Diagnosis Of Temporal Lobe Epilepsy Research Articles

Magnetic resonance spectroscopy of the brain in the diagnosis of temporal lobe epilepsy

The temporal lobe is the most epileptogenic region of the brain. 90% of patients with temporal ictal epileptomorphic EEG activity have a variable long history of seizures. Magnetic resonance spectroscopy (MRS) may be useful in identifying an epileptogenic focus in patients with epilepsy without apparent structural pathology at neuroimaging.Objective: to systematize the results of early studies on this issue.Materials and methods.An electronic search was carried out in two English-language (Medline, PubMed) and one Russian-language (eLIBRARY.RU) databases. The search queries found 18,019 citations, by which 12 full-text articles were selected.Results and discussion.The main criteria for the diagnosis of temporal lobe epilepsy by MRS is to lower the level of N-acetylaspartate (NAA), the ratio of NAA to creatinine + choline (NAA/(Cr + Cho) in the brain region where there is neuronal death or damage, as well as a change in the level of myo-inositol, the elevated level of which indicates the presence of an epileptogenic focus, while the decreased one shows the spread of pathological activity to the adjacent tissues.Conclusion.This review will contribute to a better diagnosis of temporal lobe epilepsy, as well as to the intravital noninvasive detection of metabolic changes in the brain long before the development of structural pathology.

F03. Could rash be an ictal phenomenon in temporal lobe epilepsy?

Seizures in temporal lobe epilepsy (TLE) can cause cutaneous autonomic symptoms, including flushing, pallor, sweating and piloerection. Rash, however has never been described in the literature. We report a case of 46-year-old woman presented with seizures consisting of episodes of loss of consciousness preceded by auras of excessive heat, cold, nausea and urge to defecate. Her husband observed her to flail and roll her eyes back. She was amnesic for this episode except for preserved recollection of the aura. During seizure she always developed an erythematous pruritic rash that persisted for a day. She photographically documented her rash, showing extensive erythema with raised macules and papules, especially on the buttocks. Observed episodes lasted up to 10 min, but the concomitant rash always persisted for a day. Frequency of episodes was once or twice yearly. She denied palpitations, pain, or dyspnea with episodes. Workup prior to her initial neurology visit included echocardiography, tilt table testing, and Holter monitoring, which were all normal. Magnetic resonance imaging (MRI) of the brain showed increased signal intensity and loss of left hippocampal architecture with an en plaque meningioma over the left temporal convexity. Routine electroencephalogram (EEG) demonstrated intermittent left temporal slowing. Treatment with lamotrigine reduced seizure severity and frequency. With missed days of lamotrigine, breakthrough seizure auras with rash occur. Our case is one of dyscognitive seizures due to left temporal lobe epilepsy (TLE). The diagnosis of TLE was made by seizure semiology (altered behavior, amnesia), EEG (intermittent subtle left temporal slowing) and MRI of the brain (left hippocampal abnormality and left temporal en plaque meningioma). The diagnosis is supported by her good response to antiepileptic drug therapy and reappearance of seizures with occasional medication noncompliance. She has several uncommon symptoms with her seizures, including feelings of heat and cold, nausea and urge to defecate. Her seizures also cause one symptom not previously reported in the medical literature, pruritic erythematous rash.The mechanism and localizing value of rash in seizures is unknown because of its rarity, but our patient has good evidence of left temporal lobe localization for her seizures. Rash is the most unusual feature of her case, but an ictal urge to defecate is also unusual. Ictal urge to defecate has been reported quite rarely and she is only the fourth reported case. Contrary to the present case, evidence in previously reported cases of ictal urge to defecate suggested right temporal lobe localization. TLE is known to cause cutaneous autonomic manifestations including flushing, pallor, sweating and piloerection. These symptoms are thought to localize to the left temporal lobe. The present case shows that long lasting diffuse pruritic erythematous rash could also be an ictal phenomenon in left temporal lobe epilepsy.

