Search

Factors associated with left-handedness were examined in a large sample of adults who suffered with epileptic seizures (n = 446) in an attempt to delineate the concept of pathological left-handedness. Three main pathological factors were found associated with left-handedness: (i) right-hemiparesis of early onset; (ii) cognitive deficit; (iii) evidence of left-hemisphere disease on clinical examination. Familial sinistrality was also associated with left-handedness, independently of the above-mentioned pathological factors. Results support a clear-cut distinction between normal and pathological left-handedness. This distinction seems presently important for the evaluation of the great number of anomalies proposed to be associated with left-handedness.

Jackson ( Brain 1898; 21: 580–90) observed that seizures arising in the medial temporal lobe may result in a ‘dreamy state’, consisting of vivid memory-like hallucinations, and/or the sense of having previously lived through exactly the same situation ( deja vu ). Penfield demonstrated that the dreamy state can sometimes be evoked by electrical stimulation of the lateral temporal neocortex, especially the superior temporal gyrus. Halgren et al. ( Brain 1978; 101: 83–117) showed that the dreamy state can be evoked by stimulation of the hippocampal formation and amygdala and Gloor ( Brain 1990; 113: 1673–94) has suggested that it is evoked by lateral stimulation only when the resulting after-discharge spreads medially. In order to resolve the relative importance of these areas, we considered the mental phenomena observed in epileptic patients with electrodes stereotaxically implanted into different brain areas for seizure localization prior to surgical treatment. Sixteen patients, all with seizures involving the temporal lobe, experienced the dreamy state either as a result of spontaneous seizures (nine dreamy states in six patients), or due to electrical stimulation (43 in 14) or to chemical activation (five in three). Deja vu and hallucinations of scenes were often evoked by different stimulations of the same electrode in the same patient. As Jackson had also observed, the dreamy state could occur alone but was often associated with epigastric phenomena and fear, and followed by loss of contact and oro-alimentary automatisms, and then by simple gestural automatisms, all characteristic of partial seizures beginning in the medial temporal lobe. Furthermore, as also emphasized by Jackson, the dreamy state was seldom associated with sensory illusions. Stimulation of either the neocortex (15 occurrences), anterior hippocampus (17) or amygdala (10) could evoke a dreamy state. However, since fewer hippocampal and amygdala leads were stimulated than temporal neocortical, the proportion of medial temporal electrodes where dreamy states could be evoked was much higher than in the neocortex. Most responsive lateral temporal sites were located in the superior temporal gyrus, rather than the middle temporal gyrus which was significantly less responsive. In 85% of dreamy states evoked by medial temporal lobe stimulation, the discharge spread to the temporal neocortex; and in 53% of dreamy states evoked by lateral temporal stimulation, the discharge spread medially. Considering all dreamy states, the amygdala was involved (as the stimulated structure, or as the site of ictal- or after-discharge) in 73% of cases, the anterior hippocampus in 83% and the temporal neocortex in 88%. In every spontaneous seizure where the dreamy state was observed, the amygdala, anterior hippocampus and temporal neocortex were all involved (provided that they were recorded during the seizure). Thus, we conclude that the dreamy state probably depends upon a neuronal network that engages both medial and lateral aspects of the temporal lobe, and that the anterior hippocampus, amygdala and superior temporal gyrus have relatively priviledged access to this circuit.

We have described our 25 years experience concerning 100 patients operated on for frontal epilepsy. Results show that 55% of patients are practically cured of their seizures and that 76% benefited from cortectomy (reduction of more than 75% of seizures). These results are the worst in the total series of St. Anne. Reasons for success and especially failure were analyzed in detail: 1. SEEG methods gave good indications along three dimensions of the limits and borders of the cortical excision. 2. When clinical semiology and organization of ictal discharges give evidence for rapid bilateral discharge, with involvement of axial musculature and generalized tonic-clonic manifestations, experience shows that it is necessary to combine cortectomy with a section of the adjacent cortico-subcortical fibers of the corona radiata, as if propagation of ictal discharges were impeded if not interrupted by sectioning such fibers and the primary site were incapable of expressing itself clinically. 3. If the characteristics of seizures suggest the quasisimultaneous involvement of the two frontal lobes and the existence of bilateral multifocal epilepsy, we suggest that a systematized anterior callosotomy might lead to useful results. 4. Finally, we propose general criteria for indications and contraindications for surgery.

Potentials in relation to eye movements were studied by means of direct recording of the striate cortex in a waking man. In a lighted environment, the usual evoked potential—lambda response—was obtained and was clearly visible after each eye movement. In complete darkness no individual potential was observable by means of visual analysis after each eye movement, but a slow potential of low amplitude could be obtained by superimposition and averaging of the cortical striate activity time-locked to the start of a series of eye movements. This eye-movement potential showed a longer latency and a lower amplitude than the lambda response. These data are discussed in reference to those obtained in the cat and the monkey; the significance of this eye-movement potential in darkness as a ‘corollary discharge’ is considered.

