Localization-related Epilepsy Research Articles

Exploring Various Crystal and Molecular Structures of Gabapentin—A Review

Novel antiepileptic drugs have been developed at an unparalleled rate during the past 15 years. Gabapentin (GBP), which was approved for the treatment of refractory localization-related epilepsies in the U.K. and Europe in 1993, was one of the first drugs to come out of this era. Since then, GBP has become well-known across the world, not only for its antiepileptic qualities but also for its effectiveness in the treatment of chronic pain disorders, particularly neuropathic pain. In this review, the crystal structures of GBP and GBP-related compounds have been analyzed and compared. Particular attention has been paid to the polymorphism of GBP and its hydrates, their thermodynamic stability, and conformational differences. In addition, the puckering parameters for the cyclohexane ring of a total of 118 molecules of GBP found in the analyzed crystal structures have been calculated and analyzed. The results of recent high-pressure crystallization studies and quantum chemical calculations indicate that the entire landscape of GBP has not been revealed yet.

Neurophysiological and neuropsychological parameters in patients with temporal lobe epilepsy

Temporal lobe epilepsy (TLE) is the most common type of localization-related epilepsy (LRE) and has been extensively studied in the field of neuropsychology due to its significant association with cognitive impairments. Cognitive decline has long been recognized as a consequence of this form of epilepsy, with previous studies primarily focusing on neurophysiological measures. In this study, both neurophysiological and neuropsychological factors were analyzed in TLE patients compared to healthy control subjects. The Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) tests were used to assess neuropsychological processes, while cognitive event-related potential (ERPs), particularly P300, were employed to analyze neurophysiological parameters. The study involved 21 TLE patients (mean age = 61.43) and 21 healthy control subjects. The results revealing that TLE patients scored significantly lower, indicating deficits in specific cognitive areas. The study also observed abnormalities in the ERPs, particularly in the assessment of P300 amplitude and latency, that may be indicative of underlying neural dysfunction related to attention and cognitive processing. In conclusion, the study provides compelling evidence of the association between TLE and a high incidence of cognitive deficits and decline. By considering both neurophysiological and neuropsychological factors, the study sheds light on the comprehensive impact of TLE on various cognitive domains and emphasizes the importance of early identification and management of cognitive impairments in TLE patients.

38 Language and memory outcome after frontal or temporal resection for epilepsy

Objective:The purpose of this investigation was to examine neuropsychological functioning after frontal (FL) or temporal lobectomy (ATL) in patients with localization related epilepsy. Few studies have compared cognitive changes following FL and ATL. Past research found improvement on measures of verbal and visual memory along with confrontation naming after FL (Busch et al., 2017). In contrast, a number of studies have reported verbal memory and naming decline in those undergoing left ATL. The current study examined post-operative cognitive changes in epilepsy patients who underwent either a left or right FL or ATL.Participants and Methods:Subjects include 430 patients (204 men, 225 women, 1 gender not specified), who underwent surgical resection; Right FL = 25, Left FL = 26, Right ATL = 211, Left ATL = 168. Patients had a mean FSIQ = 90, ages ranging from 18 to 71 (mean age = 37 years), right (n=359), left (n=50), or mixed (n=18) handedness, and education ranging from 3 to 22 years (mean = 12.9 years of education). Change from pre- to post FL and ATL was examined in the following domains: learning and memory [Long Term Storage for Selective Reminding Tests (SRT), Wechsler’s Memory Scale (WMS): Logical Memory Delayed Recall (LM) and Visual Reproduction Delayed Recall (VR)], and language [Boston Naming Test (BNT)].Results:A one-way ANOVA was used to examine changes in language and memory. Our findings revealed statistically significant differences between resection groups for LM, SRT, and BNT. There were significant declines (p<.001) for left ATL when compared to right ATL for LM, SRT, and BNT. There were significant declines for left ATL, when compared to the gains in both left (p<.001; p=.002) and right (p=.018; p=.008) FL for LM and BNT. Left ATL also had significant declines when compared to gains in SRT (p<.001) for right FL. There were significant declines for left FL when compared to right ATL for SRT (p=.007). Lastly, there were significant gains for right FL when compared to left FL for SRT (p=.020).Conclusions:The pre- to post-surgical neuropsychological change in learning, memory, and language is understudied in frontal lobe epilepsy (FLE); although several investigators reported some learning and memory impairments in FLE at either pre- or post-surgical time points (Johnson-Markve et al., 2011; Incisa Della Rocchetta et al., 1993). The current study suggests that resections of the frontal lobes are associated with better outcomes for naming and verbal memory (LM) when compared to left ATLs. Interestingly, verbal list learning declined more in left than right FL and right ATL patients suggesting a possible language based executive functioning component to this memory measure. As expected, our study further supports that left ATLs are associated with material specific memory declines. This pattern was not seen for those undergoing a right ATL (i.e., nonverbal memory did not decline in patients with right ATL).

