Diagnosis Of Temporal Lobe Epilepsy Research Articles

The neuropsychological and emotional consequences of living with intractable temporal lobe epilepsy: implications for clinical management

Purpose: To investigate and document the neuropsychological and emotional effects of epilepsy in people with intractable temporal lobe epilepsy (TLE).Methods: 273 patients with a diagnosis of TLE underwent a complete neuropsychological and psychological examination as a routine part of their investigation for epilepsy surgery. Neuropsychological assessment included measures of intellect, memory, language functioning, higher executive functioning, emotional well-being and the psychosocial impact of epilepsy and its treatment.Results: The sample comprised 135 females and 138 males with a clearly lateralised epileptogenic focus. Patients were mildly anxious but not depressed, although many reported that epilepsy and its treatment had a marked effect on their daily lives. Current reading ability was in the average range; the mean obtained full scale IQ was 88 (low average range). Verbal memory functioning was within the borderline impaired range with visual memory functioning within the average range. Mean language performance was between the 5–10th percentile. Higher executive functioning results were in the normal range.Multiple univariate analyses were performed according to onset laterality. There were no significant differences between the groups on measures of psychological or emotional functioning. Participants with left TLE scored significantly lower than those in the right temporal group on measures of verbal intelligence, general intelligence, attention span and expressive language functioning.Conclusions: Patients with intractable epilepsy suffer significant neuropsychological difficulties in terms of their intellect, memory and language. Higher executive functioning appears unaffected. In addition, there is also evidence of emotional distress. These all impact upon their day-to-day functioning, which can be improved by the application of various psychological therapies and interventions.

Depressive disorders preceding temporal lobe epilepsy

In this study, we investigated three female patients given a diagnosis of temporal lobe epilepsy preceded by depression. It is notable that all the patients complained of abnormal sensations, either in the throat or oral. The depression in the three patients showed no improvement with antidepressants, but carbamazepine was effective for both epileptic seizures and depression. EEG should be performed on patients who develop antidepressant treatment-refractory depression accompanied by hypochondriacal complaints.

Temporal lobe epilepsy of adult age of possible idiopathic nature

Objective: To verify the existence of sporadic cases of temporal lobe epilepsy (TLE) of possible idiopathic nature with onset in adult life and to define their characteristics.Background: Currently, the existence of these forms is not fully recognized. In the last few years, familial cases of TLE of the early adult age have been described. Besides, sporadic cases of TLE characterized by both onset in adulthood and high prevalence of familial history of epilepsy have also been reported.Method: All subjects with TLE, defined according to the ILAE criteria (1989), with onset in adult age, followed at our Centre from 1990 to 1998, were re-examined to find out the cases with possible idiopathic origin of seizures.Results: Among 159 subjects with a diagnosis of TLE, 14 subjects (8.8%) were so identified (Group 1), and compared with the remaining 145 subjects (Group 2). High familial incidence for epilepsy, prevalence of autonomic seizures, low seizure frequency, and good prognosis are the main characteristics of the group 1. The difference between the two groups is statistically significant for family history for epilepsy (chi square test: P< 0.01) and for freedom from seizures after medication (chi square test:P < 0.05).Conclusion: The distinctive features of the subjects identified suggest that at least some of these patients may have familial TLE. Whether this disorder may be present in sporadic form remains a matter of debate which must await the identification of the gene(s) responsible of this disorder. Till then, it is worthwhile to underline the better prognosis of these patients compared to those that did not meet these criteria.

Magnetic resonance imaging in temporal lobe epilepsy: usefulness for the etiological diagnosis of temporal lobe epilepsy.

With improvement in magnetic resonance (MR) imaging techniques, the ability to identify lesions responsible for temporal lobe epilepsy has increased. MR imaging has also enabled the in vivo diagnosis of hippocampal sclerosis. Brain tumors are responsible for 2-4% of epilepsies in adult population and 10-20% of medically intractable epilepsy. The sensitivity of MR imaging in the diagnosis of tumors and other lesions of the temporal lobe (vascular malformations, etc.) is around 90%. Both hippocampal sclerosis and other temporal lobe lesions are amenable to surgical therapy with excellent postsurgical seizure outcome. In this article, we characterize and underline distinguishing features of the different pathological entities. We also suggest an approach to reviewing the MR images of an epileptic patient.

