Epileptology

Introduction.-La dysplasie de trochlée est un des éléments majeurs de l'instabilité fémoropatellaire. Si sa correction par trochléoplastie apparaît logique, le résultat à long terme de cette intervention n'est pas connu et il persiste une incertitude sur l'évolution arthrosique. Aussi, nous avons mené une étude rétrospective d'une série de trochléoplasties de creusement au recul de 15 ans avec pour objectifs : (1) d'évaluer à long terme les résultats cliniques et le taux radiologique d'arthrose ; (2) de préciser les résultats en fonction du type d'instabilité et du grade de la dysplasie. Hypothèse.-La trochléoplastie de creusement est une intervention efficace sur la stabilisation de l'articulation fémoropatellaire sans augmenter le risque d'arthrose. Patients et méthodes.-Cette étude analyse rétrospectivement 34 trochléoplasties de creusement au moyen de scores cliniques (scores IKS, Lillois, Kujala et Oxford) et leurs résultats radiologiques (stade d'arthrose selon Iwano) au recul moyen de 15 ans (12-19 ans). Une plastie d'Insall était associée systématiquement et une transposition de la tubérosité tibiale antérieure dans 17 cas (7 transpositions préalables). Résultats.-Aucune récidive d'instabilité objective n'a été observée. Six genoux ont été repris par prothèse pour arthrose et un par transposition de la tubérosité tibiale pour douleur et dérobements au recul moyen de 7 ans (2-16). Les scores moyens Lillois, Kujala et IKS passaient respectivement de 53,3 (30-92), 55 (13-75) et 127 (54-184) en préopératoire à 61,5 (25-93), 76 (51-94) et 152,4 (66-200) au recul (p < 0,05) (reprises incluses). Les résultats fonctionnels étaient significativement meilleurs pour les dysplasies avec éperon (score IKS 168 [127-200] versus 153 [98-198] et Kujula 81,5 [51-98] versus 76 [51-94] [p < 0,05]). Les patients étaient satisfaits dans 65 % des cas et le score Oxford total moyen étaient de 24,1 points/60 (12-45 points). La douleur était occasionnelle ou nulle dans 53 % des cas. La saillie de la trochlée passait de 4,9 mm (3-9 mm) à −1,2 mm (−7-4 mm). L'arthrose fémoropatellaire, 10 cas en préopératoire mais aucune > Iwano 2, était présente dans 33/34 cas avec 20 cas > Iwano 2 (65 %) au recul. Discussion.-La trochléoplastie de creusement permet la stabilité fémoropatellaire même en cas de dysplasie sévère pour lesquelles elle donne de meilleurs résultats fonctionnels à long terme. En revanche, elle ne prévient pas l'arthrose fémoropatellaire. Elle doit être réservée aux dysplasies sévères avec éperon en l'associant à des gestes de réalignement de l'appareil extenseur. Niveau de preuve.-IV, étude rétrospective de cohorte.

Small focal cortical dysplasia (FCD) may be ambiguous or overlooked on magnetic resonance (MR) imaging. Source localization of EEG and magnetoencephalography (MEG) spikes was evaluated to confirm the diagnosis of small FCD. This study included 6 epilepsy patients with a single small lesion on MR imaging suggesting FCD within a single gyrus among 181 consecutive epilepsy patients admitted to our epilepsy monitoring unit over 27 months. Stereotypical interictal spikes were detected on simultaneous EEG and MEG recordings and the onset-related source of averaged spikes was estimated. All 6 patients had unique clinical characteristics as follows: leg sensori-motor seizures in 5 patients and eye version in 1 patient; a small MR imaging lesion suggesting FCD in the dorsal peri-rolandic region, which had been overlooked until our evaluation; and both EEG and MEG dipoles were estimated adjacent to the MR imaging lesion. Source localization of EEG and MEG spikes can confirm the diagnosis of F...

Inter-hemispheric coherence is decreased during the final stage of corpus callosotomy and the effect is maximized after sectioning is completed. Various patterns of coherence decrease suggest individual variations in the participation of the corpus callosum in the genesis of bilateral synchrony. Intra-operative monitoring of inter-hemispheric EEG coherence with wavelet transform coherence and trend analysis techniques is useful to estimate the physiological completeness of callosal sectioning. a b s t r a c t Objective: Corpus callosotomy limits the bilateral synchrony of epileptic discharges. However, the instantaneous changes in bilateral synchrony during corpus callosotomy are unclear. The present study investigated how and when bilateral synchrony is suppressed in the anterior and then posterior steps of corpus callosotomy. Methods: Intra-operative scalp electroencephalography (EEG) was recorded simultaneously with surgical video for six patients who underwent total corpus callosotomy for medically intractable drop attacks. The time-varying EEG inter-hemispheric coherence was quantified by wavelet transform coherence and trend analysis. Results: The 4-13 Hz coherence decreased after corpus callosotomy in five patients. Significant decrease in coherence was observed only during the posterior step of callosal sectioning in three patients, but throughout both steps in two patients. Conclusions: Decrease in inter-hemispheric coherence is not always correlated with the stages of callosal sectioning. Inter-hemispheric coherence is decreased during the final stage of corpus callosotomy and the effect is maximized after sectioning is completed. Significance: Various patterns of coherence decrease suggest individual variations in the participation of the corpus callosum in the genesis of bilateral synchrony. Time-varying inter-hemispheric EEG coherence is useful to monitor the physiological completeness of corpus callosotomy.

