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Clinical, Electroencephalographic, and Behavioral Features of Temporal Lobe Epilepsy in Childhood
Abstract
This study describes the clinical, electroencephalographic, and behavioral features of 36 children with temporal lobe epilepsy. Patients were divided into two groups: group A, with 6 patients (< 6 years), and group B, with 30 patients (6-18 years). Statistical analysis was performed considering the significance level of .05. Regarding the clinical features of the focal seizures, motor components were more frequently seen in children younger than 6 years of age (P < .01), whereas automatisms were more frequently seen in patients older than 6 years of age (P < .05). Associated myoclonic seizures were more frequent in the younger age group (P < .01). Behavioral disorders such as hyperactivity and aggressiveness and speech delay were more common in the younger age group (P < .05). Temporal lobe epilepsy in children younger than 6 years of age is more frequently associated with motor components, myoclonic seizures, behavioral disorders, and speech delay. Conversely, temporal lobe epilepsy in older patients has frequent automatisms.
... The findings of interictal EEGs in mesial temporal sclerosis are similar in adolescents and adults (Mohamed et al., 2001;Wyllie et al., 1993). In children younger than 6 years of age, in addition to epileptiform activity in temporal lobe regions, generalized epileptiform discharges are also frequent (Blume and Kaibara, 1991;Brockhaus and Elger, 1995;Franzon et al., 2004), including maximal activity in the extratemporal electrodes (Ebner, 1999). In patients with neoplastic lesions, interictal EEGs often show multifocal epileptiform activity (Wyllie et al., 1993). ...
... In patients with neoplastic lesions, interictal EEGs often show multifocal epileptiform activity (Wyllie et al., 1993). Therefore, interictal epileptiform discharges in children with TLE seem to predominate in the temporal lobe but may also be seen in other brain regions (Blume, 1997;Blume et al., 1997;Franzon et al., 2004). ...
... Clinical data on seizure semiology of our patients are presented elsewhere (Franzon et al., 2004). However, a brief summary may elucidate the clinical data. ...
To characterize clinical and interictal electroencephalographic aspects of children and adults with temporal lobe epilepsy (TLE) due to tumoral lesions.
We performed a retrospective analysis of the clinical and interictal electroencephalographic aspects of 16 children (64 exams) and 12 adults (78 exams) with lesions in the temporal lobe.
The most frequent etiologies were gangliogliomas, DNETs, followed by astrocytomas. Auras occurred in both groups, the most common being epigastric sensation. Other findings such as myoclonias, behavioral arrest and vomiting were more frequent in children. Temporal epileptiform and nonepileptiform activities, mostly unilateral, were found in both groups. Extratemporal epileptiform activities (frontal, parietal, central, occipital and generalized) were also found equally in both groups.
Our data show that children and adults with TLE due to expansive lesions present with similar EEG findings.
... The findings of interictal EEGs in mesial temporal sclerosis are similar in adolescents and adults (Mohamed et al., 2001;Wyllie et al., 1993). In children younger than 6 years of age, in addition to epileptiform activity in temporal lobe regions, generalized epileptiform discharges are also frequent (Blume and Kaibara, 1991;Brockhaus and Elger, 1995;Franzon et al., 2004), including maximal activity in the extratemporal electrodes (Ebner, 1999). In patients with neoplastic lesions, interictal EEGs often show multifocal epileptiform activity (Wyllie et al., 1993). ...
... In patients with neoplastic lesions, interictal EEGs often show multifocal epileptiform activity (Wyllie et al., 1993). Therefore, interictal epileptiform discharges in children with TLE seem to predominate in the temporal lobe but may also be seen in other brain regions (Blume, 1997;Blume et al., 1997;Franzon et al., 2004). ...
... Clinical data on seizure semiology of our patients are presented elsewhere (Franzon et al., 2004). However, a brief summary may elucidate the clinical data. ...
The authors clarified the value of interictal discharges and verified which extratemporal regions may also show epileptiform activity in temporal lobe epilepsy (TLE) in childhood. Thirty consecutive patients aged 3 to 18 years (mean age = 12.16 years; 16 male) with TLE associated with hippocampal atrophy were studied. Each patient had 1 to 15 interictal EEG recordings (mean: 5.6; total = 192 EEGs). Video-EEG monitoring was performed in 20 patients. All patients had MRI. The findings were compared with a control group of 53 consecutive TLE adult outpatients with hippocampal atrophy. Each adult patient underwent 3 to 21 routine EEGs (mean: 10.67; total = 566). Interictal EEGs of children with TLE showed extratemporal epileptiform discharges more frequently than EEGs of adults with TLE. Frontal, parietal, and occipital discharges were more frequently seen in children (P < 0.05). These results suggest a close interaction between temporal and other cerebral regions in children with epilepsy and provide further evidence of the existence of neural networks.
... 2,4,5 MTLE-HS seems to occur more rarely in children than in adults and has been less well studied in this population. [8][9][10][11][12][13][14][15][16][17][18][19][20] This may be due to the particular electroclinical features of some seizures whose temporal origin is difficult to recognize in young children. The later maturation of the limbic system may also play an important role. ...
... The syndrome is not rare and may be identified adequately even in very young children. [8][9][10][11][12][13][14][15][16][17][18][19][20][21] In our series of 42 patients suffering from MTLE-HS, we could identify three age groups. Nine (21.5%) children under the age of 2 predominantly had motor seizures, while 16 (38%) children over 10 years of age had the same clinical characteristics as adults. ...
We present the electroclinical features, treatment, and evolution of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).
We analyzed the charts of forty-two patients who met the diagnostic criteria of MTLE-HS. The mean follow-up after seizure onset was 10.5 years.
According to age, we defined three groups. The first group included nine patients that started with seizures before 2 years of age. Motor seizures were the hallmark clinical manifestation. All patients of this group also presented with motor arrest and oro-alimentary automatisms. In three of them, the interictal EEG recordings showed bilateral paroxysms predominantly in anterior regions, in addition to focal abnormalities, and two had an apparently generalized ictal pattern. The second group included 17 patients that started with seizures between 2 and 10 years of age. In this group the automatisms were also oroalimentary, but more complex and the patients had less motor manifestations. The interictal EEG recordings showed temporal abnormalities. The ictal EEG recordings showed lateralized abnormalities with a maximum in the temporal electrodes. The third group included 16 patients that started with seizures between 10 and 16 years of age. The most common clinical manifestation was abdominal aura followed by oroalimentary, gestural, and verbal automatisms. The interictal and ictal EEG recordings showed well-localized abnormalities in temporal lobes. Thirty-eight patients underwent surgical treatment. Thirty-five patients are seizure free.
MTLE-HS represents a well-defined and distinct symptomatic epileptic syndrome. Surgical treatment was successful in most patients.
... As previously reported, TLE in childhood is not rare and can be recognized correctly even in very young children (Jayakar and Duchowni, 1990;Wyllie et al., 1993;Bye and Foo, 1994;Brockhaus and Elger, 1995;Harvey et al., 1997;Rathgeb et al., 1998;Broglin, 2001;Franceschetti et al., 2001;Pachatz et al., 2001;Fogarasi et al., 2002;Franzon et al., 2004;Ray and Kotagal, 2005). In our population, age at onset was < 6 years in 82% and < 3 years in 51% of cases. ...