Intracranial electrodes monitoring improves seizure control and complication outcomes for patients with temporal lobe epilepsy - A retrospective cohort study

BackgroundAnterior temporal lobectomy (ATL) is the standard surgical treatment for temporal lobe epilepsy (TLE), but patients may suffer from recurrent seizures post-surgery. Invasive electrical monitoring plays a critical role in precisely identifying the epileptic foci. This study aimed to evaluate and compare the benefits of long-term invasive electroencephalography (EEG) monitoring and two-stage surgery with the classical approach to examine their effect on post-surgical brain function and complications. Materials and methodsPatients with TLE (N = 198) who underwent epilepsy surgery were retrospectively evaluated. Diagnosis of TLE was confirmed based on clinical grounds (semiology), EEG findings, and magnetic resonance imaging (MRI). Long-term invasive video EEG was performed; epileptiform discharges were recorded. Patients underwent either classical ATL or modified two-step surgery with electrodes implantation. Histopathological examination was performed. The patients were followed up at 1, 3, and 5 years after surgery. ResultsTwenty-three and 175 patients underwent classical ATL and two-stage surgery, respectively. On histopathological examination, inflammation, hippocampal sclerosis, and cortical dysplasia were found to be the leading pathological causes of epileptic foci in both groups. MRI results were not consistent with the pathological findings. Grade II and III Engel scores were more frequent in the ATL group compared to two-stage surgery during follow-up. No postoperative complications were reported in two-stage surgery during follow-up, but one patient had mild hemiplegia in the ATL group. ConclusionsPreoperative invasive monitoring with long-term EEG helps locate the epileptic foci precisely. Postsurgical complications are rare compared to classical ATL, with better prognosis and seizure freedom after surgery.

The Role of Temporal Lobe Epilepsy in Cardiac Structure and Function

Cardiac autonomic and structural changes may occur in temporal lobe epilepsy (TLE) patients and may contribute to the risk of sudden unexpected death in epilepsy patients (SUDEP). The purpose of this investigation was to evaluate whether the presence of TLE and lifetime seizure activity in TLE patients correlates with changes in left ventricle (LV) dimensions, ejection fraction (EF), and LV mass. We reviewed clinical charts to obtain patients’ demographics, lifetime seizure count, antiepileptic drug (AED) use, and history of heart disease. A transthoracic echocardiogram machine was used to calculate LV dimensions, EF, and LV mass. By comparing TLE patients to control subjects, we found that TLE patients had thinner LV walls, smaller EF, and no significant difference in LV mass. Analysis of TLE patients with high or low number of lifetime seizures suggested that the two groups had no significant differences in LV wall thickness, EF, or LV mass. TLE does correlate with changes in the LV and EF, but the number of lifetime seizures does not. Future investigations should address the effects of different combinations of AEDs used by patients in this study on epileptic rats’ LV wall thickness and EF. Applications of this work include early diagnosis of TLE through the use of echocardiography data and reducing risk of patients dying of SUDEP.

Racial disparities in temporal lobe epilepsy

ObjectiveThis study reports on epilepsy type period prevalence and black-white racial differences in a large patient population in the Southeastern United States. MethodsFor all patients visiting the University of Alabama at Birmingham’s seizure monitoring unit between 2000 and 2011 (n = 3240), video EEG diagnosis was recorded along with basic demographic information. Descriptive statistics and multivariate logistic regression were used to identify factors associated with temporal lobe epilepsy (TLE) diagnosis. ResultsThe racial distribution was 77.3% white, and 20.0% black (other races were only 2.3% of the population). Most patients had either TLE (n = 630) or PNES (n = 1150) compared to other focal (n = 424) or generalized epilepsies (n = 224). The diagnosis of TLE was significantly greater for blacks than whites (odds ratio [OR] = 1.87, 95% confidence interval [CI] 1.47–2.37). The period prevalence measures for the other conclusively diagnosed epilepsies were not significantly different. Women were disproportionately represented in the study population, and black women carried the most statistical weight for the TLE prevalence difference. InterpretationThe nearly two-fold larger period prevalence of TLE among black patients is a striking finding that merits explanation. Although some selection bias exists due to a moderately lower than expected representation of blacks, socioeconomic status or access to care should not be assumed to be the only factors that might be responsible for the prevalence difference. Rather, all clues for distinct pathophysiological racial differences should be explored.

