Gregory O. Walsh

Hippocampal cell loss in posttraumatic human epilepsy.

Summary:  Purpose: We performed this study to determine whether significant head trauma in human adults can result in hippocampal cell loss, particularly in hilar (polymorph) and CA3 neurons, similar to that observed in animal models of traumatic brain injury. We examined the incidence of hippocampal pathology and its relation to temporal neocortical pathology, neuronal reorganization, and other variables.

Type I complex partial seizures of hippocampal origin Excellent results of anterior temporal lobectomy

Seventeen patients had type I complex partial seizures (CPS) with three consecutive phases: initial motionless staring, oral-alimentary automatisms, and reactive quasipurposeful movements during impaired consciousness. Fifteen patients had stereoelectroencephalography. Focal or regional 8- to 20-Hz low-voltage epileptiform paroxysms in either hippocampus (10 patients), amygdala (1 patient), or both (1 patient) preceded initial motionless staring. Focal sphenoidal or nasopharyngeal ictal paroxysms preceded seizures in three other patients who underwent lobectomy. All 15 patients are seizure-free 2 to 11 years after temporal lobectomy. Type I CPS are most commonly of hippocampal origin.

Complex Partial Seizures of Hippocampal and Amygdalar Origin

Summary: We studied the first clinical manifestations of 72 complex partial seizures (CPS) in 17 drug‐resistant patients. CPS were indicated to be of hippocampalamygdalar origin by scalp and depth EEG. We asked: (a) Do all CPS of hippocampal‐amygdalar origin start with an initial motionless stare and/or oroalimentary automatisms? (b) If not, what other clinical manifestations appear at onset of the CPS? Results showed that ˜39% of CPS begin with motionless staring, 25% with nonfocal discrete movements, 21% with oroalimentary automatisms, 10% with perseverative stereotyped automatisms, and 6% with vocalizations. Nonfocal discrete movements and oroalimentary automatisms were identified as the most common second and third clinical sequential manifestations during a CPS. We conclude that although ˜60% of CPS of hippocampal‐amygdalar origin start with motionless staring or oroalimentary automatisms, 40% do not.

The safety and efficacy of chronically implanted subdural electrodes: A prospective study

BACKGROUND The popularity of subdural electrodes for the presurgical evaluation of patients with intractable seizures is increasing. However, few reports have prospectively dealt with their efficacy and safety. METHODS We conducted a 5-year prospective study of patients evaluated by the California Comprehensive Epilepsy Program, who subsequently underwent subdural electrode implantation at one of two institutions. Efficacy was examined by ultimate outcome with regards to postsurgery resection seizure frequency. Fifty-five patients underwent 58 implant procedures and postresection outcomes were available in 47 patients. Safety was defined by the incidence of expected and unexpected complications, and neuropathologic examination of tissue specimens. RESULTS The most common expected adverse effects during implant were fever < or = 102 degrees (41%), cerebrospinal fluid leakage (19%), headache (15%), and nausea (4%). There were no infections. Unexpected adverse events included fever > 102 degrees F (5%), migraine (5%), iatrogenic electrode dysfunction (5%), and temporalis muscle fibrosis (5%). The incidence of pathologic findings suggestive of foreign body reaction was 10%. There were no permanent sequelae. Surgical outcomes were excellent in all (> or = 75% seizure reduction) with 50% seizure free regardless of the focus. CONCLUSIONS Subdural electrodes are a safe, easy, and efficacious tool for evaluating seizure foci prior to resective surgery. They should no longer be considered investigational devices.

The Use of 2-Deoxy-2-[18F]Fluoro- D-Glucose (FDG-PET) Positron Emission Tomography in the Routine Diagnosis of Epilepsy

PURPOSE Positron emission tomography with 2-deoxy fluoroglucose positron emission tomography (18-FDG-PET) is widely used in the pre-surgical evaluation of subjects with epilepsy, but little is known of its usefulness in a non-surgical population. PROCEDURES We analyzed the sensitivity of PET as a diagnostic tool in a large unselected population of epilepsy subjects. Pre-surgical and non-surgical portions of this population were individually assessed as well. The relationship of PET abnormalities to other neurodiagnostic tests was examined. Statistical assessment relied primarily on contingency tables (chi-square tests), with ANOVA or non-parametric assessment used as necessary. RESULTS While PET was more likely to identify areas of decreased metabolism in the surgical population than in the non-surgical populations, it nevertheless found a significant number of abnormalities in the total population and in the non-surgical group alone. Even in groups in which the clinical diagnosis was unknown, abnormalities were found 40% of the time. PET was useful as an exclusionary diagnostic tool for non-epileptic seizures (NES) and primary generalized epilepsies (PGE) with sensitivity, specificity, and accuracy > 90%. The PET was somewhat more sensitive than magnetic resonance imaging (MRI) in finding abnormalities in the total population, but was less sensitive than electroencephalography (EEG). CONCLUSION PET may be a useful diagnostic tool in the general epilepsy population even when a definitive clinical diagnosis is not suggested by other modalities.