Summary: A retrospective clinical study is presented which is based on 133 patients with uncontrolled temporal lobe seizures who underwent bilateral stereoelectroencephalographic exploration. The aim of the study was to evaluate quantitatively the degree of agreement among spontaneous and chemically and electrically induced seizures, as well as between each of these seizures and the spontaneous interictal activity (“spiking”). To simplify the problem, only the side of origin and not the exact site of onset of the ictal discharge within the temporal lobe was dealt with. Special attention was paid to whether or not a seizure propagated to the homotopic regions of the opposite hemisphere, thus dealing with the still controversial question of the independent secondary epileptogenic lesion or “mirror” focus in man. The clinical outcome of surgery in 64 cases of temporal lobe epilepsy in which the operation was based on the conclusions of the SEEG exploration with or without recording of spontaneous seizures confirmed the outstanding importance of the spontaneous seizures in identifying the side of the primary epileptogenic zone. The degree of positive correlation between the spontaneous and the induced seizures varied from 77% for the electrically and 60% for the chemically induced seizures. On the other hand, the spontaneous interictal activity agreed only in approximately two-thirds of cases: best with the electrically induced and less with the spontaneous seizure. Chemically induced seizures agreed the least. The authors conclude: (1) Because of relatively frequent discrepancies between the side of onset of the seizures and the lateralization of interictal epileptic activity, the recording of seizures is of primary importance for assessing the results of the SEEG examination. (2) The recording of spontaneous seizures is preferable to that of electrically or chemically induced seizures. (3) The reliability of the lateralization suggested by electrically induced seizures is somewhat higher than that of chemically provoked seizures. (4) Special caution should be exercised in determining the lateralization of seizures with contralateral propagation. RESUME Une etude clinique retrospective est faite sur 133 malades presentant une epilepsie du lobe temporal resistant a la therapeutique et ayant subi une exploration stereo-EEG bilaterale. Le but de ce travail est Ďevaluer quantitativement les rapports entre les differents types de crises (spontanees, induites par des moyens chimiques et par la stimulation electrique). Une correlation a egalement ete faite entre les differents types de crises et Ľactivite intercritique spontanea (pointes). Pour simplifier le probleme, seul le cote de la decharge critique onginelle dans le lobe temporal a ete envisage. Un interet particulier a porte sur le probleme de la propagation dventuelle aux regimes homologues de l'hemisphere oppose dans le but de discuter la question controversy des lesions epileptogenes secondares independantes ou des “foyers en miroir” chez l'homme. Les interventions chirurgicales portant sur le lobe temporal gauche (64 malades) a partir des indications de Ľexploration SEEG ont servi de validation a l'importance attribute aux crises spontanea dans la delimitation de la zone epileptogene primaire. La concordance entre une crise spontanee et induite varie de 77% pour les acces induits chimiquement et 60% pour ceux provoques par la stimulation. Parailleurs, Ľactivite intercritique spontanee parait un indice de localisation plus proche des crises induites electriquement que des crises spontanees. Les acces induits par les activants chimiques ont une correlation moins bonne. Si une decharge ne se propage pas a l'hemisphere oppose la concordance avec chaque parametre etudie augmente. RESUMEN Se presenta un estudio clinico retrospectivo basado en 133 enfermos con ataques del lobulo temporal incon-trolados que fueron sometidos a una exploracion estereoelectroencefalografica (SEEG) bilateral. El proposito del estudio ha sido evaluar cuantitativamente el grado de acuerdo entre los ataques espontaneos y los inducidos quimica y electricamente y