[Show abstract][Hide abstract] ABSTRACT: Most patients do well after epilepsy surgery for mesial temporal lobe sclerosis, and in only 8 to 12% of all operations, the outcome is classified as not improved.
To analyze the outcome of reoperation in cases of incomplete resection of mesial temporal lobe structures in patients with mesial temporal lobe sclerosis in temporal lobe epilepsy.
We analyzed 22 consecutive patients who underwent reoperation for mesial temporal lobe sclerosis (follow-up, 23-112 months; mean, 43.18 months) by evaluating noninvasive electroencephalographic/video monitoring before the first and second surgeries (semiology, interictal epileptiform discharges, ictal electroencephalography with special attention to the secondary contralateral evolution of the electroencephalographic seizure pattern after the initial regionalization), and magnetic resonance imaging (resection indices after the first and second surgeries on the amygdala, hippocampus, lateral temporal lobe). In 18 of 22 patients T2 relaxometry of the contralateral hippocampus was performed.
Nine of 22 patients became seizure free; another 4 patients had a decrease in seizures and eventually became seizure free (range, 16-51 months; mean, 30.3). Recurrence of seizures is associated with (1) ictal electroencephalography with later evolution of an independent pattern over the contralateral temporal lobe (0 of 5 patients seizure free vs 5 of 7 patients non-seizure free; P = .046) and (2) a smaller amount of lateral temporal lobe resection in the second surgery (1.06 ± 0.59 cm vs 2.18 ± 1.37 cm; P = .019). No significant correlation with outcome was found for lateralization of interictal epileptiform discharges, change in semiology, other resection indices, T2 relaxometry, onset and duration of epilepsy, duration of follow-up, and side of surgery.
Patients have a less favorable outcome with a reoperation if they show ictal scalp electroencephalography with secondary contralateral propagation and if only a small second resection of the lateral temporal lobe is performed.
[Show abstract][Hide abstract] ABSTRACT: The brain, in a similar fashion to the heart, is an electrical organ. Antiepileptic medication fails to control seizures in approximately 30% of patients with epilepsy, requires local concentration in the brain following gastrointestinal absorption and has frequent, sometimes serious, side effects. Using electrical brain stimulation therapy to directly modulate neuronal discharges (the origin and basis of seizure activity) holds much promise to reduce seizures in a substantial proportion of patients with refractory epilepsy. Electrical brain stimulation is at the interface of biology, medicine and engineering.
[Show abstract][Hide abstract] ABSTRACT: The etiological misinterpretation of paroxysmal neurological symptoms frequently causes a delayed treatment or an inappropriate utilization of ICU-capacities.
In this study, the data of 208 patients admitted to a neurological ICU because of acute transient neurological deficits, loss of consciousness or unclear motor phenomena were retrospectively analyzed. The initial emergency room diagnosis was compared to the final diagnosis and the rate of misdiagnosis was related to the patients' history and diagnostic data.
In 13.9%, the emergency room diagnosis of epileptic seizures turned out to be incorrect, whereas in 15.6%, the final diagnosis of epileptic seizures was missed in the emergency room. Factors that were significantly correlated to missing the seizure diagnosis were (i) no prior history of epilepsy, (ii) old age, (iii) multi-morbidity, (iv) pathologic CT-scans demonstrating cerebrovascular lesions, (v) seizure description by non-professionals, (vi) predominantly negative seizure phenomena (aphasia, loss of consciousness, paresis), (vii) lack of tongue-bite lesions.
No preview · Article · Dec 2009 · Acta Neurologica Scandinavica
[Show abstract][Hide abstract] ABSTRACT: There are established drugs for the treatment of status epilepticus (SE) but their potentially hazardous side-effects are well known. Levetiracetam (LEV) is a novel anticonvulsant available for intravenous (i.v.) application. It could be an alternative when standard drugs fail or should be avoided. We retrospectively identified patients from two German teaching hospitals who were treated with LEV i.v. for SE. Their charts were reviewed regarding sociodemographic data, type, etiology, onset and duration of SE, dose of LEV, concurrent antiepileptic drugs (AED) treatment, tolerability, and outcome. Thirty-two patients (15 female) were found who were treated with i.v. LEV for SE (median age 71 years). Two patients were exclusively treated with LEV. Eight received a low and further 20 patients a high dose of benzodiazepines before LEV. Two patients were treated with LEV to enable discontinuation of narcosis. SE was generalized convulsive in five, nonconvulsive in 20, and simple focal in seven patients. Etiology was acute 13 times and remote symptomatic 16 times; three SE were of unknown etiology. Therapy was initiated within a median time of 3 h and LEV i.v. was applied within a median time of 6 h. Median LEV bolus was 2,000 mg; median total dose on day 1 was 3,500 mg. Benzodiazepines plus i.v. LEV terminated SE in 23 patients without application of additional anticonvulsants, 10 within 30 min. LEV could not terminate SE in seven patients. We documented nausea and emesis in one and elevation of liver enzymes in another patient that were likely to be attributed to LEV. LEV i.v. seems to be safe with relevant efficiency for the treatment of SE in elderly and multimorbid patients when comorbidity and respiratory insufficiency precludes high doses of benzodiazepines or phenytoin.
