Children with epilepsy and anxiety: Subcortical and cortical differences

Epileptogenic networks in drug-resistant epilepsy with amygdala enlargement: Assessment with stereo-EEG and 7 T MRI

OBJECTIVE

Amygdala enlargement is increasingly described in association with temporal lobe epilepsies. Its significance, however, remains uncertain both in terms of etiology and its link with psychiatric disorders and of its involvement in the epileptogenic zone. We assessed the epileptogenic networks underlying drug-resistant epilepsy with amygdala enlargement and investigated correlations between clinical features, epileptogenicity and morphovolumetric amygdala characteristics.

METHODS

We identified 12 consecutive patients suffering from drug-resistant epilepsy with visually suspected amygdala enlargement and available stereoelectroencephalographic recording. The epileptogenic zone was defined using the Connectivity Epileptogenicity Index. Morphovolumetric measurements were performed using automatic segmentation and co-registration on the 7TAMIbrain Amygdala atlas.

RESULTS

The epileptogenic zone involved the enlarged amygdala in all but three cases and corresponded to distributed, temporal-insular, temporal-insular-prefrontal or prefrontal-temporal networks in ten cases, while only two were temporo-mesial networks. Morphovolumetrically, amygdala enlargement was bilateral in 75% of patients. Most patients presented psychiatric comorbidities (anxiety, depression, posttraumatic stress disorder). The level of depression defined by screening questionnaire was positively correlated with the extent of amygdala enlargement.

CONCLUSIONS

Drug-resistant epilepsy with amygdala enlargement is heterogeneous; most cases implied "temporal plus" networks.

SIGNIFICANCE

The enlarged amygdala could reflect an interaction of stress-mediated limbic network alterations and mechanisms of epileptogenesis.

A pioneering FreeSurfer volumetric study of a series of patients with mesial temporal lobe epilepsy and hippocampal sclerosis with comorbid depression

Depression is the most frequent psychiatric comorbidity in patients with mesial temporal lobe epilepsy (MTLE) and hippocampal sclerosis (HS). This study aimed to confirm whether patients with comorbid depression have different volumetric patterns on magnetic resonance imaging, analysing the influence of HS sides. Psychiatrists conducted semi-structured interviews with 75 patients, who were divided into non-depression group (NDG, n = 52) and depression group (DG, n = 23), and compared with 98 controls. The FreeSurfer software was used in the volumetric analysis of the estimated total intracranial volume (eTIV), bilateral cortical and subcortical regions of interest (ROIs), and for presence of left (L-, n = 41) or right (R-, n = 34) MTLE-HS. Twenty-three (30.7%) patients had depression, of whom 14 (34.1%) had l-MTLE-HS and 9 (26.5%) had R-MTLE-HS. No difference was observed between DG and NDG vs. controls in terms of eTIV and cortical ROIs, regardless of the severity of depression. In patients with l-MTLE-HS, the eTIV in the DG was reduced in comparison with that in the NDG and control group, with a small effect size. Hippocampal reduction occurred ipsilateral to HS in the l-MTLE-HS and R-MTLE-HS subgroups when DG and NDG were compared with controls, as expected according to Enhancing Neuro Imaging Genetics through Meta-Analysis (2018).

Prefrontal cortex and amygdala anatomy in youth with persistent levels of harsh parenting practices and subclinical anxiety symptoms over time during childhood

Childhood adversity and anxiety have been associated with increased risk for internalizing disorders later in life and with a range of brain structural abnormalities. However, few studies have examined the link between harsh parenting practices and brain anatomy, outside of severe maltreatment or psychopathology. Moreover, to our knowledge, there has been no research on parenting and subclinical anxiety symptoms which remain persistent over time during childhood (i.e., between 2.5 and 9 years old). Here, we examined data in 94 youth, divided into four cells based on their levels of coercive parenting (high / low) and of anxiety (high / low) between 2.5 and 9 years old. Anatomical images were analyzed using voxel-based morphometry (VBM) and FreeSurfer. Smaller gray matter volumes in the prefrontal cortex regions and in the amygdala were observed in youth with high versus low levels of harsh parenting over time. In addition, we observed significant interaction effects between parenting practices and subclinical anxiety symptoms in rostral anterior cingulate cortical thickness and in amygdala volume. These youth should be followed further in time to identify which youth will or will not go on to develop an anxiety disorder, and to understand factors associated with the development of sustained anxiety psychopathology.

Longitudinal changes in emotional functioning following pediatric resective epilepsy surgery: 2-Year follow-up

OBJECTIVE

To examine longitudinal changes and predictors of depression and anxiety 2 years following resective epilepsy surgery, compared to no surgery, in children with drug-resistant epilepsy (DRE).