tambien, entre cada uno de dichos ataques y la actividad electrica espontanea (“spiking”). Para simplificar el problema se concreto solamente en el lado de origen y no en el lugar exacto del comienzo de la descarga ictal, dentro del lobulo temporal. Se presto atencidn especial a si existia o no propagacion del ataque a regiones homologas del hemisferio opuesto para analizar el problema, todavia en controversia, de la independen-cia de focos epileptogenicos secundarios o focos “en espejo” en humanos. El resultado clinico de la cirugia en 64 casos de epilepsia del lobulo temporal, en los que la intervention se baso en las conclusiones de la SEEG con o sin registro de ataques espontaneos, confirma la extraordinaria importancia de los ataques espontaneos para la identificacion del foco epileptogenico primario. El grado de correlacion positiva entre los ataques espontaneos y los inducidos vario entre un 77%, para los inducidos electricamente, y un 60%, para los inducidos quimicamente. Por otro lado la actividad espontanea interictal se correlaciono solo en 2/3 de casos, aproximadamente: mejor correlacion en los inducidos electricamente y menor en los espontaneos. Los ataques inducidos quimicamente fueron los que menos se correlacionaron. Los autores concluyen: (1) Debido a la existencia de frecuentes discrepancias entre el lugar de comienzo de los ataques y la lateralizacion de la actividad epileptica interictal, es de importancia fundamental el registro de los ataques para estar seguros de los resultados de la SEEG. (2) El registro de ataques espontaneos es preferible al que se obtiene de los ataques inducidos eldctrica o quimicamente. (3) La fiabilidad de la lateralizacibn sugerida de los ataques inducidos electricamente es algo mayor que la de los ataques provocados quimicamente. (4) Se debe tomar una precaucion especial para determinar la lateralizacion de los ataques que muestran una prop-agacion contralateral. ZUSAMMENFASSUNG Retrospektive klinische Untersuchung von 133 Patienten mit unkontrollierten Temporallappenanfallen, die bilateral stereoelektroencephalographisch untersucht wurden. Ziel der fjntersuchung war quantitativ festzulegen, in welchem Ausmas spontane und chemisch-elektrisch induzierte Krampfe untereinander ubereinstimmen bzw. ihre Relation zur spontanen interiktalen Aktivitat (spiking) vergleichbar ist. Um das Problem zu vereinfachen, wurde nur die Ursprungsseite und nicht der exakte Sitz des Beginns der iktalen Entladung innerhalb des Temorallappen un-tersucht. Besondere Aufmerksamkeit wurde der Tat-sache geschenkt, ob ein Anfall zur homotopen Region der Gegenseite fortgeleitet wurde; damit sollte ein Beitrag zur immer noch gegensatzlich beantworteten Frage uber die unabhangigen sekundaren epileptogenen Lasionen geliefert werden. Das klinische Operation-sergebnis bei 64 Fallen mit Temporallappenepilepsie bei denen die Operation auf den Schlussen aus der SEEG-Untersuchung mit oder ohne Ableitung spon-taner Anfalle basierte, bestatigte die auBerordentliche Wichtigkeit der spontanen Anfalle fur die Iden-tifizierung der Seite der primaren epileptogenen Zone. Das Ausmas der positiven Korrelation zwischen spontanen und induzierten Anfallen variierte zwischen 77% fur die elektrischen und 60% fur die chemisch induzierten Anfalle. Andererseits stimmte die spontane interik-tale Aktivitat nur in etwa 2/3 der Falle uberein, am besten mit den elektrisch induzierten und weniger mit den spontanen Anfallen. Die chemisch induzierten Anfalle zeigten die geringste Ubereinstimmung. Die Autoren folgern: (1) Wegen derrelativ haufigen Diskrepanz zwischen der Seite des Anfallsbeginns und der Lateralisation interiktaler epileptischer Aktivitat ist die Ableitung von Anfallen von erstrangiger Bedeutung fur das endgultige Resultat der SEEG-Untersuchung. (2) Die Ableitung spontaner Anfalle ist der elektrisch oder chemisch induzierter Anfalle vorzuziehen. (3) Die Verlaslichkeit der Lateralisation aufgrund elektrisch induzierter Anfalle ist etwas hoher als die nach chemisch provozierten Anfalle. (4) Mit besonderer Vorsicht sollte die Seite nach Anfallen mit kontralateraler Au-sbreitung bestimmt werden.

