Elza M.T. Yacubian

Clinical characteristics and surgical outcome of patients with temporal lobe tumors and epilepsy

This is a retrospective study of 21 surgically treated patients with temporal lobe tumors and epilepsy. Evaluation included clinical data, EEG findings, structural scans, pathological diagnosis and post-surgical follow-up. There were 9 cases of ganglioglioma, 5 pilocytic astrocytoma, 3 ganglioneuroma, 2 dysembryoplastic neuroepithelial tumor, 1 pleomorphic xantoastrocytoma, and 1 meningioangiomatosis. Mean follow-up time was 22 months and outcome was evaluated according to Engels classification; 76.2% were classified in class I and 23.8% in II and III. All patients classes II and III had been submitted to mesial and neocortical resections. There were no differences related to clinical characteristics, pathological diagnosis or duration of follow-up in patients seizure-free or not. All patients had abnormal MRI and ten of these had normal CT; the MRI characteristics were compared to pathological diagnosis and specific histological characteristics of the tumors were not discernible by MRI. We concluded that MRI was essential for the diagnosis and precise location of TL tumors. Ganglioglioma was the most frequent tumor and lesionectomy associated to mesial resection doesnt guarantee a better prognosis.

Intractable complex partial seizures associated with posterior cerebral artery giant aneurysm: a case report.

Summary: Giant aneurysms have rarely been reported in association with intractable complex partial seizures (CPS). We report a 30‐year‐old man with intractable CPS since age 18 years. Seizure onset was electrically localized to right temporal lobe. Preoperative neuroimaging studies showed a partially thrombosed giant aneurysm of the right posterior cerebral artery. Selective arnygdalo‐ hippocampectomy and occlusion of the posterior cerebral artery did not cause deficits. The patient has been seizure‐free for 15 months after operation. We review the relevant literature on aneurysms as a cause of epilepsy.

Clinical and eeg analysis of mesial and lateral temporal lobe seizures

The analysis of the temporal lobe seizures through video-EEG systems shows that they often consist of a sequence of clinical and EEG features which may suggest the localization and the lateralization of the epileptogenic lobe. We analyzed clinical and EEG features of 50 temporal lobe seizures which were separated in group 1 with 25 patients (related to mesial temporal sclerosis) and group 2 with 25 patients (other neocortical temporal lesions). Among the auras, the epigastric type was the most frequent and predominated in group 1. There were differences between the two groups, considering dystonic and tonic posturing and versive head and eye movements. Dystonic posturing was always contralateral to the ictal onset and was considered the most useful lateralizing clinical feature. Ictal speech, spitting and blinking automatisms, prolonged disorientation for place and a greatest percentage of postictal language preservation occurred in right temporal seizures. Postictal aphasia and global disorientation predominated in left temporal seizures. EEG was important for lateralizing the epileptogenic lobe, specially considering rhythmic ictal activity and postictal findings.

Surgical treatment of refractory epilepsy associated with space occupying lesions experience and review

Surgery for space occupying lesions of the brain associated with intractable epilepsy represents a special problem because relief of the epilepsy in as much an operative goal as excision of the space occupying lesion itself. This study concerns 32 patients with space occupying lesions and intractable epilepsy who underwent excision of the lesion with acute intraoperative electrocorticography guided resection of the epileptogenic focus. Of the 32 patients, 16 formed a subgroup of gangliogliomas alone. The remaining were mixed lesions, predominantly benign. The duration of seizures in these patients ranged from 2 to 30 years, and the seizure frequency varied from 1 to 300 convulsions per month. The operative procedures included temporal corticectomy, amygdalo-hippocampectomy, and extratemporal corticectomies. Twenty nine patients were in Engel class I postoperatively, and three patients were in Engel class II. The findings with gangliogliomas were also considered in a separate group. This study strongly suggests that the operative procedure under electrocorticography guidance improves seizure outcome in space occupying lesions related intractable epilepsy.

