- Email: [email protected]
PO10.13 Extent of Neocortical Resection and Surgical Outcome for Epilepsy: Intracranial EEG Analysis
2009 Asian and Oceanian Congress of Clinical Neurophysiology
S77
PO10.13 Extent of Neocortical Resection and Surgical Outcome for Epilepsy: Intracranial EEG Analysis
PO10.15 Pathologically Confirmed Ictal Vomiting as a Clinical Manifestation of Right Frontal Lobe Epilepsy
Hyun Kyung Kim *, Dong Wook Kim, Kon Chu, Chun Kee Chung, Sang Kun Lee Neurology, Seoul National University Hospital, Korea E-mail address: [email protected]
Moon Kyu Lee1 *, Yang Je Cho1 , Dong Woo Lee1 , Jong Hee Chang2 , Soochul Park1 1 Dept. of Neurology, Yonsei University College of Medicine, Korea, 2 Dept. of Neurosurgery, Yonsei University College of Medicine, Korea E-mail address: [email protected]
Background: Intracranial electroencephalographic (EEG) monitoring is an important process in the presurgical evaluation for epilepsy surgery. The objective of this study was to identify how much of the presumed “epileptogenic zone” we should remove, guided by subdural electrodes. For this purpose, we investigated the relationship between the extent of resection guided by subdural electrodes and the outcome of epilepsy surgery. Methods: Intracranial EEGs were analyzed in 177 consecutive patients who had undergone resective epileptic surgery between 1995 and 2003. We reviewed various intracranial EEG findings and the extent of resection. We analyzed the relationships between the surgical outcomes and intracranial EEG factors: the frequency, morphology distribution of ictal onset discharges, the propagation speed, and the time lag between clinical and intracranial ictal onset. We also investigated whether the extent of resection, including the area showing ictal rhythm and various interictal abnormalities, such as frequent interictal spikes, pathological delta waves, and paroxysmal fast activity, influenced the surgical outcome. Results: Seventy-five (42%) patients were seizure free (Engel class I). A seizure-free outcome was significantly associated with a resection that included the area showing ictal spreading rhythm during the first three seconds or included all the electrodes showing pathological delta waves or frequent interictal spikes. However, subgroup analysis revealed that the extent of resection did not affect the surgical outcome in lateral temporal lobe epilepsy. Conclusions: Better outcome from resective surgery is more closely related with EEG patterns of resected area than the extent of resection. PO10.14 Two-Day Video-EEG Monitoring in the Evaluation of Paroxysmal Events Ying-Ying Lee *, I-an Chen, Yu-Tai Tsai, Chung-Yang Sung, HsiangYao Hsieh, Siew-Na Lim, Tony Wu Dept. of Neurology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan E-mail address: [email protected] Background: High yield of prolonged video-electroencephalography monitoring (VEM) in events recording was documented, as well as its extensive employment in characterizing paroxysmal events and quantification of seizure frequency. Although VEM is resource-intensive and brings about certain medical costs, still few studies attached importance to the issue of optimal duration of monitoring. The current study established a protocol for VEM in duration within 2 days. The primary purpose was to analyze the yield of 2-day VEM in managing patients with paroxysmal events. Methods: We systematically collected the clinical and VEM data of patients admitted to the VEM unit in Chang-Gung Memorial Hospital from June 2006 to August 2007. The primary outcome of interest in this analysis was time to first event. These patients included were categorized into 2 groups: one is the group with events occurring during both day and night, and the other with events exclusively nocturnal or during sleep. In the former group, time to first event was ascertained by monitoring hours. In the latter group, special attention was paid on whether the event was recorded or not, documented on each recording night separately. Results: Of the total 209 patients, 123 patients (58.9%) had a clinical event recorded. Two-day VEM had a positive yield in 71.9% of the 196 patients without known sleep disorders, leading to changes in diagnoses in 82 (41.8%) and in treatment in 66 (33.7%). In the 163 patients whose events not exclusively nocturnal, 88 patients (54.0%) had events recorded, and 75 of the 88 had their first event within 24 hours of monitoring. With well-established VEM protocol and protective measures, there was no status epilepticus or seizure-related trauma ensuing from seizure clusters in 20 patients during VEM. Conclusions: Two-day VEM is safe and efficient in recording paroxysmal events, directing to significant changes in diagnosis and management.