The literature only rarely mention the genital and sexual manifestations occurring in the course of partial seizures in man. The authors presently describe 42 seizures of this type recorded with E.E.G. and Stereo-E.E.G. techniques in 15 patients. The results of this study indicate that the genital and sexual paroxystic manifestations do have a specific semeiology, and there can be related to the initial localization of the electrical discharge which may begin in one of three different regions (perisylvian region, anterior part of the cingular gyrus and the paracentral lobule). Penile erection is observed in only one seizure starting in the central region. Orgasm occurs in the only one female patient in the course of the seizures beginning in the perisylvian region (temporal region). Early sensitive symptomatology characterizes very often the seizures beginning in the perisylvian region but also in the paracentral lobule. Post-ictal or peri-ictal true masturbation occurs at the end of the ictal discharge beginning either in the perisylvian region or in the anterior part of the cingular gyrus. The sexual dyspraxic (i.e. fondling the genitals) characterizes only the post-ictal phase of the seizures beginning in any of the three regions.

A patient was studied who had posttraumatic epilepsy with adversive, psychomotor, and grand mal seizures. During tele-EEG recording from depth electrodes, 4 psychomotor seizures were accompanied by discharge originating in the frontal lobe. The patient sometimes could recall his behavior and believed it to be voluntary. Amnesia was more apt to be total after the seizure than during it.

(1) The concentrations of various anticonvulsants (PB, PHT, CBZ, VPA) were measured in brain specimens from 7 patients who had undergone neurosurgery for a therapy resistant epilepsy of tumoral origin (astrocytoma) in 6 cases, glioblastoma in 1 case). (2) Great interindividual variability of the mean brain/plasma concentration ratios was observed for PB in 5 patients (range: 0.4-1.0). A mean brain/plasma ratio of 1.0 was recorded for PHT and CBZ (one patient each). (3) In the different tissue specimens (7-14) from the same patient AED concentrations varied greatly, even in neighboring areas. (4) Intraindividual variations were more marked in the present group of patients than in previously studied non-tumoral epileptics. (5) No correlation was found between the localization of the lesions and the variations in AED concentrations. (6) Brain AED concentration appeared to be higher in the few samples of non-tumoral tissue and lower in the 'epileptogenic' areas as defined by stereo-EEG seconding. (7) On the basis of these data, the hypothesis can be formulated that the therapy resistance of these patients may be at least partly explained by the presence of low AED concentration (even in presence of 'therapeutic' AED plasma levels) in the epileptogenic areas.

Resume L'interpretation des signes electriques recueillis sur le scalp (E.E.G.) reclame dans le domaine diagnostique et therapeutique l'utilisation d'un systeme de reference emprunte a d'autres methodes d'investigation du systeme nerveux central. Deux exemples sont pris pour tâcher d'apprecier la signification et la validite des correlations utilisees. Dans le domaine des tumeurs cerebrales il semble que la seule reference aux examens neuroradiologiques de contraste ne suffise pas a donner un sens a l'E.E.G. qui necessite pour prendre toute sa valeur d'etre integre d'abord au contexte clinique. Dans le domaine de l'epilepsie le modele de la pointe intercritique emprunte surtout a la neurophysiologie experimentale ne semble pas pouvoir permettre d'affirmer un diagnostic de comitialite, encore moins d'en definir l'origine. Ce diagnostic ne peut etre valablement porte que sur la base des informations semiologiques caracterisant un acces. L'E.E.G. peut alors etre utilise comme une technique d'appoint parfois indispensable. L'emploi des methodes d'investigation directe des structures cerebrales chez l'homme represente sans doute un moyen efficace pour mieux comprendre la signification de l'E.E.G. de surface, mais seulement dans le cadre d'une etude prealable ou simultanee des manifestations cliniques.

• Retrospective analysis of the psychiatric diagnoses in a group of patients surgically relieved of medically intractable epilepsy tested the hypothesis that patients with left-sided temporal lobe epileptogenic lesions are at greater risk for the development of a so-called schizophrenic-like psychosis than are those with right-sided temporal lobe epileptogenic lesions. The data confirmed the hypothesis and also demonstrated an increased prevalence of sinistrals in the psychotic group. Thus, epilepsy involving the dominant hemisphere at the inception of the seizure disorder is the significant risk factor. The data also indicated that a psychosis is unlikely to develop in patients with other (nontemporal) forms of focal epilepsy. On the basis of these data and data from other studies, the prevalence of psychosis in patients with poorly controlled temporal lobe epilepsy was estimated to be approximately 10% to 15%.

Three patients with well-mapped, circumscribed ablations of the medial part of the frontal lobe are reported. A specific clinical evolution in 3 stages was observed: (1) post-operatively there was global akinesia, more prominent contralaterally, with an arrest of speech; (2) recovery occurred suddenly but even then there was severe reduction of spontaneous motor activity contralaterally, an emotional type facial palsy and a reduction of spontaneous speech; (3) long after the operation the only sequela was disturbance of the alternating movements of the hands. The anatomical basis of these disorders appears to be a lesion of the supplementary motor area (SMA). Three main points have been discussed, namely: (1) the nature of the motor disorder which may be a disturbance of the function of the SMA in initiating and sustaining spontaneous and automatic motor activity; (2) the nature of the arrest of speech which appears not to be aphasic; the studies reported in the present paper do not support a left cerebral dominance for the SMA as suggested by previous studies; (3) the method of clinical examination appears to be important in distinguishing between spontaneous and voluntary motor and speech performance. Differences in method may account for differences between our findings and those reported in previous studies.