Purpose: To assess neuromagnetic spike localization as an indication for extended lesionectomy of cavernoma. Methods: Electroencephalography (EEG) and magnetoencephalography (MEG) was simultaneously recorded in 17 patients (8 men, mean age 29.7 years) with single cavernoma. The location of the equivalent current dipole (ECD) of the interictal spikes was correlated with the lesion shown by magnetic resonance imaging. Results: Preoperative ECD localization was classified into four types: perilesional, adjacent to the cavernoma only (n = 6); mirror, adjacent to the lesion and at the contralateral homologous site (n = 5); remote, mainly at a remote site in the ipsilateral hemisphere (n = 3); and no spikes (n = 3). The spikes were detected by only MEG in two of five "mirror" and all three "remote" patients. In the mirror group, contralateral spikes were synchronized with the ipsilateral spikes, or also occurred independently. Two "perilesional" and two "mirror" patients became seizure-free and spikefree after extended lesionectomy. In contrast, the other two "mirror" patients had residual seizures and spikes after pure lesionectomy. Conclusion: The detectability of mirror and remote spikes was higher by MEG than by EEG, whereas the detectability of perilesional spikes was similar by MEG and EEG. Therefore, the use of both EEG and MEG will provide the maximum information about spike distribution and propagation. Residual seizures and spikes after pure lesionectomy, but not after extended lesionectomy, in the "mirror" patients suggest the importance of resection of the perilesional irritable zone. Extended resection of the irritable cortex surrounding cavernoma is recommended for better seizure control, particularly in "mirror" patients.

Corpus callosotomy is a palliative treatment indicated for patients with intractable epilepsy who are not suitable for resective surgery, 1,2 so that the benefits of corpus callosotomy are difficult to assess. The chance of seizure freedom after corpus callosotomy is 10% or less in general, so the intention of surgery is usually limited to alleviating epileptic seizures, especially seizures with risk of injury. However, recent studies reported higher rate of seizure freedom in pediatric patients with generalized epilepsy. 3,4 The efficacy against seizures has been measured by various criteria, such as more than 50% seizure reduction, and more than 75% reduction or freedom from drop attacks. 5-7 Subsequent quality of life is also difficult to assess because patients often present with severe mental retardation or developmental delay. 8,9 Few studies have assessed the outcome of corpus callosotomy based on the observations of the primary caregiver or parent. 8,9 The present study investigated parental satisfaction and assessment of seizures after corpus callosotomy in patients with infantile or early childhood onset epilepsy. 2. Methods 2.1. Subjects This study included 16 consecutive patients with infantile or early childhood onset epilepsy who underwent one-stage total corpus callosotomy for the alleviation of seizures between August 2008 and December 2011. Questionnaires were sent by mail on June 2012 to the parents, who were the primary caregivers for all patients. Answer sheets were returned anonymously. Postoperative followup period at the time of questionnaire ranged from 6 to 45 months (median 24 months). This study was approved by the Ethics Committee of Tohoku University Graduate School of Medicine. Pre-operative evaluations and indication for surgery were described previously. 4 Expected outcome after surgery was explained to parents by an author MI as follows. Meaningful

A 57-year-old right-handed woman with a history of left frontal lobe stroke had experienced episodes of language-expression difficulty followed by paraphasia lasting for approximately 30 seconds two years earlier. She was diagnosed with left frontal lobe epilepsy, and a lamotrigine regimen was initiated. This treatment had to be stopped five weeks after initiation because she developed a rash, and her drug lymphocyte stimulation test result was positive. Interestingly, she has since remained seizure free without requiring any antiepileptic medications. This adult case with a peculiar clinical course provides support for the hypothesis of immunomodulation process involvement in epilepsy, a phenomenon that was previously mainly seen in pediatric patients.