... For early diagnosis, it should be considered that ictal clinical semiology in young children is quite different compared with older patients because early onset TLE represents a more heterogeneous syndrome than in adults, since ictal symptomatology is strongly related to brain maturation and neuropsychological development. An aura was relatively rare, as reported by other authors (Jayakar and Duchowni, 1990;Brockhaus and Elger, 1995;Harvey et al., 1997;Rathgeb et al., 1998;Franceschetti et al., 2001;Franzon et al., 2004;Ray and Kotagal, 2005); it was present only in 49% of our patients who were younger than 6 years of age and in several cases it was not spontaneously reported. According to some authors (Jayakar and Duchowni, 1990;Wyllie et al., 1993;Harvey et al., 1997;Fogarasi et al., 2002;Ray and Kotagal, 2005), particularly in children younger than 3 years, symptoms are limited to motionless staring (true hypomotor seizure), possibly accompanied by transient and slight lip cyanosis and simple oral automatisms with drooling. ...
Temporal lobe epilepsy (TLE) is probably more difficult to recognize in children than in adults. In fact, ictal symptoms in children are less stereotyped and less obvious, and the neuropathological substrate is more heterogeneous than in adults. The aim of this study is to examine the relationships between etiology, age at onset and electroclinical findings in 77 children with TLE, 32 of whom were surgically treated.
Electroclinical study including video-EEG recording of seizures in 77 children with TLE. The investigation focused on the first five initial ictal symptoms.
Age at onset was less than 3 years in 39 cases, between 3 and 6 years in 17 cases and older than 6 years in 21 cases. Auras also occurred in younger children but were more common after the age of 6 years. A peculiar initial ictal semiology consisted in staring with arrest, lip cyanosis, and very slight oral automatisms. In some cases, EEG recordings documented seizures starting independently on both temporal lobes. Based on electroclinical and neuroradiological features, we recognized three subgroups: symptomatic TLE due to cortical malformations or nonevolutive tumors, TLE with mesial temporal sclerosis, and cryptogenic TLE.
A correct electroclinical and neuroradiological approach allows in several cases early recognition of TLE even when onset is earlier than the age of 6 years. A correct definition of the localization relies primarily on video-EEG recording of the seizures, possibly repeated during follow up in cases lacking obvious neuroradiological correlation.
... Os primeiros documentos acerca dos distúrbios cognitivos e comportamentais das epilepsias de difícil controle na infância são de autoria de Lindsay e Ounsted em estudo prospectivo em pacientes com ELT 11 13 . O grupo A com 6 pacientes (com idade inferior a 6 anos) e o grupo B com 30 pacientes (6 a 18 anos). ...
Introdução. A epilepsia do lobo temporal é um distúrbio neurológico com repercussões importantes de ordem neuropsicológica no desenvolvimento infantil. As alterações na memória e linguagem devem ser consideradas na clínica de saúde mental. Objetivos. Verificar os aspectos neuropsicológicos da Epilepsia do lobo temporal (ELT) na infância. Método. Neste artigo apresenta-se uma revisão de literatura pertinente acerca desta entidade, seus aspectos neuropsicológicos e respectivas repercussões. Conclusões. A criança com ELT pode apresentar distúrbios neuropsicológicos, principalmente como de memória e linguagem, além de problemas de aprendizagem, atenção e piora da qualidade de vida.
... Epilepsy, one of the most common neurologic disorders of childhood, is complicated with pharmacoresistance in one-quarter of all patients. Seizures cause delay cognitive and psychosocial development and prevent reaching normal developmental capacity in children in whom neuronal differentiation is not yet completed (1). Ketogenic diet (KD) is the last treatment option in patients whose seizures are resistant to 2 or 3 anticonvulsant drugs (2). ...
Epilepsy is an important health issue. The interest in ketogenic diet (KD) treatment in children and adolescents with drug-resistant epilepsy has increased in recent years. It was thought that KD was a last option of treatment in patients who were unresponsive to 2 or 3 anticonvulsant drugs. KD with limited protein, low carbohydrate, and high fat content was thought as a last option of treatment, previously. However, nowadays it is the most selected therapy worldwide in epileptic children and adolescents. Ketone bodies are elevated in the blood due to low carbohydrate and high lipid content of KD. Through the elevation of ketone bodies, the brain uses ketone bodies as energy sources, which results in decreased in epileptic seizures. Medical nutritional therapy during treatment of childhood epilepsies should also provide normal growth and development. For this reason, full compliance with the diet is important. The effect, place, and importance of ketogenic nutrition therapy in drug-resistant epilepsies of childhood are discussed in this review. © 2018 by Turkish Neurological Society Turkish Journal of Neurology published by Galenos Publishing House.
... Temporal lobe epilepsy in children differs from the relatively homogeneous characteristics observed in adults and shows many clinical and electroencephalographic features [7,8]. In childhood, seizure semiology varies with age, and EEG pattern may be less clear. ...
The abnormal brain discharges observed in benign childhood epilepsy with centrotemporal spikes (BECTS) and temporal lobe epilepsy (TLE) are located close to areas responsible for auditory and language processing. This study aimed to analyze the results of auditory event-related potentials (P300) in children with BECTS and TLE in order to assess whether the epileptic activity in centrotemporal and temporal regions may compromise the integrity and physiology of auditory system structures. This was a prospective, comparative, and cross-sectional study. Group I (GI) consisted of 13 children diagnosed with BECTS, group II (GII), 7 children diagnosed with TLE, and control group (GIII), 16 healthy children, with no hearing or academic complaints. After neurological and basic audiological assessments, P300 was applied. The P300 latency and amplitude were compared between groups. Regarding latency, GI showed 324.1 (+31.5) ms, GII 336.3 (+23.5) ms, and GIII 318 (+27.7) ms. Amplitudes were 4.80 (+3.2) μV in GI, 4.7 (+2.5) μV in GII, and 5.8 (+2.4) μV in GIII. Although children with BECTS showed prolonged latencies and reduced amplitudes, these differences were not considered statistically significant. Children with TLE showed statistically significant prolonged P300 latency compared with the control group (P=0.037). We speculate that abnormal electrical discharges in centrotemporal and temporal regions led to the slowing of auditory processing in our sample.
... Os primeiros documentos acerca dos distúrbios cognitivos e comportamentais das epilepsias de difícil controle na infância são de autoria de Lindsay e Ounsted em estudo prospectivo em pacientes com ELT 11 13 . O grupo A com 6 pacientes (com idade inferior a 6 anos) e o grupo B com 30 pacientes (6 a 18 anos). ...
In the elderly, the individual changes over time (physical, psychological, social and neuropsychological aspects) and according to his/her environment. In aged people the high incidence of depression and dementias can bring deficits in cognition, memory, language, executive functions, praxias and gnosias, intervening in their autonomy, and in their social and professional performance. Thus, it is important to carry out studies on this theme. Objective. A literature review of the neuropsychological aspects of the elderly and their neuropsychological evaluation, especially those which relate to dementias, was carried out. Method. Literature review. Research in the following bases of data Bireme, Scielo e Pubmed. And books and teses. Conclusion. A neuropsychological evaluation is recommended, mainly, in the identification of cognitive decline in the elderly, in the evaluation of the impairment of cerebral areas in the case of neurological alterations, in the differential diagnosis of psychological/psychiatric and neurological syndromes; and in guiding a rehabilitation intervention.
... In childhood TLE, due to the great clinical, electrographic and etiologic diversity 8 , the relationship between memory deficit and lateralization is still to be defined 9 . Some authors found that verbal memory deficit is correlated with left TLE and visual memory deficit is correlated with right TLE [10][11] . ...
