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This study explored the association between long-term epilepsy surgery outcome and changes in depressive symptoms.

To report 4 cases of hyperfamiliarity for faces (HFF) and review 5 previously reported cases.

The goal of this work was to evaluate the relationship between neuronal injury/loss in the hippocampus, thalamus, and putamen in temporal lobe epilepsy (TLE) patients using 1H magnetic resonance spectroscopic imaging.

To determine changes in depression and anxiety after resective surgery.

Focal cortical dysplasia of Taylor type (FCDT) usually presents with seizures at an early age, whereas adult onset of epilepsy is uncommon. We reviewed the medical records of 213 patients with FCDT. In 21 patients (10%), age at seizure onset ranged from 18 to 55 years (mean 25.3). The outcome of seizures in patients with FCDT and adult-onset epilepsy seems favorable vs childhood-onset seizures.

The two-thirds of patients with epilepsy who become seizure-free have a quality of life (QOL) similar to the general population. The major treatment challenge is patients with refractory epilepsy. Whereas neurologists typically focus on seizure reduction in the treatment of these patients, results of studies relating seizure frequency to QOL are conflicting. As depression is associated with reduced QOL in epilepsy and antiepileptic medications (AEDs) can cause depression, it is important to determine the relative roles of depression and seizure frequency in QOL in refractory epilepsy.

Article abstract-Eighteen patients with medically intractable Parkinson's disease that was characterized by bradykinesia, rigidity, and marked "on-off" fluctuations underwent stereotactic ventral pallidotomy under local anesthesia. Targeting was aided by anatomic coordinates derived from the MRI, intraoperative cell recordings, and electrical stimulation prior to lesioning. A nonsurgically treated group of seven similarly affected individuals was also followed. Assessment of motor function was made at baseline and at 3-month intervals for 1 year. Following the lesioning, patients improved in bradykinesia, rigidity, resting tremor, and balance with resolution of medication-induced contralateral dyskinesia. When compared with preoperative baseline, all quantifiable test scores after surgery improved significantly with the patients off medications for 12 hours: UPDRS by 65%, and CAPIT subtest scores on the contralateral limb by 38.2% and the ipsilateral limb by 24.2%. Walk scores improved by 45%. Medication requirements were unchanged, but the patients who had had surgery were able to tolerate larger doses because of reduced dyskinesia. Ventral pallidotomy produces statistically significant reduction in parkinsonism and contralateral "on" dyskinesia without morbidity or mortality and with a short hospitalization in Parkinson's disease patients for whom medical therapy has failed.

We withdrew phenytoin from 17 inpatients maintained on combination therapy with carbamazepine for complex partial seizures and analyzed seizure occurrence in relation to plasma levels and time from initiation of withdrawal. The ratio of maximum to mean weekly seizure frequency did not vary with initial level or rate of withdrawal. The week with most frequent seizures began a median of 10 days after phenytoin levels became undetectable, and mean daily seizure frequency was higher at undetectable than at falling levels for the entire 2-to 10-week study period. Four patients had a total of 6 clusters of generalized tonic-clonic seizures; only 2 occurred while levels were falling and the other 4 at 3, 9, 28, and 42 days after reaching undetectable levels. Our data argue against the occurrence of withdrawal seizures in these patients and suggest that worsening of seizures following phenytoin discontinuation more likely reflects loss of therapeutic drug effect than a true abstinence phenomenon.

We discuss four patients with the clinical diagnosis of basilar migraine and suspected coexisting epilepsy who were referred to our epilepsy center. Their symptoms suggested episodic dysfunction in the distribution of the basilar artery, followed by pulsating headache with nausea. Verbal unresponsiveness and sensory symptoms occurred in all four patients; two also had focal paresis or jerking movements. Diagnostic studies excluded other disorders with similar symptoms. None of the patients improved with antimigraine or antiepileptic drugs. Provocation tests with suggestion elicited typical events in three patients and aura and headache in one patient. There were no EEG or ECG abnormalities during spontaneous or provoked episodes. Two patients improved with psychiatric treatment. Conversion disorder or malingering should be considered in patients whose symptoms of basilar migraine are atypical or refractory to treatment.

We studied 120 generalized tonic-clonic seizures (GTCSs) in 47 patients with video-EEG telemetry. GTCSs were preceded by antecedent seizures, including 13 simple partial, 70 complex partial, 17 simple partial leading to complex partial, seven tonic, seven clonic, and one typical absence. We divided GTCSs into the following phases: onset of generalization, pretonic clonic, tonic, tremulousness, and clonic. The mean GTCS duration was 62 seconds. There was a nonsignificant trend toward longer duration on reduced antiepileptic drug doses. Marked heterogeneity in GTCS phenomenology was present; only 27 of seizures included all five phases. Individual phase duration and clinical expression, including tonic and clonic phases, was highly variable. The clinical phenomena suggest that multiple cortical and subcortical routes of spread may exist. When GTCSs last longer than 2 minutes, intravenous antiepileptic drug treatment should be initiated.

We identified seven patients with refractory partial epilepsy and sleep apnea. Treatment of the sleep apnea with nasal continuous positive airway pressure (CPAP), protriptyline, trazodone, acetazolamide, or tracheostomy reduced seizure frequency and severity in six patients. Success with CPAP depended largely on compliance. Four of five patients had a clear reduction in seizure frequency with the use of CPAP. Sleep apnea may exacerbate epilepsy by causing sleep disruption and deprivation, hypoxemia, and decreased cerebral blood flow. In epilepsy patients with risk factors (eg, obesity) or markers (eg, habitual snoring, daytime somnolence) for sleep apnea, a careful sleep history should be elicited and a polysomnogram obtained when indicated. Treatment of the sleep disorder can improve seizure control.

