Cristiane Simão

Ressonância magnética funcional na determinação da lateralização da área cerebral da linguagem

Functional magnetic resonance imaging (fMRI) is a technique for detecting minimal changes in brain perfusion and oxygenation secondary to neuronal activation. Its application in the pre-surgical evaluation of epileptic patients with temporal mesial sclerosis is currently being under investigation in several centers. This study aims to describe an activation paradigm for the evaluation of language and memory functions, as an alternative to the worldwide used Wada test, which is an invasive procedure. In order to propose a paradigm adapted to the Portuguese language, we report our experience in determining the dominant cerebral area for language through fMRI with a verbal fluency task. The results of the fMRI from 19 patients studied in Curitiba in a period of approximately two years were studied. Sixteen of them presented with left hemispheric cerebral language dominance. In five patients, results from fMRI and Wada test could be compared and agreed in localization. Our results reinforce the view that fMRI may become an essential tool for medical practice, perhaps for the determination of eloquent areas in the evaluation of candidates for epilepsy surgery.

Syncope or epileptic fits? Some examples of diagnostic confounding factors

Syncope is a condition often misdiagnosed as epileptic seizures. However, the differential diagnosis between both conditions can be quite difficult, even for well-trained physicians. Four cases of epilepsy and/or syncope are reported, to exemplify this situation. Each case is discussed individually, and the confounding factors are analyzed.

Hot-water epilepsy , "warm-water epilepsy", or bathing epilepsy? Report of three cases and considerations regarding an old theme

Partial and generalized tonic-clonic reflex seizures related to hot water bathing have been described as temperature-related. We describe three cases of bathing epilepsy: a 28 year-old white male and a 30 year-old white female with spells triggered either by warm or hot water, and a 32 year-old female with spells triggered by hot water. The later two of the three cases presented localized epilepsy and a familial history of epilepsy. A complex tactile stimuli might play the most relevant role on seizure triggering, as well as water temperature with an additive effect over cutaneous stimulation.

Vagus nerve stimulation may be a sound therapeutic option in the treatment of refractory epilepsy

INTRODUCTION Refractory epilepsy accounts for 20 to 30% of epilepsy cases and remains a challenge for neurologists. Vagus nerve stimulation (VNS) is an option for palliative treatment. OBJECTIVE It was to study the efficacy and tolerability of VNS in patients implanted with a stimulator at the Curitiba Institute of Neurology (INC). METHODS A case study of six patients with refractory epilepsy submitted to a VNS procedure at the INC in the last four years was described and discussed. RESULTS Mean age at time of implantation was 29 years. Mean follow-up was 26.6 months. Seizure frequency decreased in all patients (40-50% (n=2) and ≥80% (n=4)). Three patients no longer required frequent hospitalizations. Two patients previously restricted to wheelchairs started to walk, probably because of improved mood. CONCLUSION In this population, VNS proved to be a sound therapeutic option for treating refractory epilepsy.

Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy

PURPOSE The aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit. METHODS Patients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again. RESULTS A significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p<0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p=0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p=0.016). DISCUSSION Patient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.

Tratamento cirúrgico da epilepsia do lobo temporal: análise de 43 casos consecutivos

Quarenta e tres pacientes com epilepsia refrataria ao tratamento medicamentoso foram submetidos a cirurgia de epilepsia do lobo temporal no Instituto de Neurologia de Curitiba, entre os anos de 1998 a 2003. Trinta e nove (90,6%) pacientes apresentavam esclerose mesial temporal, e quatro (9,4%), tumores cerebrais. Dos trinta e sete pacientes que possuiam avaliacao pos-operatoria completa, 83,7% apresentaram classificacao I, segundo Engel (livres de crises incapacitantes). Complicacoes pos-operatorias ocorreram em 18,6%: uma infeccao da ferida operatoria, um caso de hidrocefalia, um de fistula liquorica, dois casos de paralisia transitoria do IV nervo craniano e um de hemiparesia transitoria. Nao houve nenhum obito relacionado a cirurgia de epilepsia no presente estudo.Forty-three patients with epilepsy resistant to drug therapy were submitted to temporal lobe epilepsy surgery at the Instituto de Neurologia de Curitiba, from 1998 to 2003. Thirty-nine patients (90.6%) had mesial temporal sclerosis, and four had brain tumors. According to Engels rating, 83.7% from 37 patients with complete postoperative evaluation were classified as Class I (free of disabling seizure). Postoperative complications (18.6%) were evaluated, with one case of surgical wound infection, one case of hydrocephalus, one case of cerebrospinal fluid fistula, two cases of transient palsy of the trochlear nerve and one case of transient hemiparesis. No death related to epilepsy surgery was found in our study.

Seizure-like activity during etomidate-modified Wada test interfere with the evaluation of cognitive functions?

1. Komninos J, Vlassopoulou V, Protopapa D, et al. Tumors metastatic to the pituitary gland: case report and literature review. J Clin Endocrinol Metab 2004;89:574-580.2. Fassett DR, Couldwell WT. Metastases to the pituitary gland. Neurosurg Focus 2004;16:E8.3. Hoellig A, Niehusmann P, Flacke S, Kristof RA. Metastasis to pituitary ade-noma: case report and review of the literature. Cen Eur Neurosurg 2009; 70:149-153.4. Bhatoe HS, Badwal S, Dutta V, Kannan N. Pituitary metastasis from med-ullary carcinoma of thyroid: case report and review of literature. J Neu-rooncol 2008;89:63-67. 5. Morita A, Meyer FB, Laws ER Jr. Symptomatic pituitary metastases. J Neu-rosurg 1998;89:69-73.

O Methohexital Sódico (Brevital ® ) no Teste de Wada: Relato de Dois Casos

ABSTRACT INTRODUCTION: The Wadas test is still being frequently used at epilepsy surgery centers in temporal lobectomy candidates to evaluate the extent, quality and lateralization of memory functions, and to estimate residual deficit, since it simulates the effects of the surgery. In Brazil, Amytal® is very difficult to be obtained due to local regulatory barriers. OBJECTIVES: To describe the Wada procedure carried out with Brevital® in two temporal lobectomy candidates, and to comment on its efficacy and differences regarding the Wada procedure carried out with Amytal®. METHODS: The Wada procedure carried out with Brevital ® in two patients in order to determine the laterality of language and memory through an adjusted protocol is reported. RESULTS: We report two cases submitted to the Wada test with sodium methohexital. RESULTS: Brevital®, a short-lasting anesthetic, showed good results as an Amytal® substitute. CONCLUSION: Brevital® may be used in Brazil for Wada tests, with the additional advantages of allowing a shorter procedure, as well as a comprehensive assessment of memory.

The usefulness of neuronavigation in functional hemispherectomy

Catastrophic epileptic encephalopathies in children comprise devastating conditions that features cerebral dysfunction in association with refractory epileptic seizures. The diagnosis is based on the clinical findings, on magnetic resonance imaging (MRI) of the brain and on electroencephalographic findings. For these conditions, surgery remains essential for attaining seizure control. We report two cases of 5-year-old girls. The first one had a diagnosis of Rasmussen’s syndrome. The second one had a large porencephalic cyst secondary to perinatal cerebral ischemia. Despite trials of anticonvulsants, both patients deteriorated, and a functional hemispherectomy guided by neuronavigation was indicated and performed, with low morbidity and excellent seizure control. The neuronavigation proved to be a valuable guidance tool in performing the functional hemispherectomy, making the disconnections more accurate, and thus decreasing the surgical time and blood loss.