A Comparative Study of Feature Selection Methods for the Discriminative Analysis of Temporal Lobe Epilepsy.

It is crucial to differentiate patients with temporal lobe epilepsy (TLE) from the healthy population and determine abnormal brain regions in TLE. The cortical features and changes can reveal the unique anatomical patterns of brain regions from structural magnetic resonance (MR) images. In this study, structural MR images from 41 patients with left TLE, 34 patients with right TLE, and 58 normal controls (NC) were acquired, and four kinds of cortical measures, namely cortical thickness, cortical surface area, gray matter volume (GMV), and mean curvature, were explored for discriminative analysis. Three feature selection methods including the independent sample t-test filtering, the sparse-constrained dimensionality reduction model (SCDRM), and the support vector machine-recursive feature elimination (SVM-RFE) were investigated to extract dominant features among the compared groups for classification using the support vector machine (SVM) classifier. The results showed that the SVM-RFE achieved the highest performance (most classifications with more than 84% accuracy), followed by the SCDRM, and the t-test. Especially, the surface area and GMV exhibited prominent discriminative ability, and the performance of the SVM was improved significantly when the four cortical measures were combined. Additionally, the dominant regions with higher classification weights were mainly located in the temporal and the frontal lobe, including the entorhinal cortex, rostral middle frontal, parahippocampal cortex, superior frontal, insula, and cuneus. This study concluded that the cortical features provided effective information for the recognition of abnormal anatomical patterns and the proposed methods had the potential to improve the clinical diagnosis of TLE.

Surgery for Temporal Lobe Epilepsy in Children

This study aimed to assess the efficacy of magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) in localizing epileptic foci in children with temporal lobe epilepsy (TLE). This prospective study was conducted on 12 patients including five males and seven females aged between 2 and 16 years old with a clinical diagnosis of TLE. All the patients underwent high-resolution MRI and if no abnormality was identified, SPECT was used for further assessment. In all the patients, visual inspection identified unilateral mesial temporal sclerosis, and the patients underwent craniotomy and lesionectomy.According to the results, eight patients were categorized in class I and two cases were classifies as class II, and all the patients survived. About 25% of the patients showed adequate memory function on the non-operated temporal lobe, and general intelligence quotient increased by 10% in 50% of the patients.According to the results, in patients with clinically suspected TLE, MRI alone is not able to localize the epileptic foci correctly, and SPECT can be helpful to localize these lesions.

Clinical Characteristics of Mesial Temporal Lobe Epilepsy With Hippocampal Sclerosis and Temporal Lobe Epilepsies Due to Other Etiologies

Objectives: This study compared the clinical characteristics of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (mTLE-HS) to patients with temporal lobe epilepsy (TLE) due to other etiologies. Methods: In this prospective study, all patients with a clinical diagnosis of TLE were recruited at “Sanus’’ outpatient neurological clinic from June 2016 to June 2017. We took note if patients had mesial temporal sclerosis (MTS) (if they had clear signs of MTS and/or atrophy in their MRI) or any other MRI abnormality. Results: A total of 88 patients (36 patients with mTLE-HS and 52 patients with TLE due to other etiologies) were included in this study. High frequency of seizure (p<0.05), oroalimentary automatism (p<0.05), postictal nose wiping (p<0.001), and absence of psychomotor automatism (p<0.05) were commonly seen in patients with mTLE-HS, while vertiginous auras (p<0.05) was more frequently seen in those with TLE due to other etiologies. Conclusion: Clinical characteristics of patients with mTLE-HS were high frequency of seizure, oroalimentary automatism, postictal nose wiping, and absence of psychomotor automatism, while vertiginous auras was more frequent in those with TLE due to other etiologies.

