Temporal Lobe Resection For Epilepsy Research Articles

Social-semantic knowledge in frontotemporal dementia and after anterior temporal lobe resection

Abstract Degraded semantic memory is a prominent feature of frontotemporal dementia (FTD). It is classically associated with semantic dementia and anterior temporal lobe (ATL) atrophy, but semantic knowledge can also be compromised in behavioural-variant FTD (bvFTD). Motivated by understanding behavioural change in FTD, recent research has focused selectively on social-semantic knowledge, with proposals that the right ATL is specialised for social concepts. Previous studies have assessed very different types of social concepts and have not compared performance to that on matched non-social concepts. Consequently, it remains unclear to what extent various social concepts are (i) concurrently impaired in FTD, (ii) distinct from general semantic memory and (iii) differentially supported by the left and right ATL. This study assessed multiple aspects of social-semantic knowledge and general conceptual knowledge across cohorts with ATL-damage arising from either neurodegeneration or resection. We assembled a test battery measuring knowledge of multiple types of social concept. Performance was compared to non-social general conceptual knowledge, measured using the Cambridge Semantic Memory Test Battery and other matched non-social-semantic tests. Our transdiagnostic approach included bvFTD, semantic dementia and “mixed” intermediate cases to capture the FTD clinical spectrum, as well as age-matched healthy controls. People with unilateral left or right ATL resection for temporal lobe epilepsy (TLE) were also recruited to assess how selective damage to the left or right ATL impacts social- and non-social-semantic knowledge. Social- and non-social-semantic deficits were severe and highly correlated in FTD. Much milder impairments were found after unilateral ATL resection, with no left vs. right differences in social-semantic knowledge or general semantic processing, and with only naming showing a greater deficit following left vs. right damage. A principal component analysis of all behavioural measures in the FTD cohort extracted three components, interpreted as capturing: (1) FTD severity, (2) semantic memory and (3) executive function. Social and non-social measures both loaded heavily on the same semantic memory component, and scores on this factor were uniquely associated with bilateral ATL grey matter volume but not with the degree of ATL asymmetry. Together, these findings demonstrate that both social- and non-social-semantic knowledge degrade in FTD (semantic dementia and bvFTD) following bilateral ATL atrophy. We propose that social-semantic knowledge is part of a broader conceptual system underpinned by a bilaterally-implemented, functionally-unitary semantic hub in the ATLs. Our results also highlight the value of a transdiagnostic approach for investigating the neuroanatomical underpinnings of cognitive deficits in FTD.

The impact of bilateral versus unilateral anterior temporal lobe damage on face recognition, person knowledge and semantic memory.

The functional importance of the anterior temporal lobes (ATLs) has come to prominence in two active, albeit unconnected literatures-(i) face recognition and (ii) semantic memory. To generate a unified account of the ATLs, we tested the predictions from each literature and examined the effects of bilateral versus unilateral ATL damage on face recognition, person knowledge, and semantic memory. Sixteen people with bilateral ATL atrophy from semantic dementia (SD), 17 people with unilateral ATL resection for temporal lobe epilepsy (TLE; left = 10, right = 7), and 14 controls completed tasks assessing perceptual face matching, person knowledge and general semantic memory. People with SD were impaired across all semantic tasks, including person knowledge. Despite commensurate total ATL damage, unilateral resection generated mild impairments, with minimal differences between left- and right-ATL resection. Face matching performance was largely preserved but slightly reduced in SD and right TLE. All groups displayed the familiarity effect in face matching; however, it was reduced in SD and right TLE and was aligned with the level of item-specific semantic knowledge in all participants. We propose a neurocognitive framework whereby the ATLs underpin a resilient bilateral representation system that supports semantic memory, person knowledge and face recognition.

Indirect structural changes and reduced controllability after temporal lobe epilepsy resection.