Of the 718 patients investigated for intractable epilepsy by stereoelectrocencephalographic (SEEG) exploration, 30 (4%) manifested gustatory hallucinations as part of their seizures. In 20 patients, it was possible to make some electrophysiological, clinical and anatomical correlates. Gustatory hallucinations occurred as one manifestation of parietal, temporal or temporoparietal seizures. A brief isolated gustatory hallucination was induced mainly by electrical stimulation of the parietal or rolandic opercula in patients with gustatory seizures, in 1 epileptic patient with parietotemporal epilepsy who had never experienced gustatory hallucinations and in another with temporal lobe epilepsy with no history of gustatory manifestations. The electrically-induced seizures, which included a gustatory hallucination as one of the ictal events, were obtained mainly by stimulation of the hippocampus and amygdala. The associated ictal events of a seizure with gustatory manifestations differed depending upon the origin of the seizure. During parietal seizures, they consisted of staring reactions, clonic contractions of the face, deviation of the eyes and salivation. During temporal lobe seizures, the associated events included mainly oral movements, autonomic disturbances, purposeless movements and epigastric or other abdominal symptoms. Seizures affecting both the infra- and suprasylvian regions were characterized by symptoms of both categories listed above. Emotional disturbances were observed mainly when there was an involvement of the cingulate gyrus. When care was taken to avoid methodological errors in the interpretation of the clinical signs occurring after electrical stimulation, it became clear that gustatory hallucinations in man were related to the disorganization of the parietal and/or rolandic operculum. electrically-induced temporal lobe seizures which included gustatory hallucinations as an ictal event probably spread to the opercular region by a functional reorganization of the connections within these epileptogenic areas.

Tonic postural changes of the upper limb accompanied by epileptic parietal lobe discharges are not well known. The authors report 3 such cases. In the 3 patients, a total of 18 spontaneous seizures were recorded, 12 by telemetry, from either scalp electrodes or stereotactically implanted electrodes. Of these 18 seizures, 14 included tonic postural changes of the upper limb accompanied by a contralateral parietal discharge. Combining these 3 cases with the 4 such cases in the literature, the authors found that the clinical pattern consisted of a tonic postural change in one upper limb associated with automatisms of the opposite upper limb. It was also found that the same patient might have automatisms involving the upper limb in some seizures and upper limb postural changes in other seizures, both accompanied by the same electrical discharge. It is concluded that tonic postural changes and automatisms in the upper limb may be interchangeable.

This study reports on 73 epileptic seizures (in 36 patients) originating in the temporal lobe (stereo-EEG) presenting motor or postural signs. Motor symptoms occur rarely in the early phase of seizures (less than 10% of our series) and they are exceptional during spontaneous seizures. The critical electrical discharge always affects extra-temporal structures such as the rolandic operculum, the cingulate gyrus, etc. The occurrence of motor symptoms during the late phase of seizures is associated with a long duration of the critical discharge and, again, with the involvement of extra-temporal structures. The characteristics of the associated clinical signs (e.g., frequent loss of contact with the environment, relatively rare oroalimentary automatic activities), together with the high frequency of secondary 'generalizations' are consistent with the stereo-EEG findings and indicate that these seizures also affect extra-temporal regions.

Summary The authors study the role of amygdala dysfunction in cases of oro-alimentary signs occuring in seizures recorded during a series of stereo-electroencephalographic investigations (S.E.E.G.) carried out for neurosurgical purposes. The patients under study have an epilepsy that is resistant to drug therapy. This work concerns 89 seizures with « oro-alimentary motor activityrecorded in 59 patients with whom it was possible to establish sufficiently rigourous anatomical — electrical — clinical correlations. This study enabled us to show that : -- a seizure characterized only by « oro-alimentary motorsigns (with the exclusion of swallowing movements) is related to a discharge that directly involves the amygdala. -- a critical discharge affecting the anterior temporal region is expressed as : oro-alimentary activity either accompanied or not by other signs (breaking contact is exceptional). -- late « oro-alimentary motor activityalso indicates disorganization of the amygdala, but offers no conclusion on the origin of the discharge.

Resume Les auteurs rapportent l'observation d'un malade presentant une epilepsie « gelastiquedont les traces E.E.G. intercritiques et surtout l'enregistrement des crises evoquent une epilepsie generalisee d'emblee. Cependant les investigations radiologiques, l'intervention chirurgicale et l'examen anatomo-pathologique montrent qu'on a affaire a un processus occupant de l'espace de la region temporale droite. L'exploration S.E.E.G. met en evidence une zone epileptogene au voisinage de la lesion. Cette observation permet en particulier de discuter deux problemes interessants du point de vue physiopathologique : celui des rapports entre acces partiels et acces generalises en mettant l'accent sur le role privilegie du cortex cerebral dans l'elaboration des crises d'origine apparemment « centrencephaliqueet celui de l'importance de certaines formations du lobe temporal ou de ses annexes dans le declenchement des acces de rire.