In children with temporal lobe epilepsy (TLE), memory deficit is not so well understood as it is in adults. The aim of this study was to identify and describe memory deficits in children with symptomatic TLE, and to verify the influence of epilepsy variables on memory. We evaluated 25 children with TLE diagnosed on clinical, EEG and MRI findings. Twenty-five normal children were compared with the patients. All children underwent a neuropsychological assessment to estimate intellectual level, attention, visual perception, handedness, and memory processes (verbal and visual: short-term memory, learning, and delayed recall). The results allowed us to conclude: besides memory deficits, other neuropsychological disturbances may be found in children with TLE such as attention, even in the absence of overall cognitive deficit; the earlier onset of epilepsy, the worse verbal stimuli storage; mesial lesions correlate with impairment in memory storage stage while neocortical temporal lesions correlate with retrieval deficits.
... Findings in infants suggestive of CPS are: arrested activity with possible alteration of consciousness, undetected aura, mild but specific orofacial automatisms, a greater number of secondary generalized tonic-clonic seizures and prolonged seizures (duration more than one minute) (12) . Infantile spasms and generalized myoclonic seizures also occur frequently (35,36) . ...
Introduction: The authors present a review article on temporal lobe epilepsy in childhood. Methods: We performed a search in the literature. Results: The main etiologies of temporal lobe epilepsy in childhood are developmental tumors and focal cortical displasia, besides temporal medial sclerosis. The clinical features may be variable particularly in children younger than six years of age. Epilepsy may present with generalized seizures. Electroencephalographic findings are also variable and show a functional dysfunction of several brain areas besides temporal lobes, especially frontal lobes. Conclusion: Recent advances demonstrate that temporal lobe epilepsy in childhood present with great etiologic, clinical and electroencephalographic diversity.
... 4,[14][15][16] Temporal lobe epilepsy in childhood has a wide range of clinical-electroencephalographic presentation. 17 In addition, the neuropsychological features in childhood temporal lobe epilepsy are not yet well defined. The neuropsychological features of children with temporal lobe epilepsy are not yet well defined. ...
The neuropsychological features of children with temporal lobe epilepsy are not yet well defined. The aim of this study was to identify the neuropsychological deficits in children with temporal lobe epilepsy. We evaluated 25 patients and compared them with 25 normal children. All children underwent a comprehensive neuropsychological assessment. We found a significant difference in favor of the control group in the following measures: IQ; forward digit; Trail Making Test for Children B; Wisconsin Card Sorting Test; block design; Boston naming test, verbal fluency; and Wide Range Assessment of Memory and Learning verbal learning, visual learning, verbal memory, visual memory, delayed recall of verbal learning, delayed recall of stories, and recognition of stories. Our findings show that children with temporal lobe epilepsy present with several neuropsychological deficits, despite normal IQ. These findings point to a dysfunction of cerebral areas other than temporal lobe, particularly the frontal lobes.
Introduction: Recent studies has shown that epilepsies are diseases related to neuro networks alterations. Functional and diffusion neuroimaging techniques explored by advanced computational methodologies, allows the functional and structural brain connectivity evaluation providing information regarding the brain networks behavior. This project aim to evaluate the functional and the structural connectivity in patients with temporal lobe epilepsy comparing its alteration patterns with other focal epilepsies.
Methods: We developed software resources to perform the analysis: 1- Structural connectivity and 2- functional connectivity. For structural evaluations, three groups of patients were included (mesial temporal lobe epilepsy [MTLE] associated to hipocampal sclerosis [HS], non-lesional temporal lobe epilepsy [TLE-NL] and frontal lobe epilepsy associated to focal cortical dysplasia [FLE-FCD]) and a control group. We performed a semi-automatic tractography procedure to evaluate the fractional anisotropy (FA), the radial diffusivity (RD) and the axial diffusivity (AD) of four anatomic relevant fasciculi: uncinate, body of fornix, inferior fronto-occipital and body of cingulum. We performed functional connectivity analysis comparing patients with left and right MTLE-HS and controls. We used 70 regions of interest (ROIs) from 12 functional networks to compute the connectivity adjacency matrices and performed a second level analysis to compare patients and controls groups.
Results: The macrostructural white matter (WM) analysis showed alterations (manly ipsilateral) on MTLE-HS and FLE-FCD. The microstructural WM analysis presented alterations on diffusion parameters for the same groups. Patients with TLE-NL showed no changes for both structural analysis. Compared to the control group, the R-MTLE and L-MTLE groups showed functional connectivity alterations. From the 12 studied networks, only the auditory and the visual networks were preserved on both groups. For the R-MTLE patients, the anterior salience and the sensorimotor networks were also not affected. Patients with L-MTLE showed more diffuse alterations, more evidently affecting both hemispheres.
Discussion and conclusion: The study and the proposal methodology were effective for the identifications and characterization of functional and structural connectivity alterations in patients with focal epilepsies. The MTLE-HS showed worse widespread
structural alterations compared to the FLE and TLE-NL. Additionally, they presented complex and widespread functional networks abnormalities. Patients with L-MTLE demonstrated worse and more bilaterally affected pattern of alterations when compared to R-MTLE. The development of toolboxes to perform the proposal methodology enabled the standardization and high data analysis efficiency, throughout clear procedures.
Key words: Epilepsy. MRI. Diffusion Magnetic Resonance Imaging. MRI. Brain Mapping.
Advances in electrophysiological assessment with improved structural and functional neuroimaging have been very helpful in the use of surgery as a tool for drug-resistant epilepsy. Increasing interest in epilepsy surgery has had a major impact on adult patients; a refined evaluation process and new criteria for drug resistance combined with refined surgical techniques resulted in large surgical series in many centers. Pediatric surgery has lagged behind this evolution, possibly because of the diverse semiology and electrophysiology of pediatric epilepsy obscuring the focal nature of the seizures and frustrating the treatment of catastrophic epileptic syndromes specific to children. Unfortunately, refractory -epilepsy is more -devastating in children than in adults as it interferes with all aspects of neural development. Nevertheless, during the last few decades, the efforts of a small number of centers with encouraging results in pediatric epilepsy surgery have motivated pediatric neurologists to gain interest. Although well behind in the number of patients compared with that of adults, pediatric series are increasing exponentially. While temporal lobe epilepsy is the focus of interest in adults, with almost 70 % of resections in the temporal lobe, the pediatric epilepsy spectrum is different. Resective or functional surgery techniques devoted to resistant extratemporal epilepsy are the major improvements in pediatric epilepsy surgery. Temporal lobe epilepsy in adults has been studied extensively but only recently has begun to receive attention in children. Several aspects of temporal lobe epilepsy in childhood remain unclear or controversial in terms of seizure semiology and its pathology. This is reflected in the surgical treatment. Information on the major contributors to a favorable outcome, such as type or extent of resection, in terms of seizure control and morbidity is not available as in adult temporal lobe epilepsy. This chapter discusses the major discrepancies between adult and pediatric temporal lobe epilepsy and outlines the current concepts in surgical treatment. The resection strategy based on the different substrates at different locations in the temporal lobe causing seizures is emphasized with respect to available literature.
Introduction. The Temporal Lobe Epilepsy (TLE) is an important neurological disturb with neuropsychological repercussions on infantile development. These memory and language alterations must be considered in the mental health clinic. Objective. To verify the psychological and neuropsychological aspects of the Temporal Lobe Epilepsy in childhood. Method. This paper presents a literature revision concerning to Temporal Lobe Epilepsy, its psychological and neuropsychological repercussions. Conclusions. The child with TLE can bring out neuropsychological disturbs, mainly those of memory and language, learning and attention problems, besides quality life worsening.