METHOD

This multicenter cohort study involved 128 children and adolescents with DRE (48 surgical, 80 nonsurgical; 8-18 years) who completed self-report measures of depression and anxiety at baseline and follow-up (6-month, 1-year, 2-year). Child demographic (age, sex, IQ) and seizure (age at onset, duration, frequency, site and side) variables were collected.

RESULTS

Linear mixed-effects models controlling for age at enrolment found a time by treatment by seizure outcome interaction for depression. A negative linear trend across time (reduction in symptoms) was found for surgical patients, irrespective of seizure outcome. In contrast, the linear trend differed depending on seizure outcome in nonsurgical patients; a negative trend was found for those with continued seizures, whereas a positive trend (increase in symptoms) was found for those who achieved seizure freedom. Only a main effect of time was found for anxiety indicating a reduction in symptoms across patient groups. Multivariate regressions failed to find baseline predictors of depression or anxiety at 2-year follow-up in surgical patients. Older age, not baseline anxiety or depression, predicted greater symptoms of anxiety and depression at 2-year follow-up in nonsurgical patients.

CONCLUSION

Children with DRE reported improvement in anxiety and depression, irrespective of whether they achieve seizure control, across the 2 years following surgery. In contrast, children with DRE who did not undergo surgery, but achieved seizure freedom, reported worsening of depressive symptoms, which may indicate difficulty adjusting to life without seizures and highlight the potential need for ongoing medical and psychosocial follow-up and support.

Psychiatric Comorbidities in Children With ASD: Autism Centre Experience

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with social communication deficits, restricted interests, and repetitive behaviours. In this lifelong condition the core features that cause impairment may also be expanded by behavioural and emotional problems. Individuals with ASD are likely to experience a higher prevalence of common mental disorders compared to the typically developed individuals. This high epidemiological burden of various psychiatric disorders among ASD population encourages further research and improvement in diagnostic practise in ASD and comorbid disorders. In this brief research report of a cross-sectional study, I aimed to estimate the psychiatric comorbidity prevalence and describe their general characteristics in children with ASD in the Autism Centre in Montenegro. The study population consisted of 152 patients who were diagnosed with ASD, 117 male and 35 female, and the mean age (SD) was 8.02 (4.26). In this brief research report prevalence of children with ASD with at least one psychiatric comorbidity was 36.84%. Only one psychiatric comorbidity disorder was reported in 17.16%, two in 9.87%, three in 8.55%, and in 0.66% patients four other psychiatric disorders. Psychiatric disorders present in this population sample were attention deficit hyperactivity disorder (17.76%), conduct disorder (13.10%), disruptive mood dysregulation disorder (9.87%), anxiety disorder and insomnia (7.89%), elimination disorder (3.29%), and depression (1.97%).

Systematic Review and Meta-Analysis of Anxiety and Depression in Youth With Epilepsy

OBJECTIVE

The aim of this systematic review and meta-analysis was to provide an estimate of the prevalence of anxiety and depressive disorders in youth with epilepsy (YWE). It also aimed to calculate the overall magnitude of observed differences in anxiety and depressive symptoms reported by YWE compared with healthy controls and investigate whether any factors moderated anxiety and depression outcomes in YWE.

METHODS

Following prospective registration, electronic databases were searched up until October 2018. Studies were included if they reported on the rate of anxiety or depression in samples of YWE, and/or if they used valid measures of anxious or depressive symptomatology in YWE compared with a healthy control sample.

RESULTS

Twenty-three studies met inclusion criteria. The overall pooled prevalence of anxiety disorders in YWE was 18.9% (95% confidence interval [CI] 12.0%-28.5%), and for depression the pooled prevalence was 13.5% (95% CI 8.8%-20.2%). In samples of YWE compared with healthy controls, significantly higher anxiety (d = 0.57, 95% CI 0.32-0.83, p < .000) and depressive (d = 0.42, 95% CI 0.16-0.68, p < .000) symptomatology was reported.

CONCLUSIONS

YWE report anxiety and depressive disorders and symptoms to a significantly higher degree than youth without epilepsy. There is also evidence that certain anxiety disorders (e.g. generalized anxiety disorder, separation anxiety disorder) are particularly elevated, perhaps reflecting the unique impact of epilepsy on youth psychopathology. Research is needed to understand the risk factors associated with anxiety and depressive disorders in epilepsy, and better understand how these symptoms change across development.

