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Original article
Incidence and clinical decision making for the Wada test over one decade: 1997-2007
Rohit R Das, Andreas V Alexopoulos, Tobias Loddenkemper
over the last decade, and to identify clinical features which are more likely associated with decision making in favour of Wada testing.MethodsWe retrospectively reviewed all temporal lobe resections performed between 1997 and 2007 at the Cleveland Clinic Epilepsy Center.ResultsA total of 410 Wada tests were conducted on 777 patients undergoing temporal lobectomy (TL). Left temporal resection was performed in 55% of cases. The most frequent pathological diagnoses were hippocampal sclerosis (42%) and non-specific gliosis (26%). Overall, Wada test frequency in patients undergoing presurgical evaluation decreased over time. In 1997, 47 of 58 (81%) TL patients underwent Wada testing compared to 11 of 76 (14.4%) in 2007. Patients with left temporal lobe epilepsy, and/or those referred for subdural electrode placement, were significantly more likely to undergo Wada testing. The most common types of surgery were antero-medial temporal resection with removal of mesial structures (59%) and temporal resection without mesial structure removal (32%). Patients with left temporal epilepsy and Wada testing were significantly more likely to undergo resection of mesial cortex.DiscussionWada testing has declined over the last decade in this single centre study. Patients with left, likely dominant, temporal lobe epilepsy and those with subdural evaluations were more likely to undergo Wada testing. We speculate that the emergence of alternative noninvasive language lateralization techniques, along with concerns about the reliability of results and awareness of complication risks, are major reasons for the decline.
Original article
Convulsions associated with gastroenteritis in the spectrum of benign focal epilepsies in infancy: 30 cases including four cases with ictal EEG recording
Raffaella Cusmai, Bosanka Jocic-Jakubi, Laura Cantonetti, Natia Japaridze, Federico Vigevano
with excellent prognosis. We observed 30 children who each experienced at least two seizures associated with mild gastroenteritis. The inclusion criteria were: afebrile seizures during gastroenteritis, dehydration at ≤ 5%, normal neurological findings, normal psychomotor development and no underlying pathology according to laboratory and neuroimaging studies. Mean age was 21 months (range: 6-38). Familial history for epilepsy was positive in 3/30 (10%) and for febrile convulsions in 11/30 (36.6%). Seizure onset was mainly on the third day of gastroenteritis. Seizures were described as generalised by parents in 16/30 patients (53.3%). We directly observed seizures in 14/30 patients (47.7%), and the semiology was partial with secondary generalisation. Focal onset was confirmed in two patients by EEG and in two patients by video-EEG recording. Twenty of 30 patients (66.6%) received antiepileptic drugs during the acute phase. Ten patients (33.3%) received no treatment. During follow-up (mean duration: 53 months), one patient had an isolated afebrile seizure and two others a febrile seizure. At the end of follow-up, antiepileptic treatment was withdrawn for all but two patients. None developed epilepsy. Although the pathogenesis of this clinical entity is unknown, we hypothesize that mild gastroenteritis may provoke a transient brain dysfunction which in turn provokes seizures in children with genetically determined susceptibility. [Published with video sequences]
Ictal kissing: a release phenomenon in non-dominant temporal lobe epilepsy
Razi M Rashid, Katherine Eder, Joshua Rosenow, Michael P Macken, Stephan U Schuele
and insight into the mechanisms of stereotyped ictal behaviour. Methods. Three of 220 patients (1.4%) admitted for video EEG monitoring between 7/2006 and 6/2009 with ictal kissing were identified. Clinical, neurophysiological and imaging data were reviewed and correlated. Results. All patients were right-handed women with a longstanding history and findings consistent with right temporal lobe epilepsy (TLE). Multiple habitual events were recorded for each patient, characterized by staring, oral automatisms and amnesia. In addition, partial preservation of responsiveness and speech were seen during seizures in all three patients. The first two patients showed kissing behaviour triggered by interactions during seizure testing. The last patient had six seizures overnight and developed spontaneous kissing behaviour in the ictal and post-ictal period of her later events, associated with hyperorality and sexual disinhibition. Conclusion. Our series supports the findings of two prior cases, of one male and one female, which reported IK behaviour associated with TLE and lateralizing to the non-dominant hemisphere. This behaviour has not been described in simple partial seizures or seen with electrical cortical stimulation suggesting that it represents a release phenomenon rather than activation of distinct symptomatogenic cortex. This is also supported by the fact that ictal kissing can occur within the spectrum of seizure-induced Kluver-Bucy syndrome and may extend into the post-ictal period. [Published with video sequences]
<sup>*</sup> These authors contributed equally to this work.