To understand the potential behavioral and cognitive effects of mesial temporal resection for temporal lobe epilepsy (TLE) a method is required to characterize network-wide functional alterations caused by a discrete structural disconnection. The objective of this study was to investigate network-wide alterations in brain dynamics of patients with TLE before and after surgical resection of the seizure focus using average regional controllability (ARC), a measure of the ability of a node to influence network dynamics. Diffusion-weighted imaging (DWI) data were acquired in 27 patients with drug-resistant unilateral mesial TLE who underwent selective amygdalohippocampectomy. Imaging data were acquired before and after surgery and a presurgical and postsurgical structural connectome was generated from whole-brain tractography. Edge-wise strength, node strength, and node ARC were compared before and after surgery. Direct and indirect edge-wise strength changes were identified using patient-specific simulated resections. Direct edges were defined as primary edges disconnected by the resection zone itself. Indirect edges were secondary measured edge strength changes. Changes in node strength and ARC were then related to both direct and indirect edge changes. We found nodes with significant postsurgical changes in both node strength and ARC surrounding the resection zone (paired t tests, p < .05, Bonferroni corrected). ARC identified additional postsurgical changes in nodes outside of the resection zone within the ipsilateral occipital lobe, which were associated with indirect edge-wise strength changes of the postsurgical network (Fisher's exact test, p < .001). These indirect edge-wise changes were facilitated through the "hub" nodes including the thalamus, putamen, insula, and precuneus. Discrete network disconnection from TLE resection results in widespread structural and functional changes not predicted by disconnection alone. These can be well characterized by dynamic controllability measures such as ARC and may be useful for investigating changes in brain function that may contribute to seizure recurrence and behavioral or cognitive changes after surgery.

Patients’ long-term perspectives on gains and losses after temporal lobe resection for epilepsy

ObjectiveTo investigate long-term (>10 years) experiences and overall satisfaction with temporal lobe resections (TLB) for epilepsy. MethodsEligible participants were identified through the administrative epilepsy surgery registry at Oslo University Hospital. Data were collected through individual, semi-structured interviews with fifty participants. Interview records were analyzed using reflexive thematic analysis. ResultsParticipants’ answers were divided into two main themes: “looking back on surgery” and”considering gains and losses from surgery”. Most participants expressed satisfaction with having undergone surgery. Nevertheless, postsurgical problems had been encountered, and presurgical hopes had only partly been fulfilled. They described memory and naming problems with a major impact on daily life. Further, they had thoughts about effects on employment, independence, and feelings of loneliness, and expressed a need for more and better preoperative information. ConclusionsPresurgical hopes go beyond seizure freedom and memory and naming problems are experienced lasting many years after surgery in the temporal lobe. Better preoperative information, particularly about unwanted cognitive effects, is of prime importance. By exploring patientś presurgical hopes, a common ground for expectations on surgery may be found along with strategies on how to cope with cognitive difficulties and possible negative life changes.

Hippocampal resection in temporal lobe epilepsy: Do we need to resect the tail?

IntroductionAnteromesial temporal lobe resection is the most common surgical technique used to treat drug-resistant mesial temporal lobe epilepsy, particularly when secondary to hippocampal sclerosis. Structural and functional imaging data suggest the importance of sparing the posterior hippocampus for minimising language and memory deficits. Recent work has challenged the view that maximal posterior hippocampal resection improves seizure outcome. This study was designed to assess whether resection of posterior hippocampal atrophy was associated with improved seizure outcome. MethodsRetrospective analysis of a prospective database of all anteromesial temporal lobe resections performed in individuals with hippocampal sclerosis at our epilepsy surgery centre, 2013–2021. Pre- and post-operative MRI were reviewed by 2 neurosurgical fellows to assess whether the atrophic segment, displayed by automated hippocampal morphometry, was resected, and ILAE seizure outcomes were collected at 1 year and last clinical follow-up. Data analysis used univariate and binary logistic regression. ResultsSixty consecutive eligible patients were identified of whom 70% were seizure free (ILAE Class 1 & 2) at one year. There was no statistically significant difference in seizure freedom outcomes in patients who had complete resection of atrophic posterior hippocampus or not (Fisher’s Exact test statistic 0.69, not significant at p < .05) both at one year, and at last clinical follow-up. In the multivariate analysis only a history of status epilepticus (OR=0.2, 95%CI:0.042–0.955, p = .04) at one year, and pre-operative psychiatric disorder (OR=0.145, 95%CI:0.036–0.588, p = .007) at last clinical follow-up, were associated with a reduced chance of seizure freedom. SignificanceOur data suggest that seizure freedom is not associated with whether or not posterior hippocampal atrophy is resected. This challenges the traditional surgical dogma of maximal posterior hippocampal resection in anteromesial temporal lobe resections and is a step further optimising this surgical procedure to maximise seizure freedom and minimise associated language and memory deficits.