We report a case of Sturge-Weber syndrome with intractable epilepsy presenting complex partial seizures(CPSs) and severe temper tantrum successfully treated with anterior temporal lobectomy. A 23-month-old girl without facial angioma presented with seizures from 8 months after birth. Neuroradiological examination demonstrated angioma in the left temporooccipital lobes and calcification in the left occipital lobe. Thus she was diagnosed as having Sturge-Weber syndrome. Her parents sought medical advice because of intractable and more frequent CPSs and a change in temperament manifesting as severe temper tantrums. Interictal electroencephalogram (EEG) showed relatively mild abnormal slow wave discharges in the left temporal region. The patient underwent left anterior temporal lobectomy based on intraoperative electrocorticography (ECoG) findings. Histopathological examination demonstrated gliotic change in the amygdala. After the surgery, she has remained seizure-free for 14 months while taking anticonvulsants and temper tantrums ultimately showed remission 10 months following surgery. This case may indicate that severe temper tantrum was associated with a change in amygdala structures.
The goals of the work described here were to determine if hippocampal and extrahippocampal atrophy in children with temporal lobe epilepsy (TLE) follows a pattern similar to that in adult patients, and to assess the clinical and neuropsychological relevance of regional brain atrophy in pediatric TLE.
Children with symptomatic TLE (n=14: 9 with mesial TLE due to hippocampal atrophy and 5 with TLE due to neocortical lesions), healthy children (n=14), and 9 adults with mesial temporal lobe epilepsy (MTLE) were compared using voxel-based morphometry (VBM) of brain magnetic resonance imaging (MRI). The children underwent a comprehensive neuropsychological battery.
Children with MTLE with unilateral hippocampal atrophy (n=9) exhibited a significant reduction in gray matter in the hippocampus ipsilateral to the seizure origin and significant atrophy in the ipsilateral cingulate gyrus and contralateral middle frontal lobe. Children with TLE (n=14) exhibited a significant reduction in the gray matter of the ipsilateral hippocampus and parahippocampal gyrus. There was a correlation between gray matter volume in children with TLE and scores on several neuropsychological tests. Atrophy in pediatric patients with MTLE was less extensive than that in adults, and involved the hippocampi and the frontal cortex.
Similar to adult MTLE, pediatric MTLE is associated with hippocampal and extrahippocampal cell loss. However, children display less intense quantifiable gray matter atrophy, which affects predominantly frontal lobe areas. There was a significant association between volume of gray matter in medial temporal and frontal regions and scores on neuropsychological tests. In childhood, TLE and the concomitant cognitive/behavior disturbances are the result of a damaged neural network.
Numerous studies have demonstrated changes in cognitive, memory, and language functioning in adults and adolescents after temporal lobectomy, yet little information is available regarding neuropsychological outcome in preadolescent children.
We studied pre- and postoperative neuropsychological test results from 14 children who underwent temporal lobe resection for intractable epilepsy at age 7-12 years (mean 9.4 years).
Thirteen patients (93%) had no seizures or less than one seizure a year at follow-up 23-48 months (mean 34 months) after operation. Postoperative neuropsychological testing was performed 6-9 months (mean 7 months) after surgery in 13 patients and 36 months after the first operation in 1 patient who underwent two-stage resection of a tumor. Verbal, Performance, and Full Scale IQ were initially in the low-average range, with no significant change across the pre- and postoperative evaluations. Immediate verbal memory performance decreased significantly in children who initially performed above the median preoperatively and tended to decrease in children who had left rather than right temporal lobe resection. Significant postoperative decreases in delayed memory scores were independent of preoperative ability or side of resection.
Our small study suggests vulnerability to postoperative decline in immediate verbal memory scores in preadolescent children who have higher baseline immediate memory function or undergo left rather than right temporal lobe resection, similar to that observed in adolescents in adults. The entire group exhibited a statistically significant decrease in delayed verbal memory. Study of larger series of patients will be important to clarify further the short- and long-term risks and benefits of temporal lobe resection in childhood.
Pervasive developmental disorder (PDD) is occasionally associated with medically intractable complex partial seizures. The outcome of PDD was explored in three males and two females who underwent epilepsy surgery at 32 months to 8 years of age (mean = 4 years) after onset of epilepsy at 1 week to 21 months of age (mean = 11 months). Four children had temporal lobe resections (three right, one left; two for focal cortical dysplasia, and two for tumors), and one had a right temporoparieto-occipital resection (for focal cortical dysplasia). Each child underwent repeated evaluations by a pediatric neuropsychologist and psychiatrist. Fourteen to 47 months (mean = 23 months) after operation, one child with persistent seizures had moderate developmental and behavioral improvement, three children (two seizure free, one with rare staring spells) had mild developmental and behavioral improvement, and the remaining child (seizure free) experienced a worsening of her PDD. The four children with mild-to-moderate improvement in postoperative cognitive and behavioral development still demonstrated persistent delay. Cognitive gains were confirmed by neuropsychologic testing in the oldest patient but were not reflected in test results from the three younger children, who had more modest improvement. The child with worsening of her PDD had cognitive and emotional deterioration to babbling, echolalia, aggressiveness, decreased social interaction, and increased mouthing of objects beginning several months postoperatively. These results suggest that families should be counseled that PDD symptoms in children with focal epileptogenic lesions may or may not improve after epilepsy surgery, even if the surgery is successful with respect to seizure control.
A revision of the International Classification of Epileptic Seizures is proposed based upon a study of videotapes of simultaneously recorded electrical and clinical manifestations of epileptic seizures.
Temporal lobectomy abolished complex partial seizures (CPSs) in 14 consecutive children (12 years or younger) whose presurgical evaluation included clinical analysis, scalp EEG, and neuroimaging. Seizures of 13 of 14 patients began with a simple partial component whose symptoms were suggestive of limbic system involvement. EEG recorded clinically typical seizures arising from the ultimately operated on temporal lobe in seven (50%) and never falsely lateralized seizure origin. Most active interictal spikes arose from the epileptogenic temporal lobe in 13 (93%) and never falsely lateralized epileptogenesis. Neuroimaging disclosed epileptogenic lesions in all: magnetic resonance imaging (MRI; 11 patients) and computed tomography (CT; three patients). Children may obtain relief from CPSs by temporal lobectomy without invasive electroencephalography.
To explore the electroclinical features of temporal lobe epilepsy (TLE) in early childhood, we studied results of video-EEG and other tests of 14 children aged 16 months to 12 years selected by seizure-free outcome after temporal lobectomy. Four children had mesiotemporal sclerosis, 1 had cortical dysplasia, and 9 had low-grade temporal neoplasms. The children had complex partial seizures (CPS) with symptomatology similar to that of adults with TLE, including decreased responsiveness and automatisms. Automatisms tended to be simpler in the younger children, typically limited to lip smacking and fumbling hand gestures. Scalp/sphenoidal EEG showed anterior/inferior temporal interictal sharp waves and unilateral temporal seizure onset in the 4 children with mesiotemporal sclerosis and in the child with cortical dysplasia, but EEG findings in 9 children with low-grade temporal tumors were complex, including multifocal interictal sharp waves or poorly localized or falsely lateralized EEG seizure onset. In children without tumors, video-EEG was critical to localization of the epileptogenic zone for resection, but in patients with tumors video-EEG was less localizing and its main value was to confirm that the reported behaviors were epileptic seizures with semiology typical of temporal lobe onset.
