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BACKGROUND Both stereoelectroencephalography (SEEG) and subdural strip electrodes (SSE) are used for intracranial electroencephalographic recordings in the invasive investigation of patients with drug-resistant epilepsy. OBJECTIVE To compare SEEG and SSE with respect to feasibility, complications, and outcome in this single-center study. METHODS Patient characteristics, periprocedural parameters, complications, and outcome were acquired from a pro- and retrospectively managed databank to compare SEEG and SSE cases. RESULTS A total of 500 intracranial electroencephalographic monitoring cases in 450 patients were analyzed (145 SEEG and 355 SSE). Both groups were of similar age, gender distribution, and duration of epilepsy. Implantation of each SEEG electrode took 13.9 ± 7.6 min (20 ± 12 min for each SSE; P

Electrical stimulation mapping (ESM) is an important tool for the localization of the seizure onset zone (SOZ) in patients with medically resistant epilepsy (MRE). ESM is the gold standard for the identification of eloquent cortex in epilepsy surgery candidates. However, there is no standard protocol outlining how to perform ESM, to obtain the most useful information possible. The objective of this study, after reviewing the literature concerning ESM, is to propose a unifying technique to validate reliable data across different centers.In this manuscript we summarize this technique from its origin to present, and review protocols used in other centers. We also describe a protocol that has been used in our institution, which utilizes depth electrodes.The most common type of ESM uses a "close-loop" system, bipolar and high frequency stimulation (50 Hz). We propose to use a pulse width of 300 µs, current spanning 1-6 mA in depth electrodes and 1-11 mA in subdural-grids. Stimulation time of 5 s maximum and at least 10 s break in between the stimulations.ESM is a useful tool for understanding eloquent cortex as well as the epilepsy network, although there is no clear consensus regarding how it should be performed.

Purpose To provide a descriptive analysis on the presurgical evaluation and surgical management of a cohort of patients with stroke related epilepsy (SRE). Methods We retrospectively examined the clinical characteristics, results of non-invasive and invasive presurgical evaluation, surgical management and outcome of consecutive patients with drug-resistant SRE in our institution from January 1, 2013 to January 1, 2020. Results Twenty-one of 420 patients (5%) who underwent intracranial EEG (iEEG), resective epilepsy surgery and/or vagus nerve stimulation (VNS) placement, had SRE. Of 13 patients who had iEEG, the ictal onset (IO) was exclusively within the stroke lesion in only one patient. In five patients the IO was extra-lesional and in the remaining seven patients it included the stroke lesion as well as extra-lesional structures. The IO included the mesial temporal region in 11 of the 13 patients (85%). The posterior margin of the stroke lesion was always involved. Five patients underwent surgery without iEEG. In total, 10 patients underwent resective surgery, four VNS placement and two had both corpus callosotomy and VNS placement. Of the patients who had resective surgery, nine were Engel I or II at last follow up. Conclusion We found that seizures in patients with drug resistant SRE were more frequently originated in the mesial temporal region than in the stroke lesion itself. Despite the complex epileptic network underlying drug-resistant SRE, a thorough presurgical assessment and adequate use of surgical options can lead to excellent surgical outcomes.

Objective To determine the contribution of stereo-EEG for localization purpose in patients with a visible lesion on MRI. Background Intracranial EEG is often used to localize the epileptogenic focus in patients with non-lesional focal epilepsy. Its role in cases where a lesion is visible on MRI can be even more complex and the relationship between the lesion and the seizure onset has rarely been addressed. Methods All consecutive patients between February 2013 and May 2018 who underwent stereo-EEG and had a lesion visible on MRI were included. We assessed the localization of the seizure onset and its relationship with the lesion. Clinical, radiological, and electrographic analyses were performed. Results Stereo-EEG revealed a seizure onset with either partial or no overlap with the lesion seen on MRI in 42 (56 %) of the 75 lesions included. Mesial temporal sclerosis was the only lesion type associated with an exclusively lesional seizure onset (p = 0.003). Conclusion Epilepsy surgery in MRI-positive cases should rely not only the results of lesions seen on MRI, which might be potentially misleading; SEEG is a gold standard method in these cases to define resective borders.

Objective To determine if the ictal onset recorded with stereoelectroencephalography (SEEG) during clusters of seizures is reliable to identify the laterality of the epileptogenic zone. Background In the presurgical evaluation of patients with focal drug-resistant epilepsy, the presence of bilateral ictal onset is usually associated with a poor surgical outcome. It has been reported that the laterality of seizures can be influenced during seizure clusters, although this remains controversial. Most studies have addressed this issue using scalp EEG which could erroneously determine the laterality of the ictal onset. Methods We examined all consecutive patients who underwent SEEG with bilateral hemispheric coverage at our institution between January 2013 and September 2018. We assessed the presence of seizure clusters (clinical or subclinical), their laterality by SEEG and the surgical outcome of the patients. A descriptive clinical and electrographic analysis was performed. Results Of 143 patients who underwent SEEG recordings, we identified only six patients who had bilateral ictal onset that went on to resective surgery. In all six patients the discordant seizures occurred during a seizure cluster. Three of these patients were seizure free at last follow up. Conclusion Discordant seizures obtained during a seizure cluster may not necessarily mean that the patient has bilateral epilepsy, and therefore a poor post-surgical outcome. Seizure clusters may not reliably lateralize the epileptogenic zone.