Validation of the Wechsler Memory Scale-Revised in a sample of people with intractable temporal lobe epilepsy.

The Wechsler Memory Scale-Revised (WMS-R) is used routinely for presurgical assessment of memory for patients considering elective resection of the temporal lobe and/or hippocampus for the relief of intractable temporal lobe epilepsy (TLE). We investigated the validity of the WMS-R in a population of people with TLE. The sample consisted of 138 patients with a diagnosis of TLE in which the epileptogenic focus was clearly and exclusively lateralized to either the right or left hemisphere. They underwent a complete neuropsychological examination as a routine part of their investigation for epilepsy surgery. Psychometric scores included in this study were: Wechsler Adult Intelligence Scale-Revised (WAIS-R) I.Q. scores, National Adult Reading Test Revised (NART-R) predicted-I.Q. scores, and WMS-R Memory Index and subtest scores. Multiple univariate analyses were performed. The group with left temporal focus had significantly lower Verbal Memory Index, Logical memory (both immediate and delayed), and Digit Span scores. Visual/Verbal discrepancy scores incorrectly identified most patients with right temporal focus. Analyses of a total group of people with epilepsy (i.e., mixed temporal, frontal, occipital and unknown foci) as compared with the normative sample indicated that the patient group scored significantly lower across all memory index scores and most memory subtests. Our results confirm that the WMS-R is capable of lateralizing to left hemispheric impairment but is more problematic in the assessment of right hemispheric impairment. The Visual/Verbal Memory Index discrepancy has questionable validity. People with epilepsy performed less well on the WMS-R than did the normative sample. The need for reliable and valid nonverbal tests of memory is therefore warranted.

A Simultaneous Comparison of Acupuncture Needle and Insulated Needle Sphenoidal Electrodes for Detection of Anterior Temporal Spikes

Uninsulated acupuncture needles have been used as sphenoidal electrodes, but the issue of insulation has not been adequately addressed. In this report, acupuncture needles and insulated needle sphenoidal electrodes were simultaneously used to compare the rate of spike detection, spike amplitude and distribution of maximal spikes from eight spike foci in seven patients with temporal lobe epilepsy. When compared to the insulated needle electrode, the acupuncture needle electrode was equally effective in spike detection, but spike amplitudes tended to be smaller and maximal spikes were less frequently encountered. Thus, insulation has an influence on the spikes recorded by the acupuncture needle sphenoidal electrode. However, the overall effect appears to be not sufficiently different from the insulated needle electrode for the purpose of detecting anterior temporal spikes in outpatient EEG recordings for the diagnosis of temporal lobe epilepsy.

Psychiatric consequences of temporal lobectomy for intractable seizures: a 20–30-year follow-up of 14 cases

Between 1958 and 1968, 14 patients from the epilepsy clinic at the University of Oregon Hospitals and Clinics with a diagnosis of temporal lobe epilepsy (TLE) had a temporal lobectomy for medically intractable seizures. Nine of the 14 patients operated on remained seizure-free over the 20-30-year period of follow-up. Between 6 months and one year following temporal lobectomy, two women, previously healthy from a psychiatric standpoint, developed psychoses, and the previous psychiatric problems of four other patients worsened. Two patients, one with incapacitating paranoid personality disorder and the other with explosive rage attacks preoperatively, had marked improvement in their psychiatric status following temporal lobectomy. The remaining six patients, all psychiatrically healthy prior to surgery, have had no change in psychiatric status following surgery. Development of psychosis or deterioration in psychiatric status after surgery was more common in patients with later age of onset, unreality or déjà vu rather than epigastric aura, pre-operative evidence of bilateral brain damage, and persistence of EEG or clinical seizure activity. Development of a chronic psychosis in psychiatrically healthy individuals many months after temporal lobectomy, even when seizures are arrested or ameliorated, suggests that anomalous synaptic regeneration may follow the surgery in these cases. Careful analysis of histories and outcomes may contribute to better understanding of the pathophysiology and anatomical substrates of psychoses.