A - 113 Strengths-Based Neuropsychology in Neurological Surgery: a Neuropsychiatric Case Study of Treatment Refractory Right-Sided Focal Seizures.

Psychiatric comorbidity is high among patients with epilepsy, found more frequently with right-sided seizure foci. Neurosurgical intervention is often the standard of care for refractory epilepsy; unfortunately, psychiatric symptoms can impact a patient's compliance and participation in the pre-surgical process. This pre-surgical epilepsy case illustrates the importance of neuropsychological evaluation in clarifying the relationship between cognitive functioning and long-standing psychiatric comorbidities to inform surgical candidacy. A 20-year-old, left-handed, bilingual Caucasian female with seven years of education with cortical dysplasia associated with intractable right-hemisphere localization-related epilepsy underwent neuropsychological evaluation for progressive short-term memory and word-finding difficulty as part of a pre-surgical workup. A clinical interview, neuropsychological testing, and comprehensive review of available electronic medical records (EMR) were completed. Neuropsychological estimates of current intellectual functioning were low average but variable, revealing a relative strength in non-verbal learning and memory compared to verbal abilities. Self-report emotional measures evidenced clinically elevated levels of anxiety and depression and reduced quality of life due to epilepsy. Psychiatric diagnoses included attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, oppositional defiant disorder, and panic attacks. EMR and clinical interview indicated medication non-compliance, alcohol intoxication, dysregulated sleep hygiene, seizure-related injuries, and history of status epilepticus. Consistent with the literature, this pre-surgical case demonstrated significant psychiatric symptoms in the context of right-sided treatment refractory epilepsy. While psychiatric comorbidities contributed to non-adherence with medical recommendations, under-functioning in vocational goals, and general hopelessness, the neuropsychological evaluation revealed strengths that impacted surgical candidacy and rapport-building that facilitated patient engagement and understanding of the surgical process.

Stereoelectroencephalography-guided radiofrequency ablation of the epileptogenic zone as a treatment and predictor of future success of further surgical intervention.

Stereoelectroencephalography (SEEG)-guided radiofrequency ablation (RFA) is increasingly being used as a treatment for drug-resistant localization-related epilepsy. The aim of this study is to analyze the successes and failures using RFA and how response correlates with surgical epilepsy treatment outcomes. We retrospectively reviewed 62 patients who underwent RFA via SEEGelectrodes. After excluding five, the remaining 57 were classified into subgroups based on procedures and outcomes. Forty patients (70%) underwent a secondary surgical procedure, of whom 32 were delayed: 26 laser interstitial thermal therapy (LITT), five resection, one neuromodulation. We determined the predictive value of RFA outcome upon subsequent surgical outcome by categorizing the delayed secondary surgery outcome as success (Engel I/II) versus failure (Engel III/IV). Demographic information, epilepsy characteristics, and the transient time of seizure freedom after RFA were calculated for each patient. Twelve of 49 patients (24.5%) who had RFA alone and delayed follow-up achieved Engel class I. Of the 32 patients who underwent a delayed secondary surgical procedure, 15 achieved Engel class I and nine Engel class II (24 successes), and eight were considered failures (Engel class III/IV). The transient time of seizure freedom after RFA was significantly longer in the success group (4 months, SD = 2.6) as compared to the failure group (.75 months, SD = 1.16; p < .001). Additionally, there was a higher portion of preoperative lesional findings in patients in the RFA alone and delayed surgical success group (p = .03) and a longer time to seizure recurrence in the presence of lesions (p < .05). Side effects occurred in 1% of patients. In this series, RFA provided a treatment during SEEG-guided intracranial monitoring that led to seizure freedom in ~25% of patients. Of the 70% who underwent delayed surgery, longer transient time of seizure freedom after RFA was predictive of the results of the secondary surgeries, 74% of which were LITT.