Objective To evaluate the efficacy and tolerability of adjunctive brivaracetam (BRV) in adults with focal seizures by the number of lifetime (previous and concomitant) antiepileptic drugs (AEDs). Methods Post-hoc analysis of data from N01358 (NCT01261325), a randomized, double-blind, placebo (PBO)-controlled Phase III trial evaluating BRV 100 and 200 mg/day in patients ≥16 years of age with uncontrolled focal seizures. Efficacy and tolerability outcomes were assessed for the 12-week Treatment Period in subgroups of patients with 1–2, 3–4, 5–6, or ≥7 lifetime AEDs. Results 764 patients received at least one dose of trial medication (BRV: 503; PBO: 261; Safety Set), of whom 14.3% had 1–2, 20.8% had 3–4, 21.3% had 5–6, and 43.6% had ≥7 lifetime AEDs. In all lifetime AED subgroups, >85% of patients completed the trial. Patients with a higher number of lifetime AEDs had a younger age at epilepsy onset, longer epilepsy duration, and higher baseline seizure frequency. In patients on BRV, 50% responder rates were 49.3%, 44.4%, 47.2% and 27.4% in patients with 1–2 (n = 75), 3–4 (n = 99), 5–6 (n = 108) and ≥7 (n = 219) lifetime AEDs; 75% responder rates were 36.0%, 21.2%, 22.2% and 12.3%. In patients on PBO, 50% responder rates were 35.3%, 25.9%, 20.4% and 15.9% in patients with 1–2 (n = 34), 3–4 (n = 58), 5–6 (n = 54) and ≥7 (n = 113) lifetime AEDs; 75% responder rates were 26.5%, 6.9%, 3.7% and 4.4%. The Kaplan-Meier estimated probability of patients achieving a sustained 50% or 75% response from the first day of treatment was generally higher in patients with a lower number of lifetime AEDs (both in patients on BRV and PBO). In patients on adjunctive BRV, the incidence of drug related treatment-emergent adverse events (TEAEs) was 34.7%, 26.0%, 44.4% and 47.7% in patients with 1–2 (n = 75), 3–4 (n = 100), 5–6 (n = 108) and ≥7 (n = 220) lifetime AEDs; the incidence of discontinuations due to TEAEs was 1.3%, 3.0%, 8.3% and 10.5%. Conclusions This post-hoc analysis suggests a numerically higher response to adjunctive BRV in patients with fewer lifetime AEDs. The lowest response was observed in patients with ≥7 lifetime AEDs, although these patients could also benefit from adjunctive BRV treatment. Patients with fewer lifetime AEDs had lower discontinuation of BRV due to TEAEs.

BACKGROUND: For patients with generalized epilepsy who do not respond to antiseizure medications, the therapeutic options are limited. Vagus nerve stimulation (VNS) is a treatment mainly approved for therapy-resistant focal epilepsy. There is limited information on the use of VNS on generalized epilepsies, including Lennox-Gastaut Syndrome (LGS) and genetic generalized epilepsy (GGE). METHODS: We identified patients with a diagnosis of generalized epilepsy (including LGS and GGE), who underwent VNS implantation at the London Health Sciences Centre and Western University, London, Ontario, since this treatment became available in Canada in 1997 until July 2018. We assessed response to the treatment, including admissions to hospital and complications. RESULTS: A total of 46 patients were included in this study with a history of therapy-resistant generalized epilepsy. The mean age at implantation was 24 years (interquartile range [IQR] = 17.8-31 years), significantly younger in the LGS group (p = 0.02) and 50% (n = 23) were female. The most common etiologies were GGE in 37% (n = 17) and LGS in 63% (n = 29). Median follow-up since VNS implantation was 63 months (IQR: 31-112.8 months). Of the LGS group 41.7% (n = 12) of patients had an overall seizure reduction of 50% or more, and 64.7% (n = 11) in the GGE group without statistical significance between the groups. The best response in seizure reduction was seen in generalized tonic-clonic seizures, with a significant reduction in the GGE group (p = 0.043). There was a reduction of seizure-related hospital admissions from 91.3% (N = 42) preimplantation, to 43.5% (N = 20) postimplantation (p

Background:“Temporal plus” epilepsy (TPE) is a term that is used when the epileptogenic zone (EZ) extends beyond the boundaries of the temporal lobe. Stereotactic electroencephalography (SEEG) has been essential to identify additional EZs in adjacent structures that might be part of the temporal lobe/limbic network.Objective:We present a small case series of temporal plus cases successfully identified by SEEG who were seizure-free after resective surgery.Methods:We conducted a retrospective analysis of 156 patients who underwent SEEG in 5 years. Six cases had TPE and underwent anterior temporal lobectomy (ATL) with additional extra-temporal resections.Results:Five cases had a focus on the right hemisphere and one on the left. Three cases were non-lesional and three were lesional. Mean follow-up time since surgery was 2.9 years (SD ± 1.8). Three patients had subdural electrodes investigation prior or in addition to SEEG. All patients underwent standard ATL and additional extra-temporal resections during the same procedure or at a later date. All patients were seizure-free at their last follow-up appointment (Engel Ia = 3; Engel Ib = 2; Engel Ic = 1). Pathology was nonspecific/gliosis for all six cases.Conclusion:TPE might explain some of the failures in temporal lobe epilepsy surgery. We present a small case series of six patients in whom SEEG successfully identified this phenomenon and surgery proved effective.

This study was aimed to longitudinally assess memory function and whole-brain memory circuit reorganization in patients with temporal lobe epilepsy (TLE) by comparing activation potentials before versus after anterior temporal lobe (ATL) resection. Nineteen patients with medically-intractable TLE (10 left TLE, 9 right TLE) and 15 healthy controls were enrolled. Group analyses were conducted pre- and post-ATL of a novelty complex scene-encoding paradigm comparing areas of blood oxygen-level-dependent (BOLD) signal activations on functional magnetic resonance imaging (fMRI). None of the pre-operative patient characteristics we studied predicted the extent of pre- to post-operative memory loss. On fMRI, extra-temporal activations were detected pre-operatively in both LTLE and RTLE, particularly in the frontal lobe. Greater activations also were noted in the contralateral hippocampus and parahippocampus in both groups. Performing within-subject comparisons, post-op relative to pre-op, pronounced ipsilateral activations were identified in the left parahippocampal gyrus in LTLE, versus the right middle temporal gyrus in RTLE patients. Memory function was impaired pre-operatively but declined after ATL resection in both RTLE and LTLE patients. Post-operative fMRI results indicate possible functional adaptations to ATL loss, primarily occurring within the left parahippocampal gyrus versus right middle temporal gyrus in LTLE versus RTLE patients, respectively.