Occipital intermittent rhythmic delta activity in absence epilepsy

Occipital intermittent rhythmic delta activity (OIRDA) is considered good prognostic factor in typical absences (TA). We report electroclinical evolution in 14 patients with TA and OIRDA, which performed video-EEG. Seven patients were female; 9 had childhood absence epilepsy and the others did not present electroclinical characteristics for syndromic classification according to ILAEs classification (1989). Pyknolepsy was referred to in 13; TA was the only seizure type in 13; one had generalized tonic-clonic seizures (GTCS) and three had myoclonic jerks during TA. VPA monotherapy controlled seizures in 11, diVPA and ESM, in one each. After seizure control EEG normalized in 10 while in three, spike-wave complexes (SWC) persisted, accompanied by OIRDA in one. Finally in another, seizures were not controlled and SWC and OIRDA persisted. In conclusion, we observed in this series of TA and OIRDA with onset before 10 years, pyknolepsy as common finding and few GTCS. VPA controlled seizures in most cases and EEG normalized in 76.92%. We suggest that OIRDA could be considered good prognostic factor in TA associated with SWC and of epileptiform nature leading to appropriate investigation.

Syndromic classification of patients with typical absence seizures

The aim of this study is to compare ILAE classification (1989) and Panayiotopoulos criteria (1997) for absence epilepsies. We studied 455 typical absences (ILAE, 1981) by video-EEG in 43 patients with normal neurological and neuroradiological examinations and interictal EEG with spike-wave complexes higher than 2.5Hz. Syndromic diagnosis was possible in 60.5% and 67.4% of the patients using ILAE classification and Panayiotopoulos proposal, respectively. According to ILAE criteria 19 patients had childhood absence epilepsy (CAE), five juvenile absence epilepsy (JAE), one juvenile myoclonic epilepsy (JME) and one epilepsy with specific modes of seizure precipitation. According to Panayiotopoulos proposal, 10 had CAE, 14 JAE, one JME, three myoclonic absence epilepsy and one eyelid myoclonia with absences. We conclude that Panayiotopoulos criteria and ILAE classification for absence epilepsies, which did not allow for the classification of 32.6% and 39.5% of cases, respectively, were still insufficient to classify all patients under specific diagnosis.

ALTERACOES SEXUAIS NA EPILEPSIA: RESULTADOS DE UMA AVALIACAO MULTIDISCIPLINAR

Eleven epileptic men who complained of epilepsy and sexual dysfunction were submitted to a multidisciplinary evaluation. Mean age was 27 years (20-34), mean epilepsy duration was 19 years (0,5-32) and the mean seizure frequency was two by week (0-7). Ten patients had partial seizures and one other had myoclonic epilepsy. Ten patients were treated with antiepileptic drugs (phenytoin - 1, carbamazepine - 8, clonazepam - 3, clobazam - 2, valproic acid - 3, vigabatrin - 1). As defined in the DSM III-R, the complaints were: erectile disorder (9), hypoactive sexual desire disorder (4), frotteurism (4), inhibited orgasm (3), premature ejaculation (3), fetishism (2), voyeurism (2), exhibitionism (2), pedophilia (1) and sexual aversion disorder (1). Two patients showed hypogonadotropic hypogonadism on endocrinologic screening. Urological evaluation disclosed organic erectile dysfunction in other two. One patient had a diagnosis of psychogenic sexual disorder. In six patients a conclusive etiologic diagnosis was not reached This report shows the multifactorial nature of sexual disorder in epilepsy and underlies the need of a multidisciplinar evaluation.