Hypnopompic seizures
Amer M Awad, Hans O Lüders
arousal from sleep as the only, or at least main, manifestation of some epileptic seizures. We coin the term “hypnopompic seizures” to describe this entity. Five patients with intractable epilepsy were monitored by continuous video-electroencephalogram. Four of them had left temporal lobe epilepsy and one patient had generalised epilepsy. Hypnopompic seizures accounted for 30-100% of their seizure types captured during monitoring. All the seizures occurred during stage II sleep and were brief. Hypnopompic seizures are extremely subtle and may be underdiagnosed and underreported. Future larger studies are needed to shed some light on this unique entity and its neuropathophysiology. Epileptologists should be aware of this type of seizure and careful review of electroencephalograms during the transition from sleep to arousal is imperative to capture these seizures. Physicians, patients and families also need to be aware of such a subtle manifestation of seizures. Improved awareness of hypnopompic seizures and subtle seizures, in general, help guide accurate and early diagnosis, thorough monitoring and appropriate management.
Correlation between child and parental perceptions of health-related quality of life in epilepsy using the PedsQL.v4.0 measurem
Zulfi Haneef, Mitzie L Grant, Ignacio Valencia, Elizabeth F Hobdell, Sanjeev V Kothare, Agustin Legido, Divya Khurana
Generic health-related quality-of-life instruments in paediatric epilepsy comparing child self-reports with simultaneous parent proxy-reports have not been previously investigated. A previously validated generic questionnaire, the Pediatric Quality of Life version 4 (PedsQL.v4.0), was used to prospectively assess parental and child perceptions of health-related quality of life in 100 children with epilepsy. The correlation between child and parental health-related quality-of-life perceptions across all domains was excellent (p < 0.001) and both were significantly lower than those for healthy controls (p < 0.001). Parents' perceptions of their children's health-related quality of life were lower than those for other chronic illnesses (p < 0.001), especially for refractory epilepsy. The presence of neurological or psychiatric comorbidities also had an adverse impact on health-related quality of life. The PedsQL.v4.0 measures health-related quality of life from both the parent's and child's perspective. Ease of use makes this instrument attractive for routine clinical use.
Prevalence of psychiatric comorbidities in temporal lobe epilepsy: the value of structured psychiatric interviews
José Augusto Bragatti, Carolina Machado Torres, Renata Gomes Londero, Juliana Bohn Assmann, Vivian Fontana, Kelin Cristine Martin, Maria Paz Loayza Hidalgo, Márcia Lorena Fagundes Chaves, Marino Muxfeldt Bianchin
which may lead to significant differences in results. Here we present a study evaluating the prevalence of major psychiatric comorbidities in a cohort of South Brazilian patients with temporal lobe epilepsy using a structured clinical interview. Methods. Neuropsychiatric symptoms were analyzed in 98 patients (39 men and 59 women) with temporal lobe epilepsy. Patient mean age was 43 years old, and mean duration of epilepsy was 25 years. Patients were diagnosed according to the ILAE Classification of Epileptic Syndromes using clinical, EEG, and neuroimaging criteria. All patients participated in the Structured Clinical Interview for DSM-IV (SCID). Results. Fifty-three patients (54.1%) presented major psychiatric comorbidities. Mood disorders were observed in 42 patients (42.9%), the most common being neuropsychiatric disorders. Anxiety disorders were the second most frequent disorders, observed in 18 patients (18.4%). Psychotic disorders and substance abuse were each observed in six patients (6.1%). There were no clinical variables regarding epilepsy characteristics (age of onset, duration, response to antiepileptic drugs) and no MRI features associated with psychiatric disorders. A seven-fold increased risk of mood disorders was identified in patients with inter-ictal EEG abnormalities associated with the left hemisphere. Conclusion. Relative to previous reports, we identify a high prevalence of psychiatric disorders in TLE patients, although our data is similar to that observed in other studies which have used similar structured interviews in populations of epileptic patients attending tertiary centres. The wide variation in percentages is probably attributable to the different patient groups investigated and to the even greater variety of diagnostic methods. Structured psychiatric interviews may contribute to a better evaluation of the true prevalence of psychiatric comorbidities in temporal lobe epilepsy.