Panic disorder in the differential diagnosis of temporal lobe epilepsy

Lepola U, Mervaala E, Nousiainen U, Riekkinen P, Rimon R. Panic disorder in the differential diagnosis of temporal lobe epilepsy.Panic disorder has received little attention in the differential diagnosis of episodic behavioural symptoms. We report four patients with panic disorder previously diagnosed and treated as having intractable temporal lobe epilepsy. Comprehensive neurologic, neuro-physiologic, and neuropsychiatric evaluation resulted in appropriate drug treatment and favourable outcome of the illness.

Focal Retrograde Amnesia: A Long Term Clinical and Neuropsychological Follow-Up

A patient (E.D.) who had displayed a selective retrograde amnesia in association with transient amnesic episodes (Kapur et al., 1986) was reexamined five years after initial assessment. At the clinical level, his transient amnesic attacks continued, but some of these had clear epileptic features. In addition, EEG investigation indicated temporal lobe abnormality, more prominent in the left temporal region, and supported a clinical diagnosis of temporal lobe epilepsy. Both CT scanning and magnetic resonance imaging were unable to detect the presence of any structural lesion. At the neuropsychological level, there was no evidence of dementia in the form of generalized cognitive dysfunction nor significant deterioration in cognitive funtioning since the earlier assessment. Our patient continued to show marked memory loss for public events over the past 20–30 years, in the context of normal or near normal performance on most tests of anterograde memory functioning. While memory for famous scenes and famous faces was markedly impaired, our patient's memory for famous cars was within normal limits and his memory for autobiographical events showed only patchy impairment. Although E.D. performed at an average or above average level on most standard tests of anterograde memory functioning, our patient did show evidence of significant memory loss for public events which had occurred over the past ten years (i.e. since the onset of his illness). The possibility is raised that E.D.'s memory disorder may represent a form of disconnection syndrome.

Psychomotorische Epilepsie - Vergleich von CT und MR bei 100 Patienten

The value of CT and MR was studied in 100 patients with temporal lobe epilepsy. Axial CT scans were obtained before and after contrast injection. Coronary MR scans were carried out with T1-(SE 400/30, GE 315/14) and T2-weighted sequences (SE 1600/30 + 70). A circumscribed lesion was demonstrated in fifteen patients by CT and in 25 patients by MR. With the exception of a small area of calcification, all lesions seen on CT could also be recognized on MR. In four patients CT, MR and pathologic specimen could be compared following partial resection of temporal lobe. Localized glial reactions, which were not seen on CT, produced a signal difference on MR. Better sensitivity and improved demonstration of the temporal lobes makes MR the method of choice in the diagnosis of temporal lobe epilepsy.

Indications for carbamazepine in mental illness: Atypical psychiatric disorder or temporal lobe syndrome?

A wide range of atypical, labile-pleomorphic psychiatric disorders respond specifically to carbamazepine. The disorders are characterized by evidence of some CNS impairment or a family history of epilepsy, and by mental changes typical for the interictal phase of temporal lobe epilepsy (TLE). Subtle seizures may be present and allow the diagnosis of TLE; in the absence of any seizures, the disorders are identified as temporal lobe syndrome (TLS). The conclusions are supported by the findings in a series of 28 consecutive psychiatric patients who were exemplary carbamazepine responders.

ELECTROCARDIOGRAPHIC ACCOMPANIMENTS OF TEMPORAL LOBE EPILEPTIC SEIZURES

74 spontaneous seizures in 26 patients with a clinical diagnosis of temporal lobe epilepsy (complex partial seizures) were recorded by simultaneous ambulatory cassette monitoring of the electrocardiogram and the electroencephalogram (EEG). In 24 patients (92%) seizures were associated with an increased heart rate. The maximum heart rates exceeded 120 beats/min in 67% of seizures, 140 beats/min in 30%, and 160 beats/min in 12%. The acceleration of heart rate was greater in patients under than in those over 25 years old (p<0·01) and in those not treated with than in those on anticonvulsant drugs (p<0·01). Ictal cardiac arrhythmias occurred in 42% of the patients and the commonest was an irregular series of abrupt rate changes which occurred towards the end of the EEG seizure discharge. Asymptomatic (clinically silent) arrhythmias occurred no more frequently in the patients than in age and sex matched healthy subjects. These secondary autonomic effects of epilepsy may lead to diagnostic errors if their cerebral origins are not suspected. They seem to be reduced in severity by anticonvulsant drugs (ACD) and they may account for sudden unexplained deaths in epileptics.