Idiopathic generalized epilepsy (IGE) is an epileptic condition with good response to antiepileptic drugs (AED). Major syndromes are epilepsy with generalized tonic-clonic seizures (GTCS) alone, absence epilepsy and juvenile myoclonic epilepsy. However, clinical practice shows drug-resistant patients. Endpoint is to identify clinical features related with refractoriness in IGE and in its each individual syndrome.We retrospectively collected 279 consecutive patients with IGE assessed in the Epilepsy Clinic of our institution. We defined drug-resistant epilepsy as a failure of adequate trials of 2 tolerated and appropriately chosen and used AED schedules. We classified patients in two groups: drug-resistant and drug-responsive. Clinical features were compared among these groups, in the whole IGE group as well as in each syndrome.There were 122 drug-resistant, 105 drug- responsive; 52 were undefined and excluded from the analysis. After multivariate analysis, early seizures onset (age13), long-time epilepsy, several generalized seizure types, status epilepticus, EEG with generalized epileptiform activity, mainly polyspikes, and side effects with AED brought up as poor outcome factors. Additionally, 50.6% identified modifiable seizure triggers. Regarding syndromes, epilepsy with generalized tonic-clonic seizures alone had the same factors except several seizure types; presence of additional GTCS, polyspikes, history of AED side effects and psychiatric disorder were poor factors for absence epilepsy; only psychiatric comorbidity revealed significance in juvenile myoclonic epilepsy.Refractoriness in IGE and its major syndromes is associated with clinical and electrographic parameters. Moreover, lifestyle advices from neurologists to the patients might help them to achieve a better seizure control.

Objective We present a single-center retrospective study of benign mesial temporal lobe epilepsy (bMTLE) between 1995 and 2014. Methods Hospital records and clinic charts were reviewed. The clinical, Eelectroencephalographic (EEG), imaging features, and response to treatment with antiepileptic drugs (AEDs) were documented. Patients were included in this study if they were seizure-free for a minimum of 24 months with or without an AED. Results Twenty-seven patients were identified. There were 19 (70%) females, mean age at first seizure was 32.2 (range: 15–80 years). In all patients, seizures were mild, and seizure freedom was readily achieved with the initiation of AED therapy. Sixteen patients (59%) had mesial temporal sclerosis (MTS). In three patients, we attempted to discontinue AED therapy after a prolonged period of remission (5–8 years), but all had seizure recurrence within 2 to 4 weeks. Significance Not all temporal lobe epilepsy is refractory to medication, despite the presence of MTS. Until clinical trials indicate otherwise, surgery is not indicated but life-long medical treatment is advocated.

At the London Health Sciences Centre Epilepsy Program, stereotactically implanted depth electrodes have largely replaced subdural electrodes in the presurgical investigation of patients with drug-resistant epilepsy over the past 4 years. The rationale for this paradigm shift was more experience with, and improved surgical techniques for, stereoelectroencephalography, a possible lower-risk profile for depth electrodes, better patient tolerability, shorter operative time, as well as increased recognition of potential surgical targets that are not accessible to subdural electrodes.

We provide an overview of the surgical outcome of extra-hypothalamic epilepsies with gelastic seizures based on an original case report and a summary of the literature. Twenty-two articles providing information on the outcome of resective surgery in 39 patients with extra-hypothalamic gelastic seizures from the temporal (19 patients) or frontal lobe (20 patients) were selected. We add another case of temporal lobe gelastic seizures to the literature with a video demonstrating the mirthful component of this patient's laughing seizures. Drug-refractory cases of gelastic seizures from the temporal or frontal lobes are amenable to surgical treatment following thorough investigation with imaging, as well as scalp and intracranial EEG.

Objective Vagus Nerve Stimulation (VNS) is a neuromodulation device approved for the treatment of medically refractory epilepsy. Worldwide, only 35 cases of pregnancies that has been described. This study aims to continue to increase the limited knowledge of the use of VNS during pregnancy. Methods We interrogated the database of the Epilepsy program at Western University (1998–2018), and identified those patients who were implanted with VNS and became pregnant. Results From 114 patients implanted with VNS in our centre, four patients had a total of seven pregnancies. This is the first report with one woman implanted with VNS having three pregnancies. Three patients had genetic generalized epilepsy and one focal epilepsy due to periventricular nodular heterotopia. The median duration since implantation was 3.17 years (IQR: 1.33–4.33) and the output was 2.75 mA (IQR: 1.5–3.5). No modifications in stimulation settings were made in any patient during pregnancy. Three patients had obstetric complications, requiring c-sections. All babies were healthy, except one with intellectual disabilities of unclear severity. Conclusion Our small sample suggests VNS could increase the obstetrical complications, but is likely safe for the fetus. However, a larger sample size should be collected to determine safety and potential teratogenicity of VNS.

Background Temporal lobe epilepsy (TLE) with unclear lateralization may require intracranial implantation of electrodes (IIE). We retrospectively assessed the association between the use of IIE and long-term outcomes in patients undergoing anterior temporal lobectomy (ATL). Participants and methods We retrospectively reviewed the records of 1,032 patients undergoing epilepsy surgery at our center from 1977 to 2006. Patients who underwent ATL were included. Seizure outcome was assessed through final follow-up. Those who underwent scalp and IIE (mostly evaluated with temporal subdural strip electrodes) were compared. Results From 497 patients who underwent ATL, 139 did so after IIE placement in the temporal lobes. Mean age at surgery was 32.3±12.3years and median duration of follow-up 24 months (range: 6–36). Fifty-three percent of those evaluated with IIE were seizure-free at their last available visit (vs. 68% evaluated with only scalp EEG, p=0.002). Patients with lesional TLE generally had a better outcome (65.5% seizure free) than those without lesions (56.3%, p=0.093), especially for unilateral TLE diagnosed with IIE. In a multivariate Cox regression analyses adjusted for gender, neuropsychological concordance, pathological findings, and post-operative seizures, bilateral TLE predicted seizure recurrence in IIE patients (HR=2.08, 95% CI: 1.08–4.0, p=0.029). Conclusions More than a half of those who undergo IIE in suspected TLE are seizure free after ATL. IIE allows for the identification of surgical candidates.