Accentuated cortico-cortical evoked potentials in neocortical epilepsy in areas of ictal onset
Masaki Iwasaki, Rei Enatsu, Riki Matsumoto, Eric Novak, Baburaj Thankappen, Zhe Piao, Tim O'Connor R, Karl Horning, William Bingaman, Dileep Nair
patients undergoing intracranial recordings with subdural electrodes for epilepsy surgery, we measured amplitudes, latencies, and stimulus thresholds of CCEPs near ictal onset zones (iCCEPs), and compared with adjacent neocortex not associated with ictal EEG (nCCEP). CCEP amplitude and latency measurements were made with each stimulation site, using graded stimulation intensities.ResultsTen patients were included in this study. CCEPs were recorded in eight of 10 patients. The first negative (N1) iCCEP amplitude was higher than that of nCCEP in seven of the eight patients. In the group analysis, this difference was statistically significant. In three of these patients, the difference was individually significant. In one patient, the amplitude was higher in nCCEP than iCCEP and the area selected as nCCEP was within primary eloquent cortex. There was no significant difference seen in latency changes or stimulus threshold.ConclusionsAccentuated CCEP amplitudes near ictal onset zones could reflect an increased excitability of the cortex associated with the epileptogenic zone in some patients with neocortical epilepsy. The response of the neocortex to low-frequency stimulation may vary depending on the presence or absence of intrinsic epileptogenicity.
Clinical commentary
Lingual myoclonus associated with brain tumour: an epileptic origin?
Rezzak Yilmaz, Busra S Arica, Aytac Yigit
numbness and slurred speech, which lasted about an hour. Neurological examination discovered dysarthric speech and repetitive, rhythmic myoclonic jerks of the tongue and the lower lip. We suggest this lingual myoclonus was an epileptic phenomenon associated with brain tumour. [Published with video sequences]
Seizure in benign epilepsy with centro-temporal spikes
Gorande Kanabar, Maggie Sully, Katy Walsh, Kavita Chawla
occur at night. Also, a high percentage of children with benign epilepsy with centro-temporal spikes (BECTS) have characteristic centro-temporal spikes based on routine EEG monitoring and therefore do not require further tests such as telemetry or sleep studies. We report a video-EEG recording of a seizure in a patient with rolandic epilepsy which may be useful for educational purposes. [Published with video sequences]
Unilateral opercular lesion and eating-induced seizures
Siresha Chaluvadi Manyam, Doris H Kung, Lisa B Rhodes, Michael E Newmark, David E Friedman
with malformations of cortical developmental, hypoxic brain injury, previous meningoencephalitis or static encephalopathy. We present a patient with eating-induced reflex seizures, which began several years after treatment for an opercular primitive neuroectodermal tumour (PNET), and who subsequently underwent in-depth clinical and video-EEG analysis for her seizures. This patient noted rapid improvement with decreased frequency of seizure activity after treatment with valproic acid. We discuss the aetiology of reflex epilepsy, the anatomical basis of eating-induced epilepsy, and review the current literature. [Published with video sequences]
Unilateral continuous subclinical paroxysmal activity: an unusual finding in a patient with recurrent absence status
Reana Velizarova, Pierre Genton
absence status epilepsy. No other pathology was identified and MRI was normal. During a follow-up of 17 years, we recorded a single unilateral continuous, strictly subclinical, paroxysmal activity which lasted for at least several hours. No control was observed under treatment with phenobarbital, lamotrigine and topiramate. Absence status was aggravated with carbamazepine and generalised tonic-clonic seizures were not controlled with ethosuximide. Total seizure control was only possible with sodium valproate, which caused weight gain, and the patient has remained seizure-free for the past 10 years under 1,000 mg/d valproate and 200 mg/d topiramate. The recorded unilateral, long-lasting, subclinical spike-and-wave discharge is quite unusual for idiopathic generalised epilepsy and, in our opinion, occupies a transitional position between generalised and focal activity. [Published with video sequences]
Subclinical rhythmic electrographic discharges of adults and transient global amnesia: a causal or casual association?