Lateralization of temporal lobe epileptic foci with automated chemical exchange saturation transfer measurements at 3Tesla.

Magnetic Resonance Imaging (MRI) is an indispensable tool for the diagnosis of temporal lobe epilepsy (TLE). However, about 30% of TLE patients show no lesion on structural MRI (sMRI-negative), posing a significant challenge for presurgical evaluation. This study aimed to investigate whether chemical exchange saturation transfer (CEST) MRI at 3 Tesla can lateralize the epileptic focus of TLE and study the metabolic contributors to the CEST signal measured. Forty TLE subjects (16 males and 24 females) were included in this study. An automated data analysis pipeline was established, including segmentation of the hippocampus and amygdala (HA), calculation of four CEST metrics and quantitative relaxation times (T1 and T2), and construction of prediction models by logistic regression. Furthermore, a modified two-stage Bloch-McConnell fitting method was developed to investigate the molecular imaging mechanism of 3T CEST in identifying epileptic foci of TLE. The mean CEST ratio (CESTR) metric within 2.25-3.25ppm in the HA was the most powerful index in predicting seizure laterality, with an area under the receiver-operating characteristic curve (AUC) of 0.84. And, the combination of T2 and CESTR further increased the AUC to 0.92. Amine and guanidinium moieties were the two leading contributors to the CEST contrast between the epileptogenic HA and the normal HA. CEST at 3 Tesla is a powerful modality that can predict seizure laterality with high accuracy. This study can potentially facilitate the clinical translation of CEST MRI in identifying the epileptic foci of TLE or other localization-related epilepsies. National Natural Science Foundation of China, Science Technology Department of Zhejiang Province, and Zhejiang University.

Electrocorticography-Guided Resection Enhances Postoperative Seizure Freedom in Low-Grade Tumor-Associated Epilepsy: A Systematic Review and Meta-Analysis.

Low-grade cerebral neoplasms are commonly associated with medically intractable epilepsy. Despite increasing evidence that epileptogenic brain regions commonly extend beyond visible tumor margins, the utility of extended surgical resections leveraging intraoperative electrocorticography (ECoG) remains unclear. To determine whether ECoG-guided surgery is associated with improved postoperative seizure control. We performed a systematic review and meta-analysis encompassing both adult and pediatric populations. The primary outcome measure was postoperative seizure freedom as defined by Engel class I outcome. Class I/II outcome served as a secondary measure. Relevant clinical and operative data were recorded. A random-effects meta-analysis based on the pooled odds ratio (OR) of seizure freedom was performed on studies that reported comparative data between ECoG-guided surgery and lesionectomy. A total of 31 studies encompassing 1115 patients with medically refractory epilepsy met inclusion criteria. Seven studies reported comparative data between ECoG-guided surgery and lesionectomy for meta-analysis. Tumor resection guided by ECoG was associated with significantly greater postoperative seizure freedom (OR 3.95, 95% CI 2.32-6.72, P < .0001) and class I/II outcome (OR 5.10, 95% CI 1.97-13.18, P = .0008) compared with lesionectomy. Postoperative adverse events were rare in both groups. These findings provide support for the utilization of ECoG-guided surgery to improve postoperative seizure freedom in cases of refractory epilepsy associated with low-grade neoplasms. However, this effect may be attenuated in the presence of concomitant cortical dysplasia, highlighting a need for improved presurgical and intraoperative monitoring for these most challenging cases of localization-related epilepsy.

The changing landscape in epilepsy imaging: Unmasking subtle and unique entities.