Automated diagnosis of temporal lobe epilepsy in the absence of interictal spikes.

ObjectiveTo diagnose and lateralise temporal lobe epilepsy (TLE) by building a classification system that uses directed functional connectivity patterns estimated during EEG periods without visible pathological activity.MethodsResting-state high-density EEG recording data from 20 left TLE patients, 20 right TLE patients and 35 healthy controls was used. Epochs without interictal spikes were selected. The cortical source activity was obtained for 82 regions of interest and whole-brain directed functional connectivity was estimated in the theta, alpha and beta frequency bands. These connectivity values were then used to build a classification system based on two two-class Random Forests classifiers: TLE vs healthy controls and left vs right TLE. Feature selection and classifier training were done in a leave-one-out procedure to compute the mean classification accuracy.ResultsThe diagnosis and lateralization classifiers achieved a high accuracy (90.7% and 90.0% respectively), sensitivity (95.0% and 90.0% respectively) and specificity (85.7% and 90.0% respectively). The most important features for diagnosis were the outflows from left and right medial temporal lobe, and for lateralization the right anterior cingulate cortex. The interaction between features was important to achieve correct classification.SignificanceThis is the first study to automatically diagnose and lateralise TLE based on EEG. The high accuracy achieved demonstrates the potential of directed functional connectivity estimated from EEG periods without visible pathological activity for helping in the diagnosis and lateralization of TLE.

P362 Automated diagnosis of temporal lobe epilepsy in the absence of interictal spikes

Objective To diagnose and lateralise Temporal Lobe Epilepsy (TLE) by building a classification system that uses directed functional connectivity patterns estimated during EEG periods without visible pathological activity. Methods Resting-state high-density EEG recording data from 20 left TLE patients, 20 right TLE patients and 35 healthy controls was used. Epochs without interictal spikes were selected. The cortical source activity was obtained for 82 regions of interest and whole-brain directed functional connectivity was estimated in the theta, alpha and beta frequency bands. These connectivity values were then used to build a classification system based on two two-class Random Forests classifiers: TLE vs healthy controls and left vs right TLE. Feature selection and classifier training were done in a leave-one-out procedure to compute the mean classification accuracy. Results The diagnosis and lateralization classifiers achieved a high accuracy (90.7% and 90.0% respectively), sensitivity (95.0% and 90.0% respectively) and specificity (85.7% and 90.0% respectively). The most important features for diagnosis were the outflows from left and right medial temporal lobe, and for lateralization the right anterior cingulate cortex. The interaction between features was important to achieve correct classification. Conclusions This is the first study to automatically diagnose and lateralise TLE based on EEG. The high accuracy achieved demonstrates the potential of directed functional connectivity estimated from EEG periods without visible pathological activity for helping in the diagnosis and lateralization of TLE.

Classification of Temporal Lobe Epilepsy with and without Hippocampal Sclerosis Via Two-level Feature Selection

Hippocampal sclerosis (HS) is one of the most common histopathological abnormalities encountered in patients with temporal lobe epilepsy (TLE), which often serves as a diagnosis index of TLE. However, some patients with TLE have no pathologic characteristics of HS, which brings challenge to the diagnosis of TLE. Therefore, exploring effective methods to classify TLE patients with and without HS is meaningful to understanding the pathogenesis of TLE. In this paper, we propose a two-level feature selection method for classification. We select the categories of features as the first level and pick out the discriminating dimensions as the second level. Furthermore, we combine six regional brain characteristics as our features, including regional homogeneity (ReHo), amplitude of low-frequency fluctuation (ALFF), regional functional connectivity strength (RFCS) and three graph-based features. Results show that our method yields higher classification performance compared against the classifiers with single feature and without any level feature selection using functional magnetic resonance imaging (fMRI) data. Moreover, the discriminative brain regions selected by our method are consistent with previous studies. Thus, our method can accurately classify TLE patients with and without HS, which is interpretable from the perspective of physiology at the same time.

