Robert J. Gumnit

Practice parameter: Temporal lobe and localized neocortical resections for epilepsy Report of the Quality Standards Subcommittee of the American Academy of Neurology, in Association with the American Epilepsy Society and the American Association of Neurological Surgeons

Objectives/Methods: To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures by systematic review and analysis of the literature since 1990. Results: One intention-to-treat Class I randomized, controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available. Conclusions: A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

Practice Parameter: Temporal Lobe and Localized Neocortical Resections for Epilepsy

Summary:  Purpose: To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures.

Neurologic prognosis after cardiopulmonary arrest III. Seizure activity

Nineteen (30%) of 63 adult survivors of cardiopulmonary arrest had seizures after admission to the hospital. Eleven of 19 had more than one type of seizure. Myoclonic seizures began within 12 hours of the arrest in eight patients, and after 3 or more days in four patients. Only two (17%) patients with myoclonic seizures survived. Partial seizures usually began within 12 hours of the arrest and were controllable with anticonvulsants; 4 of 12 patients survived. Two of four patients with generalized tonic-clonic seizures survived; one of four with “shivering” lived. Overall, patients with seizures had a survival rate of 32% (6 of 19), compared with 43% for patients without seizures. None of the survivors had recurrent seizures within 6 months after hospital admission.

Discontinuation of levetiracetam because of behavioral side effects A case-control study

Background: Levetiracetam (LEV) is a recently approved anticonvulsant with proven efficacy and safety in the treatment of partial seizures. LEV may cause behavioral abnormalities that can be severe and require discontinuation of this drug. Risk factors for discontinuing LEV have not been established. Objective: To determine incidence of behavioral abnormalities severe enough to require discontinuation of LEV and identify risk factors for such behavioral abnormalities. Methods: All patients treated with LEV at MINCEP between January 2000 and February 2002 constituted the study population (n = 553). Patients who had discontinued LEV for behavioral reasons were selected as index cases. Case controls were patients starting LEV immediately after the index case. Potential risk factors for LEV discontinuation included age, gender, cognitive function, history of psychiatric diagnosis, epilepsy syndrome, number of antiepileptic drugs, titration rate, maximum dose of LEV, and LEV level at maximum dose. Results: Thirty-eight patients (6.9%) discontinued LEV because of behavioral abnormalities. Variables associated with LEV discontinuation included faster titration rate to maximal dose, history of a psychiatric disorder, and diagnosis of symptomatic generalized epilepsy. Patients who discontinued LEV owing to behavioral reasons had significantly lower maximum LEV doses than controls. Conclusions: This study identified variables associated with discontinuation of LEV due to behavioral abnormalities. Slower titration of LEV should be considered in those patients at higher risk of discontinuing LEV for behavioral reasons.

Corpus callosotomy: clinical and electroencephalographic effects

Summary: Six persons (five male, one female), 15–41 years of age (mean, 23 years), with medically intractable epilepsy for 7–35 years (mean, 15 years) underwent total corpus callosum section (anterior commissure to posterior commissure) for treatment of seizures resulting in falls and injuries. Preoperative EEGs demonstrated two or more morphologically distinct interictal discharges, at least one of which was generalized. Generalized ictal EEG discharges were documented in all cases to account for the clinical seizures resulting in injury. A comparison of generalized epileptiform discharges in comparable states of arousal pre‐ and postoperatively demonstrated a statistically significant (p < 0.05) reduction of generalized discharges after surgery. Postoperative observation periods have ranged from 10 to 30 months (mean, 17.6 months) and have documented a statistically significant (p < 0.05) decrease in the number of falling seizures (means: preoperative, 23.2 seizures/month; postoperative, 0.7 seizures/month). A statistically significant difference in pre‐ and postoperative total (generalized and focal) interictal discharges was not demonstrated. Long‐term, clinically apparent complications of surgery did not occur in our patients. Thus, sectioning of the corpus callosum interrupts generalized epileptiform discharges (as documented by the postoperative EEG) and usually results in a significant decrease in generalized seizures.