This study determined differences in clinical-pathologic characteristics of intractable temporal lobe epilepsy (TLE) patients whose mechanism of cerebral injury and chronic seizures involved a prior history of cerebral trauma compared to those with non-traumatic initial injuries. TLE patients (n = 120) from a single epilepsy center were retrospectively and blindly catalogued into pathogenic groups (independent variables) based on if there was a significant Birth injury (n = 11) or Cerebral trauma (n = 26). These two ‘trauma’ categories were compared to TLE patients with non-seizure non-trauma histories (Non-Sz/Non-Trauma; n = 17), or a first Prolonged seizure (n = 66). The four groups were compared for differences in the time course of their clinical injuries and seizures, quantified hippocampal neuron counts, other temporal neocortical pathologies, and seizure outcomes (dependent variables). Between group statistically significant (at least P < 0.05) results showed: (1) In Birth injury, 33% had Ammon's Horn (AH) neuron loss under 50%, 54% had other temporal neocortical pathologies, they showed the most CA4 neuron loss, and the worse seizure outcomes. (2) Cerebral trauma were older when injured, 29% had AH loss under 50%, 50% showed other pathologies, and they had the best seizure outcomes. (3) Non-Sz/Non-Trauma showed the least AH and CA4 neuron losses, only 12% had other temporal pathologies, and they had seizure outcomes that were intermediate. (4) Prolonged seizure showed the youngest age of habitual TLE onsets, the greatest AH, CA1, and prosubiculum neuron loss, only 11% had other temporal pathologies, and their seizure outcomes were excellent. These results indicate that in intractable surgically treated TLE, a history of cerebral trauma or birth injury as the pathogenic mechanism of their seizures show different clinical-pathologic features and seizure outcomes compared to non-trauma patients. This supports the notion that in TLE there are different pathogenic mechanisms associated with different types of initial injuries and that patients will have different responses to surgical therapy.
Avaliação de 34 crianças (2 a 16 anos), com epilepsia do lobo temporal, divididas em, grupos: G1 (lesão neocortical; n=16), G2 (esclerose mesial temporal; n=16) e G3 (patologia dupla; n=2), comparando-se apenas G1 e G2. A epilepsia teve iníciomédio aos 5,2 anos em G1 e aos 5,1 em G2. O intervalo médio entre um evento mórbido e o início da epilepsia foi de 3,8 anos. As crises parciais complexas permaneceram inalteradas. Crises parciais simples com sensação epigástrica ascendente eestado de mal epiléptico predominaram no G2. Houve um intervalo médio de 8,4 anos em G1 e 6,2 em G2, para a projeção da atividade epileptiforme no lobo temporal. Dissertação (Mestrado).
Temporal-lobe epilepsy commonly has its origins in childhood, particularly when the lesion involved is mesial temporal (Ammon's horn) Sclerosis. Evidence suggests that this lesion is probably a common cause of chronic epilepsy in adults and that often it is probably the result of a severe febrile convulsion in infancy. 40 children, fifteen years of age and younger, who had an anterior temporal lobectomy were followed up for one to twenty-four years. The findings confirm those already established in adults, that the best results of surgery, not only in seizure relief but also in behaviour, are obtained when mesial temporal sclerosis is the lesion found at operation, and also indicate that a severe febrile convulsion in infancy is often the chief provocative factor in the development of epilepsy.
Children with medically resistant temporal lobe seizures that persist into adolescence often experience psychosocial deterioration and medical morbidity. It is therefore especially important to evaluate the contribution of surgical therapy in preadolescent children. We describe our experience with temporal lobectomy in 16 children less than 12 years (mean age 7 years) who had intractable seizures of temporal lobe origin. Structural lesions were identified on neuroimaging studies in 11 patients. In all patients, the standard anterior temporal lobectomy was tailored according to the extent of the lesion and epileptogenic field. At follow-up, 11 children were seizure-free, three were 90% improved, one was 50% improved, and one was unchanged. Neuropathological abnormalities were identified in virtually all children. Prenatally acquired abnormalities of neurogenesis were the most common, whereas mesial temporal sclerosis was found in only two children. We conclude that tailored temporal lobectomy in the first decade of life is highly beneficial in carefully selected children with medically refractory seizures.
We observed unilateral dystonic posturing of an arm or leg in 41 complex partial seizures (CPS) from 18 patients. In all cases this was contralateral to the ictal discharge. Unilateral automatisms occurred in 39 of 41 seizures on the side opposite the dystonic limb. Version occurred in 11 of the 41 CPS to the same side as the dystonic posturing and always followed the posturing. Subdural recordings of seven seizures showed ictal onset from the mesial basal temporal lobe. At the onset of dystonic posturing, maximum ictal activity was in the basal temporal lobe with minimal involvement of the cerebral convexity. Unilateral dystonic posturing occurs frequently in CPS of temporal lobe onset and is a lateralizing sign with a high degree of specificity. It probably reflects spread of the ictal discharge to basal ganglia structures.
Hippocampal neuron densities in three areas (H1 zone, end folium, and dentate gyrus) were counted in each of 32 temporal lobectomy excision specimens using the technique of Mouritzen Dam. The association between severe neuronal loss in all three areas and early childhood convulsions that were prolonged and/or lateralized was highly significant. Lesser degrees of neuron loss in H1 and/or end folium were common and were not associated with early childhood convulsions, but were most often found in older patients with a particularly long history of epilepsy.
Aggression and psychosis were frequent preoperative complications in over 250 patients with temporal-lobe epilepsy who underwent unilateral temporal lobectomy. Pathological findings in the resected specimens, which included the hippocampus and the lateral amygdala, were mesial temporal sclerosis in about 1/2, hamartomas in 1/4, miscellaneous lesions such as scars and infarcts in 1/10, and nonspecific lesions in the remainder. Follow-up evaluations after six to 20 years were carried out independently by psychiatrists. In a series of 100 patients, 27 had aggression, which was relieved most often after operation in patients who had mesial temporal sclerosis (seven of 13). In the first 100 patients psychosis complicated long standing temporal-lobe epilepsy due to many substrates in 12 cases and was benefited by operation in seven. When a schizophrenia-like state supervenes, the substrate is likely to be a hamartoma. In patients with schizophrenia, operation relieved epilepsy, but the psychosis persis...
The semiology of complex partial seizures (CPS) of temporal lobe origin in adults is well known and is important in establishing seizure localization in patients considered for epilepsy surgery. In contrast, the behavioral features of temporal lobe seizures (TLS) in children described in the literature have not been consistent. In the present study, we investigated children with TLS to compare their attacks to TLS occurring in adults. The study was based on video recordings of 29 children with TLS aged 18 months to 16 years. Children were included, if they became seizure-free after temporal lobectomy (except 4 children with a marked reduction in seizure frequency and 1 with isolated auras), and if clear unitemporal seizure onset in ictal EEG-recordings, unilateral radiological lesions, and corresponding histopathological findings were detected. Children aged > 6 years had TLS with features similar to those of adults. In younger children, typical semiology included symmetric motor phenomena of the limbs, postures similar to frontal lobe seizures in adults, and head nodding as in infantile spasms. We concluded that the clinical features of TLS in younger children can be misleading and should therefore be considered with caution in selecting patients for surgical procedures on the temporal lobe.
We studied seizure localization and surgical pathology in 25 patients who developed intractable complex partial seizures following head trauma. All patients underwent an extensive presurgical evaluation that included MRI, neuropsychological evaluation, and surface EEG monitoring, and 21 had intracranial EEG monitoring. Seizures were successfully localized in nine patients; all nine underwent a surgical procedure and are seizure-free. Six of these patients had a mesial temporal lobe seizure focus, of whom five had a pathologic diagnosis of mesial temporal sclerosis. All five patients who developed mesial temporal sclerosis sustained their head injury at or before age 5 years. The three remaining patients whose seizures were successfully localized had neocortical foci and circumscribed radiographic abnormalities, which were presumed to be secondary to head trauma, and all had successful surgical resections of the epileptogenic focus. The remaining 16 patients sustained later trauma, and all had successful surgical resections of the epileptogenic focus. The remaining 16 patients sustained later trauma and did not have a focal MRI lesion, and their seizures were not adequately localized. We conclude that as a group, seizure foci secondary to head trauma are difficult to localize accurately, and this should deter surgical intervention. There was an association between early head injury (ie, at or before age 5 years) and mesial temporal sclerosis, and this association aided seizure localization and successful surgical intervention. Therefore, under the right circumstances, trauma can be a suitable historical element in the profile of patients in whom epilepsy surgery is successful.
