Soochul Park

The prognosis for control of seizures with medications in patients with MRI evidence for mesial temporal sclerosis.

Summary: Purpose: Mesial temporal sclerosis (MTS) is the most common and important pathology in temporal lobe epilepsy (TLE), and its presence in magnetic resonance imaging (MRI) scans is strongly correlated with a successful surgical outcome. Despite the general assumption that patients with MTS respond poorly to medication, the long‐term prognosis for such patients has not yet been investigated. We studied the overall clinical prognosis of patients with MTS and analyzed the factors related to the degree of medical responsiveness.

Ictal electrocorticographic findings related with surgical outcomes in nonlesional neocortical epilepsy.

PURPOSE To characterize ictal electrocorticographic features related to surgical outcomes in nonlesional neocortical epilepsy (NE). METHODS We analyzed 187 ictal electrocorticograms (ECoG) obtained from 18 patients who had undergone presurgical evaluation and subsequent neocortical resections (frontal: seven, parietal: one, occipital: four, multilobar: six). None of them had any MRI-detectable lesions. Various ECoG data sets recorded from eight patients who achieved a favorable surgical outcome (either seizure free or more than 90% reduction of seizure frequencies) were compared with that from ten patients with unfavorable outcome (less than 90% reduction of seizure frequencies) (follow up duration: 47+/-11 months). RESULTS Reproducible ictal onset zone (IOZ) in recurrent seizures (P=0.013) and persistent ictal discharges in IOZ from the onset to the end of seizure (P=0.004) were found more frequently in the patients with good outcome. Ictal onset patterns consisting of low voltage fast or high amplitude beta spikes predicted a good surgical outcome while rhythmic sinusoidal activity or rhythmic spike/sharp waves of slow frequency were predictive of poor outcome (P=0.01). The ictal onset rhythm consisting of gamma or beta frequencies was more prevalent in the favorable group (P=0.015). CONCLUSIONS The presence of stable ictal circuit suggested by the consistent earliest activation of specific electrodes in the repetitive seizures (reproducible IOZ) and the active participation of IOZ throughout the attack were valuable prognostic factors in addition to the morphology and frequency of ictal onset rhythm.

Prolonged Ictal Amnesia with Transient Focal Abnormalities on Magnetic Resonance Imaging

Summary: A previously healthy woman had a prolonged amnestic state caused by complex partial status epilepticus with bilateral mesiotemporal lobe involvement confirmed by EEG with nasopharyngeal electrodes. A magnetic resonance imaging (MRI) scan obtained shortly after recovery from the amnesia showed reversible focal abnormalities consisting of increased signal intensity on T2‐weighted scan in the mesiotemporal lobe.

Clinical courses of pure sleep epilepsies.

This study aims to understand seizure control outcomes and the risk of developing new wake seizures (WS) related to the different types of pure sleep epilepsies (SE), which is important in making rational management plans. A retrospective review of the Yonsei Epilepsy Clinic Registry identified 63 patients with pure SE not belonging to any specific epileptic syndromes. They were divided into the group of generalized tonic-clonic seizures during sleep (S-GTCS : n = 21) and the group of partial epilepsies during sleep (S-PE: n = 42) on the basis of seizure phenomenology, EEG, and neuroimaging data. These patients were followed for 2 years and their clinical variables were analysed for seizure control outcomes and development of new WS. Of 21 patients with S-GTCS, 17 achieved a seizure-free outcome and only one patient developed a new WS, which was consistent with a partial-onset secondary GTCS in phenomenology. Of 42 patients with S-PE only 15 patients achieved a seizure-free outcome and 11 patients developed WS during the 2-year follow-up period. Higher baseline seizure frequency and longer duration of epilepsy were associated with a higher incidence of new WS. The results suggest that the patients with S-GTCS carry a favorable clinical course, thus driving privileges or freedom of daily activities can be conferred without delay once their seizures are well controlled. However, the seizure control outcome was poor and the development of WS was frequent in patients with recurrent S-PE.

The adenoviral vector-mediated increase in apurinic/apyrimidinic endonuclease inhibits the induction of neuronal cell death after transient ischemic stroke in mice

Despite the correlation between changes in the levels of apurinic/apyrimidinic endonuclease and ischemic neuronal damage, no studies have addressed the question of whether increased APE/Ref-1 can prevent ischemic neuronal cell death in vivo. Using an adenoviral vector, we investigated whether increased APE/Ref-1 can inhibit the loss of APE/Ref-1 and thereby prevent oxidative DNA damage after transient focal cerebral ischemia. Mice were subjected to intraluminal suture occlusion of the middle cerebral artery for 1 h, followed by reperfusion. Pre-ischemic treatment of the adenoviral vector was introduced intracerebrally. An adenoviral vector harboring the entire APE/Ref-1 gene sequence or a control virus without the APE/Ref-1 sequence was introduced 3 days before ischemia/reperfusion (I/R). The reduction of APE/Ref-1 occurred before DNA fragmentation, which was shown by temporal and spatial analysis. Increased APE/Ref-1 significantly decreased DNA damage and infarct volume after I/R. In conclusion, increased APE/Ref-1 enhanced DNA repair and inhibited the induction of ischemic oxidative DNA damage and cerebral infarction after I/R.