Epidemiologic evidence supporting antiseizure properties of cannabis is limited and controversial. We determined the prevalence of marijuana use and its perceived effects in patients with and without epilepsy.Information was collected over 14months from consecutive adult patients admitted to an epilepsy monitoring unit using a 27-item anonymous questionnaire. Patients with cognitive impairment unable to understand the questions or give informed consent and readmissions were not recruited. Subjects were divided into 4 groups, those with epileptic seizures, those with psychogenic nonepileptic seizures (PNES), those with both epileptic and PNES, and those with other nonepileptic events. Patients with exclusively epileptic seizures were compared with those with exclusively PNES.From 310 patients, 18 undiagnosed cases were excluded leaving a cohort of 292 patients with median age 35 (range: 27-49) years; 57.2% female. Epilepsy was documented in 190 (65.1%), PNES in 64 (21.9%), and both types of seizures in 26 (8.9%). Median duration of seizure disorder was longer (2 [1-9] vs. 13 [5.7-25] years; p0.001) and seizure frequency lower (daily or weekly in 62.3% vs. 44.9%; p=0.03) in patients with epilepsy compared with those in patients with PNES. Overall, 166 (57%) had tried marijuana, and 36.2% used it over the past year. Utilization was 57.1% in sole epilepsy and 64.1% in sole PNES, but daily use was more likely in epilepsy (59% vs. 33.3%). Estimated mean dose was 1g/day. Marijuana use was associated with tobacco smoking (p0.001) but not alcohol use. Eight patients used other street drugs. Improvement in seizures was perceived by 84% in those with epilepsy and 72.7% in those with PNES. In the 2 groups, stress was decreased in 84.9% and 88%, sleep improved in 77.3% and 88%, and memory/concentration was better in 32% and 28%, respectively. Antiepileptic drug side effects were decreased in 53.2% of marijuana users. Perceived effect on epileptic seizures correlated with effect on stress (r=0.35, p=0.004). Adverse effects of marijuana were mild and reported in 30.7% but included possible seizure precipitation in 5 patients with epilepsy.Patients with uncontrolled epilepsy or nonepileptic events had a high rate of marijuana use with associated perceived improvements in seizure control, stress, sleep, and drug side effects. Stress reduction may contribute to the perceived impact of marijuana on seizures and nonepileptic events in adults.

The biology of the endocannabinoid system in the brain provides a possible basis for a beneficial pharmacological effect of marijuana on seizures. However, evidence for efficacy of cannabis treatment of epilepsy is anecdotal because no acceptable randomized controlled trials have been done. Proper dosage and means of administration remain unknown. Cannabis is safer than other controlled substances, including tobacco or alcohol, and appears to be relatively safe compared with most pharmaceuticals used to treat epilepsy. This is a review of this topic from a Canadian perspective.

Background Orbitofrontal epilepsy (OFE) is less known and is poorly characterized in comparison with temporal lobe epilepsy, partly because it is rare and possibly because it is unrecognized and therefore underestimated. Objective This paper aimed to better characterize seizure semiology, presurgical findings, and surgical outcomes in patients with OFE. Methods We retrospectively reviewed all confidently established OFE cases from six Canadian epilepsy monitoring units between 1988 and 2014, and in the literature between 1972 and 2017. Inclusion criteria were identification of an epileptogenic lesion localized in the OFC or if the patient was seizure-free after surgical removal of the OFC in nonlesional cases. Results Sixteen cases were identified from our databases. Fifty percent had predominantly sleep-related seizures; 56% had no aura (the remaining had nonspecific or vegetative auras), and 62.5% featured hypermotor (mostly hyperkinetic) behaviors. Interictal epileptiform discharges over frontal and temporal derivations always allowed lateralization. Magnetic resonance imaging (MRI) identified an orbitofrontal lesion in 8/16, positron emission tomography (PET) identified a hypometabolism extending outside the orbital cortex in 4/9, ictal single-photon emission computed tomography (SPECT) identified an orbital hyperperfusion in 1/5, magnetoencephalography (MEG) identified lateral orbital sources in 2/4, and intracranial electroencephalography (EEG) identified an orbitofrontal onset in 9/10. Fourteen patients underwent surgery, all reaching a favorable outcome (71.4% Engel 1; 28.6% Engel 2; mean FU = 5.6 years). Pre- and postoperative neuropsychological assessments revealed heterogeneous findings. Our review of literature identified 71 possible cases of OFE, 32 with confident focus localization. Extracted data from these cumulated cases supported observations made from our case series. Conclusions Orbitofrontal epilepsy should be suspected with sleep-related, hyperkinetic seizures with no specific aura, and frontotemporal interictal discharges. Several patients have nonmotor seizures with or without auras which may resemble temporal lobe seizures. Postoperative seizure outcome was favorable, but there is inherent bias as we only included patients with a seizure-free outcome if the MRI was negative. A larger study is required to address identified gaps in knowledge such as identifying discriminative features between medial and lateral OFE, evaluating the value of more recent diagnostic tools, and assessing the neuropsychological outcome of orbital epilepsy surgery.

SummaryObjective To examine the 30-day risk of hospitalization with hyponatremia associated with carbamazepine, valproic acid (V), phenytoin (P), or topiramate (T) use compared to nonuse in the outpatient setting among older adults. Methods We conducted two population-based, retrospective cohort studies in Ontario, Canada, between 2003 and 2015 using administrative health care databases of older adults. The first study compared carbamazepine users to a propensity-score matched group of antiepileptic drug nonusers, whereas the second compared V-P-T users to a propensity-score matched group of antiepileptic nonusers. The primary outcome was hospitalization with hyponatremia within 30 days of an antiepileptic prescription. Results The baseline characteristics between matched groups were similar in both cohorts. Carbamazepine use versus nonuse was associated with a higher 30-day risk of hospitalization with hyponatremia (82/21,191 [0.39%] versus 30/63,573 [0.05%]; relative risk [RR] 8.20, 95% confidence interval [CI] 5.40–12.46). Similarly, V-P-T use versus nonuse was associated with a higher 30-day risk of hospitalization with hyponatremia (34/20,155 [0.17%] versus 26/40,310 [0.06%]; RR 2.62, 95% CI 1.57–4.36). Significance Older adults prescribed carbamazepine and V-P-T have a higher risk of being hospitalized with hyponatremia compared to other adults with similar indicators of baseline health who were not prescribed antiepileptic drugs. Physicians should be mindful of this risk; when a patient presents to a hospital with symptomatic hyponatremia these drugs should be considered as potential causes.

Objective The aim of this study was to investigate the lateralizing and localizing value of ictal coprolalia and brain areas involved in its production. Methods A retrospective search for patients manifesting ictal coprolalia was conducted in our EMU database. Continuous video-EEG recordings were reviewed, and EEG activity before and during coprolalia was analyzed using independent component analysis (ICA) technique and was compared to the seizures without coprolalia among the same patients. Results Nine patients were evaluated (five women), eight with intracranial video-EEG recordings (icVEEG). Four had frontal or temporal lesions, and five had normal MRIs. Six patients showed impairment in the language functions and five in the frontal executive tasks. Two hundred six seizures were reviewed (60.7% from icVEEG). Ictal coprolalia occurred in 46.6% of them, always associated with limbic auras or automatisms. They arose from the nondominant hemisphere in five patients, dominant hemisphere in three, and independently from the right and left hippocampus–parahippocampus in one. Electroencephalographic activity always involved orbitofrontal and/or mesial temporal regions of the nondominant hemisphere when coprolalia occurred. Independent component analysis of 31 seizures in seven patients showed a higher number of independent components in the nondominant hippocampus–parahippocampus before and during coprolalia and in the dominant lateral temporal region in those seizures without coprolalia (p = 0.009). Five patients underwent surgery, and all five had an ILAE class 1 outcome. Significance Ictal coprolalia occurs in both males and females with temporal or orbitofrontal epilepsy and has a limited lateralizing value to the nondominant hemisphere but can be triggered by seizures from either hemisphere. It involves activation of the paralimbic temporal–orbitofrontal network.