424 The Role of the Mid Fusiform Gyrus in Lexical Retrieval

INTRODUCTION: Temporal lobe resections for epilepsy or neoplasms often result in significant confrontation naming decline. This can be socio-economically disabling and prevent patients from returning to independent functioning. While the exact substrates responsible are unknown, it was previously assumed that injury to the superior temporal gyrus or resection size predicts these declines. A clear understanding of the most critical constituents might influence surgical strategies to minimize language declines. METHODS: Data were obtained from 95 patients who underwent surgical resection in the dominant left temporal lobe for medication-resistant epilepsy. Patients underwent neuropsychological testing and MRI prior to and 6 months following surgery. Lesion masks were traced on postoperative MRIs and aligned to a normative space. The effects of preoperative scores and seizure outcomes were removed from postoperative scores via linear regression. VLSM using multivariate support vector regression was used to assess postoperative test scores. Beta maps were converted to p values and corrected using a permutation-based cluster level correction. Additionally, a surface-based mixed-effects multilevel analysis was used to estimate broadband gamma activity during picture naming across a subset of subjects with ECoG recordings, and results were integrated with VLSM. Lastly, fMRI (picture naming) was used to assess SNR in significant regions. RESULTS: VLSM analysis revealed that the loss of basal temporal regions was associated with a prominent decline in BNT scores (p &lt; 0.005). Similarly, ECoG analysis showed a significant increase in activity in the mid fusiform gyrus (mFus) immediately preceding articulation. Many of these voxels were associated with low SNR on fMRI, perhaps explaining why this region has been under-appreciated as the locus responsible for postoperative deficits. CONCLUSION: The importance of the ventral temporal cortex in lexical access is shown using multivariate VLSM and supported with ECoG. While it has previously been assumed that mFus lesions do not cause pervasive impairment, our data and recent work (FATES study) argue against this and support the role of the mFus as a critical semantic access hub.

339 Influence of SEEG on Temporal Lobectomy

INTRODUCTION: Seizure outcomes after surgical resection in temporal lobe epilepsy (TLE) are historically better in the presence of a discrete MRI lesion, as the surgical hypothesis is better informed by imaging. The role of intracranial monitoring via stereotactic electroencephalography vs. proceeding directly to surgery in this patient population remains under debate. METHODS: SEEG usage trends were investigated for 391 consecutive patients who had temporal lobectomy performed from 2015 to 2020. Correlation with Engel scores at 1 year post-op was performed using chi-square for 259 patients in whom this data was available. RESULTS: Sparing of mesial structures was more common in patients who had SEEG (35% vs 20%, p &lt; 0.01). There was a nonsignificant trend towards better outcomes in patients who did not have SEEG (63.5% Engel 1 vs 50.5%, p &lt; 0.55). MRI abnormalities were significantly more prevalent in the cohort that underwent SEEG (92% vs. 58%, p &lt; 0.001), and there was no significant association between the presence of MRI abnormality and outcome (p = 0.59). CONCLUSION: We found no statistically significant difference in seizure freedom in patients who undergo temporal lobectomy with SEEG in the presurgical workup. This likely results from SEEG being used when the surgical hypothesis is difficult to formulate, reflected by the increased prevalence of distinct imaging abnormalities in the non-SEEG cohort. Thus it seems that the use of SEEG helps close the gap in outcomes for patients with non-lesional temporal lobe epilepsy. There was no difference in outcomes associated with the decision to spare mesial structures, indicating this effect likely stems from patient selection for surgery. Our future work will look into the connection between SEEG and volumes of surgical resection.

