The relationship between seizure subtype and interictal personality. Results from the Vietnam Head Injury Study

Surgical treatment may improve depressive and hysterical traits in temporal lobe epilepsy with hippocampal sclerosis: Study using the Minnesota Multiphasic Personality Inventory

Aim

The influence of surgeries on psychiatric symptoms and personality traits is not well known in patients with intractable temporal lobe epilepsy (TLE). We investigated changes in personality traits with respect to postoperative seizure outcomes, etiology, side of surgery, and sex differences.

Methods

Clinical information was retrospectively collected for 44 patients whose Minnesota Multiphasic Personality Inventory (MMPI) was examined before and 1 year after surgical treatment for drug-resistant TLE. Postoperative changes in MMPI T-scores were analyzed using a paired t-test. Participants were divided into two groups based on postoperative seizure outcome, the presence or absence of hippocampal sclerosis (HS) as the etiology, side of surgery, and sex differences. The effect of these clinical factors on postoperative changes in MMPI T-scores was evaluated using analysis of covariance (P-values < 0.05).

Results

The hypochondria (Hs) scale decreased significantly in all patients (p = 0.022). The postoperative seizure-free group had a significant decrease in the depression (D) scale (p = 0.037). The HS group had significant decreases in the D scale and the hysteria (Hy) scale (p = 0.016 and 0.004, respectively), and a significant increase in the masculinity-femininity (Mf) scale (p = 0.009). No significant differences existed between the sides of surgery or sex.

Conclusion

Depressive traits were improved in patients with postoperative seizure freedom. Depressive and hysterical traits were improved in patients with HS, which may be attributed to a reduction in anxiety and fear associated with aura. Most personality traits are not significantly changed or exacerbated by surgical treatment of TLE.

Neurological findings in pediatric penetrating head injury at a university teaching hospital in Durban, South Africa: a 23-year retrospective study

OBJECTIVES Penetrating traumatic brain injuries (TBIs) can be divided into gunshot wounds or stab wounds based on the mechanisms of injury. Pediatric penetrating TBIs are of major concern as many parental and social factors may be involved in the causation. The authors describe the penetrating cranial injuries in pediatric patient subgroups at risk and presenting to the Department of Neurosurgery at the University of KwaZulu-Natal, by assessment of the Glasgow Coma Scale (GCS) score and review of the common neurological manifestations including cranial nerve abnormalities. METHODS The authors performed a retrospective chart review of children who presented with penetrating TBIs between 1985 and 2007 at a university teaching hospital. Descriptive statistical analysis with univariate and multivariate logistic regression was used to assess the variables. RESULTS Out of 223 children aged 16 years and younger with penetrating TBIs seen during the study period, stab wounds were causal in 127 (57%) of the patients, while gunshot injuries were causal in 96 (43%). Eighty-four percent of the patients were male. Apart from abnormal GCS scores, other neurological abnormalities were noted in 109 (48.9%) of the patients, the most common being cranial nerve deficits (22.4%) and hemiparesis. There was a strong correlation between left-sided stab wounds and development of seizures. The mean age of patients with neurological abnormalities was 11.72 years whereas that of patients with no neurological abnormalities was 8.96 years. CONCLUSIONS Penetrating head injuries in children are not as uncommon as previously thought. There was no correlation between the age group of the patients and the mechanism of injury, which implies that stab or gunshot injuries could occur in any of our pediatric population with the same frequency. While gunshot injuries accounted for 56% of the patient population, stab injuries still accounted for 44%. Following penetrating head injuries, neurological abnormalities tend to occur in the older subgroup of the pediatric patients. The most common neurological abnormalities were hemiparesis followed by cranial nerve deficits. Facial nerve deficits were the most commonly seen cranial nerve abnormality. Immediate convulsions were a significant feature in patients with stab injuries to the head compared to those with gunshot injuries.