Full-text · Article · Jun 2009 · Journal of Neurology
[Show abstract][Hide abstract] ABSTRACT: Twenty-six Austrian, Dutch, German, and Swiss epilepsy centers were asked to report on use of the Wada test (intracarotid amobarbital procedure, IAP) from 2000 to 2005 and to give their opinion regarding its role in the presurgical diagnosis of epilepsy. Sixteen of the 23 centers providing information had performed 1421 Wada tests, predominantly the classic bilateral procedure (73%). A slight nonsignificant decrease over time in Wada test frequency, despite slightly increasing numbers of resective procedures, could be observed. Complication rates were relatively low (1.09%; 0.36% with permanent deficit). Test protocols were similar even though no universal standard protocol exists. Clinicians rated the Wada test as having good reliability and validity for language determination, whereas they questioned its reliability and validity for memory lateralization. Several noninvasive functional imaging techniques are already in use. However, clinicians currently do not want to rely solely on noninvasive functional imaging in all patients.
Full-text · Article · Aug 2008 · Epilepsy & Behavior
[Show abstract][Hide abstract] ABSTRACT: Infection with the human immunodeficiency virus (HIV) is associated both with infections of the central nervous system and with neurological deficits due to direct effects of the neurotropic virus. Seizures and epilepsy are not rare among HIV-infected patients. We investigated the frequency of acute seizures and epilepsy of patients in different stages of HIV infection. In addition, we compared the characteristics of patients who experienced provoked seizures only with those of patients who developed epilepsy.
[Show abstract][Hide abstract] ABSTRACT: To examine the predictive value of demographic data for the seizure outcome after extratemporal epilepsy surgery.
Eightyone patients who underwent resective extratemporal epilepsy surgery were retrospectively studied concerning (a) age at surgery, (b) onset of epilepsy, (c) duration of epilepsy, (d) number of seizures at the time of presurgical evaluation, (d) number of presurgically tested antiepileptic substances and (f) number of seizure types. The data were correlated to the postoperative seizure outcome after two years.
33 patients (40.7%) were seizure free two years after surgery. Univariate and multivariate analysis revealed that both tumor etiology and low presurgical seizure frequency were independently associated with seizure freedom after epilepsy surgery. The recurrence rate in patients with one or more seizures per day was more than two-fold if compared with patients with fewer seizures. The remaining demographic factors did not show a significant association with seizure outcome in our 81 patients.
Fewer than daily seizures prior to surgery and a tumoral etiology independently increase the likelihood of remaining seizure free two years after extratemporal epilepsy surgery.
No preview · Article · Sep 2007 · Journal of Neurology
[Show abstract][Hide abstract] ABSTRACT: Status epilepticus (SE) is a frequent neurological emergency with an annual incidence of 10-20/100,000 individuals. The overall mortality is about 10-20%. Patients present with long-lasting fits or series of epileptic seizures or extended stupor and coma. Furthermore, patients with SE can suffer from a number of systemic complications possibly also due to side effects of the medical treatment. In the beginning, standardized treatment algorithms can successfully stop most SE. A minority of SE cases prove however to be refractory against the initial treatment and require intensified pharmacologic intervention with nonsedating anticonvulsive drugs or anesthetics. In some partial SE, nonpharmacological approaches (e.g., epilepsy surgery) have been used successfully. This paper reviews scientific evidence of the diagnostic approach, therapeutic options, and course of refractory SE, including nonpharmacological treatment.
[Show abstract][Hide abstract] ABSTRACT: The recent proposal by the ILAE Task Force for Epilepsy Classification is a multiaxial, syndrome-oriented approach. Epilepsy syndromes--at least as defined by the ILAE Task Force--group patients according to multiple, usually poorly defined parameters. As a result, these syndromes frequently show significant overlap and may change with patient age. We propose a five-dimensional and patient-oriented approach to epilepsy classification. This approach shifts away from syndrome orientation, using independent criteria in each of the five dimensions similarly to the diagnostic process in general neurology. The main dimensions of this new classification consist of (1) localizing the epileptogenic zone, (2) semiology of the seizure, (3) etiology, (4) seizure frequency, and (5) related medical conditions. These dimensions characterize all information necessary for patient management, are independent parameters, and include information more pertinent than the ILAE axes with regard to patient management. All cases can be classified according to this five-dimensional system, even at initial encounter when no detailed test results are available. Information from clinical tests such as MRI and EEG are translated into the best possible working hypothesis at the time of classification, allowing increased precision of the classification as additional information becomes available.