Resection of the piriform cortex for temporal lobe epilepsy: a Novel approach on imaging segmentation and surgical application

Background The piriform cortex (PC) occupies both banks of the endorhinal sulcus and has an important role in the pathophysiology of temporal lobe epilepsy (TLE). A recent study showed that resection of more than 50% of PC increased the odds of becoming seizure free by a factor of 16. Objective We report the feasibility of manual segmentation of PC and application of the Geodesic Information Flows (GIF) algorithm to automated segmentation, to guide resection. Methods Manual segmentation of PC was performed by two blinded independent examiners in 60 patients with TLE (55% Left TLE, 52% female) with a median age of 35 years (IQR, 29–47 years) and 20 controls (60% Women) with a median age of 39.5 years (IQR, 31–49). The GIF algorithm was used to create an automated pipeline for parcellating PC which was used to guide excision as part of temporal lobe resection for TLE. Results Right PC was larger in patients and controls. Parcellation of PC was used to guide anterior temporal lobe resection, with subsequent seizure freedom and no visual field or language deficit. Conclusion Reliable segmentation of PC is feasible and can be applied prospectively to guide neurosurgical resection that increases the chances of a good outcome from temporal lobe resection for TLE.

Nomograms to Predict Verbal Memory Decline After Temporal Lobe Resection in Adults With Epilepsy.

To develop and externally validate models to predict the probability of postoperative verbal memory decline in adults after temporal lobe resection (TLR) for epilepsy using easily accessible preoperative clinical predictors. Multivariable models were developed to predict delayed verbal memory outcome on 3 commonly used measures: Rey Auditory Verbal Learning Test (RAVLT) and Logical Memory (LM) and Verbal Paired Associates (VPA) subtests from Wechsler Memory Scale-Third Edition. With the use of the Harrell step-down procedure for variable selection, models were developed in 359 adults who underwent TLR at the Cleveland Clinic and validated in 290 adults at 1 of 5 epilepsy surgery centers in the United States or Canada. Twenty-nine percent of the development cohort and 26% of the validation cohort demonstrated significant decline on at least 1 verbal memory measure. Initial models had good to excellent predictive accuracy (calibration [c] statistic range 0.77-0.80) in identifying patients with memory decline; however, models slightly underestimated decline in the validation cohort. Model coefficients were updated with data from both cohorts to improve stability. The model for RAVLT included surgery side, baseline memory score, and hippocampal resection. The models for LM and VPA included surgery side, baseline score, and education. Updated model performance was good to excellent (RAVLT c = 0.81, LM c = 0.76, VPA c = 0.78). Model calibration was very good, indicating no systematic overestimation or underestimation of risk. Nomograms are provided in 2 easy-to-use formats to assist clinicians in estimating the probability of verbal memory decline in adults considering TLR for treatment of epilepsy. This study provides Class II evidence that multivariable prediction models accurately predict verbal memory decline after TLR for epilepsy in adults.

Predicting verbal memory decline following temporal lobe resection for epilepsy.

The aim of the study was to develop a prediction model for verbal memory decline after temporal lobe resection (TLR) for epilepsy. The model will be used in the preoperative counselling of patients to give individualized information about risk for verbal memory decline. A sample of 110 consecutive patients who underwent TLR for epilepsy at Sahlgrenska University Hospital between 1987 and 2011 constituted the basis for the prediction model. They had all gone through a formal neuropsychological assessment before surgery and 2years after. Penalized regression and 20×10-fold cross-validation were used in order to build a reliable model for predicting individual risks. The final model included four predictors: side of surgery; inclusion or not of the hippocampus in the resection; preoperative verbal memory function; and presence/absence of focal to bilateral tonic-clonic seizures (TCS) the last year prior to the presurgical investigation. The impact of a history of TCS is a new finding which we interpret as a sign of a more widespread network disease which influences neuropsychological function and the cognitive reserve. The model correctly identified 82% of patients with post-operative decline in verbal memory, and the overall accuracy was 70%-85% depending on choice of risk thresholds. The model makes it possible to provide patients with individualized prediction regarding the risk of verbal memory decline following TLR. This will help them make more informed decisions regarding treatment, and it will also enable the epilepsy surgery team to prepare them better for the rehabilitation process.