Dramatic changes have occurred recently in the field of epilepsy, including a fundamental shift in the etiology of epileptogenic substrates found at surgery. Hippocampal sclerosis is no longer the most common etiology found at epilepsy surgery and this decrease has been associated with an increase in the incidence of focal cortical dysplasia and encephaloceles. Significant advances have been made in molecular biology and genetics underlying the basis of malformations of cortical development, and our ability to detect epileptogenic abnormalities with MR imaging has markedly improved. This article begins with a discussion of these trends and reviews imaging techniques essential for detecting of subtle epilepsy findings. Representative examples of subtle imaging findings are presented, which are often overlooked but should not be missed. These include temporal lobe encephaloceles, malformations of cortical development (and especially focal cortical dysplasia), hippocampal sclerosis, hippocampal malformation (also known as HIMAL), ulegyria, autoimmune encephalitis, and Rasmussen's encephalitis. Recent findings on the pathophysiology and genetic underpinnings of several causes of localization-related epilepsy are incorporated. For instance, it has been recently found that focal cortical dysplasia IIb, tuberous sclerosis, hemimegalencephaly, and gangliogliomas are all the result of mutations of the mTOR pathway for cell growth.

Cross sectional descriptive study to study the prevalence of metabolic syndrome among patients with epilepsy on antiepileptic drugs in a tertiary care centre

Epilepsy is the commonest neurological condition affecting people of all ages, race and social class. Patients with epilepsy have two to three times higher risk of mortality compared to general population. The role of epilepsy as a potential risk factor for metabolic syndrome and coronary artery disease is of interest.To study the prevalence of metabolic syndrome among patients with epilepsy.This is a hospital based cross-sectional descriptive study. The subjects were selected from patients attending the epilepsy outpatient clinic of a single tertiary centre (GMCH, Udaipur) during the period of 15 months from January 2021 to March 2022. Fasting blood samples were drawn from them to estimate fasting blood glucose and fasting lipid profile.: Males constituted two thirds of the subjects. Average age was 32.5 years. Mean duration of treatment was 13.6 years (range 3–48 years). 51.9% were on monotherapy. Valproate was used in 33 of the 45 (73.33%) patients. In localization related epilepsy, the commonest drug was carbamazepine used in 57.48%. Eight of the enrolled patients had diabetes mellitus and 35 had impaired fasting glucose. Systemic hypertension was detected in 11.5% patients. No significant association was noted between drug use and cardiovascular risk factors – diabetes mellitus, hypertension or dyslipidemia. Very significant association was noted on lipid profile for carbamzepine, phenytoin and clobazam.Antiepileptic medications, especially valproate and carbamazepine have significant effects on the lipid profile and abdominal obesity in patients on treatment. Metabolic syndrome is more prevalent among adult patients &amp;#60;50 years of age with epilepsy compared to the general population in the same age group. This difference could be related to the effect of the antiepileptic medications, especially valproate. There is a need to monitor patients on antiepileptic medications regularly for development of dyslipidemia and obesity.

Interictal discharges delay target-directed eye movements and impair attentional set-shifting in children with epilepsy.

The theory of transient cognitive impairment in epilepsy posits that lapses in attention result from ephemeral disruption of attentional circuitry by interictal events. Eye movements are intimately associated with human attention and can be monitored in real time using eye-tracking technologies. Here, we sought to characterize the associations between interictal epileptiform discharges (IEDs), gaze, and attentional behavior in children with epilepsy. Eleven consecutive children undergoing invasive monitoring with stereotactic electrodes for localization-related epilepsy performed an attentional set-shifting task while tandem intracranial electroencephalographic signals and eye-tracking data were recorded. Using an established algorithm, IEDs were detected across all intracranial electrodes on a trial-by-trial basis. Hierarchical mixed-effects modeling was performed to delineate associations between trial reaction time (RT), eye movements, and IEDs. Hierarchical mixed-effects modeling revealed that both the presence of an IED (β±SE=72.74± 24.21 ms, p= .003) and the frequency of epileptiform events (β±SE=67.54± 17.30 ms, p< .001) were associated with prolonged RT on the attentional set-shifting task. IED occurrence at the time of stimulus presentation was associated with delays in gaze initiation toward the visual targets (p= .017). The occurrence of epileptiform activity in close temporal association with stimulus presentation is associated with delays in target-directed gaze and prolonged response time, hallmarks of momentary lapses in attention. These findings provide novel insights into the mechanisms of transient impairments in children and support the use of visual tracking as a correlate of higher order attentional behavior.

Morphometric analysis program and quantitative positron emission tomography in presurgical localization in MRI-negative epilepsies: a simultaneous PET/MRI study.