The effect of continuous electrical stimulation of the hippocampus bilaterally on seizures and memory was assessed in two subjects with seizures from both mesial temporal lobes who were not candidates for resective epilepsy surgery. A double blind, randomized, controlled, cross-over trial design was utilized. Two electrodes with four contacts each were implanted along the axis of the hippocampus bilaterally. Simultaneous stimulation of all electrodes contacts was either on or off during each 3-month interval. Seizure frequency decreased by 33% in the two patients during stimulation and remained lower by 25% for the 3 months after stimulation was turned off before returning to baseline (p < 0.01). No consistent change in objective or subjective measures of memory occurred. No other adverse effects occurred. Seizure frequency is reduced both during and for a period after bilateral hippocampal stimulation, but the overall impact in this study is not as robust as has been previously reported.

Invasive intracranial electrodes (IE) are an important part of the work-up in many patients being considered for epilepsy surgery. Because IE are usually reserved for cases where seizure localization is ambiguous, one might expect that the eventual outcome of epilepsy surgery in these patients would be worse than in patients who did not require IE as part of their work-up. The purpose of this study was to specifically examine those patients who underwent insertion of subdural electrodes, to determine how many of these patients eventually underwent resective surgery of any type and to assess the eventual outcome. All cases admitted for subdural electrodes between January 2000 and June 2005 were reviewed. Surgical outcomes were reported using the Engel classification and a multivariate analysis was used to determine which factors were associated with successful surgery. 177 IE implantations were performed in 172 patients. Of these, 130 patients went on to have surgery. In the 113 of the 130 surgical patients in whom 1-year follow-up was available, 47% were seizure free at 1 year. Age was a major predictor of outcome with only 21% of patients over age 40 becoming seizure free with surgery compared to 58% in patients aged under 40 years (p=0.0004). Other predictors of an Engel I outcome included having a temporal lobectomy or supplementary motor area resection. Good results from eventual resective surgery can be achieved in patients needing invasive recordings. Younger patients with temporal lobe epilepsy seem to have the highest likelihood of seizure freedom.

✓ Temporal lobe epilepsy (TLE) is the most common type of surgically treatable epilepsy, with a considerable number of patients needing invasive electroencephalography monitoring. The authors describe a surgical technique used in the placement of subdural strip electrodes for coverage of the temporal lobe. The electrodes are inserted through an enlarged temporooccipital bur hole using fluoroscopic guidance. With this technique, subdural electrode strips can be safely placed to cover the mesial, inferior, and lateral temporal surfaces, and the seizure focus can be lateralized and localized within the temporal lobe. The technique does not require the use of a craniotomy, stereotactic frame, or neuronavigation systems. The authors compare this technique with previous descriptions of subdural electrode placement for the evaluation of TLE.

Objective: To determine the accuracy of the clinical history performed by epileptologists in the identification of seizures in patients with suspected temporal lobe epilepsy. Methods: The clinical and EEG telemetry (EEGT) monitoring data of 88 patients with suspected refractory temporal lobe seizures referred for evaluation of epilepsy surgery were prospectively evaluated. All clinical events obtained by history in these patients were adjudicated as being a seizure or not by two blinded (without access to EEG data) independent epileptologists. Each clinical event was then matched with the corresponding clinical event recorded with EEG telemetry in the epilepsy monitoring unit (gold standard). Sensitivity, specificity, overall accuracy, predictive value, and interrater agreement for the clinical assessment were obtained. Results: Of 357 clinically different events, 175 (49%) were reproduced in the epilepsy monitoring unit. Only 10 events were misidentified by history as being a seizure or not, resulting in an overall clinical accuracy of 94%. Epileptologists’ sensitivity for seizure identification was 96% (95% CI 92, 98%) but specificity was only 50% (95% CI 22, 79%). Accuracy for complex partial seizures and generalized seizures was higher than for simple partial seizures (SPS). Misidentification occurred only with SPS and nonepileptic events. Agreement beyond chance among epileptologists was good. Conclusion: In this selected group of patients with temporal lobe epilepsy, seizure identification by clinical history is highly accurate. Epileptologists rarely miss seizures (high sensitivity) but more often overcall nonepileptic events as seizures (low specificity).

We assessed the impact of vagus nerve stimulation on a cohort of patients with intractable epilepsy. A 1-year prospective trial of vagus nerve stimulation for intractable epilepsy was done in 26 patients. Seizure frequency, anti-epileptic drugs, and quality of life were assessed using QOLIE-89, ELDQOL, and a Likert scale of impact of treatment. Seizures were reduced by more than 50% in 19% of the patients, by less than 50% in 46%, and were unchanged in 35% of them. Antiepileptic drugs were reduced in 43% of the patients. There was a significant improvement in the mean overall QOLIE-89 score and other measures of quality of life, but these did not correlate with changes in seizure frequency. Subjective improvement occurred in 84% of the patients. The quality of life improves in some patients following vagus nerve stimulation for intractable epilepsy. The favorable effects of this treatment may be attributable to additional factors besides seizure control which in this study was modest.

This study investigated whether the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) items reflecting seizure symptoms spuriously inflate MMPI-2 scores in persons with epilepsy. In a repeated measures prospective design, patients with epilepsy completed the MMPI-2 prior to epilepsy surgery and again two years later when they were either seizure-free or not seizure-free. Compared to baseline scores, only seizure-free patients showed a decline in endorsement of seizure items, and only on one scale, Hypochondriasis (Hs). Clinical profiles were not meaningfully different when readministered when seizures were no longer present. Moreover, profiles generated by individuals with and without seizures were not significantly different. We conclude the MMPI-2 is a valid test in an epilepsy population, as seizure content did not alter its clinical interpretation. In using the MMPI-2 in patients with epilepsy, a modest correction on the Hs and Schizophrenia (Sc) scales is warranted in selected cases. In MMPI-2 research, assessing both statistical and clinical significance is recommended.

