Gary Gronich

Surgical treatment of temporal lobe epilepsy with interictal psychosis: results of six cases

We describe the postsurgical outcome of six patients with medically intractable temporal lobe epilepsy and interictal psychosis who underwent temporal lobe resection. All patients were submitted to a comprehensive presurgical investigation, including prolonged video-EEG monitoring. Despite their psychotic disorders, all patients were able to provide informed consent and we were able to complete the investigation of all cases. Surgical complications occurred in two cases. Seizure outcome was Engel class I (free from incapacitating seizures) in all except one patient. There was no worsening of their psychoses. Until now, there has been relative improvement in the mental conditions of five patients. Although psychosis has been considered by some authors as a contraindication to epilepsy surgery, with appropriate psychiatric intervention, patients with refractory epilepsy and chronic interictal psychosis may be submitted to prolonged presurgical investigation and undergo surgery successfully.

The diagnostic role of short duration outpatient V-EEG monitoring in children

Video-electroencephalographic monitoring enables correlation between behavioral and EEG data, however, because it requires prolonged hospitalization, it may be stressful and expensive. This study aimed to assess the benefits and limitations of this procedure in children. We analyzed 39 children classified according to clinical complaints: doubts about epilepsy classification in 23 (Group I); differential diagnosis with nonepileptic events in eight (Group II); and differential diagnosis between cognitive decline and subtle seizures in eight (Group III). Clinical episodes were recorded in 37 patients (94.9%). In Group I, seizure type was reclassified in 11 patients and epileptic syndrome in nine. In two patients a previously unnoticed seizure type was recorded. In Group II, four patients presented epileptic seizures. In Group III, nonconvulsive status was detected in five. Video-electroencephalographic monitoring enabled major modification of therapeutic approach in 21 patients and guided new neuroimaging studies in 10 patients. In conclusion, in patients with frequent seizures, short video-electroencephalographic monitoring allows proper classification of epileptic syndromes, and diagnosis of nonepileptic seizures, promoting introduction of appropriate treatment with a relatively low cost.

Complete remission of epileptic psychosis after temporal lobectomy: case report

We report a case of a female patient with refractory complex partial seizures since 15 years of age, recurrent postictal psychotic episodes since 35 which evolved to a chronic refractory interictal psychosis and MRI with right mesial temporal sclerosis (MTS). After a comprehensive investigation (video-EEG intensive monitoring, interictal and ictal SPECT, and a neuropsychological evaluation including WADA test) she was submitted to a right temporal lobectomy. Since then, she has been seizure-free with remission of psychosis, although with some persistence of personality traits (hiperreligiosity, viscosity) which had been present before surgery. This case supports the idea that temporal lobectomy can be a safe and effective therapeutic measure for patients with MTS, refractory epilepsy and recurrent postictal epileptic psychosis or interictal epileptic psychosis with postictal exacerbation.

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.

Selective electroencephalograph-guided microsurgical callosotomy for refractory generalized epilepsy

Between 1978 and 1985, 35 patients with medically refractory multiform seizures were submitted for sections of variable portions of the corpus callosum. Guided by intraoperative electroencephalographic and electrocorticographic monitoring, the section was carried out only in the portion of callosum that was involved in the maintenance of the bilaterally synchronous slow spike and wave discharge (as documented by intraoperative electrocorticography). In our patients, only part of the frontal corpus callosum needed to be sectioned to interrupt the bilateral synchrony of epileptic discharge. Of the 35 patients, operated on, 28 have had an adequate long-term follow up and are presented herein. All had significant improvement in seizure frequency and psychosocial functioning.

Corpus callosum stimulation and stereotactic callosotomy in the management of refractory generalized epilepsy: preliminary communication

Corpus callosum stimulation produced by chronically implanted electrodes, placed either by craniotomy or stereotactically, failed to control refractory generalized epilepsy in humans and also in experimentally produced penicillin epilepsy in cats. However, the patients that suffered craniotomy, frontal lobe retraction or pneumoencephalograms, without callosal section, showed remarkable improvement of their seizure condition due to these unspecific manipulation effects. Stereotactic anterior callosotomy emerged as a sequel of these functional neurosurgical findings, and as an alternative procedure to preclude undesirable neuropsychological and neurological side effects of split brain syndrome and of brain retraction, associated to conventional callosotomy. Ten patients with various disabling convulsive disorders have undergone this new operation, which showed to be less traumatic and better tolerated than open callosotomy.