Temporal lobe epilepsy: social and psychological considerations.

The diagnosis of temporal lobe epilepsy (TLE) holds significant psychosocial ramifications for the patient and family. TLE is a type of seizure disorder which challenges the usual notions of epilepsy. Patients with TLE may never experience the stereotypical convulsion; rather, TLE seizures are more likely to take the form of changes in behavior and deepened emotionality. The symptoms are confusing and often frightening for the patient, his family and the larger community. This article explores the patient's and the family's reactions to TLE--myths that influence them, the practical and emotional dilemmas that confront them, and the benefits of social work intervention.

Diagnosis of temporal lobe epilepsy by positron emission tomography.

Temporal lobe epilepsy was studied by the 11C-glucose method of positron emission tomography. The temporal lobe at the level 25 mm above the orbitomeatal line showed the amygdala, hippocampus and hippocampal gyrus medially, and the T1, T2 and T3 neocortices laterally. The focus locations in these structures were divided into mesial, lateral and combined groups on the PECT images. This classification showed a close correlation between the clinical symptoms and the anatomical focus sites.

Epileptic psychosis: an evaluation of PSE profiles.

Data are presented on 24 patients with epilepsy and psychosis whose clinical presentation was rated using the Present State Examination (PSE). Seventeen had complex partial seizures and a diagnosis of temporal lobe epilepsy, seven had generalised epilepsy. An association between a CATEGO category of nuclear schizophrenia (NS) and a lesion of the left side was noted. No clear link between depressive symptoms and a right-sided focus was discovered. Affective disorders were noted in both groups of epileptic patients, although paranoid psychoses were commoner in the temporal lobe group. There was also a tendency for the latter to have more delusions of persecution, ideas of reference, and special features of depression. The group rated as NS appear less likely to show evidence of intellectual deterioration than the other psychotic patients; in addition, the interval between the onset of their epilepsy and the onset of their psychosis is shorter. Radiological assessment by CAT reveals few differences between groups, but the psychotic samples do show higher than expected values on a number of variables, in particular the bilateral septum-caudate distance and the size of the third and fourth ventricle.

Temporal lobe epilepsy: neurological and behavioral aspects.

It is perhaps fair to say that in no other disorder do the disciplines of neurology and psychiatry overlap so extensively as in epilepsy. Despite this, lay and at times professional organizations have mounted well-intended but unfortunate (for the patient) propaganda campaigns to deny this special association. As a consequence, the serious psychiatric complications of epilepsy have often gone unrecognized by the internist or neurologist and have generally been of little interest to the psychia­ trist. A better understanding of this association is of paramount importance if we are to provide these patients with comprehensive treatment for a complex disorder. Although the prevalence of psychical aberrations in epileptics has been recog­ nized since ancient times (1), it was not until the advent of modern electroencephalo­ graphic (EEG) technology (2) that a special association of severe psychiatric disorders with the psychomotor (temporal lobe) form of epilepsy was documented. Interest in this association of epilepsy and in particular temporal lobe epilepsy (TLE) with various forms of behavioral disorder has produced a rich but confusing and often contradictory literature. In part this is due to the loose nosology character­ izing much of the psychiatric literature and also because of the varying neurological and EEG criteria chosen for making the diagnosis of TLE. Diagnostic difficulties arise on the one hand from the protean manifestations which characterize the clinical seizures and on the other from the fact that electrical discharges deep in the temporal lobe frequently go undetected in the scalp-recorded EEG. For our purposes, the individual temporal lobe seizures of TLE may be defined operationally as focal seizures produced by discharging lesions situated in or [secondarily] projecting to the temporal lobes (3). It would undoubtedly be more correct to speak of limbic rather than temporal lobe epilepsy since many clinical features appear to depend upon the propagation of the discharges from the temporal

Temporal lobe "spike focus" associated with confusion, complete amnesia and fugues in a paranoid schizophrenic.