The Ketogenic Diet for the Treatment of Mood Disorders in Comorbidity With Epilepsy in Children and Adolescents

The ketogenic diet, used for over a century as an alternative therapy for the control of drug-resistant seizures in both children and adults, has recently drawn increasing interest in various neurological or psychiatric disorders other than epilepsy. In particular, there are a few preliminary studies in mood and neurodevelopmental disorders such as anxiety, depression and autism spectrum disorders. Mood disorders in comorbidity with epilepsy are commonly seen in adolescents and young adults both at the onset and during the course of the epileptic disorder. The rationale for the use of the ketogenic diet is based on the potential mood stabilizing effects through level modifications of metabolites such as dopamine and serotonin and the regulation of GABA/glutamatergic neurotransmission, mitochondrial function and oxidative stress. In this review, epilepsies with a higher risk of mood disorders in adolescents will be considered. A brief overview of the various types of ketogenic diet that can currently be offered to young patients in order to improve palatability and compliance with the diet, is also included. The efficacy and tolerability of the ketogenic diet options for the treatment of mood disorders, with or without drug therapy including mood stabilizers and antidepressant drugs, are as well discussed.

Pathways to quality of life in adolescents with genetic generalized epilepsy: The role of seizure features and affective symptoms

Both clinical features of seizures and affective problems (i.e., depressive and/or anxious symptoms) affect quality of life perception in patients with epilepsy. Although genetic generalized epilepsies (GGEs) represent one-third of all epilepsies, very few studies focused on the association among seizures, affective problems, and perceived quality of life in pediatric patients with GGE. Here, we assessed the relative contributions of seizure characteristics and affective symptoms on quality of life in patients with adolescence-onset GGE. Forty pediatric outpatients completed self-report questionnaires on affective symptoms and quality of life. Sociodemographic and clinical variables were obtained from medical charts. Affective symptoms were present in 40% of patients. Higher scores emerged in patients who were seizure-free at the time of the survey for both the physical and mental components of quality of life. Higher seizure frequency was significantly associated with lower quality of life scores in the mental component, whereas the presence of depressive and/or anxious symptoms was significantly associated with lower scores in the physical component. These associations were confirmed after controlling for sociodemographic confounders. These findings suggest that adolescents with GGE are at increased risk for affective symptoms. Moreover, both GGE-related clinical features (i.e., seizure frequency) and the presence of affective symptoms (i.e., depression, anxiety) are relevant and independent contributors to quality of life. The investigation of affective problems is warranted to be included in routine assessments of GGE in pediatric populations.

Clinical evaluation of psychiatric and behavioral disorders in adolescents with epilepsy: a cross-sectional study

Background: Epilepsy is a neurological disease that is often associated with psychiatric comorbidities.Subjects and methods: The aim of the study was to examine the frequency of psychic symptoms and their association with different types of epilepsy in the adolescent population. The study involved 100 adolescents with epilepsy and 100 healthy adolescents of both sexes at the age of 13-19. The examinees completed a standardized Symptom Checklist-90-R (SCL-90-R) questionnaire, concerning self-assessment of psychological disorders in the previous week. The value system of ​​nine dimensions and three global indexes of SCL-90-R scales were analyzed.Results: Our results suggest that adolescents with epilepsy have more than one psychic disorder compared to a healthy group of respondents. Somatic symptoms are more common in non-epileptic subjects, while obsessive-compulsive, depressive and phobic symptoms, as well as anxiety, aggressiveness, interpersonal vulnerability and paranoia, are more common in adolescents with epilepsy. Due to the type of epilepsy, obsessive compulsive symptoms are more common in adolescents with focal epilepsy, while the symptoms of phobia are more present in those with generalized epilepsy. The depth and intensity of psychological stress is higher in the group of adolescents with epilepsy compared to the healthy group of respondents.Conclusions: Psychiatric comorbidity is very common in epileptic patients and depending on the type of diagnosed epilepsy, various symptoms are expressed. Furthermore, psychological stress is more observable in adolescents with epilepsy. For patients with epilepsy, mental health care and seizure control is extremely important in the prevention of serious mental disabilities.

Systematic Review: Anxiety in Children and Adolescents With Chronic Medical Conditions

OBJECTIVE

Youth with chronic medical conditions (CMCs) have been reported to be at increased risk for developing anxiety disorders. Importantly, suffering from anxiety may also have an impact on their disease-related outcomes. This study set out to systematically review the literature on anxiety and seven CMCs (asthma, congenital heart disease, diabetes, epilepsy, inflammatory bowel disease, juvenile idiopathic arthritis, and sickle cell disease) among youth.

METHOD

A systematic review was performed according to the PRISMA statement. Searches were conducted across PubMed, PsycNET, Embase, and reference lists of the included studies (1990-2018). Three independent reviewers screened titles and abstracts and conducted full-text assessment. Studies were included if they reported the prevalence of anxiety or the association of anxiety on disease-related outcomes in children and/or adolescents with the focal CMCs.