Secondary bilateral synchrony due to fronto-mesial lesions: an invasive recording study

Frontal lobe epilepsies may present difficulties in focus localization in the pre-operative work-up for epilepsy surgery. This is specially true in patients with normal MRIs. We report on a 16 years-old girl that started with seizures by the age of 8 years. They were brief nocturnal episodes with automatisms such as bicycling and boxing. Seizure frequency ranged from 4-10 per night. Scalp EEG showed few right frontal convexity spiking and intense secondary bilateral synchrony (SBS). High resolution MRI directed to the frontal lobes was normal. Ictal SPECT suggested a right fronto-lateral focus. Ictal video-EEG showed no focal onset. She was submitted to invasive recordings after subdural plates implantation. Electrodes covered all the frontal convexity and mesial surface bilaterally. Ictal recordings disclosed stereotyped seizures starting from the right mesial frontal. Using a high-resolution tool to measure intra and interhemispheric latencies, the timing and direction of seizure spread from the right fronto-mesial region were studied. Motor strip mapping was performed by means of electrical stimulation. She was submitted to a right frontal lobe resection, 1.5 cm ahead of the motor strip and has been seizure free since surgery (8 months). Pathological examination found a 4 mm area of cortical dysplasia. Invasive studies are needed to allow adequate localization in patients with non-localizatory non-invasive work-up and may lead to excellent results in relation to seizures after surgery.

Secondary bilateral synchrony associated to a parasagittal tumor case report

A 32 years old woman who had postural limbic and primarily generalized tonic-clonic seizures since the age of 11 presented to us with a CT image strongly suggestive of a mesial meningioma near the right cingulum. Her ictal EEG pattern was characterized by regular 1.5-2.0 Hz sharp and slow wave complexes. A right craniotomy was performed under general anesthesia and intraoperative electroencephalographic and electrocorticographic recordings were obtained by means of scalp steel electrodes and modified cerebellar stimulation electrodes, respectively. These recordings demonstrated that surface spikes were often independent from the electrocorticographically recorded ones. Before tumor excision, electrical stimulation of the peritumoral mesial cortex resulted in an increase in the epileptic activity. The stimulation of the cavity left after tumor excision led to a prolonged electrographic seizure and neurophysiological procedures were stopped. Post-operatively, the patient has remained seizure free for 6 months and her EEG was normal. The pre-, intra- and postoperative findings in this case suggest that the gliotic peritumoral mesial cortex was at least involved in the epileptogenic process.

O vídeo-EEG dia no diagnóstico de eventos paroxísticos na infância

OBJECTIVE: the objective of this study was to investigate the value of short-term video-EEG monitoring in a pediatric population with distinct clinical complaints in order to verify the benefits and limitations of this procedure. PATIENTS AND METHODS: a prospective protocol, developed in the University of Sao Paulo, analyzed 38 consecutive patients (age ranging from 4 months to 17 years; mean 6.9 years). All patients were referred in order to establish the diagnosis. The patients were divided in the following groups according to the main clinical complaint: doubts about seizure/syndromic classification (Group I, n = 22); differential diagnosis with non-epileptic events (Group II, n = 8) and differential diagnosis between cognitive decline and status epilepticus (Group III, n = 8). RESULTS: clinical episodes were observed in 36 patients (94.7%). In group I, seizures were reclassified in 11/22 (50%) patients and confirmed in eight (36.4%). One patient presented a sleep disorder and two did not present clinical events during monitoring. Syndromic classification was modified in nine (40.9%). In group II, four patients (50%) presented epileptic seizures; two had movement disorders and two, non-epileptic events. The cognitive deterioration was correlated with non-convulsive status epilepticus in five children (62.5%) of group III. Alterations of therapeutic and/or diagnostic approaches, as a consequence of monitoring, were performed in 21/38 (55.3%) patients. CONCLUSION: in our series, short-term video-EEG monitoring established a reliable diagnosis in most patients due to correlation between clinical and EEG data. This procedure was well tolerated by children, including infants and those with psychiatric disorders.

Open and Stereotactic Segmental Callosotomy: Effects on Seizure Frequency

Corpus callosum section has been used as a palliative procedure in the treatment of the secondary generalized epilepsies and secondarily generalized seizures.