Mark Rayport

Similarities in mental content of psychotic states, spontaneous seizures, dreams, and responses to electrical brain stimulation in patients with temporal lobe epilepsy.

&NA; The present study was guided by the hypothesis that temporal lobe epilepsy psychosis is associated with a definable syndrome of deficits in the higher cortical functions. Comparison was made of the mental content and mechanisms observed during psychotic episodes, seizures, dreams, and responses to electrical brain stimulation occurring in diverse combinations in 5 patients with drug‐refractory temporal lobe epilepsy referred for neurosurgical treatment. Neurological, neuroradiological, EEG, and neuropsychiatric base lines were available before onset of the psychosis. Psychiatric manifestations were related to the interaction of disturbances in specific higher cortical functions and individual dynamic configurations. Interpatient variation in psychotic symptomatology arose from significant elements in the patients past and current emotional life which provided the psychosis with form and content.

Outcomes and Indications of Corpus callosum Section for Intractable Seizure Control

Callosotomy (CCS) was performed in 9 cases of rigorously classified drug-refractory epilepsy not eligible for focal cortical resection. Complete CCS was carried out in two stages in 8 patients. 1 case had an anterior CCS only. None of the 9 patients has become seizure free. In 7, seizure frequency has diminished by a factor of 3-60 for at least one seizure type. Drop attacks in 2 cases have ceased. Clinical seizure patterns appeared more helpful in predicting outcome than preoperative EEG and stereoelectroencephalographic studies. Complete CCS may result in prolonged behavioral disturbances in the areas of language, hemisphere competition and attention-memory sequencing with impact on the sphere of daily living.

Typical cerebral hemisphere disconnection deficits following corpus callosum section despite sparing of the anterior commissure

Abstract Cerebral corpus callosum section is possibly as therapeutically effective as multiple cerebral commissurotomy while, according to the report of Risse et al. (Neuropsychologia 16, 23–31, 1978), allowing a substantially greater retention of the important adaptive function of inter-hemispheric exchange of information. We report results of visual, auditory and tactile tasks administered to three callosotomy patients. Results show typical “split-brain” deficits, in each modality. These results suggest that the anterior commissure is not an affective commissure in the transfer of stimulation effects over the follow-up period studied.

Abdominal Cerebrospinal Fluid Pseudocyst: Occurrence after Intraperitoneal Urological Surgery in Children with Ventriculoperitoneal Shunts

Increasingly, children with ventriculoperitoneal shunts are undergoing urinary tract reconstructive surgery with bowel. The peritoneal end of the ventriculoperitoneal shunt tubing usually is exposed during the procedure, making the system vulnerable to infections and malfunction. The records of 103 myelomeningocele children with ventriculoperitoneal shunts and bowel-bladder reconstructive surgical procedures (27) were reviewed for evidence of an abdominal cerebrospinal fluid pseudocyst (6). Pseudocyst formation occurred in only 1 of 76 ventriculoperitoneal shunt patients (1.3%) who had not undergone versus 6 of 27 (22%) who had undergone an intra-abdominal procedure. The 6 children had a total of 8 pseudocysts, including 7 pseudocysts that developed 8 days to 47 months (average 15.1 months) after the reconstructive surgery and 1 that developed before reconstructive surgery. All patients had abdominal symptoms (pain or mass) or symptoms of increased intracranial pressure. Treatment included computerized tomography-guided needle aspiration or abdominal exploration with cyst evacuation and shunt repositioning or replacement. The walls of the pseudocyst were formed by matted loops of bowel. Additional shunt surgery was required in 5 patients with conversion to ventriculoatrial shunts. We conclude that the development of an abdominal cerebrospinal fluid pseudocyst is at least in part related to the prior abdominal surgery. Thus, pediatric urological and general surgeons caring for children with ventriculoperitoneal shunts should be aware of this complication.

Computed Tomography-guided Intracranial Biopsy and Cyst Aspiration

A coordinated series of instruments has been developed for use in computed tomography (CT)-guided brain lesion biopsy and cyst aspiration: a plastic guide needle that is relatively free of CT artifacts, a ball-and-socket holding device for multidirectional sampling, and an aspiration-cutting biopsy needle that reliably produces consistent cores of tissue. Twenty-six biopsy and/or aspiration procedures have been performed on 24 patients with an overall biopsy success rate of 79%. The method is most reliable with highly malignant astrocytomas and least reliable with metastases and unusual primary tumors. There were 3 complications: 2 intratumoral hematomas and 1 death due to hemorrhage. A survey of published CT biopsy series shows an overall success rate of 85%. The rate of serious complications is 3.5% (including 3 deaths). The incidence of intratumoral hematomas that are clinically silent or associated with relatively minor clinical problems is 9%. CT-guided intracranial biopsy is more reliable than the earlier freehand methods and simpler than stereotactic techniques. It is the procedure of choice for percutaneous biopsy of superficial and deep hemispheric lesions.

