. Die Befunde von 41 konsekutiven Patienten mit NMS wurden mit denen von 20 HTU- und 17 HS-Patienten verglichen. Bei Patienten mit HTU und HS war mittels MRT (85, 100%) und interiktalen (95, 100%) sowie iktalen EEGs (85, 88,2%) eine vorwiegende oder ausschliesliche temporale Lokalisation der Abnormitat, bei solchen mit NMS eine meist extratemporale (58,1%, 58%, 68,6%) zu finden. Eine verzogerte fruhkindliche Entwicklung (46,3%), Intelligenzminderung (78,4%), Verhaltensstorungen (68,3%), pathologische neurologische Befunde (61%) und masige Operationsergebnisse (Klasse I A–D: 37,5%) waren bei Patienten mit NMS, wesentlich gunstigere Befunde bei denen mit HTU (0%, 45%, 65%, 10%, Klasse I A–D: 80%) und denen mit HS (6,3, 29,4, 29,4, 29,4%, Klasse I A–D: 64,7%) zu finden. Mogliche Ursachen fur diese unterschiedlichen Befunde werden diskutiert. Atiologisch konnten lediglich vorausgegangene Fieberkrampfe (Fk) (47,1%) bei den HS-Patienten als wesentliche Ursache angesehen werden. Partialanfalle infolge NMS sind durchschnittlich ungunstigere Anfallstypen im Vergleich zu denen mit HTU und HS. more...

We present the case of a patient with ictal monocular nystagmus and ictal diplopia who became seizure-free after resection of a right frontal focal cortical dysplasia (FCD), type 2B. Interictal neuroophthalmological examination showed several beats of a monocular nystagmus and a spasm of the contralateral eye. An exclusively ictal monocular epileptic nystagmus could be an argument for an exclusively cortical involvement in monocular eye movement control. The interictal findings in our patient, however, argue for an irregular ictal activation of both the cortical frontal eye field and the brainstem. peerReviewed more...

Purpose : To investigate the factors which influence the persistence of interictal epileptiform discharges (IED) after epilepsy surgery. Methods : In this retrospective study we included patients with intractable medial temporal lobe epilepsy (MTLE) who underwent presurgical evaluation including high-resolution MRI and video-EEG monitoring with seizure registration prior to an anterior temporal lobe resection. The postsurgical outcome was assessed by our team 6 months and 2 years after the surgery. Results : One hundred and forty-seven patients fulfilled the inclusion criteria. The mean age of the patients was 31.8 (range 16–59 years). In 22 patients (15%) interictal epileptiform discharges were present on the postoperative routine EEG. We found that both the preoperative spike frequency ( P P =0.04) were independently associated with the presence of IED on the postoperative routine EEG. The preoperative spike frequency was not associated with the postoperative outcome. The extent of resection showed no influence on the presence of postoperative IED. Conclusion : We hypothesize that two factors independently influence the presence of postoperative spikes: chronic interictal disturbance (represented as preoperative spike frequency) and the acute (postoperative) seizures. Our study confirmed that persistent postoperative IED had a prognostic value regarding the outcome of the epilepsy surgery. more...

Objectives – To evaluate magnetic resonance imaging (MRI) and electro-encephalogram (EEG) findings of patients with therapy-resistant partial seizures due to neuronal migration disorders (NMD), and compare them with each other and with surgery outcome. Material and methods – The MRI, interictal and ictal EEG findings, and their relations to each other in 41 patients with NMD were compared with class IA surgery outcome. Results – The patients showed an MRI lesion in decreasing frequency from the frontal to the occipital areas. A predominantly extratemporal location of the interictal EEG foci (73.3%) and ictal patterns (82.4%) was therefore apparent, also showing a diminishing frequency from the anterior to the posterior areas. Comparing the EEG foci with the MRI lesions, the same location of the interictal foci was found in 68.4% and of the ictal foci in 52.7%, including several cases with a more widespread EEG focus or MRI lesion. The same location of interictal as well as ictal foci was evident in 85.7%. The most favourable surgery outcome (class IA) was, on average, apparent in patients with an MRI lesion (28.6% vs 25%), a main interictal EEG focus (50% vs 18%) and an ictal seizure pattern (37.5% vs 16.7%) located in the temporal area; likewise, if the interictal focus (30.8% vs 18.2%) and the ictal pattern (31.8% vs 12.5%) showed the same location as the MRI lesion, as well as when the interictal and ictal EEG changes had an equal location (30% vs 20%). Conclusion – MRI and EEG recordings show relatively close relations to each other and might be important methods to predict surgery outcome in NMD patients. more...

