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Langbein J, Boddeti U, Kreinbrink M, Khan Z, Rampalli I, Bachani M, Ksendzovsky A. Therapeutic approaches targeting seizure networks. FRONTIERS IN NETWORK PHYSIOLOGY 2024; 4:1441983. [PMID: 39171119 PMCID: PMC11335476 DOI: 10.3389/fnetp.2024.1441983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/16/2024] [Indexed: 08/23/2024]
Abstract
Epilepsy is one of the most common neurological disorders, affecting over 65 million people worldwide. Despite medical management with anti-seizure medications (ASMs), many patients fail to achieve seizure freedom, with over one-third of patients having drug-resistant epilepsy (DRE). Even with surgical management through resective surgery and/or neuromodulatory interventions, over 50 % of patients continue to experience refractory seizures within a year of surgery. Over the past 2 decades, studies have increasingly suggested that treatment failure is likely driven by untreated components of a pathological seizure network, a shift in the classical understanding of epilepsy as a focal disorder. However, this shift in thinking has yet to translate to improved treatments and seizure outcomes in patients. Here, we present a narrative review discussing the process of surgical epilepsy management. We explore current surgical interventions and hypothesized mechanisms behind treatment failure, highlighting evidence of pathologic seizure networks. Finally, we conclude by discussing how the network theory may inform surgical management, guiding the identification and targeting of more appropriate surgical regions. Ultimately, we believe that adapting current surgical practices and neuromodulatory interventions towards targeting seizure networks offers new therapeutic strategies that may improve seizure outcomes in patients suffering from DRE.
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Affiliation(s)
- Jenna Langbein
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ujwal Boddeti
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
- Surgical Neurology Branch, National Institute of Neurological Disorders, National Institutes of Health, Bethesda, MD, United States
| | - Matthew Kreinbrink
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ziam Khan
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ihika Rampalli
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Muzna Bachani
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Alexander Ksendzovsky
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
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Passaro EA. Neuroimaging in Adults and Children With Epilepsy. Continuum (Minneap Minn) 2023; 29:104-155. [PMID: 36795875 DOI: 10.1212/con.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article discusses the fundamental importance of optimal epilepsy imaging using the International League Against Epilepsy-endorsed Harmonized Neuroimaging of Epilepsy Structural Sequences (HARNESS) protocol and the use of multimodality imaging in the evaluation of patients with drug-resistant epilepsy. It outlines a methodical approach to evaluating these images, particularly in the context of clinical information. LATEST DEVELOPMENTS Epilepsy imaging is rapidly evolving, and a high-resolution epilepsy protocol MRI is essential in evaluating newly diagnosed, chronic, and drug-resistant epilepsy. The article reviews the spectrum of relevant MRI findings in epilepsy and their clinical significance. Integrating multimodality imaging is a powerful tool in the presurgical evaluation of epilepsy, particularly in "MRI-negative" cases. For example, correlation of clinical phenomenology, video-EEG with positron emission tomography (PET), ictal subtraction single-photon emission computerized tomography (SPECT), magnetoencephalography (MEG), functional MRI, and advanced neuroimaging such as MRI texture analysis and voxel-based morphometry enhances the identification of subtle cortical lesions such as focal cortical dysplasias to optimize epilepsy localization and selection of optimal surgical candidates. ESSENTIAL POINTS The neurologist has a unique role in understanding the clinical history and seizure phenomenology, which are the cornerstones of neuroanatomic localization. When integrated with advanced neuroimaging, the clinical context has a profound impact on identifying subtle MRI lesions or finding the "epileptogenic" lesion when multiple lesions are present. Patients with an identified lesion on MRI have a 2.5-fold improved chance of achieving seizure freedom with epilepsy surgery compared with those without a lesion. This clinical-radiographic integration is essential to accurate classification, localization, determination of long-term prognosis for seizure control, and identification of candidates for epilepsy surgery to reduce seizure burden or attain seizure freedom.
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Wu S, Nordli DR. Motor seizure semiology. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:295-304. [PMID: 37620075 DOI: 10.1016/b978-0-323-98817-9.00014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Motor semiology is a major component of epilepsy evaluation, which provides essential information on seizure classification and helps in seizure localization. The typical motor seizures include tonic, clonic, tonic-clonic, myoclonic, atonic, epileptic spasms, automatisms, and hyperkinetic seizures. Compared to the "positive" motor signs, negative motor phenomena, for example, atonic seizures and Todd's paralysis are also crucial in seizure analysis. Several motor signs, for example, version, unilateral dystonia, figure 4 sign, M2e sign, and asymmetric clonic ending, are commonly observed and have significant clinical value in seizure localization. The purpose of this chapter is to review the localization value and pathophysiology associated with the well-defined motor seizure semiology using updated knowledge from intracranial electroencephalographic recordings, particularly stereoelectroencephalography.