We performed MRI volumetric measurements of the amygdala (AM) and hippocampal formation (HF) in a group of 43 patients with temporal lobe epilepsy not controlled by optimal drug treatment. Fifteen patients (35%) had a history of prolonged febrile convulsions (PFC) in early childhood; 30 patients underwent surgery, and histopathology was available in twenty-four. The mean values of AM and HF volumes ipsilateral to the EEG focus were significantly smaller than those of normal controls. The volumetric measurements showed a more pronounced atrophy of the AM in patients with a history of PFC, although the HF volumes were also smaller in this group. Patients with a history of PFC had a higher proportion of more severe mesial temporal sclerosis (MTS) compared with those with no PFC. These findings confirm a correlation between early childhood PFC, the severity of atrophy of mesial structures, and MTS.
Sixty-seven patients with temporal lobe epilepsy without circumscribed, potentially epileptogenic lesions, who were studied with intracranial electrodes and who became seizure free following temporal lobectomy were retrospectively evaluated with regard to preoperative scalp electroencephalographic (EEG) findings, neuropsychological test results, neuroimaging findings, results of surgery, and pathology of resected tissue. Interictal scalp EEG showed paroxysmal abnormalities during prolonged monitoring in 64 patients (96%). These were localized in the anterior temporal region in 60 (94%) of these 64 patients. Bilateral independent paroxysmal activity occurred in 42% of the patients and was preponderant over the side of seizure origin in half. Ictal EEG changes were rarely detected at the time of clinical seizure onset, but lateralized buildup of rhythmic seizure activity during the seizure occurred in 80% of patients. In 13%, the scalp EEG seizure buildup was, however, contralateral to the side of seizure origin as subsequently determined by depth EEG and curative surgery. Lateralized postictal slowing, when present, was a very reliable lateralizing finding. Neuropsychological testing provided lateralizing findings concordant with the side of seizure origin in 73% of patients. When neuropsychological testing produced discordant results or nonlateralizing findings, those patients were usually found to have right temporal seizure origin. Intracarotid amobarbital (Amytal) testing demonstrated absent or marginal memory functions on the side of seizure onset in 63% of patients, but 26 patients (37%) had bilaterally intact memory. In those patients who had magnetic resonance imaging, it was very sensitive in detecting subtle medial temporal abnormalities. These abnormalities were present in 23 of 28 magnetic resonance images, and corresponded with mesial temporal sclerosis on pathological examination in all but 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Twenty-three infants and children underwent cortical resection (n = 15) or hemispherectomy (n = 8) for intractable infantile spasms. Infantile spasms were present at the time of surgery in 17 of the 23 patients; in six, spasms had evolved to other seizure types during surgical evaluation. Children with a remote history of infantile spasms were excluded from this study. Focal or hemispheric lesions were identified by magnetic resonance imaging in seven children; an additional two showed focal atrophy without a discrete lesion. Positron emission tomography (PET) showed lateralized or localized abnormalities of cerebral glucose utilization in all patients; in 14, PET was the only neuroimaging modality to identify the epileptogenic cortex. When this occurred, neuropathological examination of resected brain tissue typically showed malformative and dysplastic cortical lesions. Focal interictal and/or ictal electrographic abnormalities were present in all patients, and corresponded well with localization from neuroimaging. None of the patients were subjected to chronic invasive electrographic monitoring with intracranial electrodes. At follow-up (range 4-67 months; mean 28.3 months), 15 children were seizure-free, three had 90% seizure control, one had 75% seizure control, and four failed to benefit from surgery with respect to seizure frequency.
Sixty-three children with new-onset temporal lobe epilepsy (TLE) underwent extensive clinical, EEG, and neuroimaging investigation as part of a prospective, community-based cohort study of the natural history of TLE in childhood. Complex partial seizures occurred in 94% of the children, and tonic-clonic seizures occurred in 14%. Developmental, behavioral, or learning problems were present in 38%. Eighteen children (29%) had a significant illness/event prior to the onset of TLE, including febrile status epilepticus in seven, meningitis in four, respiratory arrest in two, and head injury in one. Magnetic resonance imaging or computed tomography revealed structural abnormalities of the temporal lobe in 24 children (38%), including hippocampal sclerosis (HS) in 13 and tumor in eight. There was a strong association between HS and a history of significant illness/event prior to the onset of TLE (p < 0.001). Analysis of past history and neuroimaging findings led us to propose three etiologically defined subgroups of TLE; developmental TLE (10 children with long-standing, nonprogressive temporal lobe tumors and malformations), TLE with HS/significant antecedents (18 children with HS or a history of a significant illness/event), and cryptogenic TLE (34 children with normal neuroimaging findings and no significant past history). Etiologic differences between children with new-onset TLE may confer prognostic information that will be useful for counselling families and planning treatment.
There is controversy in the literature regarding the importance of risk factors in developing epilepsy and seizure outcome following anterior temporal lobectomy. Some of the existing studies may be biased because of patient selection and limitations in determining predisposition.
To investigate the role of risk factors for epilepsy in determining outcome following anterior temporal lobectomy.
We identified 102 patients in a consecutive surgery series for epilepsy from a tertiary center with a minimum of 1-year postoperative follow-up. Risk factors for epilepsy were determined prospectively on at least 3 occasions before anterior temporal lobectomy. Risk factors investigated were a history of febrile convulsions, family history of epilepsy, significant head trauma, history of meningitis, history of encephalitis, or significant perinatal insult. Foreign tissue lesions on magnetic resonance imaging was also included if an anterior temporal lobectomy was performed for presumed dual pathologic findings (hippocampus and lesion). Outcome was determined using Engel's classification. For statistical analysis we used successive logistic regression analysis, chi(2) test, Fisher exact test, and t test.
Of the 102 patients, 13 had no identified risk factor for epilepsy, 49 had 1 identified risk factor, and 40 had more than 1. Frequencies were 39 febrile convulsions (15 complex febrile convulsions), 29 head trauma, 22 with lesions seen on magnetic resonance imaging, 12 history of meningitis, 2 history of encephalitis, 19 family history of epilepsy, and 4 perinatal insult. Seventy-one (70%) were classified as Engel's class I, with 56 patients continuously free of seizures at follow-up. Those without risk factor were as likely to be rendered free of seizures following anterior temporal lobectomy as those with a risk factor (P = .27). No risk factor alone or in combination was correlated with complete freedom from seizures following anterior temporal lobectomy, but the presence of head trauma, alone or in combination, was correlated with continued seizures following anterior temporal lobectomy (P = .03; odds ratio, 2.6). Better outcomes were not seen in those with head trauma before the age of 5 years (P = .57). These findings did not change if all those with lesions on magnetic resonance imaging were excluded in the analysis. Those with a history of head trauma were as likely to have pathologic evidence of mesial temporal sclerosis as others (P = .82).
Patients with a history of significant head trauma are less likely to become free of seizures following anterior temporal lobectomy. No other risk factor correlated with a statistically significant greater or lesser chance of freedom from seizures. This information may be used in preoperative counseling of patients.
Our patient underwent right anteromesial temporal resection at 17 years of age for intractable complex partial seizures due to hippocampal sclerosis, and then developed juvenile myoclonic epilepsy after a change in medication. Postoperative seizures ceased after a change to valproate monotherapy. Our patient reminds us to remain aware that generalized and focal epilepsy may coexist as an unusual cause for surgical failure. We feel that these patients may still be favorable candidates for epileptic surgery, as long as the focal epileptogenic zone is amenable to resection and the generalized epilepsy appears to be readily controllable.