Improved Detection of Subtle Mesial Temporal Sclerosis: Validation of a Commercially Available Software for Automated Segmentation of Hippocampal Volume.

Identification of mesial temporal sclerosis is critical in the evaluation of individuals with temporal lobe epilepsy. Our aim was to assess the performance of FDA-approved software measures of hippocampal volume to identify mesial temporal sclerosis in patients with medically refractory temporal lobe epilepsy compared with the initial clinical interpretation of a neuroradiologist. Preoperative MRIs of 75 consecutive patients who underwent a temporal resection for temporal lobe epilepsy from 2011 to 2016 were retrospectively reviewed, and 71 were analyzed using Neuroreader, a commercially available automated segmentation and volumetric analysis package. Volume measures, including hippocampal volume as a percentage of total intracranial volume and the Neuroreader Index, were calculated. Radiologic interpretations of the MR imaging and pathology from subsequent resections were classified as either mesial temporal sclerosis or other, including normal findings. These measures of hippocampal volume were evaluated by receiver operating characteristic curves on the basis of pathologic confirmation of mesial temporal sclerosis in the resected temporal lobe. Sensitivity and specificity were calculated for each method and compared by means of the McNemar test using the optimal threshold as determined by the Youden J point. Optimized thresholds of hippocampal percentage of a structural volume relative to total intracranial volume (<0.19%) and the Neuroreader Index (≤-3.8) were selected to optimize sensitivity and specificity (89%/71% and 89%/78%, respectively) for the identification of mesial temporal sclerosis in temporal lobe epilepsy compared with the initial clinical interpretation of the neuroradiologist (50% and 87%). Automated measures of hippocampal volume predicted mesial temporal sclerosis more accurately than radiologic interpretation (McNemar test, P < .0001). Commercially available automated segmentation and volume analysis of the hippocampus accurately identifies mesial temporal sclerosis and performs significantly better than the interpretation of the radiologist.

A lexical semantic hub for heteromodal naming in middle fusiform gyrus.

Semantic memory underpins our understanding of objects, people, places, and ideas. Anomia, a disruption of semantic memory access, is the most common residual language disturbance and is seen in dementia and following injury to temporal cortex. While such anomia has been well characterized by lesion symptom mapping studies, its pathophysiology is not well understood. We hypothesize that inputs to the semantic memory system engage a specific heteromodal network hub that integrates lexical retrieval with the appropriate semantic content. Such a network hub has been proposed by others, but has thus far eluded precise spatiotemporal delineation. This limitation in our understanding of semantic memory has impeded progress in the treatment of anomia. We evaluated the cortical structure and dynamics of the lexical semantic network in driving speech production in a large cohort of patients with epilepsy using electrocorticography (n = 64), functional MRI (n = 36), and direct cortical stimulation (n = 30) during two generative language processes that rely on semantic knowledge: visual picture naming and auditory naming to definition. Each task also featured a non-semantic control condition: scrambled pictures and reversed speech, respectively. These large-scale data of the left, language-dominant hemisphere uniquely enable convergent, high-resolution analyses of neural mechanisms characterized by rapid, transient dynamics with strong interactions between distributed cortical substrates. We observed three stages of activity during both visual picture naming and auditory naming to definition that were serially organized: sensory processing, lexical semantic processing, and articulation. Critically, the second stage was absent in both the visual and auditory control conditions. Group activity maps from both electrocorticography and functional MRI identified heteromodal responses in middle fusiform gyrus, intraparietal sulcus, and inferior frontal gyrus; furthermore, the spectrotemporal profiles of these three regions revealed coincident activity preceding articulation. Only in the middle fusiform gyrus did direct cortical stimulation disrupt both naming tasks while still preserving the ability to repeat sentences. These convergent data strongly support a model in which a distinct neuroanatomical substrate in middle fusiform gyrus provides access to object semantic information. This under-appreciated locus of semantic processing is at risk in resections for temporal lobe epilepsy as well as in trauma and strokes that affect the inferior temporal cortex-it may explain the range of anomic states seen in these conditions. Further characterization of brain network behaviour engaging this region in both healthy and diseased states will expand our understanding of semantic memory and further development of therapies directed at anomia.

