White-matter change in mesial temporal sclerosis: correlation of MRI with PET, pathology, and clinical features

Voxel-based morphometric comparison of hippocampal and extrahippocampal abnormalities in patients with left and right hippocampal atrophy

We used voxel-based morphometry (VBM), an automatic whole-brain MR image analysis technique, to investigate gray matter abnormalities in patients with temporal lobe epilepsy (TLE), in whom hippocampal atrophy (HA) was demonstrated by application of the Cavalieri method of modern design stereology. VBM results (P < 0.05, corrected) indicated preferential gray matter concentration (GMC) reduction in anterior hippocampus in patients with left HA and posterior hippocampus in patients with right HA. GMC reduction was also found in right dorsal prefrontal cortex in left and right HA patients. Prefrontal atrophy may be due to epileptiform excitotoxic discharges from the reciprocally connected pathological hippocampus, and may be the underlying biological cause for executive dysfunction in patients with TLE. GMC excess in ipsilateral parahippocampal, cerebellar, and pericallosal regions was common to both left and right HA groups relative to controls, and is hypothesized to reflect diminished gray-white matter demarcation, underlying white matter atrophy, or structural displacement due to cerebrospinal fluid expansion. However, bilateral temporal lobe GMC excess was observed in left HA patients, while ipsilateral temporal lobe GMC excess was observed in right HA patients. This work demonstrates methodological consistency between automated VBM and manual stereological analysis of the hippocampus in group comparisons, indicates widespread extrahippocampal gray matter abnormalities in unilateral HA, and suggests that there may be inherent differences in the effect of TLE on temporal lobe structures depending on the side of HA.

Mesial temporal lobe epilepsy with lateral temporal lobe abnormalities in magnetoencephalography and glucose metabolism

Magnetoencephalography (MEG) and positron emission tomography (PET) revealed abnormal findings in the lateral temporal lobe of a 22 year old female with mesial temporal lobe epilepsy. Electroencephalography identified the epileptogenic focus in the left mesial temporal lobe and standard anterior temporal lobectomy resulted in a good surgical outcome. These discrepancies can be explained by the presence of anatomical and functional pathways between the mesial and lateral temporal structures, or pathophysiological abnormalities in both the mesial and lateral temporal lobes. Careful evaluation is necessary for analysis of MEG and PET findings in patients with temporal lobe epilepsy.

Seizure outcome after temporal lobectomy: current research practice and findings

PURPOSE

The literature regarding seizure outcome and prognostic factors for outcome after temporal lobectomy is often contradictory. This is problematic, as these data are the basis on which surgical decisions and counseling are founded. We sought to clarify inconsistencies in the literature by critically examining the methods and findings of recent research.

METHODS

A systematic review of the 126 articles concerning temporal lobectomy outcome published from 1991 was conducted.

RESULTS

Major methodologic issues in the literature were heterogeneous definitions of seizure outcome, a predominance of cross-sectional analyses (83% of studies), and relatively short follow-up in many studies. The range of seizure freedom was wide (33-93%; median, 70%); there was a tendency for better outcome in more recent studies. Of 63 factors analyzed, good outcome appeared to be associated with several factors including preoperative hippocampal sclerosis, anterior temporal localization of interictal epileptiform activity, absence of preoperative generalized seizures, and absence of seizures in the first postoperative week. A number of factors had no association with outcome (e.g., age at onset, preoperative seizure frequency, and extent of lateral resection).

CONCLUSIONS

Apparently conflicting results in the literature may be explained by the methodologic issues identified here (e.g., sample size, selection criteria and method of analysis). To obtain a better understanding of patterns of long-term outcome, increased emphasis on longitudinal analytic methods is required. The systematic review of possible risk factors for seizure recurrence provides a basis for planning further research.

[Neurofunctional tests in presurgical strategies for partial epilepsies]

The presurgical evaluation of drug-resistant partial epilepsies primarily relies on two major investigations, including a long term video-EEG monitoring which aimed at recording the patient's typical seizures, and a specifically designed high quality magnetic resonance imaging (MRI). The latter demonstrates an abnormality within the epileptogenic lobe in the majority of cases, which might not, however, necessarily match the epileptogenic zone. Numerous functional neuro-imaging techniques have been progressively added to the pre-surgical evaluation of refractory partial epilepsies, such as the study of cerebral glucose metabolism, benzodiazepine receptor availability, and methionine incorporation using positron emission tomography (PET), the evaluation of ictal cerebral blood flow changes using single photon emission computerized tomography (SPECT), the measurement of N-acetyl-aspartate concentration with magnetic resonance spectroscopy, and the mapping of eloquent areas using functional MRI. These investigations can help to confirm the origin of seizure onset previously suggested by MRI and electro-clinical data, and provide independent prognostic information regarding the chance of a successful surgical treatment. Moreover, functional neuro-imaging data can have a critical diagnostic value when MRI is strictly normal or shows multifocal abnormalities. However, the variety and rapid evolution of functional neuro-imaging techniques makes it difficult to propose a standard protocol. Finally, it remains mandatory to proceed to an intracranial EEG investigation in a substantial number of patients, including the majority of those suffering from an extra-temporal epilepsy.