Objective: To clarify whether the presence and timing of peri-ictal heart rate (HR) change is a seizure lateralizing sign in patients with mesial temporal lobe epilepsy (mTLE). Methods: Long-term video EEGs were retrospectively reviewed in 21 patients, 7 men and 14 women aged 13 to 67 years, diagnosed as mTLE with MRI lesions in the mesial temporal structures (hippocampal sclerosis in 20 cases, amygdala hypertrophy in 1 case). Seventy-seven partial seizures without secondary generalization were extracted. Peri-ictal HR change was compared between 29 right seizures (9 patients) and 48 left seizures (12 patients). Results: HR abruptly increased in all 29 right seizures and 42 of 48 left seizures. Onset time of HR increase in relation to ictal EEG onset was significantly earlier in right seizures than in left seizures (mean 6 SD, 211.5 6 14.8 vs 9.2 6 21.7 seconds; p , 0.0001). Time of maximum HR was also significantly earlier in right seizures than in left seizures (36.0 6 18.1 vs 58.0 6 28.7 seconds; p , 0.0001). Maximum HR changes from baseline showed no significant difference between right and left seizures (47.5 6 19.1 vs 40.8 6 20.0/min). Conclusions: Significantly earlier tachycardia in right than left mTLE seizures supports previous hypotheses that the right cerebral hemisphere is dominant in the sympathetic network. No HR change, or delayed tachycardia possibly due to seizure propagation to the right hemisphere, may be a useful lateralizing sign of left mTLE seizures. Neurology ® 2014;83:1332-1336 GLOSSARY CI 5 confidence interval; HR 5 heart rate; mTLE 5 mesial temporal lobe epilepsy.

Corpus callosotomy is usually intended to alleviate-not to achieve total control of-epileptic seizures. A few patients experience complete seizure control after callosotomy, but the associated clinical factors are unknown. The object of this study was to investigate clinical factors associated with long-term seizure remission after total corpus callosotomy in patients with infantile or early childhood onset epilepsy. Thirteen consecutive patients with infantile or early childhood onset epilepsy underwent 1-stage total corpus callosotomy for alleviation of seizures. Their age at surgery ranged from 1 year and 5 months to 24 years (median 7 years). Eleven patients had West syndrome at the onset of disease, and the other 2 had Lennox-Gastaut syndrome. All patients suffered from spasms, axial tonic seizures, or atonic seizures. Six patients had proven etiology of epilepsy, including tuberous sclerosis, polymicrogyria, trauma, and Smith-Magenis syndrome. The association between postopera...

We hypothesized that high frequency oscillations (HFOs) are differently suppressed during rapid eye movement sleep (REM) between epileptogenic and less epileptogenic cortices, and that the suppressive effect can serve as a specific marker of epileptogenicity. Intracranial electroencephalography (EEG) was recorded in 13 patients with drug-resistant epilepsy. HFOs between 80 and 200Hz were semi-automatically detected from total 15-min EEG epochs each for REM and slow wave sleep (SWS). z-Score of HFO occurrence rate was calculated from the baseline rate derived from non-epileptogenic cortex. Intracranial electrodes were labeled as REM dominant HFO (RdH) if REM z-score was greater than SWS z-score or as SWS dominant HFO (SdH) if SWS z-score was greater than REM z-score. Relationship of electrode location to the area of surgical resection was compared between RdH and SdH electrodes. Out of 1070 electrodes, 101 were defined as RdH electrodes and 115 as SdH electrodes. RdH electrodes were ...

This study was aimed to determine what preoperative profiles were associated with seizure remission after corpus callosotomy and whether such seizure outcome was associated with the postoperative developmental outcome. This retrospective study included 26 consecutive patients with childhood onset epilepsy who underwent one-stage total corpus callosotomy at our institution and were followed up for a minimum of 1year. The age at surgery ranged from 13months to 32years (median 6years). The association between postoperative seizure freedom and preoperative profiles, post-operative developmental gains was examined. Five patients achieved seizure freedom (Engel class I), and 10 patients achieved worthwhile reduction of seizures (class III), whereas the remaining patients had a class IV outcome. All five seizure-free patients had &quot;lack of abnormal magnetic resonance imaging findings&quot;, &quot;lack of proven etiology of seizures&quot;, and underwent &quot;surgery at age 6years or yo...

The primary motor cortex of the oro-facial level can be removed without permanent deficits, because of the bilateral representation of the innate functions. In contrast, resective surgery of the hand motor cortex or higher levels presents more challenges. We treated two adult patients with intractable epilepsy caused by small focal cortical dysplasia in the pre-central gyrus located between the foot and hand primary motor cortices. Focal cortical resection was guided by cortical EEG and intra-operative motor evoked potential, resulting in seizure freedom without neurological deficits in both cases. These cases illustrate that resective surgery can be safely performed in the primary motor cortex even dorsal to the oro-facial level, as long as the critical regions of the hand and foot motor cortices remain intact. Accurate delineation of the anatomical lesion and functional areas using intra-operative neurophysiological monitoring is crucial for successful outcome of the surgery.