Essential services, personnel, and facilities in specialized epilepsy centers-Revised 2010 guidelines

This document was developed by the members of the Committee to Revise the Guidelines for Services, Personnel, and Facilities at Specialized Epilepsy Centers. After discussions with the general membership they were adopted by the Board of the National Association of Epilepsy Centers. The Guidelines will be reviewed and updated when considered necessary by the Board.

Progressive myoclonus epilepsy treated with zonisamide

Two patients with progressive myoclonus epilepsy of the Unverricht-Lundborg type and with intractable seizures in spite of standard anticonvulsant regimens were treated with zonisamide. After zonisamide therapy was initiated, both had a marked decrease in seizure frequency and significant improvement of functioning. Serum zonisamide concentrations were 43 and 27 μg/ml, respectively, with doses of 8.8 and 10.5 mg/kg/d. Both patients also continue to receive valproic acid and a benzodiazepine.

Neurologic prognosis after cardiopulmonary arrest; II. Level of consciousness

Sixty-three patients with isolated global anoxic-ischemic injury were prospectively evaluated after cardiopulmonary arrest (CPA); 25 (40%) survived, 16 to an excellent recovery, 8 to a good recovery, and 1 with severe deficits. Forty-six percent of the patients achieved full alertness, and only patients who did so survived. Seventy-five percent of patients arousable or initially alert (level of consciousness [LOC] ≥ 4) survived, all but two with excellent outcomes. Twenty-eight percent of patients initially in deep coma (LOC ≤ 3) survived, all with excellent or good outcomes. Ninety percent of patients who became fully alert did so within 72 hours. The likelihood of alerting is correlated with the LOC at given intervals after CPA. Reliable predictions of survival and outcome can often be based upon LOC alone within 2 days after CPA.

8–12 Hz rhythmic oscillations in human motor cortex during two-dimensional arm movements: evidence for representation of kinematic parameters ☆

Direct cortical recordings were taken from 12 patients with implanted subdural electrode arrays during performance of a 2-dimensional, multi-joint, visually guided arm movement task. Task-related changes in the amplitude of the motor cortex 8-12 Hz surface local field oscillations were evaluated for the encoding of direction and amplitude of movement in the 6 patients in whom no epileptogenic or ECoG background abnormalities were detected over the motor-sensory cortical areas under the recording electrode array. The topography, time of onset and duration of these responses were evaluated in the context of motor cortex somatotopy, as defined by cortical stimulation delivered through the electrode array. Multi-joint arm movements were accompanied by a decrease in the power of the 8-12 Hz frequency components of the ECoG signal. These power changes were spatially distributed over the upper extremity, motor-sensory representation. Movement amplitude influenced the magnitude, duration, and extent of the spatial distribution of ECoG power changes in the 8-12 Hz band. These effects occurred predominantly over cortical areas corresponding to the upper extremity motor-sensory representations. Direction of movement had a weaker influence on the 8-12 Hz frequency components of the ECoG over the upper extremity motor-sensory representations, but influenced the patterns of 8-12 Hz ECoG response on adjacent cortical regions. These results show that the amplitude of surface electrical oscillations generated over the rolandic cortex are correlated with the kinematics of multi-joint arm movements. These changes in the ECoG signal appear to reflect shifts in the functional state of neuronal ensembles involved in the initiation and execution of motor tasks.

Neurologic prognosis after cardiopulmonary arrest IV. Brainstern reflexes

we conducted a prospective study of 63 patients resuscitated from cardiopulmonary arrest (CPA) to analyze the prognostic significance of changes in brainstem reflex activity. Brainstem reflex abnormalities were common in the early postresuscitation period. Among survivors, reflexes returned to normal within 48 hours. Reflex abnormalities were significant predictors of poor outcome by 6 hours after CPA. No survivor had absent pupil light or corneal responses from 6 hours after CPA, and loss of reflex response after this time occurred in only one survivor.