SUMMARY The study presented in this paper gives a complete account of a familial epilepsy through four successive generations, in both lineages, and clinical and EEG data on the parents and 11 children of the same sibship. This seems to make it possible to define the relations which may exist between the various types of “generalized” or “focal” seizures and between the seizures and their EEG manifestations. In this context, the presence of certain EEG changes in non-epileptic subjects may be considered a sign of a hereditary affection, the origin of which must be identified. The study finally demonstrates that the manifestation of an epilepsy in various members of the same family probably requires the coincidence of several factors, which merits careful investigation. RESUME L'observation rapportee permet de faire un bilan assez complet d'une epilepsie familiale au cours de quatre generations successives dans les deux lignees et une etude electro-clinique des parents et des onze enfants d'une meme fratrie. Aussi il parait possible de definer les rapports qui peuvent exister entre les divers types de crises “generalises” ou “partielles” mais aussi entre les acces et leurs modalites d'expression electrique. L'existence de certaines perturbations de l'E.E.G. chez des sujets non epileptiques peut etre considered, dans ce cadre, comme le signe d'une affection hereditaire, dont l'origine demande a etre precisee. Enfin l'observation montre que Fepilepsie dans une meme famille reclame proba-blement, pour se manifester, la conjonction de differents facteurs qu'on ne saurait trop rechercher.

Resume Les auteurs ont etudie le mode d'apparition des 159 premieres crises epileptiques partielles spontanees, presentees par 33 malades adultes et adolescents au cours de 36 tele-E.E.G. Ces malades avaient ete hospitalises pour une epilepsie grave, rebelle a la therapeutique medicamenteuse. Ils avaient subi des examens cliniques, paracliniques, neuro-radiologiques et notamment de nombreux E.E.G. Ces 33 malades pouvaient etre divises en deux groupes : le groupe I etait forme de 19 malades ayant presente des crises spontanees a la fois en E.E.G. et en tele-E.E.G. ; le groupe II etait forme de 14 malades ayant presente des crises spontanees uniquement en tele-E.E.G. Les 36 traces pouvaient etre divises en deux groupes : le groupe A comprenait 31 traces et 54 crises ; le groupe B comprenait 5 traces et 105 crises. Cette division des malades et des traces en 4 groupes permettait d'etudier le mode d'apparition des crises en general ou celui de la premiere crise en particulier. Ceci en fonction du type clinique des crises, des tranches horaires a partir du debut de l'enregistrement, de l'activite. La necessite de disposer d'un controle tele-E.E.G. etait ensuite demontree, afin de pouvoir classer certaines crises psychomotrices a symptomatologie purement nevropathique en tant que crises epileptiques. La conclusion la plus interessante de cette etude est que les crises uniquement enregistrees en tele-E.E.G. sont d'une nature particuliere et qu'elles sont d'origine frontale ou temporale. Les auteurs terminent en constatant que certaines crises partielles sont plus fragiles que d'autres et plus sensibles aux conditions d'enregistrement.

Summary The authors review the work on neurosurgery used in infantile cerebral hemiplegia when complicated by epilepsy which does not respond to medication. They first discuss the indications, contraindications and results of hemispherectomy carried out in 400 cases reported in the literature. After mentioning the « palliativeoperations used by certain workers, they report their own experience with partial cortectomy performed after a stereo EG exploration. They suggest the following scheme : first stereo EG examination should be used to search for and define the contraindications and to map out an epileptogenic zone for excision which has good chances of being beneficial. Hemispherectomy then remains the best method if limited surgery is not applicable or not successful in curing the patient.

Summary StereoEG exploration in Kojewnikow's syndrome has revealed that the myoclonus originates cortically in the primary somatomotor areas ( Bancaud et al. , 1967–1970) and electrophysiological studies contribute additional useful information. The authors used these techniques to study a case of motor epilepsia partialis continua of both crural regions, and demonstrated the probably primary role of one of the epileptogenic zones (« mirrorfoci), basing their research on the s pontaneous asynchronous seizure discharges and on the effect of central and peripheral stimulation (« paroxysmalevoked potentials and reorganization of somatotopy).

Resume Les auteurs etudient les modifications de la reactivite du trace en fonction de troubles psycho-pathologiques dans les lesions hemispheriques localisees. L'abolition unilaterale de la reaction d'arret s'observe lors des troubles des fonctions symboliques (phasiques, gnosiques, praxiques) sans confusion associee. L'abolition bilaterale de la reaction d'arret s'observe lors de syndromes confusionnels. L'interpretation des diverses modalites reactionnelles du trace suivant le degre du trouble de la conscience est discutee.