Neuropsychiatric Observations on Behavioral Consequences of Corpus Callosum Section for Seizure Control

The epilepsy group at the Medical College of Ohio has been concerned both with the effectiveness of corpus callosum section (CCS) for seizure control and with its repercussions on the patient’s personality and cognitive functions. We have considered the possible effects of the divided state of the brain on the whole person.

Unimanual tactile anomia consequent to corpus callosotomy: Reduction of anomic deficit under hypnosis

Abstract Unimanual tactile anomia for objects palpated with the left-hand was studied in a 28-year-old callosotomy patient. Previous assessment of this patient Larrabee et al ., [9]) and two currently reported assessments without inducing hypnosis showed marked anomic deficit. A series of assessments conducted under hypnosis showed substantially improved naming ability, especially in hypnotic sessions suggesting that the patient did not feel like speaking and that speaking was difficult. Among the possible mediators of this reduction of anomic impairment one can suggest factors such as motivational and attentional enhancements, suppression of left hemisphere interference, and even right hemisphere speech facilitation under hypnosis. These and other results also suggest that an hypothesized right hemisphere dominance during hypnosis may be accurate and possibly more obvious in callosotomy patients than in normal persons.

Life after surgery for temporolimbic seizures.

Publisher Summary This chapter presents data in regard to postoperative outcome in terms of effect on seizures and on facets of the patients life, including his self-evaluation, psychiatric symptoms, marital experiences, and functioning in the spheres of education and work. The neuropsychiatrist carried out Dr. Rayports dedication by addressing the mechanisms of behavioral problems in terms of brain dysfunction interacting with the patients life history and psychodynamics. This contrasts with the more frequent approach of neurological surgery epilepsy centers that emphasizes painstaking definition of the epileptic process and careful surgery, but accumulates behavioral data objectively, mainly from the neuropsychologist, who focuses almost exclusively on cognitive function. If behavioral responses are investigated, the methodology consists of limited interviews and/or questionnaires. Outcome is often reported after short periods of observation.

Corpus Callosum Section for Control of Clinically and Electroencephalo-Graphically Classified Intractable Seizures

Among 55 consecutive patients with drug-refractory epileptic seizures referred to the multidisciplinary Epilepsy Program of the Medical College of Ohio for possible neurosurgical intervention for seizure control, 17 (30.90%) of those completing the multidisciplinary assessment were found to have seizure mechanisms unsuitable for treatment by focal cortical excision. Because these patients had a clear need for additional antiseizure therapy, we felt compelled to reexamine our hesitation to perform corpus callosum section (CCS) for seizure control. Viewing CCS from a background in cortical resection for seizure control, with its defined case selection criteria, known outcome probabilities for seizure control, and low neurological and neuropsychological morbidity and operative mortality (Rasmussen, 1975; Talairach et al., 1974), we experienced concern over (1) the neuropsychological consequences of callosal commisurotomy (e.g., Gazzaniga, 1970), (2) the surgical morbidity and mortality in the early series (Van Wagenen and Herren, 1940; Akelaitis, 1941a,b, 1943; Akelaitis etal., 1942; Smith and Akelaitis, 1942; Bogen and Vogel, 1962, 1975; Bogen et al., 1965; Luessenhop, 1970; Luessenhop et al., 1970; Gordon

ID, EGO, and Temporal Lobe Revisited

Publisher Summary This chapter discusses the relevance of observations during electrical brain stimulation (EBS) in patients with intractable partial temporolimbic seizures to unconscious mental processes as these were elaborated and defined by Sigmund Freud. The chapter briefly outlines Freuds evolution from neurobiologist to neurologist to psychoanalytic psychiatrist. Exploration of the patients experience of his seizures in relation to his psychodynamics provides an illustration of the physiological underpinnings of Freuds ego structure. Reflected in the seizure-related behavior may be emotional trauma of early life, negative feelings toward specific individuals because of past incidents or situations, extrapolation from the content of the seizure, and/or present emotional stress. Elimination of the seizures made it possible for the patient to respond to life situations, with reality oriented ego function and without the disruptive intrusion of id and superego.