[Show abstract][Hide abstract] ABSTRACT: The recent proposal by the ILAE Task Force for Epilepsy Classification is a multiaxial, syndrome-oriented approach. Epilepsy syndromes – at least as defined by the ILAE Task Force – group patients according to multiple, usually poorly defined parameters. As a result, these syndromes frequently show significant overlap and may change with patient age. We propose a five-dimensional and patient-oriented approach to epilepsy classification. This approach shifts away from syndrome orientation, using independent criteria in each of the five dimensions similarly to the diagnostic process in general neurology. The main dimensions of this new classification consist of (1) localizing the epileptogenic zone, (2) semiology of the seizure, (3) etiology, (4) seizure frequency, and (5) related medical conditions. These dimensions characterize all information necessary for patient management, are independent parameters, and include information more pertinent than the ILAE axes with regard to patient management. All cases can be classified according to this five-dimensional system, even at initial encounter when no detailed test results are available. Information from clinical tests such as MRI and EEG are translated into the best possible working hypothesis at the time of classification, allowing increased precision of the classification as additional information becomes available.
[Show abstract][Hide abstract] ABSTRACT: Pregabalin is a novel anticonvulsive and analgesic drug that has been marketed in Europe for more than a year. The typical side effects are dizziness, somnolence and weight gain. We present a patient who, after unintended rapid up-titration of pregabalin, experienced psychotic symptoms associated with rhythmic EEG-changes resolving completely after discontinuation of pregabalin and benzodiazepine administration. (c) 2006 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Zusammenfassung Wegen eines unbefriedigenden postoperativen Anfallergebnisses kommt es bei einer kleinen Zahl von Patienten mit Temporallappenepilepsie (TLE) und mesialer temporaler Sklerose (MTS) zu einer Nachresektion. Unsere Untersuchung umfasste 12 aufeinander folgende Patienten mit MTS (Nachbeobachtung 14 bis 71 Monate postoperativ, im Durchschnitt 42,4 Monate); wir analysierten nichtinvasives Video-EEG-Monitoring vor der ersten und vor der zweiten Operation (interiktale epilepsietypische Potenziale—ETP, iktales EEG, Semiologie) und MRI nach der ersten und der zweiten Operation (Resektionsindex von Mandelkern, Hippokampus und lateralem Temporallappen). Fnf von 12 Patienten wurden anfallsfrei. Das Wiederauftreten von Anfllen war korreliert mit: 1) im iktalen EEG Ausprgung eines unabhngigen Musters ber dem kontralateralen Temporallappen (0 von 5 Patienten anfallsfrei versus 5 von 7 Patienten; p=0,028); 2) der Ausdehnung der lateralen Temporallappenresektion bei der Nachresektion (1,060,59 cm versus 2,18 1,37 cm; p=0,037). Keine signifikante Korrelation fanden wir fr die Lateralisation der interiktalen ETP, Wechsel der Anfallssemiologie, andere Resektionsindices, Beginn und Dauer der Epilepsie, Dauer der Nachbeobachtung und Seite der Resektion. Patienten mssen demnach bei einer Zweitoperation mit einem weniger gnstigen Ergebnis rechnen, wenn sie im iktalenEEG eineAusbreitung des Anfallmusters zur Gegenseite haben oder wenn schon die erste Temporallappenresektion eine groe laterale Ausdehnung hat.
No preview · Article · Feb 2006 · Zeitschrift für Epileptologie
[Show abstract][Hide abstract] ABSTRACT: Der Status epilepticus (SE) gehört mit einer jährlichen Inzidenz von 10–20/100.000 Einwohnern zu den häufigsten Notfällen in der Neurologie. Die Gesamtmortalität liegt abhängig von einer Reihe klinischer Parameter zwischen 10% und 20%. Die Patienten zeigen lang andauernde oder in Serie auftretende motorische Anfälle oder prolongierte Bewusstseinsstörungen bis hin zum Koma. Darüber hinaus können eine Reihe systemischer Komplikationen auftreten, die auch als Folge einer aggressiven medikamentösen Therapie möglich sind. Während sich der überwiegende Teil der SE durch standardisierte Behandlungsalgorithmen unterbrechen lässt, erweisen sich einige SE als refraktär gegen diese Initialtherapie und bedürfen einer intensivmedizinischen Intervention. Hier kommen vornehmlich nicht sedierende Antikonvulsiva und bei Bedarf zusätzlich Injektionsnarkotika zum Einsatz. In Einzelfällen stellen nichtmedikamentöse Therapieansätze (z. B. die Epilepsiechirurgie) eine zusätzliche Behandlungsalternative dar. Die vorliegende Arbeit präsentiert einen Überblick über die Studienlage zu Verlauf, Diagnostik und Therapie des refraktären SE einschließlich nichtmedikamentöser Behandlungsstrategien.
[Show abstract][Hide abstract] ABSTRACT: Alien limb phenomena (ALPs) are characterized by limb movements, which are subjectively experienced as involuntary or alien induced. ALPs regularly remain unchanged and occur as a consequence of frontal, callosal, or posterior cerebral lesions. The authors present two patients with paroxysmal ALP proved to be focal seizures by using video-EEG monitoring. In another two patients, ALP could experimentally be induced by electrical cortical stimulation. Based on the stimulation results, the authors suspect a functional disconnection of 1) sensory cortical areas providing information about the extrapersonal space; and 2) areas of the frontal and/or limbic cortex that are regularly involved in the processing and executing of intentional motor activity as a pathophysiologic substrate for ictal ALP.