An unusual case is reported of a man who had no history of difficulties at birth, head trauma, brain infection, febrile convulsions, genetic disposition or undue schizoid traits but suddenly developed at the age of 27 a paranoid psychosis which necessitated hospitalization. Examined over a 10-year period by many experienced psychiatrists in three different hospitals, he was labeled a paranoid schizophrenic. A decade later while in a hospital he experienced a fugue episode, his second, associated with severe confusion, complete amnesia and an EEG spike focus in the left temporal area which established the diagnosis of temporal lobe epilepsy. His first fugue episode almost a year earlier was over-looked as a temporal lobe automatism due to the prominence of mental symptoms of many years' duration. The pathogenesis and the relationship between the late onset of epilepsy in temporal lobe cases, complete amnesia, and mental symptomatology are discussed. A point of interest is not only a flare-up of acute psychotic manifestations each time phenobarbital and Dilantin were instituted, but also a precipitation of seizures following phenobarbital therapy for a three-week period. The dramatic change twice observed with chlorpromazine and trifluoperazine, without untoward influence or convulsive activity, must not be overlooked.

Biological Factors in Temporal Lobe Epilepsy, by Christopher Ounsted, Janet Lindsay, and Ronald Norman. London: Published by the Spastics Society Medical Education and Information Unit in association with William Heinemann Medical Books Ltd. (Clinics in Developmental Medicine No. 22), 1966, 135 pp., $3.00

In Gilbert Glaser's "Foreword" to this book, the term "temporal lobe seizures" is taken to mean "psychomotor seizures." The authors also apparently consider these terms synonymous, for on page 2 they cite a case which meets their criteria for the diagnosis of temporal lobe epilepsy. The patient had an aura of abdominal discomfort, a succession of autonomic signs, semi-purposeful psychomotor movements, visual hallucinations, and a spike focus in the anterior temporal area. By considering temporal lobe epilepsy and anterior temporal lobe or psychomotor epilepsy as identical, they follow a usage that is almost universal in Europe and one that is also common in the United States.

An assessment of the value of sleep-electroencephalography for the diagnosis of temporal lobe epilepsy

1. 1. The diagnostic importance of sleep electroencephalography for the EEG diagnosis of temporal lobe epilepsy was studied in two groups of patients. Group I consisted of 228 temporal lobe epileptics who underwent temporal lobectomy for their seizures. Group II represents a sample of 100 patients who gave a typical history of temporal lobe attacks, but were not subjected to surgical therapy. 2. 2. In group I the EEG diagnosis of temporal lobe epilepsy was made without sleep in 94.3 per cent of the cases. In group II the EEG diagnosis of temporal lobe epilepsy was make in 72 out of the total number of 100 patients. In group II sleep was only necessary for the diagnosis in 6.9 per cent of the 72 patients in whom a positive EEG diagnosis of temporal lobe epilepsy could be made. Out of 25 cases in whom no clear EEG diagnosis was made 10 had sleep records taken with negative results. 3. 3. Among the 77 patients of groups I and II in whom sleep records were obtained 44 showed more active epileptic discharge during sleep, whereas 23 showed no such activating effect or even some reduction of epilepti-form abnormality during sleep. 4. 4. Patients with a history of nocturnal attacks are more likely than others to require sleep activation to bring out the epileptiform abnormality, although even in this group the number of cases in which the diagnosis can be made from the waking record is still high. The higher incidence of cases in which sleep is necessary for the EEG-diagnosis among patients giving a history of nocturnal attacks is statistically significant. 5. 5. No statistically significant difference was found between natural and drug-induced sleep with regard to their propensity to activate temporal lobe abnormalities. 6. 6. It seems that electrocorticograms taken in temporal lobe epileptics during general anesthesia tend to show less clear diagnostic signs than those taken under local anesthesia. 7. 7. The pathological lesions found in patients whose temporal lobe EEG abnormalities were activated by sleep and those found in patients where no such activation occurred show the same relative incidence of atrophic versus space-occupying lesions. 8. 8. The main conclusion drawn from these findings is that although sleep tends to activate the temporal lobe epileptiform abnormality in a majority of cases, sleep electroencephalography in a majority of cases, sleep electroencephalography need not be carried out as a routine procedure in patients giving a history of temporal lobe seizures, since in more than 90 per cent of the cases in which a positive EEG diagnosis can be made this diagnosis can be established in the waking record.