Background:Epilepsy is a common medical condition for which physicians perform driver fitness assessments. The Canadian Medical association (CMA) and the Canadian Council of Motor transportation administrators (CCMTA) publish documents to guide Canadian physicians’ driver fitness assessments.Objectives:We aimed to measure the consistency of driver fitness counseling among epileptologists in Canada, and to determine whether inconsistencies between national guidelines are associated with greater variability in counseling instructions.Methods:We surveyed 35 epileptologists in Canada (response rate 71%) using a questionnaire that explored physicians’ philosophies about driver fitness assessments and counseling practices of seizure patients in common clinical scenarios. Of the nine scenarios, CCMTA and CMA recommendations were concordant for only two. Cumulative agreement for all scenarios was calculated using Kappa statistic. Agreement for concordant (two) vs. discordant (seven) scenarios were split at the median and analyzed using the Wilcoxon signed rank sum test.Results:Overall the agreement between respondents for the clinical scenarios was not acceptable (Kappa=0.28). For the two scenarios where CMa and CCMta guidelines were concordant, specialists had high levels of agreement with recommendations (89% each). A majority of specialists disagreed with CMa recommendations in three of seven discordant scenarios. The lack of consistency in respondents’ agreement attained statistical significance (pConclusions:Canadian epileptologists have variable counseling practices about driving, and this may be attributable to inconsistencies between CMa and CCMta medical fitness guidelines. This study highlights the need to harmonize driving recommendations in order to prevent physician and patient confusion about driving fitness in Canada.

Purpose:To describe a delayed severe complication of temporal lobectomy for intractable epilepsy.Method:A case of amnesia occurring 24 years after surgery is described and five similar cases from the literature reviewed.Results:Mean age at surgery (5 right) was 40 years (19-62 years), 3 female. Four of five tested had impaired visual and verbal memory preoperatively but not sufficient to contraindicate surgery. Pathology was mesial temporal sclerosis in 3, 1 cavernoma, 1 dysembryoplastic neuroepithelial tumor (DNET) and 1 normal. Postoperatively, four were seizure free 3-12 years off medication and two continued with seizures. There was no unexpected postoperative memory change until incapacitating anterograde amnesia developed 1-24 years after surgery. In five patients, including ours, this followed definite or possible status epilepticus with new mesial temporal sclerosis on the opposite side in the four that were investigated by MRI. One patient developed a glioblastoma in the opposite temporal lobe.Conclusion:Continuing or late recurrence of seizures from the remaining temporal lobe after temporal lobectomy can result in incapacitating amnesia if status epilepticus occurs. Other new lesions on the opposite side to surgery can have the same effect.

Subjective memory (SM), a self-evaluation of memory, in contrast to objective memory (OM) measured by neuropsychological testing, is less well studied in patients with epilepsy. We assessed SM before and after temporal lobectomy. The Frequency of Forgetting 10 scale (FOF-10), developed to evaluate SM in dementia, was given before and one year after temporal lobectomy. Reliability and validity for use in epilepsy were first assessed. Measures of depression (CES-D) and neuroticism (PANAS) were done before and after surgery as well as complete neuropsychological assessment of OM. Correlation analysis between FOF-10 results and all the other variables was implemented. In 48 patients the FOF-10 was reliable and valid showing high internal consistency in all items (Cronbach's alpha >0.82) and high reproducibility (p

Summary Purpose: The intracarotid amobarbital procedure (LAP) is widely used to help predict who might be at risk for postoperative amnesia after unilateral temporal lobectomy for intractable seizures. We describe the memory outcome in 10 patients who underwent standard temporal lobectomy, including mesial temporal structures, despite failing the memory portion of the LAP after injections both ipsilateral and contralateral to the resected seizure focus. Methods: Data for seven of the study subjects were obtained through a retrospective review of patients assessed on a surgical epilepsy unit during a 15-year period who failed the Montreal Neurological Institute LAP memory protocol after both ipsilateral and contralateral injections and subsequently underwent unilateral temporal lobectomy. More recently, we have studied temporal lobectomy patients who failed the Medical College of Georgia memory protocol after both ipsilateral and contralateral injections (n = 3). Preoperative and postoperative memory test scores were compared, and data regarding seizure outcome and self-perception of postoperative memory were collected. Results: At follow-up, none of the patients presented with a pattern indicative of a global amnesia, and 80% demonstrated >90% improvement in their seizure disorder or were seizure-free. Conclusions: These findings indicate that bilateral memory failure on the LAP does not preclude the removal of an epileptogenic temporal lobe or a successful surgical outcome. In addition, the findings raise questions regarding the validity of the LAP and the possibility that memory may be reorganized in patients with a long history of temporal lobe epilepsy.

The management of uncontrolled partial epilepsy is a process dependent on a multidisciplinary and analytic approach. It is necessary to understand which lesions are epileptogenic, and if they are indeed responsible for the generation of seizures. In addition to localizing seizure onset, the functional and eloquent areas of the brain need to be identified. As in many other centres, we perform resective surgeries on the basis of combined information derived from seizure semiology, EEG abnormalities, neuroimaging and other tests of cerebral function. If surface EEG recording yields inconclusive or ambiguous results, then invasive intracranial techniques using intracerebral depth or subdural electrodes can be used to improve diagnostic or prognostic accuracy. The indications, principles, results and complications of these recording techniques based on extensive experience at two epilepsy surgery centres are reviewed.

The favourable impact of surgery for intractable epilepsy on seizures is well documented. However, few studies have determined what changes in antiepileptic drug (AED) therapy occur following surgery. Alterations in AED blood levels in the immediate postoperative period can result in breakthrough seizures. In long term follow-up, one-third to one-half of seizure-free patients after temporal lobectomy, the most common type of epilepsy surgery, still require AED treatment which usually has been reduced from polytherapy to monotherapy. In our study of 93 patients followed two years after temporal lobectomy, polytherapy decreased from 78% before surgery to 14% postoperatively, while medication was discontinued in 44%. Early reduction from polytherapy to monotherapy can often be carried out in the immediate postoperative period but the most appropriate timing of cessation of AED treatment has yet to be determined. Patients undergoing extratemporal resections and other forms of epilepsy surgery associated with less favourable postoperative seizure control may achieve comparatively less reduction in antiepileptic medication. We generally do not recommend stopping AEDs prior to one year after surgery.