Cerebrospinal fluid microRNAs are potential biomarkers of temporal lobe epilepsy and status epilepticus

There is a need for diagnostic biomarkers of epilepsy and status epilepticus to support clinical examination, electroencephalography and neuroimaging. Extracellular microRNAs may be potentially ideal biomarkers since some are expressed uniquely within specific brain regions and cell types. Cerebrospinal fluid offers a source of microRNA biomarkers with the advantage of being in close contact with the target tissue and sites of pathology. Here we profiled microRNA levels in cerebrospinal fluid from patients with temporal lobe epilepsy or status epilepticus, and compared findings to matched controls. Differential expression of 20 microRNAs was detected between patient groups and controls. A validation phase included an expanded cohort and samples from patients with other neurological diseases. This identified lower levels of miR-19b in temporal lobe epilepsy compared to controls, status epilepticus and other neurological diseases. Levels of miR-451a were higher in status epilepticus compared to other groups whereas miR-21-5p differed in status epilepticus compared to temporal lobe epilepsy but not to other neurological diseases. Targets of these microRNAs include proteins regulating neuronal death, tissue remodelling, gliosis and inflammation. The present study indicates cerebrospinal fluid contains microRNAs that can support differential diagnosis of temporal lobe epilepsy and status epilepticus from other neurological and non-neurological diseases.

Psychiatric comorbidities in temporal lobe epilepsy: A case study

IntroductionPsychiatric disorders frequently occur in patients with temporal lobe epilepsy (TLE) (70%). This combination further reduces the quality of life of patients as diagnosis is difficult and therapeutic opportunities are often missed.ObjectivesThe aim of this case study is to show the possible association between TLE and psychiatric semiology and its therapeutic implications.MethodsPresentation of the clinical case of Mr BH who experienced psychosis like symptoms, was finally diagnosed with TLE and put under anti-epileptic drugs.ResultsMr BH, aged 22, with no family or personal history, was admitted for aggressive behavior, self-harm, pyromania, and depression. Three years prior to onset of psychiatric symptoms, he reports episodes of pulsatile- left-temporal headache followed by hypertonic movements of the neck. Symptoms were intermittently followed by total amnesia or impaired consciousness. The patient explained symptoms by an inner presence that he called “his twin” and to whom he attributed those behaviors contrary to his will. The discovery of bilateral hippocampal atrophy in magnetic resonance imaging with a normal electroencephalography suggested the diagnosis of TLE with post-ictal psychotic disorders. Patient was put initially on diazepam and olanzapine with partial improvement. Association of valproate led to progressive but then complete disappearance of symptoms and so confirmed our diagnosis.ConclusionsIt is often difficult to attach psychiatric symptoms to epilepsy. The diagnosis should be done on a set of clinical, radiological and electrical arguments.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Hippocampal analysis, using diffusion tensor imaging (DTI) and surface based analysis (SBA), to assist in temporal lobe epilepsy (TLE) research. Preliminary results

Introduction Epilepsy is the fourth most common, serious neurological disorder. Especially in Drug-Resistant Epilepsy (DRE), which is mostly treated with surgical intervention, the detection of a structural brain lesion is of paramount importance for the pre-surgical workup to identify the seizure focus. Purpose In this study we sought to investigate the contribution of advanced MRI techniques, combined with Surface-Based Analysis (SBA) to the exploration of epilepsy underlying pathophysiology. Methods and materials MRI, DTI and Spectroscopy (MRS) were acquired from a group of 35 young healthy adults (19-years old) and five young patients (19–25 years old) with TLE, using a 3T scanner. Hippocampal volumes were measured on high resolution T1-weighted MRI using the FreeSurfer software package which is based on SBA. Furthermore the DTI eigenvalues λ 1 , λ 2 , λ 3 , Fractional Anisotropy (FA) and Mean Diffusivity measurements were performed from two different software packages, Functool GE Healthcare and ExploreDTI. Results Hippocampal volume reduction is detected by automated segmentation via FreeSurfer in patients with TLE compared to the hippocampal volume measurements of the healthy adults. Using extracted data for hippocampal volume, Mean Diffusivity, FA, DTI eigenvalues and MRS, from the group of healthy volunteers, we generated a normative database in order to facilitate potential differentiation between physiological and pathological hippocampus. Conclusion In conclusion, our initial results indicate a strong contribution of advanced MRI combined with SBA towards the optimization of TLE diagnosis.