Background: Ictal vomiting is a rare manifestation of epilepsy usually originated in the temporal lobe. We report a patient with an ictal vomiting as a clinical presentation of the right frontal lobe epilepsy, which was pathologically confirmed. Case report: 27-year-old right-handed woman suffered from ictal vomiting for 20 years. She experienced nausea especially on awakening in the morning one to two times per week with occasional vomiting and rare 2 GTC. MRI was not remarkable. Ictal and subclinical ictal discharges with habitual seizures were picked up on right inferior frontal region during video-EEG monitoring with subdural electrodes. Epileptic focus was localized on the posteroinferior frontal area through functional mapping. Cortisectomy was done and cortical dysplasia type IIa was confirmed. The patient remained seizure free one year after surgery. Conclusions: We present a rare case of ictal vomiting, originated in the non-dominant frontal lobe region, which was supported by functional neuroimagings, invasive electrophysiologic studies, and pathologic findings. PO10.16 Subclinical Ictal Build up during of PLEDs in a Case with Status Epilepticus due to Herpes Simplex Encephalitis Hee Jin Kim1 *, Joo-Hyun Seo1 , Jin-Yong Hong1 , Bosuk Park1 , Yeung-Yeob Kim2 , Soochul Park1 1 Dept. of Neurology, Yonsei University College of Medicine, Korea, 2 Dept. of Neuroradiology, Yonsei University College of Medicine, Korea E-mail address: [email protected] Background: Most commonly, periodic lateralized epileptiform discharges (PLEDs) are seen with an acute structural lesion such as a tumor, infarct, or encephalitis, with or without a superimposed metabolic disturbance. PLEDs are typically self-limited and resolve within days to weeks, although longstanding PLEDs have been described. The incidence of clinical seizures in the acute setting of PLEDs ranges from 58% to 100%; which are most commonly focal motor seizures or epilepsia partialis continua. Whether PLEDs represent a definitely ictal pattern has been debated in the literature. We experienced a case showing bilaterally independent subclinical ictal discharges in spite of PLEDs on EEG according to clinical evolution in status epilepticus due to Herpes simplex encephalitis Case report: A 68-year-old woman was admitted due to generalized ache for 4 days. Headache with fever and mental confusion was followed by status epilepticus. EEG showed unilateral PLEDs and FLAIR image on Brain MRI showed high signal intensity in mesial temporal area on left side. Herpes simplex encephalitis was confirmed serologically. Clinical seizures were controlled by midazolam infusion but subclinical ictal discharges build up on left hemisphere independently with PLEDs. 18F FDG-PET showed decreased glucose uptake on left mesial temporal area. According to spread to contralateral side of the lesion on MRI with bilateral independent PLEDs, subclinical ictal discharges developed on right side. Bilateral PLEDS finally evolved to bilateral synchronous generalized periodic discharges. Patient was fixed to vegetative state with diffuse insults on both hemispheres. Conclusions: The EEG findings suggested that subclinical ictal discharges developed irrespective of PLEDs, which meant PLEDs were not true ictal discharges.
S77
PO10.13 Extent of Neocortical Resection and Surgical Outcome for Epilepsy: Intracranial EEG Analysis
PO10.15 Pathologically Confirmed Ictal Vomiting as a Clinical Manifestation of Right Frontal Lobe Epilepsy
Hyun Kyung Kim *, Dong Wook Kim, Kon Chu, Chun Kee Chung, Sang Kun Lee Neurology, Seoul National University Hospital, Korea E-mail address: [email protected]
Moon Kyu Lee1 *, Yang Je Cho1 , Dong Woo Lee1 , Jong Hee Chang2 , Soochul Park1 1 Dept. of Neurology, Yonsei University College of Medicine, Korea, 2 Dept. of Neurosurgery, Yonsei University College of Medicine, Korea E-mail address: [email protected]
Background: Intracranial electroencephalographic (EEG) monitoring is an important process in the presurgical evaluation for epilepsy surgery. The objective of this study was to identify how much of the presumed “epileptogenic zone” we should remove, guided by subdural electrodes. For this purpose, we investigated the relationship between the extent of resection guided by subdural electrodes and the outcome of epilepsy surgery. Methods: Intracranial EEGs were analyzed in 177 consecutive patients who had undergone resective epileptic surgery between 1995 and 2003. We reviewed various intracranial EEG findings and the extent of resection. We analyzed the relationships between the surgical outcomes and intracranial EEG factors: the frequency, morphology distribution of ictal onset discharges, the propagation speed, and the time lag between clinical and intracranial ictal onset. We also investigated whether the extent of resection, including the area showing ictal rhythm and various interictal abnormalities, such as frequent interictal spikes, pathological delta waves, and paroxysmal fast activity, influenced the surgical outcome. Results: Seventy-five (42%) patients were seizure free (Engel class I). A seizure-free outcome was significantly associated with a resection that included the area showing ictal spreading rhythm during the first three seconds or included all the electrodes showing pathological delta waves or frequent interictal spikes. However, subgroup analysis revealed that the extent of resection did not affect the surgical outcome in lateral temporal lobe epilepsy. Conclusions: Better outcome from resective surgery is more closely related