David Taylor and Murray Falconer suggested that some patients may develop a psychotic illness after resection of a ganglioglioma that led to intractable seizures. They implied that the mechanism of this association remained unclear. This concept is currently not universally accepted (M. Trimble, personal communication).
We studied six children or young adults from four centers who developed psychosis after resection of a ganglioglioma or dysembryoplastic neuroepithelioma (DNET).
All patients were operated on because of intractable epilepsy. The lesions involved mainly the temporal lobe. Patients had good outcomes for seizure control. In none of the six was potentially psychogenic medication used nor were the psychotic symptoms postictal in nature. The psychosis was schizophreniform with paranoid features and prominent depressive symptoms. Although some behavioral abnormalities were described preoperatively, none had been psychotic before operation. This type of psychotic reaction was not encountered in the four centers in a comparable period after resection of other types of lesions. This complication is rare; it occurred in only one of 39 patients who had such a lesion resected.
Psychotic illness may rarely occur after resection of a ganglioglioma or DNET for treatment of intractable epilepsy. This does not seem to occur after removal of other types of lesions. Because the patients had good outcomes for seizures, the mechanism may be related to "forced normalization." The original observations of Taylor and Falconer are confirmed by this study; the reasons for the selective occurrence, however, remain speculative.
To assess the interrelation of idiopathic generalized epilepsy (IGE) and temporal lobe epilepsy (TLE) when they coexist in the same patient.
The authors reviewed the electroclinical features of 350 consecutive patients who had temporal resection between 1975 and 1997 at the Maudsley and King's College Hospitals, London.
Two patients had the unusual combination of TLE and IGE (0.57%). In the first, the clinical onset of juvenile myoclonic epilepsy followed the surgical resolution of his partial seizures but had been heralded for at least 5 years by subclinical spontaneous and photically induced generalized spike-wave discharges. In the second, TLE and juvenile absence epilepsy had a long parallel course before surgery. After surgery he had no further partial seizures.
These cases suggest that when an idiopathic absence or myoclonic syndrome manifests in a patient with symptomatic TLE, the phenotype may not be a merged syndrome. Rather, the two conditions can retain their inherent electroclinical profile, responsiveness to treatment, and prognosis.
A diagnostic scheme for epileptic seizures and epilepsies with five levels or Axes is proposed (1, ictal semiology; 2, seizure type[s]; 3, epilepsy syndrome; 4, etiology, and 5, resulting impairment). A standardized Glossary of Descriptive Terminology is used for the description of the ictal semiology and the description of seizure types is derived from a list of accepted seizure types constructed by the Task Force. If possible, the syndromic diagnosis follows according to a list of accepted epilepsy syndromes as well as syndromes in development provided by the Task Force. Regarding etiology another list or classification of diseases frequently associated with epileptic seizures or syndromes is provided. The (optional) designation of a resulting impairment will be derived from the WHO International Classification of Functioning and Disability. In addition, the use of some diagnostic terms is discouraged or they are replaced by others (e.g. simple and complex partial seizures", partial" and localization related syndromes", convulsive" and convulsion"), the meaning of other terms is clarified (cryptogenic" = probably symptomatic") and some new concepts are proposed (e.g. epileptic disease" with a single, specific etiology or epileptic encephalopathy" as condition, in which the epileptic processes themselves lead to cerebral dysfunction). It is emphasized that this proposal is not a new classification of seizures and epilepsies or epilepsy syndromes. The proposed scheme should lead to an updated and uniformed use of the diagnostic vocabulary in the preparation of a future new classification or rather multiple classifications for different purposes (e.g. for teaching and research purposes or clinical trials). It is flexible and will be periodically changed and updated in the future as needed.
To characterize the clinical, EEG, MRI, and histopathologic features and explore seizure outcome in pediatric candidates for epilepsy surgery who have temporal lobe epilepsy (TLE) caused by hippocampal sclerosis (HS).
The authors studied 17 children (4 to 12 years of age) and 17 adolescents (13 to 20 years of age) who had anteromesial temporal resection between 1990 and 1998.
All patients had seizures characterized by decreased awareness and responsiveness. Automatisms were typically mild to moderate in children and moderate to marked in adolescents. Among adolescents, interictal spikes were almost exclusively unilateral anterior temporal, as opposed to children in whom anterior temporal spikes were associated with mid/posterior temporal, bilateral temporal, extratemporal, or generalized spikes in 60% of cases. MRI showed hippocampal sclerosis on the side of EEG seizure onset in all patients. Fifty-four percent of children and 56% of adolescents had significant asymmetry of total hippocampal volumes, whereas the remaining patients had only focal atrophy of the hippocampal head or body. Subtle MRI abnormalities of ipsilateral temporal neocortex were seen in all children and 60% of adolescents studied with FLAIR images. On histopathology, there was an unexpectedly high frequency of dual pathology with mild to moderate cortical dysplasia as well as HS, seen in 79% of children and adolescents. Seventy-eight percent of patients were free of seizures at follow-up (mean, 2.6 years). A tendency for lower seizure-free outcome was observed in patients with bilateral temporal interictal sharp waves or bilateral HS on MRI. The presence of dual pathology did not portend poor postsurgical outcome.
TLE caused by HS similar to those in adults were seen in children as young as 4 years of age. Focal hippocampal atrophy seen on MRI often was not reflected in total hippocampal volumetry. Children may have an especially high frequency of dual pathology, with mild to moderate cortical dysplasia as well as HS, and MRI usually, but not always, predicts this finding. Postsurgical seizure outcome is similar to that in adult series.
To describe the clinical manifestations of partial seizures in the pediatric population as a function of age.
Using the database of the pediatric epilepsy monitoring unit (Children's Hospital of New York), clinical and EEG characteristics of partial seizures were distributed by age groups 0-2, 2-6, and 6+ years for 123 patients who had at least one such seizure with a clear EEG correlate during their admission. chi2 tests for trend were used to examine clinical and EEG features as a function of age.
The frequency of aura, limb automatisms, dystonic posturing, secondary generalization, and unresponsiveness increased with age, whereas asymmetric clonus and symmetric tonic posturing decreased with age. There were no clear changes in the types of EEG ictal patterns observed with age; however, partial seizures emanating from the anterior regions of the brain tended to increase with age, whereas those from the posterior regions tended to decrease with age.
Important differences exist in the clinical expression of seizures between young children and adults. These findings will contribute to a better understanding of ictal ontogeny that will promote more accurate classification of seizures and of the epilepsies in young patients. Such efforts can be used to identify young patients for focal epilepsy surgery and to select appropriate anticonvulsive medications.
To evaluate the localizing value of abdominal aura and its evolution into other seizure types.
The seizures of 491 consecutive patients with focal epilepsies were prospectively classified according to a recently introduced semiologic seizure classification. All patients underwent prolonged EEG video monitoring and MRI scan. Two hundred twenty-three patients (45%) had temporal lobe epilepsies (TLE); 113 patients (23%) had extratemporal epilepsies; and for 155 (32%) patients, the epilepsy could not be localized to one lobe.