Minimally Invasive Transpalpebral Endoscopic-Assisted Amygdalohippocampectomy.

Although anterior temporal lobectomy may be a definitive surgical treatment for epileptic patients with mesial temporal sclerosis, it often results in verbal, visual, and cognitive dysfunction. Studies have consistently reported the advantages of selective procedures compared with a standard anterior temporal lobectomy, mainly in terms of neuropsychological outcomes. To describe a new technique to perform a selective amygdalohippocampectomy (SAH) through a transpalpebral approach with endoscopic assistance. A mini fronto-orbitozygomatic craniotomy through an eyelid incision was performed in 8 patients. Both a microscope and neuroendoscope were used in the surgeries. An anterior SAH was performed in 5 patients who had the diagnosis of temporal lobe epilepsy with mesial temporal sclerosis. One patient had a mesial temporal lesion suggesting a ganglioglioma. Two patients presented mesial temporal cavernomas with seizures originating from the temporal lobe. The anterior approach allowed removal of the amygdala and hippocampus. The image-guided system and postoperative evaluation confirmed that the amygdala may be accessed and completely removed through this route. The hippocampus was partially resected. All patients have discontinued medication with no more epileptic seizures. The patients with cavernomas and ganglioglioma also had their lesions completely removed. One-year follow-up has shown no visible scars. The anterior route for SAH is a rational and direct approach to the mesial temporal lobe. Anterior SAH is a safe, less invasive procedure that provides early identification of critical vascular and neural structures in the basal cisterns. The transpalpebral approach provides a satisfactory cosmetic outcome.

Individual feature maps: a patient-specific analysis tool with applications in temporal lobe epilepsy.

MRI-based diagnosis of temporal lobe epilepsy (TLE) can be challenging when pathology is not visually evident due to low image contrast or small lesion size. Computer-assisted analyses are able to detect lesions common in a specific patient population, but most techniques do not address clinically relevant individual pathologies resulting from the heterogeneous etiology of the disease. We propose a novel method to supplement the radiological inspection of TLE patients (n = 15) providing patient-specific quantitative assessment. Regions of interest are defined across the brain and volume, relaxometry, and diffusion features are extracted from them. Statistical comparisons between individual patients and a healthy control group (n = 17) are performed on these features, identifying and visualizing significant differences through individual feature maps. Four maps are created per patient showing differences in intensity, asymmetry, and volume. Detailed reports were generated per patient. Abnormal hippocampal intensity and volume differences were detected in all patients diagnosed with mesial temporal sclerosis (MTS). Abnormal intensities in the temporal cortex were identified in patients with no MTS. A laterality score correctly distinguished left from right TLE in 12 out of 15 patients. The proposed focus on subject-specific quantitative changes has the potential of improving the assessment of TLE patients using MRI techniques, possibly even redefining current imaging protocols for TLE.

Identifying clinical correlates for suicide among epilepsy patients in South Korea: A case-control study.