Temporal lobe epilepsy (TLE) is frequently associated with hippocampal sclerosis (HS) and complex febrile convulsions (CFC). The causal relationship between TLE, HS, and CFC is unclear. There is also contradictory data whether CFC-associated TLE is a distinct epilepsy syndrome and has different surgical outcome than other medial TLEs.We investigated 133 patients (aged 16-59 years) with HS-associated TLE. Thirty-six patients with CFC (CFC group) versus 97 patients without febrile convulsions (NFC group) were compared for clinical history, video-EEG recorded seizure semiology, and surgical outcome.In the CFC group the right-sided HS (67% versus 32%) occurred more frequently than in the NFC group (P0.001). The two groups did not differ according to the clinical features, both groups share the typical symptoms and findings of the medial TLE. In the CFC group, seizure-freedom 2 years after surgery was 91%, while in the NFC group it was only 64% (P=0.023). This difference was significant even after considering the other known predictive factors for medial TLE.Medial TLE with CFC is not a distinct epilepsy syndrome. The surgical outcome, however, is much more favorable in these patients in comparison with medial TLE patients who had no history of febrile convulsions. more...

Videodokumentierte Anfallssemiologie und nichtinvasives EEG sind routinemasige und unverzichtbare Bestandteile prachirurgischer Epilepsiediagnostik. Das nichtinvasive interiktale und iktale EEG gibt wertvolle diagnostische und prognostische Hinweise besonders bei nichttumorosen mesialen Temporallappenepilepsien (TLE), aber auch bei Frontallappenepilepsien (FLE). Die Anfallssemiologie liefert bei TLE und FLE Hinweise fur die Lateralisation der Epilepsie und tragt damit zur Konsistenz der Befunde vielfaltiger Methoden bei. Bei posterioren Epilepsien ist der Beitrag des Oberflachen-EEGs zur Diagnostik deutlich geringer, hingegen sind die klinischen Lateralisationszeichen der Semiologie von Auren und Anfallen hier nicht nur hinsichtlich der Lokalisation der Epilepsie, sondern auch bezuglich der Prognose einer Operation wertvoll.¶ Zum langfristigen Verlauf vermag das Routine-EEG in den ersten zwei Jahren prognostische Hilfen zu geben. Weitere Arbeiten uber langfristige Verlaufe von mehr als 5 Jahren waren wunschenswert.¶ Uber das nichtinvasive Video-EEG-Monitoring hinaus werden in der prachirurgischen Epilepsiediagnostik eine Vielfalt weiterer apparativer und nichtapparativer Verfahren eingesetzt, sehr viele darunter ebenfalls nichtinvasiv. Den Stellenwert dieser Verfahren zu erortern, sollte Gegenstand einer separaten Darstellung sein. more...

Summary: Purpose: The anticonvulsant effects of the novel antiepileptic drug (AED) levetiracetam (LEV) were tested in neocortical slice preparations from 23 patients who underwent surgery for the treatment of refractory epilepsy. Methods: Slices were used to evaluate the effects of LEV on two different models of epilepsy: low-Mg2+–induced untriggered and bicuculline-evoked stimulus-triggered epileptiform burst discharges and spontaneously appearing rhythmic sharp waves. Results: LEV (0.1–1 mM) did not influence spontaneously appearing rhythmic sharp waves or Mg2+-free aCSF-induced epileptiform field potentials. LEV affected neither the amplitudes or duration nor the repetition rates of burst discharges in these epilepsy models. However, LEV (100–500 μM) significantly suppressed the ictal-like discharges elicited by the γ-aminobutyric acid subtype A (GABAA)-receptor antagonist bicuculline. A marked reduction of the amplitude and duration of bicuculline-evoked field response in the presence of LEV was observed. Conclusions: The results indicate the potential for LEV to inhibit epileptiform burst discharges in human neocortical tissue, which is consistent with its effects in animal models of epilepsy. These results also support the seizure reduction observed in clinical trials and support that this may, in part, be related to the ability of LEV to inhibit epileptiform discharges. more...