The authors recorded 10 to 67 TLS (mean 29) in 10 patients (5 M, 5 F; 9 to 41 years, mean 23) during 'acute' (4-6 hours) stereo-EEG exploration. At the onset of seizures, we observed: subjective manifestations (often epigastric), autonomic symptoms, and oro-alimentary 'automatisms'. Affective, unpleasant, manifestations occurred in only 2 patients. The discharges may only affect the Ammon's horn, but they never involve only the amygdala. There is a strong relationship between the duration of the discharge, the number of cerebral structures (temporal and, later, extratemporal) involved in the discharge, and the clinical symptomatology. Somatomotor lateralized manifestations, and gestural 'automatisms' only occur when the discharges spread to extratemporal cerebral structures. The secondary generalizations are very rare and are also linked to a large extratemporal spread of the discharge.

It has been postulated for some time that GABA (gamma-aminobutyric acid) functions as the major inhibitory neurotransmitter in the brain (cf. Roberts, 1976). Over the past 5–6 years the interest in GABAergic function has increased enormously, with at least 7 symposia or books devoted specifically to this neurotransmitter (Roberts et al, 1976; Fonnum, 1978; Krogsgaard-Larsen et al, 1979; Mandel and De Feudis, 1979; 1980; Fielding and Lal, 1980; Costa et al, 1980) not to mention other speciality symposia where GABA has received major attention (eg. see Chase et al, 1979; Poirier et al, 1979; Yamamura et al, 1980). The amount of information available on central GABA systems is almost reaching overload proportions in all fields (eg. neurophysiology, neurochemistry, neuropharmacology, neuroendocrinology). The result of this is that a picture is beginning to emerge as to which human CNS disorders may involve a GABA neuron dysfunction and therefore may be amenable to treatment by GABAergic drugs. From these various studies and from the sparse clinical information available (Shoulson et al, 1975; Bartholini et al, 1979a; Chase and Tamminga, 1979; Morselli et al, 1980) it appears that abnormal GABAergic function is involved in the genesis of several neurological diseases, but that convincing evidence for GABAergic dysfunction in psychiatric states is still lacking.

The authors report 5 cases of avoiding phenomenon of the hand from parietal lesions. Four of these patients were operated for intractable epilepsy, from a parietal cortectomy that implicated a certain amount of white matter. The avoiding phenomena observed are analyzed as elementary motor perturbations rather than a disturbance of motor comportment. The authors distinguish two types of avoiding phenomena: 1--Avoiding phenomenon of dystonic type occurs during any motor activity and persists during all its development. It is probably related to the removal of the cortex of the post-central gyrus and of the anterior part of the superior parietal lobule; 2--The initial avoiding phenomenon is brief and occurs only at the beginning of the movements which implicate solely the upper limb; it seems related to the removal of the internal part of the superior parietal lobule that corresponds approximately to areas 5 and 7 from Brodmann. Some hypotheses are discussed concerning the possible physio-pathological mechanisms of these disturbances.

Twenty three patients are described with a Kojewnikow syndrome in order to identify possible etiological factors. According to their history, clinical and E.E.G. features, patients could be classified into two groups; 1) Eleven patients corresponded to the classical description of the Kojewnikow syndrome: variable age at onset of the disease, rare somatomotor seizures, delay of onset of myoclonic jerks often of long duration, myoclonus limited to a small region, normal neurological examination, stable hemiplegia, normal results of psychometric tests, localised E.E.G. alterations. In most of these patients the etiology of the disorder was known, and the symptoms could be related to a localised lesion of the central cortex; 2) the second group (11 patients) presented with completely different characteristics: early onset of fits (age: 2 to 10 years), presence of other seizure types, short delay of onset of myoclonic jerks, high frequency of seizures, localization of myoclonus over large parts of the body, progressive evolution of a motor syndrome, associated neurological signs and disorders of sleep and behavior, progressive mental deterioration, characteristic E.E.G. pattern with long subclinical paroxysms of slow spikes (sharp waves) with variable localization, diffuse cerebral lesions of unknown etiology were found. Only one patient could not be allocated to either group. Several circumstantial data suggest that patients of the second group may suffer from a slow virus infection. Should this hypothesis be confirmed, a reconsideration of the Kojewnikow syndrome from the etiological standpoint would be of great theoretical and practical interest.