To investigate whether seizure lateralization affects sleep macrostructure in patients with left and right temporal lobe epilepsy (TLE), as rapid eye movement (REM) sleep is shorter in patients with right hemispheric cerebral infarction than with left. We retrospectively analyzed data from 16 patients with TLE (6 men and 10 women aged 34.9 ± 11.4 years) who underwent polysomnography as well as long-term video electroencephalography. Ten patients were diagnosed with left TLE and six patients with right TLE. Sleep stages and respiratory events were scored based on the American Academy of Sleep Medicine criteria. Sleep and respiratory parameters were compared between the patient groups. Percentage of REM stage sleep was significantly (p &lt; 0.05) lower in patients with left TLE (median 8.8 %, interquartile range 5.5-13.8 %) than in patients with right TLE (median 17.0 %, interquartile range 14.1-18.3 %). The other parameters showed no significant differences. Shorter REM sleep in pati...

Multiple chemical sensitivity (MCS) is a disorder of unknown etiology with no effective treatment. Many clinicians accept that a diagnosis of somatic symptoms disorder (SSD) is an appropriate diagnostic category for MCS. We found that administration of levetiracetam improved recurrent symptoms of MCS in a patient. A 23-year-old female presented with recurrent multiple symptoms of musculoskeletal, airway or mucous membrane, heart/chest-related, gastrointestinal, cognitive, affective, neuromuscular, head-related, and skinrelated induced by exposure to diesel or gas engine exhaust, tobacco smoke, insecticide, gasoline, paint or paint thinner, cleaning products, fragrances, tar or asphalt, nail polish or hairspray, and new furnishings. Gastrointestinal, cognitive, and skin-related symptoms were precipitated by some food additives. She suffered partial seizures from the age of 17 years, and was diagnosed with right parietal lobe epilepsy. Administration of levetiracetam (250 mg/day) eliminated her MCS symptoms. Levetiracetam reduces the release of presynaptic neurotransmitter including glutamate by binding to presynaptic vesicle protein. A recent study established the presence of glutamatergic overactivation in somatization disorder, a form of SSD. Our case may indicate that a subset of patients with SSD have glutamatergic overactivation, which levetiracetam can normalize.

The effects of asynchrony between audio and visual (A/V) stimuli on the N100m responses of magnetoencephalography in the left hemisphere were compared with those on the psychophysical responses in 11 participants. The latency and amplitude of N100m were significantly shortened and reduced in the left hemisphere by the presentation of visual speech as long as the temporal asynchrony between A/V stimuli was within 100 ms, but were not significantly affected with audio lags of-500 and +500 ms. However, some small effects were still preserved on average with audio lags of 500 ms, suggesting similar asymmetry of the temporal window to that observed in psychophysical measurements, which tended to be more robust (wider) for audio lags; i.e., the pattern of visual-speech effects as a function of A/V lag observed in the N100m in the left hemisphere grossly resembled that in psychophysical measurements on average, although the individual responses were somewhat varied. The present results suggest that the basic configuration of the temporal window of visual effects on auditory-speech perception could be observed from the early auditory processing stage.

To evaluate whether a teleconference-based lecture provides similar understanding of seizure semiology to a face-to-face lecture for physicians. Subjects were 66 physicians consisting of adult and pediatric neurologists, neurosurgeons, psychiatrists, and general practitioners. All attended the 30-minute lecture to introduce various types of seizure semiology using video-clips by one of the authors (Yo.K.) and then joined the comprehensive case conference which discussed three cases in 1.5 h. Group A received the lecture and conference using a teleconference system (N = 43) and Group B attended in person (N = 23) for geographical reasons. After the conference, 32 subjects (23 in Group A and nine in Group B) scored their own post-lecture understanding of seizure semiology using the four-point Likert scale from 1 (not at all) to 4 (very well) as well as the estimated pre-lecture score. Data was analyzed to assess whether their understanding was improved after the lecture. No significan...

Predictive factors of higher drug load for seizure freedom were investigated in idiopathic generalized epilepsy (IGE), focusing on the difference between juvenile myoclonic epilepsy (JME) and other types of IGE (non-JME IGE). Twelve patients with JME and 12 patients with non-JME IGE, who achieved seizure freedom for 1 year or longer with appropriate antiepileptic drugs (AEDs) after video electroencephalography monitoring, were reviewed retrospectively. The sum of prescribed daily dose/defined daily dose ratio of all prescribed AEDs at the final visit was defined as total AED load. Patients requiring total AED load &gt;1 were classified into the higher AED load group. Clinical background and the presence of interictal focal epileptiform abnormalities (FEAs) were compared between the higher and lower AED load groups. Higher AED load group of patients with JME had interictal FEAs and family history of epilepsy more frequently than the lower AED load group (p = 0.03 and p = 0.03). Simil...