with EEG patterns of resected area than the extent of resection. PO10.14 Two-Day Video-EEG Monitoring in the Evaluation of Paroxysmal Events Ying-Ying Lee *, I-an Chen, Yu-Tai Tsai, Chung-Yang Sung, HsiangYao Hsieh, Siew-Na Lim, Tony Wu Dept. of Neurology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan E-mail address: [email protected] Background: High yield of prolonged video-electroencephalography monitoring (VEM) in events recording was documented, as well as its extensive employment in characterizing paroxysmal events and quantification of seizure frequency. Although VEM is resource-intensive and brings about certain medical costs, still few studies attached importance to the issue of optimal duration of monitoring. The current study established a protocol for VEM in duration within 2 days. The primary purpose was to analyze the yield of 2-day VEM in managing patients with paroxysmal events. Methods: We systematically collected the clinical and VEM data of patients admitted to the VEM unit in Chang-Gung Memorial Hospital from June 2006 to August 2007. The primary outcome of interest in this analysis was time to first event. These patients included were categorized into 2 groups: one is the group with events occurring during both day and night, and the other with events exclusively nocturnal or during sleep. In the former group, time to first event was ascertained by monitoring hours. In the latter group, special attention was paid on whether the event was recorded or not, documented on each recording night separately. Results: Of the total 209 patients, 123 patients (58.9%) had a clinical event recorded. Two-day VEM had a positive yield in 71.9% of the 196 patients without known sleep disorders, leading to changes in diagnoses in 82 (41.8%) and in treatment in 66 (33.7%). In the 163 patients whose events not exclusively nocturnal, 88 patients (54.0%) had events recorded, and 75 of the 88 had their first event within 24 hours of monitoring. With well-established VEM protocol and protective measures, there was no status epilepticus or seizure-related trauma ensuing from seizure clusters in 20 patients during VEM. Conclusions: Two-day VEM is safe and efficient in recording paroxysmal events, directing to significant changes in diagnosis and management.
Background: Ictal vomiting is a rare manifestation of epilepsy usually originated in the temporal lobe. We report a patient with an ictal vomiting as a clinical presentation of the right frontal lobe epilepsy, which was pathologically confirmed. Case report: 27-year-old right-handed woman suffered from ictal vomiting for 20 years. She experienced nausea especially on awakening in the morning one to two times per week with occasional vomiting and rare 2 GTC. MRI was not remarkable. Ictal and subclinical ictal discharges with habitual seizures were picked up on right inferior frontal region during video-EEG monitoring with subdural electrodes. Epileptic focus was localized on the posteroinferior frontal area through functional mapping. Cortisectomy was done and cortical dysplasia type IIa was confirmed. The patient remained seizure free one year after surgery. Conclusions: We present a rare case of ictal vomiting, originated in the non-dominant frontal lobe region, which was supported by functional neuroimagings, invasive electrophysiologic studies, and pathologic findings. PO10.16 Subclinical Ictal Build up during of PLEDs in a Case with Status Epilepticus due to Herpes Simplex Encephalitis Hee Jin Kim1 *, Joo-Hyun Seo1 , Jin-Yong Hong1 , Bosuk Park1 , Yeung-Yeob Kim2 , Soochul Park1 1 Dept. of Neurology, Yonsei University College of Medicine, Korea, 2 Dept. of Neuroradiology, Yonsei University College of Medicine, Korea E-mail address: [email protected] Background: Most commonly, periodic lateralized epileptiform discharges (PLEDs) are seen with an acute structural lesion such as a tumor, infarct, or encephalitis, with or without a superimposed metabolic disturbance. PLEDs are typically self-limited and resolve within days to weeks, although longstanding PLEDs have been described. The incidence of clinical seizures in the acute setting of PLEDs ranges from 58% to 100%; which are most commonly focal motor seizures or epilepsia partialis continua. Whether PLEDs represent a definitely ictal pattern has been debated in the literature. We experienced a case showing bilaterally independent subclinical ictal discharges in spite of PLEDs on EEG according to clinical evolution in status epilepticus due to Herpes simplex encephalitis Case report: A 68-year-old woman was admitted due to generalized ache for 4 days. Headache with fever and mental confusion was followed by status epilepticus. EEG showed unilateral PLEDs and FLAIR image on Brain MRI showed high signal intensity in mesial temporal area on left side. Herpes simplex encephalitis was confirmed serologically. Clinical seizures were controlled by midazolam infusion but subclinical ictal discharges build up on left hemisphere independently with PLEDs. 18F FDG-PET showed decreased glucose uptake on left mesial temporal area. According to spread to contralateral side of the lesion on MRI with bilateral independent PLEDs, subclinical ictal discharges developed on right side. Bilateral PLEDS finally evolved to bilateral synchronous generalized periodic discharges. Patient was fixed to vegetative state with diffuse insults on both hemispheres. Conclusions: The EEG findings suggested that subclinical ictal discharges developed irrespective of PLEDs, which meant PLEDs were not true ictal discharges.