Summary: Purpose: Other outcome measures besides seizure control must be considered when assessing the benefit of epilepsy surgery. We investigated the effect of preoperative psychosocial adjustment on postoperative depression in epilepsy patients followed up prospectively for 2 years after temporal lobectomy. Methods: The Washington Psychosocial Seizure Inventory (WPSI) evaluated psychosocial functioning; the Centre for Epidemiological Studies Depression Scale (CES-D) measured depression. Both were completed at baseline and follow-up. Results: Follow-up occurred in 39 temporal lobectomy patients at 2 years after surgery. Greatest improvement in depression scores was limited to patients with good seizure outcomes (seizure free, or marked reduction in seizure frequency), and seizure outcome was a significant predictor of postoperative depression. Despite this, preoperative scores on the emotional adjustment scale of the WPSI were most highly correlated with depression 2 years after surgery. To clarify this relation, moderated hierarchic regression suggested that good preoperative emotional adjustment (WPSI) was generally associated with less depression after surgery. Moreover, poorer preoperative adjustment combined with older age, generalized seizures, the finding of preoperative neurologic deficits, a family history of psychiatric illness, and/or a family history of seizures was related to higher depression scores 2 years after surgery. Conclusions: Depression after temporal lobectomy is dependent on a complex interaction of variables and can have a significant effect on indices of postoperative adjustment. The WPSI emotional adjustment scale may help to predict which patients are likely to be chronically depressed after surgery.

Summary: Purpose: 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). Methods: We studied six children or young adults from four centers who developed psychosis after resection of a ganglioglioma or dysembryoplastic neuroepithelioma (DNET). Results: 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. Conclusions: 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.

Background:The assessment of thalamocortical function in comatose patients in the intensive care unit (ICU) can be difficult to determine. Since the electroencephalogram (EEG) affords such assessment, we have developed an EEG classification for comatose patients in our general ICU.Methods:One hundred EEGs were classified in a blinded fashion by two EEGers, using our method and that of Synek. Interobserver agreement was assessed using kappa score determination.Results:Kappa scores were 0.90 for our system and 0.75 for the Synek system. (The Kappa score represents the inter-rater agreement that is beyond chance; 0.90 is almost perfect agreement, while 0.75 is substantial agreement).Conclusion:Our system for classifying EEGs in comatose patients has a higher interobserver reliability than one that was previously published. This EEG classification scheme should be useful in clinical electrophysiological research involving ICU patients, allowing for internal consistency and comparisons among centres.

Background:A seizure is the most common cause of loss of driving privileges for medical reasons but there is variability in how physicians and the authorities who regulate driving approach this issue.Methods:A questionnaire regarding epilepsy and driving was sent to all adult neurologists in Canada (n = 494).Results:Of 289 (59%) neurologists responding, 50% usually report patients with seizures to the department of motor vehicles compared to only 4% for stroke/TIA, 26% for dementia and 8% for other neurologic disorders (p < 0.0001). In the five provinces with mandatory reporting laws, seizures were reported most of the time by 84% compared to only 19% in the five provinces with discretionary reporting (p < 0.0001). Nationwide, 44% agreed with mandatory reporting but this also differed in provinces with and without mandatory reporting legislation (63% vs. 37%, p < 0.0001). Only 49% agreed with the current recommendation of at least one year seizure free interval before resuming driving.Conclusions:Seizures are disproportionately reported compared to other neurological conditions. Many neurologists disagree with the recommended Canadian standards for duration of driving restriction after seizures. Variability in the attitude and practice of neurologists in regard to reporting of seizures is confirmed.

We investigated whether seizure content items inflate MMPI-2 scores in persons with epilepsy. A mean MMPI-2 profile was generated for 100 epilepsy patients. Two expert raters then identified MMPI-2 items reflecting seizure symptoms. When individual profiles were rescored to remove elevations caused by seizure content, some statistically significant (but not clinically significant) decreases were observed. The MMPI-2 appears to be a valid assessment instrument in epilepsy. In most cases seizure content did not alter clinical interpretation. When the interest is in detecting symptom change, assessing both statistical and clinical significance is recommended in future MMPI-2 research.

Summary: Purpose: Few data exist on the ability of instruments to detect within-patient change over time in epilepsy, a property referred to as responsiveness. Our aim was to compare the responsiveness of three instruments [i.e., Epilepsy Surgery Inventory-55 (ESI-55) and Washington Psychosocial Inventory (WPSI), both epilepsy specific, and Symptom Checklist-90–Revised (SCL-90–R), non-epilepsy specific]. Methods: Instruments were administered at baseline and at 1 year in a prospective cohort of surgically (43) and medically (14) treated patients with temporal lobe epilepsy. Coefficient of Responsiveness and relative efficiency were computed for each scale and for the dimensions of mental health, physical health, and role function. Results: The ESI-55 contained the most responsive scales, whereas SCL-90–R contained the largest number of scales with moderate responsiveness. The largest number of scales with low responsiveness belonged to the WPSI. Sensitivity to between-treatment differences in change was highest for ESI-55 and SCL-90–R. The most efficient scales in detecting differences between treatment groups in the mental, physical, and role-function dimensions were ESI-55 emotional well-being, ESI-55 health perceptions, and SCL-90–R hostility, respectively. Conclusions: Our results support the responsiveness of ESI-55 scales and suggest that SCL-90–R is a responsive tool for the assessment of psychologic function and distress in epilepsy. Comparatively, WPSI is relatively unresponsive to small or medium-size changes.

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.

THE CASE: A 45-year-old right-handed man was admitted to hospital for evaluation of seizures that had begun when he was 10 years old but were not responding to treatment. The events were characterized by an initial butterfly sensation in his stomach, sometimes associated with a bad taste in his

article i nfo Purpose:Thepurposeofthisstudywastodescribeaseriesofpatientswithpathologicallyprovenchronicenceph- alitis who had a nonprogressive course during a long follow-up, suggestive of a "benign" variant of Rasmussen's encephalitis (RE). Methods: Four patients who were referred to our Comprehensive Epilepsy Program at London Health Science Centre in London, Ontario, were diagnosed with chronic encephalitis on a pathological basis after epilepsy sur- gery to treat their partial-onset seizures. Results: None of our four cases followed the typical course of RE despite their childhood-onset seizures between ages 2 and 12 years. One was preceded by a mild head trauma and fever at onset. None had epilepsia partialis continua (EPC). Their long-term follow-up revealed a nonprogressive form of the syndrome with respect to the neurological examination, EEG, MRI, and neuropsychological findings. Conclusion:These casesextend the spectrum of childhood-onset intractableepilepsy with chronic encephalitisto include nonprogressive variants of RE. The absence of EPC may be a prognostic indicator of a nonprogressive course.