Evidence for degraded low frequency verbal concepts in left resected temporal lobe epilepsy patients

According to a large neuropsychological and neuroimaging literature, the bilateral anterior temporal lobe (ATL) is a core region for semantic processing. It seems therefore surprising that semantic memory appears to be preserved in temporal lobe epilepsy (TLE) patients with unilateral ATL resection. However, recent work suggests that the bilateral semantic system is relatively robust against unilateral damage and semantic impairments under these circumstances only become apparent with low frequency specific concepts. In addition, neuroimaging studies have shown that the function of the left and right ATLs differ and therefore left or right ATL resection should lead to a different pattern of impairment. The current study investigated hemispheric differences in the bilateral semantic system by comparing left and right resected TLE patients during verbal semantic processing of low frequency concepts. Picture naming and semantic comprehension tasks with varying word frequencies were included to investigate the pattern of impairment. Left but not right TLE patients showed impaired semantic processing, which was particularly apparent on low frequency items. This indicates that, for verbal information, the bilateral semantic system is more sensitive to damage in the left compared to the right ATL, which is in line with theories that attribute a more prominent role to the left ATL due to connections with pre-semantic verbal regions.

Accelerated long-term forgetting in resected and seizure-free temporal lobe epilepsy patients

Episodic memory impairments caused by temporal lobe epilepsy (TLE) are well documented in the literature. Standard clinical episodic memory tests typically include a 30-min delayed recall test. However, in the past decade, it has become apparent that this standard test does not capture the full range of memory problems in TLE patients. Some patients perform well on a standard 30-min delayed recall test, but show Accelerated Long-term Forgetting (ALF) after 24 h. Although ALF has been investigated in patients with different types of epilepsy, current research on resected TLE patients is missing. In the present study, resected TLE patients were compared to a control group matched on initial learning. They showed normal performance on verbal recall after 30 min, but impairments became apparent after one week. Moreover, the significant interaction between participant group and memory test delay demonstrated that the patients indeed showed an acceleration in forgetting. Furthermore, ALF was present in both left and right resected TLE patients, which contradicts the presence of material-specific hemispheric differences in ALF. In addition, ALF was observed in seizure-free resected TLE patients, thereby demonstrating that this factor is not crucial for long-term memory deficits. The outcome shows that clinicians are likely to underestimate memory deficits in resected TLE patients and, therefore, advocates for the inclusion of ALF tests in standard clinical batteries for both pre- and post-surgery testing sessions.

The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients.

The presence and degree of specialization between the anterior temporal lobes (ATLs) is a key issue in debates about the neural architecture of semantic memory. Here, we comprehensively assessed multiple aspects of semantic cognition in a large group of postsurgical temporal lobe epilepsy (TLE) patients with left versus right anterior temporal lobectomy (n = 40). Both subgroups showed deficits in expressive and receptive verbal semantic tasks, word and object recognition, naming and recognition of famous faces and perception of faces and emotions. Graded differences in performance between the left and right groups were secondary to the overall mild semantic impairment; primarily, left resected TLE patients showed weaker performance on tasks that required naming or accessing semantic information from a written word. Right resected TLE patients were relatively more impaired at recognizing famous faces as familiar, although this effect was observed less consistently. These findings unify previous partial, inconsistent results and also align directly with fMRI and transcranial magnetic stimulation results in neurologically intact participants. Taken together, these data support a model in which the 2 ATLs act as a coupled bilateral system for the representation of semantic knowledge, and in which graded hemispheric specializations emerge as a consequence of differential connectivity to lateralized speech production and face perception regions.