The role of mirror focus in the surgical outcome of patients with indolent temporal lobe tumors

PURPOSEnTo review the clinical and neurophysiological data of 21 patients with epilepsy due to temporal lobe tumors and who had undergone evaluation and surgery at the Hospital das Clínicas da Universidade de São Paulo. The aim of this study was to investigate whether the occurrence of a mirror focus was influenced either by certain clinical factors or if the surgical outcome was influenced by the presence of a mirror focus.nnnMETHODnWe included these 21 patients who had undergone at least one interictal electroencephalogram in the pre- and post-surgical periods. They had had a minimum follow-up of one year.nnnRESULTSnEight patients had mirror focus (Group 1) and 13 did not (Group 2). The mean age at seizure onset, duration of epilepsy disorder and total number of seizures did not vary statistically between the two groups of patients. Generalized tonic-clonic seizures occurred more frequently in the mirror focus group. All, but one patient, with a mirror focus were seizure free at follow- up. The mirror focus disappeared in all eight patients in the post-surgical electroencephalogram. In this group, the patient who was not seizure - free had a seizure recorded in his post-surgical electroencephalogram with seizure onset ipsilateral to the resected tumor. The patients who were not seizure-free had either been submitted to an incomplete resection of the tumor or showed evidence of associated cortical dysplasia.nnnCONCLUSIONnThe occurrence of mirror focus is not a contraindication to surgery even when interictal epileptiform activity predominates contralaterally to the tumor and neither when seizures appear to arise from the mirror focus on scalp EEG. Good surgical outcome is expected despite EEG findings that may conflict with tumor location.

MRI and brain spect findings in patients with unilateral temporal lobe epilepsy and normal CT scan

26 patients with temporal lobe epilepsy clinically documented by several abnormal interictal surface EEGs with typical unitemporal epileptiform activity and a normal CT scan were studied. Interictal 99mTC HMPAO brain SPECT and MRI were performed in all subjects. Abnormalities were shown in 61.5% of MRI (n = 16) and 65.4% of SPECT (n = 17). Hippocampal atrophy associated to a high signal on T2-weighted MRI slices suggesting mesial temporal sclerosis was the main finding (n = 12; 75% of abnormal MRI). MRI correlated well to surface EEG in 50% (n = 13). There was also a good correlation between MRI and SPECT in 30.7% (n = 8). SPECT and EEG were in agreement in 57.7% (n = 15). MRI, SPECT and EEG were congruent in 26.9% (n = 7). These results support the usefulness of interictal brain SPECT and MRI in detecting lateralized abnormalities in temporal lobe epilepsy. On the other hand, in two cases, interictal SPECT correlated poorly with surface EEG. This functional method should not be used isolately in the detection of temporal lobe foci. MRI is more useful than CT as a neuroimaging technique in temporal lobe epilepsy. It may detect small structural lesions and mesial temporal lobe sclerosis which are not easily seen with traditional CT scanning.

Bradicardia como manifestação epiléptica em epilepsia temporal: relato de caso

We describe a patient who had cardiac arrhythmia as epileptic manifestation. In a 34-year-old woman who had many episodes of loss of consciousness, the simultaneous ECG and video-EEG monitoring recorded bradycardia with a short episode of asystole (4 seconds) and left temporal rhythmic theta activity on EEG. MRI showed a small mass lesion in the left parahippocampal gyrus. Alterations in cardiac rhythm have been reported in epileptic seizures and tachycardia is the most common finding associated with them; bradyarrhythmia during seizures was uncommon. Many interconnections among insular cortex, limbic system and hypothalamus, may be responsible for vegetative manifestations in temporal lobe epilepsy.We describe a patient who had cardiac arrhythmia as epileptic manifestation. In a 34-year-old woman who had many episodes of loss of consciousness, the simultaneous ECG and video-EEG monitoring recorded bradycardia with a short episode of asystolia (4 seconds) and left temporal rhythmic teta activity on EEG. MRI showed a small mass lesion in the left parahippocampal gyrus. Alterations in cardiac rhythm have been reported in epileptic seizures and taquycardia is the most common finding associated with them; bradyarrhythmia during seizures was uncommon. Many interconnections among insular cortex, limbic system and hypothalamus, may be responsible for vegetative manifestations in temporal lobe epilepsy.