Since cytomegalovirus (CMV) has been implicated in the pathogenesis of Rasmussen's syndrome, we treated four patients with ganciclovir, a potent anti-CMV drug. A 7-year-old girl with seizures escalating to 60/day over 3 months despite triple antiepileptic drug therapy became seizure-free 5 days after initiation of treatment with no recurrence at 1.5 years follow-up. Focal neurologic signs, cognitive function, and the EEG returned to normal. Two patients treated 34 and 72 months after disease onset in association with epilepsy surgery had a reduction in seizures and one had no response. CMV genome was detected in the brains of two of the three patients in whom it was assessed. The response to antiviral therapy supports a viral etiology for chronic encephalitis of Rasmussen. If the disease is suspected, treatment with ganciclovir should be considered as early as possible.

Senile plaques are characteristic of Alzheimer's disease but also occur as an age-related change in some neurologically normal individuals at autopsy. The significance of these "incidental" senile plaques, with regard to the development of dementia, is unknown and cannot be assessed by postmortem studies. Patients with biopsy proven senile plaques offer an important opportunity for prospective followup. We identified senile plaques in temporal lobectomy specimens, removed in the surgical treatment of intractable epilepsy, from 11 patients. Review of preoperative neuropsychological test results showed no suggestion of dementia in any of the patients with senile plaques and no significant difference compared with controls. Postoperative followup ranged from 2 to 7 years (mean, 3.7 yr). There was no evidence of generalized cognitive deterioration in any of the study patients. These findings indicate that an abundance of senile plaques may be present without associated dementia and without cognitive deterioration for at least several years.

Five patients had brief simple partial seizures that mimicked panic disorder. The following features assisted diagnosis: Seizures were briefer and more stereotyped than panic attacks; some progressed to typical complex partial seizures; and aphasia and dysmnesia occurred during seizures in some patients. Each patient had one mesial temporal structural lesion. Routine waking EEG was normal in 2 patients. Inadequate response to anti-epileptics necessitated partial temporal lobectomy in 4 patients, 3 of whom remain seizure free.

Isolated amygdalar sclerosis (AS) in the presence of an intact hippocampus has been described in a subset of patients who have undergone a temporal lobectomy for the relief of seizures. Clinical observation suggested that these patients might be distinguishable, before and after operation, from those with typical mesial temporal sclerosis, which implies combined amygdalar and hippocampal sclerosis (AHS). From a three year series, all 11 patients classified as having AS were included in this study. These patients were compared with a group of 20 randomly chosen patients with AHS. The groups were found to be well matched in duration of ongoing seizures, full scale IQ, and duration of follow up (mean 19 months). Compared with patients with AHS, patients in the AS group were less likely to have had a seizure in early childhood, a variety of auras, EEG abnormalities localised to one temporal lobe, or an abnormal MRI before operation. They also performed better on preoperative memory tests. At follow up, patients in the AS group were less likely to be seizure free and more likely to have a deterioration in memory after undergoing anterior temporal lobectomy, including part of the hippocampus. The results show that there are preoperative indicators of mesial temporal pathology that are also of prognostic importance given the differences in outcome between the two pathological groups.

Allergic reactions to antiepileptic drugs in the form of skin rash are not uncommon but angioedema, an acute life threatening reaction is rare. Angioedema has been reported with the use of oxcarbazepine and carbamazepine. We report a case of a 33-year-old woman with focal epilepsy who developed angioedema following levetiracetam monotherapy. The patient had previous skin rashes with both phenytoin and lamotrigine. Levetiracetam was stopped and she improved after treatment with norepinephrine, antihistamines and corticosteroids.

Background:Escalating focal sensorimotor seizures, progressive neurologic deficit and cognitive decline with associated typical magnetic resonance imaging (MRI) findings or pathological confirmation constitute the syndrome of Rasmussen's encephalitis.Methods:Three patients with this clinical scenario had long-term follow-up after being given the antiviral drug ganciclovir 10 mg/kg/day IV for ten days within one to three months of disease onset.Results:Seizures occurred at least hourly and were localized to the Rolandic region. The MRIs were normal in one patient and in two showed changes consistent with ongoing seizures. Two patients, one whose short-term outcome was reported previously, had immediate and sustained cessation of seizures and resolution of their neurologic deficit. One patient with seizures from both hemispheres did not respond and went on to hemispherectomy that confirmed chronic encephalitis. Seizures continued in five other patients treated 6 to 72 months after disease onset.Conclusion:The sustained seizure control after ganciclovir in two of three patients suggests this drug may be effective when given early in the course of this subacute intractable focal epilepsy syndrome.

• Objective. —Rasmussen's chronic encephalitis, a cause of intractable epilepsy in childhood, is described in three adults. Setting. —Inpatient epilepsy unit. Patients. —Of 11 patients with pathological confirmation of Rasmussen's encephalitis, three were adults with intractable seizures, progressive sensorimotor deficits, and cognitive decline beginning at the ages of 36, 24, and 16 years. Results. —Clinical, electroencephalographic, and magnetic resonance imaging findings indicated patchy, multifocal involvement of primarily one hemisphere, but the adults had more evidence of disease in the opposite hemisphere than occurs in children. The sensorimotor deficit that the adults developed was greater and the cognitive decline was less than in children. Seizure control following multilobe resection was proportionate to the amount of tissue removed. Cytomegalovirus genome was found in the resected cortical tissue of all three patients. Conclusions. —Rasmussen's encephalitis is a cause of intractable epilepsy with progressive neurological deficit in adults as well as children. Cytomegalovirus may be involved in the pathogenesis of the disease.

This is a case report of Julius Caesar's epilepsy that onset when he was 54-years-old. The differential diagnosis of late onset epilepsy is discussed and the rationale presented for concluding from the clinical presentation that the cause was neurocysticercosis. That this man's disease and its consequences altered the course of history is a very real possibility.