Motor disorders reported in the present paper do not result from cortical ablations stricto sensu since some white matter was excised in every patient. However they appear to suggest that, as suggested by Walshe (1935), the central region and premotor area are a functional entity, i.e. they work as a whole. The extensive lesions of the premotor area, leaving untouched the motor region, have the same motor and tonic consequences as lesions limited to the central region. This point which appears specific for man does not imply that the premotor region subserves activities similar to those subserved by the central region. Rather it may suggest a deafferentiation of the central region, the consequences of which would be more important than is generally assumed. Extensive central or premotor lesions determine various tonic disorders: a well known spasticity, with exaggeration of the stretch reflex, associated with an increase in passive swinging of segments of limbs and in extensibility of joints. These two latter phenomena are usually defined as hypotonia. With premotor and precentral lesions the hypotonia disappears and a hemiplegic posture is observed. This hemiplegic posture is a dystonia which apparently does not result directly from the exaggeration of the stretch reflex. Anatomically it appears to result from lesions of both central and premotor regions. This is in agreement with Denny-Brown's (1966) contention that an extrapyramidal region lies rostral to the prerolandic sulcus. As suggested by Evarts (1973) motor regions appear to control automatic as well as voluntary movements. They probably play a role in the trophic function of muscle, since, despite rehabilitation, amyotrophy was present in every case reported in the present paper.

Five hundred and nine electrical stimulations were performed in the frontal lobes of 10 epileptic patients presenting “generalized” spontaneous attacks. These stimulations were carried out by means of stereotaxically implanted electrodes. Of these 509 stimulations, 150 induced either simple electro-clinical absences (67), complex absences (29), generalized tonic-clonic seizures (17), or only bilaterally synchronous, symmetrical spike and wave paroxysms (37). These responses, which in each case reproduced the spontaneous attacks of the patient, occurred from the beginning of stimulation and ended with it, except for the tonic-clonic seizures. The active electrodes were always located in the frontal lobe, particularly in the mesial cortex. Although the bilateral responses were related to stimulation of a restricted unilateral zone, most often they could be obtained from stimulation of either frontal lobe, in quasi-symmetrical regions. The type of electro-clinical response obtained was largely related to the parameters of stimulation: thus, in the same patient, a discharge of sub-clinical spikes and waves could become an absence and subsequently a “generalized” tonic-clonic seizure, when increasing the intensity or duration of the shocks. These results point to the preponderant role of the cerebral cortex, particularly that of its frontal portion, in elaboration of generalized epileptic attacks.

Waves associated with horizontal saccadic eye movements were recorded from cortical occipital areas through multilead intracerebral electrodes implanted for a few days in 6 drug-resistant epileptic patients in order to localize epileptogenic foci. The waves were studied statistically when the EEG activity was not disturbed by interictal discharges. Cortical occipital waves related to free eye movements while scanning complex material started at the end of the eye movement, later in fact than the corresponding scalp parieto-occipital phenomena. The amplitude of the cortical waves increased with the complexity of the external field (contrasts having no marked effect) and was reduced in an unpatterned field and in dim light. Waves persisted in darkness. Their amplitude was independent of the size of the eye movement. The latency of the waves, calculated from the onset of eye movement, increased with the size of the movement, the complexity of the external field and also in darkness. Imposed eye movements induced cortical waves of larger amplitude and shorter latency and anticipatory potential changes beginning before onset of the eye movement. Waves related to eye movements differed from blinks and from responses to several types of light stimulation more strikingly in cortical records than in those from the scalp. These findings are discussed in relation to lambda waves, activation waves and eye movement potentials, expectancy waves and premotor potentials, and to the phenomena of perceptual blanks preceding normal perception after fixation of gaze. The importance of the subject's attention is emphasized.

Many discrepancies still exist in the description of clinical symptoms and signs attributable to a paroxysmal disorganization of temporal structures. They result from various methodological appraisals of clinical, electrophysiological and neuroradiological data concerning partial epilepsies. However a study of anatomo-electroclinical correlations in temporal seizures yield an easy pattern when the methods of elaboration, the criteria of validity and their meaning are strictly defined. An analysis of temporal seizures, recorded, filmed and described clinically in 300 patients having had a pre-surgical SEEG examination is the basis of a proposed classification of their main clinical features. The structures supposed to be ictally disorganized are, for each category, as follows: simple and complex visual and auditory hallucinations and illusions are due to a discharge beginning in the temporal-occipital or superior (posterior or anterior) temporal cortex. Memory troubles like dreamy-state are due to a simultaneous impairment of some neo-cortical areas and of Ammon's horn. Instinctive-affective troubles, like genital and sexual signs, or symptoms, emotional, mood, affective troubles seem to be linked to discharges in hippocampal and juxta-insular, internal perisylvian areas. Autonomous (cardiac, digestive, etc.) troubles are linked to a disorganization of basal limbic structures and especially of the perisylvian cortex. Motor and verbal automatisms have different meanings: only chewing is due to a discharge in the amygdalian area and in its hypothalamic efferents. Cognitive impairment is difficult to classify.(ABSTRACT TRUNCATED AT 250 WORDS)