Francesco Brigo, Luigi Giuseppe Bongiovanni, Antonio Fiaschi
amnesia in whom an EEG recording, performed after the acute phase of the neurological event, showed SREDA. Based on this EEG finding, we discuss about a possible correlation between SREDA and transient global amnesia. The presence of SREDA in our patient with transient global amnesia seems to be incidental. When described in association with transient global amnesia, SREDA should be recognized in order to avoid misdiagnosis. Although SREDA has been fortuitously described in association with transient global amnesia, a patho-physiological correlation with mechanisms which produce it seems unlikely.
Statistical analysis of transcallosal propagation of spikes arising from the mesial frontal area
Shuichi C Umeoka, Hans O Lüders, Masoud Abed Sangani, John P Turnbull
using cross correlation in MF epilepsy. A seven-year-old boy with intractable daily bilateral asymmetric tonic seizures and a normal MRI was investigated. To confirm the lateralization of epileptogenicity, subdural electrodes were implanted bilaterally. Only spikes of an amplitude of 400 μV or more were analyzed.ResultsOf 92.4% (194/210) of the left MF spikes recorded for 30 minutes, an approximately synchronous spike was also detected in the right MF region. Cross correlation analysis demonstrated that for 88.7% of the bilateral MF spikes (172/194, 88.7%) the left MF spike led the contralateral spikes with relative fixed peak-to-peak intervals (18.9 ± 11.1 ms) and high cross correlation values (0.81 ± 0.10). An estimated conduction velocity of 7.2 ± 9.8 m/sec was calculated (assuming no synaptic delay). After a second period of more extended invasive EEG monitoring, a left partial frontal lobectomy was performed and the patient immediately had a few brief seizures before remaining seizure-free for a follow-up period of 14 months.ConclusionWe conclude that the propagation of spikes between bilateral MF regions most likely occurs mainly through myelinated callosal fibres. In addition, this cross correlation method showed that the left MF spikes, most of the time, preceded the right MF spikes suggesting that the epileptogenic zone was localized in the left MF region.
Regression of stroke-like lesions in MELAS-syndrome after seizure control
Josef Finsterer, Peter Barton
stroke-like episodes (MELAS) syndrome or other syndromic mitochondrial disorders. A 41-year-old Caucasian female with MELAS syndrome, presenting with short stature, microcytic anaemia, increased blood-sedimentation rate, myopathy, hyper-gammaglobulinaemia, an iron-metabolism defect, migraine-like headaches, and stroke-like episodes, developed complex partial and generalised seizures at age 32 years. Valproic acid was ineffective but after switching to lamotrigine and lorazepam, she became seizure-free for five years and stroke-like episodes did not recur. Cerebral MRI initially showed enhanced gyral thickening and a non-enhanced T2-hyperintensity over the left parieto-temporo-occipital white matter and cortex and enhanced caudate heads. After two years without seizures, the non-enhanced hyperintense parieto-temporo-occipital lesion had disappeared, being attributed to consequent seizure control. The caudate heads, however, remained hyperintense throughout the observational period. This case indicates that adequate seizure control in a patient with MELAS syndrome may prevent the recurrence of stroke-like episodes and may result in the disappearance of stroke-like lesions on MRI.
A case of levetiracetam-induced thrombocytopenia
Roger Oghlakian, Charles Nock, Mohamad Koubeissi
with subsequent development of thrombocytopenia. After ruling out all other possible causes of a decreased platelet count, we conclude that levetiracetam was the cause of this adverse event.
Letter to the Editor
Varenicline-induced grand mal seizure
Anna Serafini, Arielle Crespel, Reana Velizara, Philippe Gelisse
Congresses and meetings
List of reviewers for 2010
Articles published in 2010