Tuberculous encephalopathy without meningitis: pathology and brain MRI findings.

Tuberculous encephalopathy (TBE) is an established disease entity of diffuse cerebral damage occurring with tuberculosis and an underlying immune pathogenesis. However, the presence of this disease entity remains controversial. We report a 15-year-old boy with seizures and a progressive decline of cognitive function. Brain MRI showed diffuse, hyperintense lesions in the white matter on a T2-weighted image, with gadolinium enhancement on a T1-weighted image. Brain biopsy revealed demyelination and granuloma in the white matter. Ziehl-Neelsen staining showed acid-fast bacilli in the granulomas. Antituberculous medication with concomitant steroid treatment resulted in radiological resolution in addition to clinical improvement. Clinicopathological evidence in this case provides additional convincing evidence of TBE as a disease entity distinct from tuberculous meningitis.

Prognostic analysis of patients with epilepsy according to time of relapse after withdrawal of antiepileptic drugs following four seizure-free years

We performed a retrospective, prognostic analysis of a cohort of patients with epilepsy according to time of relapse after four seizure‐free years.

Hippocampal sclerosis and encephalomalacia as prognostic factors of tuberculous meningitis-related and herpes simplex encephalitis-related epilepsy

BACKGROUND Tuberculous meningitis (TBM) and herpes simplex encephalitis (HSE) are common neurological diseases involving the brain parenchyma, and both can result in chronic epilepsy. Here, we identified possible variables affecting the prognosis of central nervous system (CNS) infection-related epilepsy. METHODS The clinical seizure characteristics and demographic data of 20 TBM- and 55 HSE-related epilepsy patients were compared. Statistically significant prognostic variables were identified using multiple regression analysis. RESULTS Sex, age at infection, age at epilepsy onset, presence of seizures at the time of infection, latency period, and seizure characteristics between two groups were similar except for the pattern of brain lesions observed on the MRI and their overall prognosis. Patients with hippocampal sclerosis (HS) only comprised 30% and 52.7% of the TBM and HSE groups, respectively. Encephalomalacia had a positive effect in the HSE group while HS had a negative effect in this group, but no significant effects were found in the TBM group. Through a multiple regression analysis with a correction for group effects, HS was associated with a poor prognosis. However, encephalomalacia was concomitantly associated with a good prognosis. In addition, a short latency period, with a one-year interval, and being male were both associated with a good prognosis, while the age at the onset of epilepsy was associated with a poor prognosis. CONCLUSIONS This study suggests that HS and encephalomalacia could have mutual but contradictory effects on the prognosis of CNS infection-related epilepsy.

PO14.10 Metabolic Mismatch between Glucose Metabolism and Blood Flow on Neuroimaging Studies in a Case with Severe Hypoglycemic Encephalopathy

Parit Wongphaet1 *, Waree Chira-Adisai1, Phafan Chanubol3, Darunee Tantisupawongse1, Jiraporn Lauthamatas2, Chattaya Jitpraphai1, Patcharawimol Kuptniratsaikul1, Kwanrat Wangpholpattanasiri4, Nopawan Sanjaroensuttikul1 1Dept. of Rehabilitation Meidicine Mahidol University, Thailand, 2Dept. of Radiology Mahidol University, Thailand, 3Dept. of Rehabilitation Meidicine Prasart Neurological Institute, Thailand, 4Dept. of Neurology Prasart Neurological Institute, Thailand E-mail address: spine.clinic@yahoo.com

PO10.15 Pathologically Confirmed Ictal Vomiting as a Clinical Manifestation of Right Frontal Lobe Epilepsy

Background: Intracranial electroencephalographic (EEG) monitoring is an important process in the presurgical evaluation for epilepsy surgery. The objective of this study was to identify how much of the presumed “epileptogenic zone” we should remove, guided by subdural electrodes. For this purpose, we investigated the relationship between the extent of resection guided by subdural electrodes and the outcome of epilepsy surgery. Methods: Intracranial EEGs were analyzed in 177 consecutive patients who had undergone resective epileptic surgery between 1995 and 2003. We reviewed various intracranial EEG findings and the extent of resection. We analyzed the relationships between the surgical outcomes and intracranial EEG factors: the frequency, morphology distribution of ictal onset discharges, the propagation speed, and the time lag between clinical and intracranial ictal onset. We also investigated whether the extent of resection, including the area showing ictal rhythm and various interictal abnormalities, such as frequent interictal spikes, pathological delta waves, and paroxysmal fast activity, influenced the surgical outcome. Results: Seventy-five (42%) patients were seizure free (Engel class I). A seizure-free outcome was significantly associated with a resection that included the area showing ictal spreading rhythm during the first three seconds or included all the electrodes showing pathological delta waves or frequent interictal spikes. However, subgroup analysis revealed that the extent of resection did not affect the surgical outcome in lateral temporal lobe epilepsy. Conclusions: Better outcome from resective surgery is more closely related with EEG patterns of resected area than the extent of resection.