Abdominal auras were more frequent with TLE (117 of 223 patients, 52%) than in extratemporal epilepsy (13 of 113 patients, 12%, p < 0.0001) and more frequent in mesial TLE (70 of 110 patients, 64%) than in neocortical TLE (16 of 41 patients, 39%, p = 0.007). No preponderance to one side existed. Abdominal auras were followed by ictal oral and manual automatisms (automotor seizure) in at least one seizure evolution in all patients with TLE (117 patients, 100%). In contrast, only two patients with extratemporal epilepsy (2 of 13 patients, 15%, p < 0.0001) had abdominal auras evolving into automotor seizures. An abdominal aura is associated with TLE with a probability of 73.6%. The evolution of an abdominal aura into an automotor seizure, however, increases the probability of TLE to 98.3%.
These results demonstrate that evolution of abdominal aura into automotor seizure permits differentiation between temporal lobe epilepsy and extratemporal epilepsy, showing that analysis of seizure evolution provides more localizing information than does the frequency of particular seizure types.
The aim of this study was to characterize the incidence and etiology of temporal lobe epilepsy (TLE) in a community-based cohort of children with new-onset disease.
A community-based cohort of 30 children with TLE was studied. The patients had new-onset disease before age 14 years between 1995 and 1999. They underwent clinical, EEG, and magnetic resonance imaging investigations.
The patients could be divided in three main groups according to likely etiology, as suggested by Harvey et al. (Neurology 1997;49:960-8). Group 1 consisted of eight (26.7%) children with malformations or long-standing, nonprogressive tumors (developmental TLE). Arachnoid cysts were found in three, dual pathology [cortical dysplasia and hippocampal sclerosis (HS)] in one, and focal cortical dysplasia with glioproliferative changes in one patient. Dysembryoplastic neuroepithelial tumor was responsible for the epilepsy in one, and ganglioglioma, in two children. Group 2 consisted of seven (23.3%) children with a significant antecedent and/or HS. Five children had a significant illness or event before the onset of TLE, including perinatal hypoxic-ischemic encephalopathy in one, encephalitis in one, traumatic brain injury in two, and complex febrile seizures in one. HS was found in the patients with traumatic brain injury and complex febrile seizures in the history in addition to two children without known antecedents. Group 3 comprised 15 (50%) children with no abnormality on neuroimaging and no significant antecedents (cryptogenic TLE).
Etiologic differences between children with new-onset TLE may have prognostic implications: children with TLE and significant antecedents/HS are expected to have the greatest risk of continued seizures and psychological problems.
Complex partial seizure is the characteristic seizure type observed in epilepsy arising from temporal lobe structures. The seizure evolution in adult patients is quite stereotyped and well characterized, manifesting initially with an aura, behavioral arrest, and oroalimentary and gestural automatism. A greater variability of semiology including motor features with tonic or myoclonic components, as well as a paucity of automatism, has been reported in young children with temporal lobe epilepsy. The aim of our study was to examine in more detail the effects of age on individual ictal features to be able to determine the critical age when lesional temporal lobe seizure semiology undergoes transition from the pediatric to the more adult-type clinical pattern.
We performed a video analysis of 83 seizures from 15 children (aged 11-70 months) selected by post-temporal lobectomy seizure-free outcome, looking specifically at the motor and behavioral (nonmotor) manifestations in relation to age of the children.
All of the children younger than 42 months had seizures with early and marked motor features, which included tonic and myoclonic components and epileptic spasms. Parallel with age, the frequency of these motor components decreased, and in five of 11 children older than 3 years, motor features were totally absent. Analyzed quantitatively, we saw a linear and inverse correlation of the ratio of motor components with age at monitoring.
These findings support the hypothesis that events in brain maturation significantly affect clinical seizure semiology and may override the more typical localizing features seen in adult-type temporal lobe epilepsy. These findings are important to consider in the early diagnosis of childhood temporal lobe epilepsy.
The purpose of this study is to explore the possibility of progressive neuropsychological decline in chronic temporal lobe epilepsy (TLE) and determine how this vulnerability may be associated with the neurodevelopmental impact of the disorder. 53 patients with TLE and 62 healthy controls underwent quantitative MRI volumetric imaging of total brain tissue and hippocampal volumes as well as assessment of intelligence and memory function. In addition to reduced hippocampal volume, childhood onset (< 14 years) but not adult onset TLE was associated with significantly reduced total brain tissue that was generalized in nature and extended into extratemporal regions. In addition to this adverse impact on brain structure, there was significantly reduced intellectual status as well as memory function in childhood onset TLE patients, consistent with the generalized nature of the MRI volumetric abnormalities. Finally, cross-sectional correlational analyses indicated that increasing duration of epilepsy in childhood onset patients was associated with declining performance across both intellectual and memory measures, suggestive of progressive cognitive effects. We propose that childhood onset TLE is associated with an adverse neurodevelopmental impact on brain structure and function which represents an early acquired vulnerability, effectively reducing cerebral reserve, placing patients at risk for progressive cognitive decline in the context of chronic and unremitting epilepsy.
To characterize the neurodevelopmental correlates of childhood-onset temporal lobe epilepsy on brain structure and cognition compared with late-onset chronic temporal lobe epilepsy and healthy controls.
Healthy controls (n = 62) and patients with early (n = 37) versus late (n = 16) age at onset of temporal lobe epilepsy were compared with high-resolution quantitative magnetic resonance imaging (MRI) volumetrics and comprehensive neuropsychological assessment.
Patients with childhood-onset temporal lobe epilepsy (mean onset age, 7.8 years) exhibited widespread compromise in neuropsychological performance and substantial reduction in brain tissue volumes extending to extratemporal regions compared with healthy controls and late-onset temporal lobe epilepsy patients (mean onset age, 23.3 years). Most evident was reduced total white-matter volume among the childhood-onset patients. Reduction in brain tissue volume, especially total white-matter volume, was associated with significantly poorer cognitive status, attesting to the clinical significance of the volumetric abnormalities.
Childhood-onset temporal lobe epilepsy appears to be associated with an adverse neurodevelopmental impact on brain structure and cognition that appears generalized in nature and especially evident in white-matter tissue volume.
Temporal lobe epilepsy in childhood: Clinical, EEG, and neuroimaging findings and syn-drome classification in a cohort with new-onset seizures
- Harvey As Berkovic
- Sf
- Ja
Harvey AS, Berkovic SF, Wrennall JA, et al: Temporal lobe epilepsy in childhood: Clinical, EEG, and neuroimaging findings and syn-drome classification in a cohort with new-onset seizures. Neu-rology 1997;49:960-968.
Auras na epilepsia do lobo temporal
- Dantas Fg Yacubian
- Emt
Dantas FG, Yacubian EMT: Auras na epilepsia do lobo temporal. Braz J Epilepsy Clin Neurophysiol 2001;7:13-17.
Contribuições & a g r a v e ; Caracterização da Epilepsia Sin-tomática do Lobo Temporal na Infância, dissertação. São Paulo
- Pedreira
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Pedreira CC: Contribuições & a g r a v e ; Caracterização da Epilepsia Sin-tomática do Lobo Temporal na Infância, dissertação. São Paulo, Faculdade de Medicina da Universidade de São Paulo, USP-São Paulo, 1998.
Neuropsychology in School Children With Temporal Lobe Epilepsy Temporal Lobe Epilepsy in Children: Eurepa Teach-ing Course, Bethel. Assapheum Bielefeld-Bethel
- Lendt
Lendt M: Neuropsychology in School Children With Temporal Lobe Epilepsy. Temporal Lobe Epilepsy in Children: Eurepa Teach-ing Course, Bethel. Assapheum Bielefeld-Bethel. Presented at the 10th International Bethel. Cleveland Clinic Epilepsy Symposium, 1999.
Proposal for revised clinical and electroencephalographic classification of epileptic seizures
Proposal for revised classification of epilepsies and epileptic syndromes
Auras na epilepsia do lobo temporal. Braz J Epilepsy
- F G Dantas
- Yacubian Emt