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Affiliation(s)
- Shasha Wu
- Department of Neurology and the Comprehensive Epilepsy Center, The University of Chicago, Chicago, IL, United States.
| | - Douglas R Nordli
- Department of Pediatrics and the Comprehensive Epilepsy Center, The University of Chicago, Chicago, IL, United States
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Neural networks underlying hyperkinetic seizures: A quantitative PET and SEEG study. Epilepsy Behav 2021; 122:108130. [PMID: 34153637 DOI: 10.1016/j.yebeh.2021.108130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/29/2021] [Accepted: 05/29/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Hyperkinetic seizures (HKS) are characterized by complex movements that commonly occur during seizures arising from diverse cortical structures. A common semiology network may exist and analyzing the anatomo-electrical mechanisms would facilitate presurgical evaluation. Here, quantitative positron emission tomography (PET) and stereoelectroencephalography (SEEG) analysis was used to explore the underlying mechanism of HKS. METHODS We retrospectively collected patients with epilepsy with HKS between 2014 and 2019. The interictal PET data of patients with epilepsy with HKS were compared with those of 25 healthy subjects using statistical parametric mapping to identify regions with significant hypometabolism. Then, regions of interest (ROI) for SEEG analysis were identified based on the results of PET analysis. Patients in which the ROIs were covered by intracerebral electrodes were selected for further analysis. Stereoelectroencephalography -clinical correlations with latency measurements were analyzed, and we also performed coherence analysis among ROIs both before and during HKS. RESULTS Based on the inclusion criteria, 27 patients were analyzed. In the PET analysis, significant hypometabolism was observed in the ipsilateral dorsoanterior insular lobe, bilateral mesial frontal lobes (supplementary motor area/middle cingulate cortex, SMA/MCC), and the bilateral heads of the caudate nuclei in patients with HKS compared with the control group (p < 0.001). We selected dorsoanterior insula and SMA/MCC as ROIs for SEEG analysis. Eight patients with 23 HKS events were selected for further analysis. There was a linear correlation between the ictal involvement of both the dorsoanterior insula and SMA/MCC with the onset of HKS. Stereoelectroencephalography analysis indicated alpha range activity seemed more often associated with dorsoanterior insula and SMA/MCC involvement during HKS. CONCLUSIONS The dorsoanterior insular lobe, mesial frontal lobes (SMA/MCC), and the bilateral heads of the caudate nuclei were probably involved in the generation of HKS. The SEEG analysis further indicated that the occurrence of HKS might be partly associated with synchronized rhythmical alpha activity between dorsoanterior insula and SMA/MCC.
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McGonigal A, Bartolomei F, Chauvel P. On seizure semiology. Epilepsia 2021; 62:2019-2035. [PMID: 34247399 DOI: 10.1111/epi.16994] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/30/2022]
Abstract
The clinical expression of seizures represents the main symptomatic burden of epilepsy. Neural mechanisms of semiologic production in epilepsy, especially for complex behaviors, remain poorly known. In a framework of epilepsy as a network rather than as a focal disorder, we can think of semiology as being dynamically produced by a set of interconnected structures, in which specific rhythmic interactions, and not just anatomical localization, are likely to play an important part in clinical expression. This requires a paradigm shift in how we think about seizure organization, including from a presurgical evaluation perspective. Semiology is a key data source, albeit with significant methodological challenges for its use in research, including observer bias and choice of semiologic categories. Better understanding of semiologic categorization and pathophysiological correlates is relevant to seizure classification systems. Advances in knowledge of neural mechanisms as well as anatomic correlates of different semiologic patterns could help improve knowledge of epilepsy networks and potentially contribute to therapeutic innovations.