To evaluate morphometric analysis program (MAP) and quantitative positron emission tomography (QPET) in epileptogenic zone (EZ) identification using a simultaneous positron emission tomography/magnetic resonance imaging (PET/MRI) system in MRI-negative epilepsies. Seventy-one localization-related MRI-negative epilepsies who underwent preoperative simultaneous PET/MRI examination and surgical resection were enrolled retrospectively. MAP was performed on a T1-weighted volumetric sequence, and QPET was analyzed using statistical parametric mapping (SPM) with comparison to age- and gender-matched normal controls. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MAP, QPET, MAP + QPET, and MAP/QPET in EZ localization were assessed. The correlations between surgical outcome and modalities concordant with cortical resection were analyzed. Forty-five (63.4%) patients had Engel I seizure outcomes. The sensitivity, specificity, PPV, and NPV of MAP were 64.4%, 69.2%, 78.3%, and 52.9%, respectively. The sensitivity, specificity, PPV, NPV of QPET were 73.3%, 65.4%, 78.6%, and 58.6%, respectively. MAP + QPET, defined as two tests concordant with cortical resection, had reduced sensitivity (53.3%) but increased specificity (88.5%) relative to individual tests. MAP/QPET, defined as one or both tests concordant with cortical resection, had increased sensitivity (86.7%) but reduced specificity (46.2%) relative to individual tests. The regions determined by MAP, QPET, MAP + QPET, or MAP/QPET concordant with cortical resection were significantly associated with the seizure-free outcome. QPET has a superior sensitivity than MAP, while the combined MAP + QPET obtained from a simultaneous PET/MRI scanner may improve the specificity of the diagnostic tests in EZ localization coupled with the preferable surgical outcome in MRI-negative epilepsies.

The American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy.

Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a novel tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the recent introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN position statement is based.

Dynamics of interhemispheric coherence in changing functional states in adults with localization-related epilepsy

Study of the dynamics of interhemispheric coherence in patients with localization-related epilepsy with different responses to anticonvulsants in the physiological state (FS) of active, relaxed wakefulness and sleep.

Gender aspects of localization-related and generalized epilepsy

Aim. To study gender and age aspects of epilepsy in patients with localization-related and generalized forms of epilepsy in the village of Mashtaga, Baku city.Material and methods. The gender structure of epilepsy in the village study was conducted simultaneously with a cohort pro- and retrospective research of its epidemiology at the United City Hospital (OGB) No. 7 in the village of Mashtaga and at the Department of Neurology of the Educational and Therapeutic Corps of AMU during the period from 2016 till 2019. Psychoemotional state (Ziqmond scale), severity of seizures (NHS3 scale), quality of life (QOLIE-10 questionnaire) were studied. For statistical processing, Fisher LSD and Pearson’s rank correlation coefficient were used at the level of significant results — p &lt; 0.05.Results and discussion. Among 197 patients with epilepsy, 121 (61.4%) men and 76 (38.6%) women were examined. Most of them were accounted for localization-related epilepsy — 129 people (65.4%). 68 patients (33.5%) suffered from generalized epilepsy. The indigenous (37,505 people) and nonindigenous (8295 people) population were represented mainly by Azerbaijanis. The number of male patients with SPE exceeded the number of females (χ2 = 8.515; p = 0.004), (p &lt; 0.05). There were more male patients with HE (41 (60.3%)) than females (27 (39.7%)). The severity of seizures, evaluated with the use of the NHS3 scale, was higher in male patients than in females. The psychoemotional state according to the Ziqmond scale in female patients from non-indigenous inhabitants was lower (9.05 ± 0.30; m = 6, M = 13) than in those of indigenous (8.83 ± 0.21; m = 5, M = 12), (p = 0.046). Assessment of the quality of life of patients with epilepsy according to QOLIE-10, did not reveal any gender diff erence.Conclusions. A gender-specific approach to the condition of patients with epilepsy will contribute to the improvement of both, clinical and psychoemotional parameters, thereby having a positive effect on the quality of life.