The Impact of Migraine on Epilepsy: A Prospective Prognosis Study

The effect of migraine on the prognosis of epilepsy has not been reported. The aim of this prospective 5-10-year follow-up study was to examine some outcome measures and the cumulative probability of being seizure-free in epilepsy patients with migraine, and to compare their results with those of epilepsy patients without migraine. Fifty-nine patients (40 women; mean age 25 years) were diagnosed with both epilepsy and migraine (EM group). The control group consisted of 56 patients with epilepsy but without migraine (E group). Both groups were recruited and followed up over similar periods. We compared the outcome variables in the EM group with those in the E group. Kaplan-Meier methods were used to assess the seizure-free curves. The EM group had a significantly lower cumulative probability of being seizure-free over 10 years compared with the E group. The other epilepsy outcome measures at follow-up differed significantly between the groups, with the EM group having a longer duration of epilepsy, a lower early treatment response, and a higher incidence of intractable epilepsy and achieving remission with polytherapy, and more seizure control and medication problems for at least the last 2 years of follow-up. Comorbid migraine had a negative effect on the prognosis of epilepsy.

Post-traumatic epilepsy: clinical clues to pathogenesis and paths to prevention

Post-traumatic epilepsy (PTE) remains one of the most intractable consequences of traumatic brain injury (TBI) and its incidence and characteristics have remained relatively constant through the past century, in spite of significant advances in medical management. Survivors of military penetrating head injury (PHI) suffer by far the highest incidence of (PTE), ranging from 32% to 55%, and they are a particularly valuable group in which to study this complication. Clues to the high incidence of PTE in PHI survivors are likely related to dural penetration with free intracerebral blood, and perhaps to retained ferric metal fragments. The failure of well-reasoned and well-conducted trials evaluating conventional anticonvulsants for prevention of PTE also offers important clues and has forced us to reconsider our approach to management. Here we briefly review the clinical characteristics of PHI patients with PTE, with an emphasis on clues to pathogenesis that can generalize to other types of head injury; followed by a discussion of the pathogenetic mechanisms common to epilepsy, PHI, and TBI in general, with an eye to future neuroprotection and PTE prophylaxis. Future studies that more directly target the basic pathogenesis of TBI, including neuroinflammation and lipid peroxidation with their consequent excitotoxic mechanisms and aberrant regeneration, may ultimately prove to be more fruitful in the struggle to understand and control this especially stubborn complication of head injury.

"Studying injured minds" - the Vietnam head injury study and 40 years of brain injury research

The study of those who have sustained traumatic brain injuries (TBI) during military conflicts has greatly facilitated research in the fields of neuropsychology, neurosurgery, psychiatry, neurology, and neuroimaging. The Vietnam Head Injury Study (VHIS) is a prospective, long-term follow-up study of a cohort of 1,221 Vietnam veterans with mostly penetrating brain injuries, which has stretched over more than 40 years. The scope of this study, both in terms of the types of injury and fields of examination, has been extremely broad. It has been instrumental in extending the field of TBI research and in exposing pressing medical and social issues that affect those who suffer such injuries. This review summarizes the history of conflict-related TBI research and the VHIS to date, as well as the vast range of important findings the VHIS has established.

[The development of the personality in childhood epilepsy with complex-partial seizures]

The study presented addresses the association between severity and course of childhood epilepsy with complex-partial seizures and subsequent personality development. Participants in the study were 84 patients first seen when they were 8 years on average. A follow-up examination was conducted about 13 years thereafter. At the first examination about half of the patients showed a psychiatric disorder, another quarter showed developmental delays and 35% were mentally retarded. It could be demonstrated that a high frequency of complex-partial seizures was related to depressive symptoms. However, additional generalized seizures did not further contribute to the severity of psychiatric problems. Patients who continued to show seizures reported less life satisfaction, a more passive attitude and higher emotional instability at follow-up in comparison to patients with a complete remission of epilepsy.

Role of androgens in epilepsy

Accumulating evidence suggests that both male- and/or female-typical sex steroids contribute to seizure susceptibility in epilepsy. Although there is rich literature regarding how female-typical sex steroids, such as progestins and estrogens, influence epilepsy, the role of androgens in seizure processes are just beginning to be understood. Given that some of the effects and mechanisms of androgen action on ictal activity may converge with that of progestins and/or estrogens, this review discusses what is known concerning the role of each of these sex steroids on seizures. Additionally, evidence that seizures and/or antiepileptic drugs can themselves influence steroid-dependent behaviors, such as affective, cognitive and reproductive function, is also reviewed. Considerations for therapeutic management and future directions for research and drug discovery are summarized.