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Affiliation(s)
- Aileen McGonigal
- Inserm, INS, Institut de Neurosciences des Systèmes, Aix Marseille Univ, Marseille, France.,Clinical Neurophysiology, APHM, Timone Hospital, Marseille, France
| | - Fabrice Bartolomei
- Inserm, INS, Institut de Neurosciences des Systèmes, Aix Marseille Univ, Marseille, France.,Clinical Neurophysiology, APHM, Timone Hospital, Marseille, France
| | - Patrick Chauvel
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Jobst BC, Conner KR, Coulter D, Fried I, Guilfoyle S, Hirsch LJ, Hogan RE, Hopp JL, Naritoku D, Plueger M, Schevon C, Smith G, Valencia I, Gaillard WD. Highlights From AES2020, a Virtual American Epilepsy Society Experience. Epilepsy Curr 2021; 21:15357597211018219. [PMID: 33998298 PMCID: PMC8512915 DOI: 10.1177/15357597211018219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Due to COVID-19 a live, in-person meeting was not possible for the American Epilepsy Society in 2020. An alternative, virtual event, the AES2020, was held instead. AES2020 was a great success with 4679 attendees from 70 countries. The educational content was outstanding and spanned the causes, treatments, and outcomes from epileptic encephalopathy to the iatrogenicity of epilepsy interventions to neurocognitive disabilities to the approach to neocortical epilepsies. New gene therapy approaches such as antisense oligonucleotide treatment for Dravet syndrome were introduced and neuromodulation devices were discussed. There were many other topics discussed in special interest groups and investigators' workshops. A highlight was having a Nobel prize winner speak about memory processing. Human intracranial electrophysiology contributes insights into memory processing and complements animal work. In a special COVID symposium, the impact of COVID on patients with epilepsy was reviewed. Telehealth has been expanded rapidly and may be well suited for some parts of epilepsy care. In summary, the epilepsy community was alive and engaged despite being limited to a virtual platform.
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Affiliation(s)
| | | | | | | | - Shanna Guilfoyle
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Neural correlates of rhythmic rocking in prefrontal seizures. Neurophysiol Clin 2020; 50:331-338. [DOI: 10.1016/j.neucli.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 01/18/2023] Open
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Wang H, McGonigal A, Zhang K, Guo Q, Zhang B, Wang X, Wang X, Lin J, Song X, Feng Q, Wang S, Wang M, Shao X, Liu X, Wang L, Zhou W. Semiologic subgroups of insulo-opercular seizures based on connectional architecture atlas. Epilepsia 2020; 61:984-994. [PMID: 32314372 DOI: 10.1111/epi.16501] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Insulo-opercular seizures are characterized by diverse semiology, related to the insula's multiple functional roles and extensive connectivity. We aimed to identify semiologic subgroups and correlate these with insulo-opercular subregions based on connectional architecture. METHODS We retrospectively collected a large series of 37 patients with insulo-opercular seizures explored by stereoelectroencephalography (SEEG) from three epilepsy centers. A new human brain atlas (Brainnetome Atlas, BNA) based on both anatomic and functional connections was employed to segment insulo-opercular cortex. Semiology and SEEG changes were carefully reviewed and quantified. Principal component analysis and cluster analysis were used to correlate semiologic characteristics with insulo-opercular subregions. RESULTS Four main semiologic subgroups were identified, organized along an anteroventral to posterodorsal axis based on BNA. Group 1 was characterized by epigastric sensation and/or integrated gestural motor behaviors with or without feelings of fear or rage, involving the anteroventral insular regions and mesial temporal lobes. Group 2 was characterized by auditory sensations and symmetric proximal/axial tonic signs involving the posteroventral temporal operculum. The characteristics of group 3 were orofacial and laryngeal signs, involving the intermediate insulo-opercular regions. The features of group 4 were somatosensory signs followed by nonintegrated gestural motor behaviors and/or asymmetric tonic signs involving the posterodorsal insulo-opercular regions with propagation to the mesial frontal lobes. Thus anteroventral seizure organizations predominantly showed limbic system semiology, whereas more posterodorsal regions were associated with semiology involving mainly the sensorimotor system. Subjective symptoms proved to be particularly discriminating factors. SIGNIFICANCE Insulo-opercular seizures can be categorized in terms of clinical semiology and correlate with connectional architecture subregions along an anteroventral-posterodorsal axis in line with the cytoarchitectonic gradient rather than the gyral anatomy of the insula cortex. This provides new insights into facilitating differential diagnosis and presurgical localization but also highlights the importance of considering connectional architecture in determining neural correlates of complex semiologic patterns.
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Affiliation(s)
- Haixiang Wang
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Aileen McGonigal
- Aix Marseille University, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Clinical Neurophysiology and Epileptology Department, Timone Hospital, APHM, Marseille, France
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Guo
- Epilepsy Center, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Bingqing Zhang
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao Wang
- Epilepsy Center, Guangdong Sanjiu Brain Hospital, Guangzhou, China
| | - Jiuluan Lin
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Xiancheng Song
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Qian Feng
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Siyu Wang
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
| | - Mengyang Wang
- Department of Neurology, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiaoqiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Liang Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China.,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
| | - Wenjing Zhou
- Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing, China
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