Complex Partial Seizures of Frontal Lobe Origin

As early as 400years B.C., Hippocrates [26] recognized the warning signs or symptoms (aura) of epilepsy. In 1677, Thomas Willis [59] gave the first description of a psychomotor attack, and in 1822 Prichard [42] first used the term “partial epilepsy.” However, it was John Hughlings Jackson who developed the conceptual framework and meaning of epileptic symptomatology and signs. Jackson, a true scholar, completely refounded epileptology and collated bedside observations with anatomical facts. By 1889, he [24, 25] had linked the symptoms and signs of psychomotor seizures to the “sphenoidal lobe” or the medial temporal areas of the uncus. Since then, modern studies, notably by Ajmone-Marsan and Abraham [1–3], Bancaud, Talairach and collaborators in Paris [4–12,20,21, 31–33,48, 53], Wieser and Ya§argil [52, 54, 55] in Zurich, the Spencers et al. [45, 46] and Williamson et al. [56–58] in New Haven, Rasmussen [44], Gloor [22, 23], and Quesney et al. [43] in Montreal, and our Comprehensive Epilepsy Program in Los Angeles [12–15, 34], have characterized a wide range of psychomotor automatisms on cine film or closed-circuit television videotape (CCTV) from simple lip smacking, chewing, pursing lips, and, eye blinking, to running, mimicry, gesticulations, and sometimes bizarre complex bilateral hand and leg movements. These clinical signs have been related to epileptiform discharges recorded by scalp and sphenoidal electroencephalography (EEG) and stereoelectroencephalography (SEEG).

Surface ictal electroencephalographic patterns in frontal vs temporal lobe epilepsy.

The effectiveness of long term EEG monitoring in the localization of the epileptic focus was studied in 37 patients with temporal lobe epilepsy comprising 190 recorded seizures, in 19 frontal lobe epileptic patients with 172 recorded seizures and in 12 additional patients which were classified as fronto-temporal. In the temporal lobe group, 49/190 seizures began focally (26%) and 20/190 seizures exhibited a regional onset (10%). In the frontal lobe group, only 21 out of 172 seizures (12%) had a focal ictal onset. 41/172 seizures began regionally (24%). In the fronto-temporal group, 31/55 seizures disclosed a focal EEG onset (57%). This study demonstrates that there is a two-fold increase in seizures beginning focally in the temporal lobe epilepsy group versus the frontal lobe group.

Body part asymmetry in partial seizure

Clinically differentiating between localisation related and generalised epilepsy is important because it carries significant implications for planning diagnostic management strategy. Asymmetry of body parts such as toes, popliteal crease levels, thumbs, cubital crease levels, and forehead and facial structures, are common in patients with localisation related epilepsy syndromes. We retrospectively studied 337 patients with seizure disorders. Body part asymmetry was routinely documented. Fifty-six were excluded because of non-epileptic seizures, pure psychiatric disorders, non-epileptic neurological disorders, brain tumours and strokes. The relationship between clinically detectable body asymmetry (BA) and the electro-anatomic characteristics of their epilepsy was explored. Body asymmetry was found in 88 out of 282 cases, in which 64 (73.5%) suffered from localisation related epilepsy. Among localisation related epilepsy, BA were found in 41.5% (n=64/154) of patients. In contrast, only 18.75% (n=24/128) of patients with generalised seizure disorders showed similar findings (P<0.0001). Among patients with partial onset seizures, lateralisation of BA was concordant with their seizure origin in 75.9% (n=41/54) and discordant in 24.1% (n=13/54). Investigation results of 10 partial epilepsy cases were non-lateralising at the time of study. Peak age of onset of concordant case was 0-5 years old while discordant group was 6-15 years old. We conclude that BA in patients with seizure disorder is a useful clue to diagnosis of localisation related seizure and may provide clues for lateralising seizure origin in partial onset seizures.

URINARY INCONTINENCE SECONDARY TO BRAIN NEOPLASM

Abstract The recommendation for vesicourethropexy is often made without adequate preoperative evaluation. The necessity to demonstrate urinary leakage during an increase in intra-abdominal pressure is fundamental to recommending this particular operative procedure. This report is of a woman complaining of continuing incontinence who had been advised to undergo vesicourethropexy by several urologists. Preliminary investigation did not reveal the typical findings of stress incontinence, and neurologic evaluation confirmed the presence of a brain neoplasm. The circumstances which led to the correct diagnosis and to incontinence caused by neoplasms of the central nervous system are discussed.