The psychiatric comorbidity of epilepsy

Several studies have assessed the prevalence of psychiatric disorders in epilepsy. They are characterized by considerable heterogeneity, because of differences in the population setting and type of study. A non-systematic review of the literature allows us to draw some useful, although not definite, conclusions. Six per cent of people with epilepsy in the general population appear to suffer from a psychiatric disorder, while this rises to 10-20% in populations with temporal lobe and/or refractory epilepsy. Mood disorders are the most common culprit (24-74%), particularly depression (30%), followed by anxiety disorders (10-25%), psychoses (2-7%) and personality disorders (1-2%). This comorbidity appears to be related to endogenous and exogenous (including iatrogenic) factors and to the severity and chronicity of epilepsy. Conditions such as schizophrenia-like psychosis of epilepsy and interictal dysphoric disorder are represented only in epilepsy. Adequate recognition and treatment of psychiatric conditions in epilepsy is essential for patient management because of their considerable burden in morbidity and quality of life.

Posttraumatic epilepsy: neuroradiologic and neuropsychological assessment of long-term outcome

PURPOSE

We sought to detect the incidence and the risk factors of posttraumatic epilepsy (PTE) in rehabilitation patients; to define the influence of PTE for late clinical and functional outcome; and to assess the cognitive and behavioral features of the patients with PTE.

METHODS

Patients were examined with (a) cognitive and behavioral examinations, which included a clinical interview and psychometric tests performed by an expert clinical psychologist; (b) single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); and (c) functional evaluation including the Glasgow Outcome Scale (GOS) and the Functional Independence Measure (FIM).

RESULTS

Of the 143 patients examined in this study, in 27 (19%), seizures developed after a mean time from trauma of 11.9 +/- 8.6 months. The occurrence of PTE was significantly correlated with the hypoperfusion in temporal lobes (p < 0.004), the degree of hydrocephalus (p < 0.04), the evidence of intracerebral hematoma (p < 0.01), and operative brain injury (p < 0.001). Patients with epilepsy showed a significantly higher incidence of personality disorders than did patients without epilepsy. The uninhibited behavior, irritability, and agitated and aggressive behavior were significantly more frequent and severe in PTE patients. The psychometric tests intended to explore memory, language, intelligence, attention, and spatial cognition did not show any significant difference between those with and without epilepsy. PTE also was significantly correlated with a worse functional outcome 1 year after the trauma.

CONCLUSIONS

The degrees of hydrocephalus and of hypoperfusion in the temporal lobes are significant risk factors for late PTE. Another main finding of our study is the absence of influence of epilepsy on cognitive disorders; its influence on neurobehavioral disorders and functional outcome is discussed.

The relationship of psychiatric illnesses and seizures

The relationship between epilepsy and behavioral disturbances has been a subject of controversy since the 19th century. Affective changes may occur prior, during, or after the ictal discharge. Depression is the most prevalent comorbidity. Anxiety, panic attacks, and pseudoseizures may resemble complex partial seizures, and their diagnosis and treatment may be confusing, even to experienced clinicians. Epilepsy-related psychosis is less common, manifesting occasionally with symptoms that are indistinguishable from schizophrenia. There is no clear evidence of a distinct "epileptoid" personality, and interictal violence is extremely rare. Pharmacologic treatment with anticonvulsants remains the cornerstone of treatment. In case of psychiatric comorbidities or refractory seizures, the diagnosis should be re-examined.

Inter-ictal and post-ictal psychoses in frontal lobe epilepsy: a retrospective comparison with psychoses in temporal lobe epilepsy

There have been few studies of the psychopathology of patients with frontal lobe epilepsy (FLE). The majority of studies of both inter-ictal and post-ictal psychoses have strongly suggested the influence of temporal lobe disturbance on psychoses. Patients with organic brain damage or schizophrenia, however, sometimes show frontal lobe dysfunction. The purpose of this study was to better understand the effect, if any, of frontal lobe disturbance and seizure on psychopathology. Patients were divided into four groups based on epilepsy type and preceding seizures; 8 with FLE/inter-ictal psychosis, 3 with FLE/post-ictal psychosis, 29 with temporal lobe epilepsy (TLE)/inter-ictal psychosis, and 8 with TLE/post-ictal psychosis. Psychopathologic symptoms were retrospectively reviewed based on case notes, using a modified brief psychiatric rating scale (BPRS). Psychomotor excitement, hostility, suspiciousness, and hallucinatory behaviour were prominent features in all four groups. Six orthogonal factors were derived by factor analysis from the original data based on the 18 BPRS items. FLE patients with inter-ictal psychosis showed marked hebephrenic characteristics (i.e. emotional withdrawal and blunted effect). Our findings suggest that patients with FLE can exhibit various psychiatric symptoms. However, their psychotic symptoms, hebephrenic symptoms in particular, may often be overlooked.

Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service

In this retrospective study, the authors evaluated confounding risk factors, which are allegedly influential in causing unprovoked posttraumatic epilepsy, in 489 patients from the frontlines of the Iran–Iraq War.

Four hundred eighty-nine patients were followed for 6 to154 months (mean 39.4 months, median 23 months), and important factors precipitating posttraumatic epilepsy were evaluated using uni- and multivariate regression analysis.

One hundred fifty-seven (32%) of 489 patients became epileptic during the study period. The results of univariate analysis indicated a significant relationship between epilepsy and Glasgow Outcome Scale (GOS) score (X2 = 76.49, p < 0.0001, df = 2), Glasgow Coma Scale score at admission (X2 = 19.48, p < 0.0001, df = 3), motor deficit (X2 = 11.79, p < 0.001, df = 1), mode of injury (X2 = 10.731, p < 0.05), transventricular injury (X2 = 6.9, p < 0.008, df = 1), dysphasia (X2 = 5.3, p < 0.02), central nervous system infections (X2 = 5.3, p < 0.02), and early-onset seizures (X2 = 4.1, p < 0.04, df = 1). The results of multivariate analysis, on the other hand, indicated that the GOS score and motor deficit were of greater statistical importance (X2 = 35.24, p < 0.0001; and X2 = 7.1, p < 0.07, respectively). Factors that did have much statistically significant bearing on posttraumatic epilepsy were the projectile type, site of injury on the skull, patient age, number of affected lobes, related hemorrhagic complications, and retained metallic or bone fragments.

Glasgow Outcome Scale score and focal motor neurological deficit are of particular importance in predicting posttraumatic epilepsy after missile head injury.

Anxiogenic-like consequences in animal models of complex partial seizures

Several kinds of psychiatric symptoms (anxiety, depression, schizophrenia) have been associated with epilepsies, and clinical data suggest that patients with seizures involving limbic structures are the most prone to develop behavioural disorders between the seizures (i.e. interictally). Studying the neurobiological mechanisms that underlie these symptoms is difficult in humans because of different interfering factors (e.g. psychosocial difficulties, pharmacological side-effects, lesions), which can be avoided in animal models. Using repetitive electrical stimulations (kindling) or local applications of a neuroexcitotoxin in limbic structures (mainly the amygdala and hippocampus), several authors have reported lasting changes of emotional reactivity in cats and rats. These changes appear as anxiety-related reactions expressed as a hyperdefensiveness in the cat, or a reduction of spontaneous exploration in tests predictive of anxiogenic effects in the rat. Some neuroplasticity processes known to develop during epileptogenesis (neuronal-hyperexcitability, modulation of GABA/benzodiazepine transmission) may participate in these lasting changes of behaviour, especially in structures involved in the control of fear-promoted reactions (amygdala, periaqueductal grey matter). In addition, endogenous control systems may also play a critical role in the occurrence of interictal behavioural disorders.

Amygdala kindling in the rat: anxiogenic-like consequences

Patients with complex partial seizures of temporal lobe origin may experience behavioural disorders like depressive, anxiety-related or schizophrenic-like symptoms between seizures, i.e. interictally. The neural mechanisms underlying these enduring interictal disorders remain to be investigated. The aim of the present study was to examine the behavioural consequences of kindling of the basolateral nuclei of the amygdala, an animal model of limbic complex partial seizures. Animals having experienced 15 stage 5 seizures were compared to non-kindled controls in different behavioural tests performed at least seven days after the last seizure. Kindled animals showed a significant reduction of exploration of open arms in the elevated plus-maze test. In the social interactions test, they showed a decrease of non-social behaviour and an increase of immobility. No modifications were observed in kindled animals when tested in the open field, the sucrose preference or the forced swimming test. The reduction of open arm exploration in the elevated plus-maze was reversed by a pretreatment with chlordiazepoxide (2 mg/kg i.p.), a benzodiazepine anxiolytic. Finally, a similar reduction of open arm exploration was observed when animals were kindled only until a stage 3 seizure occurred. These data, along with previous studies, suggest that kindling of the amygdala has anxiogenic consequences and provide an animal model to study the neuroplasticity phenomena underlying enduring interictal disorders in humans.