Visual field defects after temporal lobe resection for epilepsy

PurposeTo determine visual field defects (VFDs) using methods of varying complexity and compare results with subjective symptoms in a population of newly operated temporal lobe epilepsy patients. MethodsForty patients were included in the study. Two patients failed to perform VFD testing. Humphrey Field Analyzer (HFA) perimetry was used as the gold standard test to detect VFDs. All patients performed a web-based visual field test called Damato Multifixation Campimetry Online (DMCO). A bedside confrontation visual field examination ad modum Donders was extracted from the medical records in 27/38 patients. All participants had a consultation by an ophthalmologist. A questionnaire described the subjective complaints. ReultsA VFD in the upper quadrant was demonstrated with HFA in 29 (76%) of the 38 patients after surgery. In 27 patients tested ad modum Donders, the sensitivity of detecting a VFD was 13%. Eight patients (21%) had a severe VFD similar to a quadrant anopia, thus, questioning their permission to drive a car. In this group of patients, a VFD was demonstrated in one of five (sensitivity=20%) ad modum Donders and in seven of eight (sensitivity=88%) with DMCO. Subjective symptoms were only reported by 28% of the patients with a VFD and in two of eight (sensitivity=25%) with a severe VFD. Most patients (86%) considered VFD information mandatory. ConclusionVFD continue to be a frequent adverse event after epilepsy surgery in the medial temporal lobe and may affect the permission to drive a car in at least one in five patients. Subjective symptoms and bedside visual field testing ad modum Donders are not sensitive to detect even a severe VFD. Newly developed web-based visual field test methods appear sensitive to detect a severe VFD but perimetry remains the golden standard for determining if visual standards for driving is fulfilled. Patients consider VFD information as mandatory.

Human temporal cortical single neuron activity during working memory maintenance

The Working Memory model of human memory, first introduced by Baddeley and Hitch (1974), has been one of the most influential psychological constructs in cognitive psychology and human neuroscience. However the neuronal correlates of core components of this model have yet to be fully elucidated. Here we present data from two studies where human temporal cortical single neuron activity was recorded during tasks differentially affecting the maintenance component of verbal working memory. In Study One we vary the presence or absence of distracting items for the entire period of memory storage. In Study Two we vary the duration of storage so that distractors filled all, or only one-third of the time the memory was stored. Extracellular single neuron recordings were obtained from 36 subjects undergoing awake temporal lobe resections for epilepsy, 25 in Study one, 11 in Study two. Recordings were obtained from a total of 166 lateral temporal cortex neurons during performance of one of these two tasks, 86 study one, 80 study two. Significant changes in activity with distractor manipulation were present in 74 of these neurons (45%), 38 Study one, 36 Study two. In 48 (65%) of those there was increased activity during the period when distracting items were absent, 26 Study One, 22 Study Two. The magnitude of this increase was greater for Study One, 47.6%, than Study Two, 8.1%, paralleling the reduction in memory errors in the absence of distracters, for Study One of 70.3%, Study Two 26.3% These findings establish that human lateral temporal cortex is part of the neural system for working memory, with activity during maintenance of that memory that parallels performance, suggesting it represents active rehearsal. In 31 of these neurons (65%) this activity was an extension of that during working memory encoding that differed significantly from the neural processes recorded during overt and silent language tasks without a recent memory component, 17 Study one, 14 Study two. Contrary to the Baddeley model, that activity during verbal working memory maintenance often represented activity specific to working memory rather than speech or language.

Is phosphorylated tau unique to chronic traumatic encephalopathy? Phosphorylated tau in epileptic brain and chronic traumatic encephalopathy