English

BACKGROUND Though epilepsy remains a significant problem for children and adolescents in our country, studies delineating the clinical profile and response to treatment in childhood epilepsy are lacking. The current study was carried out for obtaining a baseline profile and to predict the response to treatment in childhood epilepsy in India that may be helpful in planning management strategies from a public health point of view. METHODS Patients with clinical suggestion of active epilepsy (N = 141) from one month to 12 years, were enrolled into the study over a period of 1 year (February 2010 to January 2011) from the out-patient department and epilepsy clinic of Bangur Institute of Neurology. Detailed history was taken along with neurological examination. Electroencephalography (EEG) and neuroimaging (MRI / CT scan) were done on all patients. Each patient included in the study was kept in followup for a period of 6 months and their response to the treatment was recorded. RESULTS About 48.9 % (N = 69) patients had localisation related epilepsy while the rest had generalised epilepsy. Of those with generalised epilepsy, generalised tonicclonic seizures (GTCS) was by far the most common type. Of those with focal EEG activity, the highest proportion (50 %), were localised to the temporal lobe. Symptomatic aetiology accounted for 59.6 % (N = 84) of the patients. 20.6 % (N = 29) had poor response to treatment at 6 months follow-up. Abnormal neuroimaging (OR = 6.708) and abnormal EEG (OR = 6.357) were effective factors in predicting poor response to treatment. CONCLUSIONS Our study highlights the need to link specialised epilepsy services with primary health centres for early detection and treatment. EEG is an essential cost-effective modality in determining seizure localisation and response to treatment. KEYWORDS Paediatric, Epilepsy, Clinical Profile, Response to Treatment

Chapter 1 - Neurologic complications of pediatric congenital heart disease

Improved medical management and surgical outcomes have significantly decreased mortality in children with congenital heart disease; however, with increased survival, there is a greater lifetime exposure to neurologic complications with serious long-term neurodevelopmental consequences. Thus, recent focus has shifted to recognition and reduction of these extracardiac comorbidities. Vascular and infective complications, such as arterial ischemic stroke, infective endocarditis, and localization-related epilepsy are some of the most common neurologic comorbidities of congenital heart disease. In addition, it is now well recognized that congenital heart disease has an impact on overall brain development and contributes to adverse neurodevelopmental outcomes across multiple domains. The goal of this chapter is to summarize the most common neurologic comorbidities of congenital heart disease and its management.

Epileptogenic Temporal lobe Intrinsic Epidermoid Tumor: A Rare Case Report and Review of the Literature

Intracerebral epidermoid cysts are uncommon, accounting for only around 1.5 percent of intracranial tumors. Among these, Temporal lobe intracerebral epidermoid tumors are exceedingly rare. The great majority of these slow-growing tumors are asymptomatic, whereas few exhibit overt symptomatologies. We report a case of epidermoid tumors in a unique location, presented as a secondary complex partial seizure. A forty-year-old female presented with multiple episodes of convulsions followed by loss of consciousness for nine months, increasing in frequency over the last two months. MRI of the brain without contrast showed a well-circumscribed right temporal lobe mass, appearing hypointense on the T1 and hyperintense on the T2 sequence. In addition to our experience and review of existing literature demonstrate gross total resection of these lesions confers control of localization-related epilepsy.

Reinterpretation of magnetic resonance imaging findings with magnetoencephalography can improve the accuracy of detecting epileptogenic cortical lesions

ObjectiveThis study examined whether the application of magnetoencephalography (MEG) to interpret magnetic resonance imaging (MRI) findings can aid the diagnosis of intractable epilepsy caused by organic brain lesions. MethodsThis study included 51 patients with epilepsy who had MEG clusters but whose initial MRI findings were interpreted as being negative for organic lesions. Three board-certified radiologists reinterpreted the MRI findings, utilizing the MEG findings as a guide. The degree to which the reinterpretation of the imaging results identified an organic lesion was rated on a 5-point scale. ResultsReinterpretation of the MRI data with MEG guidance helped detect an abnormality by at least one radiologist in 18 of the 51 patients (35.2%) with symptomatic localization-related epilepsy. A surgery was performed in 7 of the 51 patients, and histopathological analysis results identified focal cortical dysplasia in 5 patients (Ia: 1, IIa: 2, unknown: 2), hippocampal sclerosis in 1 patient, and dysplastic neurons/gliosis in 1 patient. ConclusionsThe results of this study highlight the potential diagnostic applications of MEG to detect organic epileptogenic lesions, particularly when radiological visualization is difficult with MRI alone.