We examined material-specific memory in 45 left hemisphere language dominant patients with temporal complex partial seizures (24 right, 21 left) during the intracarotid amobarbital procedure (IAP) by showing eight cards displaying two line drawings of common objects, two printed words, one colored shape, one math expression, one face, and one abstract shape following amobarbital injection (mean 109.9 mg). We assessed delayed recall and recognition following clearing. Patients with right foci recognized significantly fewer verbally mediated stimuli (words, object drawings, colored shape) with left than with right injection. Patients with left foci recognized a nonverbal stimulus (abstract shape) more poorly following right versus left injection. Discriminant function analysis lateralized 85 of the sample from memory predictors, upheld to 81 on crossvalidation. Material-specific memory remains intact in the hemisphere contralateral to a seizure focus, but wider representation may occur for stimuli normally dominant for the hemisphere with the seizure focus. The IAP significantly lateralizes a seizure focus with use of both types of stimuli.

Since symptoms of chronic dissociative disorders such as multiple personality disorder (MPD) may be shared by patients with seizure disorders, we investigated the possible relationship between dissociative states and epilepsy. We monitored 6 MPD patients with intensive video-EEG recordings to determine whether epileptic phenomena have any correlation to the dissociative symptoms experienced by these patients. Previously, physicians had diagnosed epilepsy in all 6 patients; however, none proved to have epilepsy. In addition, we studied dissociative symptoms in 71 epileptic patients with the aid of a standardized questionnaire, the Dissociative Experiences Scale, and compared them with age-matched controls. While the group median score of cases with complex partial seizures was higher than that of normal controls, it was significantly lower than that of the psychiatric patients with MPD. Partial seizure patients with dominant hemisphere foci had higher depersonalization subscale scores than those with nondominant foci. Our data suggest that epilepsy is not a primary pathophysiologic mechanism for developing dissociative symptoms.

The occurrence of an aura is often considered evidence of a partial rather than an idiopathic generalized epilepsy syndrome. The authors examined this hypothesis by prospectively recording reports of auras by patients being admitted for video-EEG monitoring. Auras were equally common (70%) among patients with idiopathic generalized epilepsy as they were among those with localization-related epilepsy. Presence of an aura is not a reliable indicator of localization-related epilepsy.

Severe emotional outbursts (SEOs) during intracarotid amobarbital procedures (IAP) rarely jeopardize preoperative language and memory testing. Four of four patients (100) with outbursts had experienced significant emotional trauma (three were raped and one witnessed a decapitation), compared with 26 of 546 patients (4.8) without outbursts (269.8, p< 0.0001). Evocative injections were ipsilateral to seizure focus. IAP may disrupt emotional balance in some traumatized patients. Counseling may prevent SEOs.

We studied 92 secondary generalized tonic-clonic seizures (SGTCS) in 29 patients with a clearly lateralized seizure focus using video-EEG telemetry. An examiner, blind to the EEG, reviewed direction and type (forced versus nonforced) of head/eye deviation (HD). Forced HD consisted of sustained, unnatural tonic or clonic movements. Nonforced HD consisted of sustained deviations that were neither tonic nor clonic and were similar to volitional head movements. Eighty-three of the 92 SGTCS (26 of 29 patients) had lateralized and sustained HD. The direction of HD was contralateral in over 90 of seizures when the movement either (1) continued as the seizure generalized, or (2) occurred in the 10 seconds prior to generalization. The direction of HD was ipsilateral in over 90 of seizures if the movement ended before the seizure began to generalize (in all cases, the movement ended more than 10 seconds before generalization). HD occurring within the first 10 seconds after seizure onset was not of lateralizing significance. Forced HD was 89 contralateral, while nonforced HD was not of lateralizing significance. HD in SGTCS provides information on seizure focus lateralization.

We report two cases of ictal vomiting in patients who had left temporal lobe epilepsy.In one patient, vomiting developed when the discharge spread to the right temporal lobe as seen during depth electrode recording. In the second patient, ictal vomiting occurred with a restricted left temporal discharge, but the patient was lefthanded and had right-hemisphere language dominance. These cases provide additional evidence of the involvement of the nondominant temporal lobe in ictus emeticus.

Epileptic seizures (ES) and nonepileptic seizures (NES) often coexist in patients with treatment-refractory seizures. There are few data on ictal features of these different seizure types in the same patient. We identified 20 patients with ES from a group of 99 NES patients (ES/NES) and compared this group with patients with only ES or NES. All 20 ES/NES patients developed NES after ES. Clinical features of NES clearly differed from ES in 18 of 20 cases. In patients with ES/NES their ES were similar to seizures in patients with only ES, and their NES were similar to spells in patients with only NES. ES/NES patients were similar to ES patients in electrodiagnostic and neuroimaging studies, and similar to NES patients in psychiatric interviews and inventories. The clinical manifestations of ES and NES in the same patient are usually different. Both types of events may be stereotypic and can be distinguished and characterized during video-EEG recording. Determining what events are more prevalent or disturbing is critical. Psychiatric and antiepileptic drug treatment may be provided accordingly.