Repetitive traumatic brain injury (rTBI) is one of the major risk factors for the abnormal deposition of phosphorylated tau (PT) in the brain and chronic traumatic encephalopathy (CTE). CTE and temporal lobe epilepsy (TLE) affect the limbic system, but no comparative studies on PT distribution in TLE and CTE are available. It is also unclear whether PT pathology results from repeated head hits (rTBI). These gaps prevent a thorough understanding of the pathogenesis and clinical significance of PT, limiting our ability to develop preventative and therapeutic interventions. We quantified PT in TLE and CTE to unveil whether a history of rTBI is a prerequisite for PT accumulation in the brain. Six postmortem CTE (mean 73.3 years) and age matched control samples were compared to 19 surgically resected TLE brain specimens (4 months-58 years; mean 27.6 years). No history of TBI was present in TLE or control; all CTE patients had a history of rTBI. TLE and CTE brain displayed increased levels of PT as revealed by immunohistochemistry. No age-dependent changes were noted, as PT was present as early as 4 months after birth. In TLE and CTE, cortical neurons, perivascular regions around penetrating pial vessels and meninges were immunopositive for PT; white matter tracts also displayed robust expression of extracellular PT organized in bundles parallel to venules. Microscopically, there were extensive tau-immunoreactive neuronal, astrocytic and degenerating neurites throughout the brain. In CTE perivascular tangles were most prominent. Overall, significant differences in staining intensities were found between CTE and control (P<0.01) but not between CTE and TLE (P=0.08). pS199 tau analysis showed that CTE had the most high molecular weight tangle-associated tau, whereas epileptic brain contained low molecular weight tau. Tau deposition may not be specific to rTBI since TLE recapitulated most of the pathological features of CTE.

Diffusion tensor imaging tractography of Meyer's loop in planning resective surgery for drug-resistant temporal lobe epilepsy

Whether Meyer's loop (ML) tracking using diffusion tensor imaging tractography (DTIT) can be utilized to avoid post-operative visual field deficits (VFD) after anterior temporal lobectomy (ATL) for drug-resistant temporal lobe epilepsy (TLE) using a large cohort of controls and patients. Also, we wanted to create a normative atlas of ML in normal population. DTIT was used to study ML in 75 healthy subjects and 25 patients with and without VFD following ATL. 1.5T MRI echo-planar DTI sequences with DTI data were processed in Nordic ICE using a probabilistic method; a multiple region of interest technique was used for reconstruction of optic radiation trajectory. Visual fields were assessed in patients pre- and post-operatively. Results of ANOVA showed that the left ML-TP distance was less than right across all groups (p = 0.01). The average distance of ML from left temporal pole was 37.44 ± 4.7 mm (range: 32.2-46.6 mm) and from right temporal pole 39.08 ± 4.9 mm (range: 34.3-49.7 mm). Average distance of left and right temporal pole to tip of temporal horn was 28.32 ± 2.03 mm (range: 26.4-32.8 mm) and was 28.92 ± 2.09 mm, respectively (range: 25.9-33.3 mm). If the anterior limit of the Meyer's loop was ≤38 mm on the right and ≤35 mm on the left from the temporal pole, they are at a greater risk of developing VFDs. DTIT is a novel technique to delineate ML and plays an important role in planning surgical resection in TLE to predict post-operative visual performance and disability.

Complications after mesial temporal lobe surgery via inferiortemporal gyrus approach

The purpose of this study was to identify the complications associated with the inferior temporal gyrus approach to anterior mesial temporal lobe resection for temporal lobe epilepsy. This retrospective study examined complications experienced by 483 patients during the 3 months after surgery. All surgeries were performed during 1998-2012 by the senior author (F.L.V.). A total of 13 complications (2.7%) were reported. Complications were 8 delayed subdural hematomas (1.6%), 2 superficial wound infections (0.4%), 1 delayed intracranial hemorrhage (0.2%), 1 small lacunar stroke (0.2%), and 1 transient frontalis nerve palsy (0.2%). Three patients with subdural hematoma (0.6%) required readmission and surgical intervention. One patient (0.2%) with delayed intracranial hemorrhage required readmission to the neuroscience intensive care unit for observation. No deaths or severe neurological impairments were reported. Among the 8 patients with subdural hematoma, 7 were older than 40 years (87.5%); however, this finding was not statistically significant (p = 0.198). The inferior temporal gyrus approach to mesial temporal lobe resection is a safe and effective method for treating temporal lobe epilepsy. Morbidity and mortality rates associated with this procedure are lower than those associated with other neurosurgical procedures. The finding that surgical complications seem to be more common among older patients emphasizes the need for early surgical referral of patients with medically refractory epilepsy.