Altered Mental Status in a 5-year-old Girl

1. Tara M. Kopp, MD, MS* 2. Jacob M. Redel, MD†,‡ 3. Holly E. Depinet, MD, MPH§,¶ 1. *Department of Pediatrics, University of Louisville, Louisville, KY 2. †Division of Endocrinology, Children’s Mercy Hospital, Kansas City, MO 3. ‡Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 4. §Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 5. ¶Department of Pediatric, College of Medicine, University of Cincinnati, Cincinnati, OH A 5-year-old fully immunized girl with a history of tuberous sclerosis, localization-related epilepsy with remote resection of a seizure focus, developmental delay, oral aversion with gastrostomy tube dependence, and necrotizing pancreatitis presents with reported episodes of gait instability and altered mental status described as her head falling down, sudden diffuse loss of muscle tone, and unresponsiveness lasting 15 to 45 seconds. During the past few hours, the mother has noticed that the child appears wobbly. She had 1 episode of wobbliness with subsequent fall but denies any head injury, loss of consciousness, or tonic-clonic movements. On presentation to the emergency department she had 2 additional episodes of hypotonia and unresponsiveness to verbal stimuli lasting less than 1 minute. She had not recently missed any of her antiepileptic medications, which included levetiracetam, perampanel, vigabatrin, and taurine. In addition, her medications had not been changed in the past 6 months. Due to her oral aversion, her mother assures us that she would not have accidentally ingested any medications or other household substances. Initial temporal temperature is 98.2°F (36.8°C), heart rate is 124 beats/min, blood pressure is 107/77 mm Hg, respiratory rate is 24 breaths/min, and oxygen saturation is 96% on room air. Physical examination reveals a wakeful crying girl fighting medical personnel and intermittently becoming hypotonic and unresponsive to verbal commands. Mucous membranes are moist, and extremities have brisk capillary refill. Respiratory effort is normal except for episodes of periodic shallow breathing. Pupils are midline and reactive but become dilated with minimal responsiveness during the episodes of hypotonia and unresponsiveness. Upper and lower extremity hypotonia is noted (with intermittent worsening during …

Utility of invasive electroencephalography in children 3 years old and younger with refractory epilepsy.

Early surgical intervention for pediatric refractory epilepsy is increasingly advocated as surgery has become safer and data have demonstrated improved outcomes with early seizure control. There is concern that the risks associated with staged invasive electroencephalography (EEG) in very young children outweigh the potential benefits. Here, the authors present a cohort of children with refractory epilepsy who were referred for invasive monitoring, and they evaluate the role and safety of staged invasive EEG in those 3 years old and younger. The authors conducted a retrospective review of children 3 years and younger with epilepsy, who had been managed surgically at two institutions between 2001 and 2015. A cohort of pediatric patients older than 3 years of age was used for comparison. Demographics, seizure etiology, surgical management, surgical complications, and adverse events were recorded. Statistical analysis was completed using Stata version 13. A p < 0.05 was considered statistically significant. Fisher's exact test was used to compare proportions. Ninety-four patients (45 patients aged ≤ 3 [47.9%]) and 208 procedures were included for analysis. Eighty-six procedures (41.3%) were performed in children younger than 3 years versus 122 in the older cohort (58.7%). Forty-two patients underwent grid placement (14 patients aged ≤ 3 [33.3%]); 3 of them developed complications associated with the implant (3/42 [7.14%]), none of whom were among the younger cohort. Across all procedures, 11 complications occurred in the younger cohort versus 5 in the older patients (11/86 [12.8%] vs 5/122 [4.1%], p = 0.032). Two adverse events occurred in the younger group versus 1 in the older group (2/86 [2.32%] vs 1/122 [0.82%], p = 0.571). Following grid placement, 13/14 younger patients underwent guided resections compared to 20/28 older patients (92.9% vs 71.4%, p = 0.23). While overall complication rates were higher in the younger cohort, subdural grid placement was not associated with an increased risk of surgical complications in that population. Invasive electrocorticography informs management in very young children with refractory, localization-related epilepsy and should therefore be used when clinically indicated.