Suicide is a major cause of premature mortality in patients with epilepsy. We aimed to identify the clinical correlates of suicide in these patients. We conducted a matched, case-control study based on a clinical case registry of epilepsy patients (n = 35,638) treated between January 1994 and December 2011 at an academic tertiary medical center in Seoul, Korea. Each epilepsy patient in the suicide group (n = 74) was matched with three epilepsy patients in the nonsuicide group (n = 222) by age, gender, and approximate time at first treatment. The clinical characteristics of the patients in both groups were then compared. In a univariate analysis, seizure frequency during the year before suicide, use of antiepileptic drug polytherapy, lack of aura before seizure, diagnosis of temporal lobe epilepsy, use of levetiracetam, psychiatric comorbidity, and use of antidepressants were all significantly higher in the suicide group than in the nonsuicide group. Multivariate analysis revealed that a high seizure frequency (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.04-10.2), a lack of aura before seizure (OR 4.0, 95% CI 1.7-9.3), temporal lobe epilepsy (OR 3.7, 95% CI 1.6-8.6), and use of levetiracetam (OR 7.6, 95% CI 1.1-53.7) and antidepressants (OR 7.2, 95% CI 1.5-34.1) were all associated with a higher probability of suicide. Patients with temporal lobe epilepsy who experience seizures weekly or more frequently, experience a lack of aura, use levetiracetam, or take antidepressants are all at a higher risk of suicide and should be monitored closely.

Visual and auditory socio-cognitive perception in unilateral temporal lobe epilepsy in children and adolescents: a prospective controlled study.

A high rate of abnormal social behavioural traits or perceptual deficits is observed in children with unilateral temporal lobe epilepsy. In the present study, perception of auditory and visual social signals, carried by faces and voices, was evaluated in children or adolescents with temporal lobe epilepsy. We prospectively investigated a sample of 62 children with focal non-idiopathic epilepsy early in the course of the disorder. The present analysis included 39 children with a confirmed diagnosis of temporal lobe epilepsy. Control participants (72), distributed across 10 age groups, served as a control group. Our socio-perceptual evaluation protocol comprised three socio-visual tasks (face identity, facial emotion and gaze direction recognition), two socio-auditory tasks (voice identity and emotional prosody recognition), and three control tasks (lip reading, geometrical pattern and linguistic intonation recognition). All 39 patients also benefited from a neuropsychological examination. As a group, children with temporal lobe epilepsy performed at a significantly lower level compared to the control group with regards to recognition of facial identity, direction of eye gaze, and emotional facial expressions. We found no relationship between the type of visual deficit and age at first seizure, duration of epilepsy, or the epilepsy-affected cerebral hemisphere. Deficits in socio-perceptual tasks could be found independently of the presence of deficits in visual or auditory episodic memory, visual non-facial pattern processing (control tasks), or speech perception. A normal FSIQ did not exempt some of the patients from an underlying deficit in some of the socio-perceptual tasks. Temporal lobe epilepsy not only impairs development of emotion recognition, but can also impair development of perception of other socio-perceptual signals in children with or without intellectual deficiency. Prospective studies need to be designed to evaluate the results of appropriate re-education programs in children presenting with deficits in social cue processing.

EAR WORMS AND AUDITORY CHARLES BONNET SYNDROME

Background Visual hallucinations of Charles Bonnet syndrome (CBS) secondary to visual deprivation occur in 11–15% of elderly patients with acquired visual impairment. It is increasingly recognised that there is an auditory form of CBS consisting of musical hallucinations in elderly patients with acquired hearing loss. Here we present two cases of auditory CBS. Case 1: An 82 year old man with age related macular degeneration and deafness presented with a 2 year history of transient visual hallucinations which met proposed diagnostic criteria for CBS and a 1 year history of auditory musical hallucinations with retained insight. Case 2: An 85 year old lady was referred by psychiatrists querying a diagnosis of temporal lobe epilepsy. She described a 10 year history of depression, severe hearing loss, tinnitus and auditory hallucinations. The hallucinations took the form of a limited repertoire of songs, they were more likely to occur when the patient was alone and they affected sleep. The patient retained insight into the hallucinations and had learnt to control them using distraction. Conclusion Neurologists should be aware of the entity of auditory CBS in the form of musical hallucinations in elderly patients with significant hearing loss.

Temporal lobe epilepsy with apparent suicidal gestures

AbstractVarious ictal (during the seizure) behaviour patterns have been described in patients with epilepsy. Here, Drs Guruvaiah and Veerasamy describe unusual high‐risk ictal behaviours with the appearance of suicidal gestures in a patient who was subsequently given a diagnosis of temporal lobe epilepsy.