RESULTS

A total of 53 studies met the predetermined inclusion criteria. Across the CMCs, the prevalence of anxiety disorder was increased in youths with CMCs compared to the general population. Evidence for a relationship between anxiety and adverse disease-related outcomes was limited. For asthma, inflammatory bowel disease, and sickle cell disease, there was some evidence indicating that anxiety was associated with adverse outcomes; supported by two longitudinal studies, one in asthma and one in inflammatory bowel disease. For diabetes, results were inconsistent; with some studies indicating that anxiety was associated with worse and others with better treatment adherence.

CONCLUSION

The prevalence of anxiety disorders in youth with CMCs is higher than that in the general population. Anxiety may also be associated with adverse disease-related outcomes for youths, but it is not possible to draw definitive conclusions. Longitudinal studies making use of parent/youth composite anxiety measures and a combination of parent/youth reported and objective measures of disease-related outcomes are needed. Given the burden of disease of anxiety disorders, regardless of the impact on the disease outcomes, screening for and treatment of anxiety is recommended in youths with CMCs.

The intersections of stress, anxiety and epilepsy

Stress is ubiquitous in chronic medical conditions; however, the connections to psychiatric and neurologic conditions are not always clearly established. Epilepsy is a unique illness that is intimately intertwined with stress and anxiety not only as a result of the disease process but also as a cause of disease exacerbation. Anxiety and depression also involve stress management and often overlap with epilepsy. Anxiety symptoms themselves may be present as intrinsic aspects of seizure phenomena, either during the events or closely related to them. The pathways of stress and anxiety involve the hypothalamic pituitary adrenal (HPA) axis and explain at least in part how stress may lead to worsening seizure control. Ultimately, the study of stress, anxiety, and epilepsy offers insight into mind and body connections, and furthers understanding of neuropsychiatric illness.

Internalizing symptoms in intractable pediatric epilepsy: Structural and functional brain correlates

Internalizing disorders (i.e., depression and anxiety) are common comorbidities in people with epilepsy. In adults with epilepsy, comorbid depression or anxiety is associated with worse seizure control and reduced quality of life, and may be linked to specific neural biomarkers. Less is known about brain correlates of internalizing symptoms in pediatric populations. In the current study, we performed a retrospective analysis of 45 youth between the ages of 6 and 18 years old with intractable epilepsy. Individuals were evaluated for internalizing symptoms on the Child Behavior Checklist (CBCL) and underwent magnetic resonance (MR) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging as part of the clinical evaluation for surgical treatment of epilepsy. Forty-two percent of patients experienced clinically significant internalizing symptoms based on parent report. Compared with individuals who scored in the normal range, youth with clinical levels of internalizing problems showed overall reductions in cortex volume, as well as widespread reductions in cortical thickness and functional activation in the bilateral occipital/parietal lobe, left temporal regions, and left inferior frontal cortex on MR and PET scans. There were no group differences in amygdala or hippocampus volumes, nor other patient- or illness-related variables such as age, sex, or the type, lateralization, or duration of epilepsy. Results suggest that high rates of internalizing disorders are present in youth with refractory epilepsy. Multifocal reductions in cortical thickness and function may be nonspecific risk factors for clinically meaningful internalizing symptoms in youth with chronic epilepsy. As such, the presence of broad cortical thinning and reduced glucose uptake upon radiological examination may warrant more focused clinical evaluation of psychological symptoms.

Major Depressive Disorder Associated With Reduced Cortical Thickness in Women With Temporal Lobe Epilepsy

Background: Major Depressive Disorder (MDD) is highly prevalent in patients with mesial temporal lobe epilepsy (MTLE), especially in women, carrying significant morbidity. This study aimed to investigate the cortical thickness (CT) abnormalities associated with MDD in women with MTLE and hippocampal atrophy (HA). Also, we investigated the impact of MDD upon the volumes of the hippocampus and amygdala in these patients.

Methods: We included 50 women with MTLE and HA (20 left, LMTLE; 30 right, RMTLE), 41 healthy women in the control group, and 15 women with MDD without epilepsy. MTLE patients were subdivided into three groups: MTLE-without-MDD (23 MTLE patients without MDD), MTLE-mild-MDD (nine MTLE patients with mild symptoms of MDD), and MTLE-severe-MDD (18 MTLE patients with moderate to severe symptoms of MDD). The five groups were balanced for age (p = 0.56). All participants had high-resolution 3D T1-weighted images in a 3T scanner. We used FreeSurfer 6.0 for volumetry and CT parcellation. All participants were submitted to a clinical psychological evaluation through the Structured Clinical Interview for DSM-IV (SCID-IV) and completed the Beck Depression Inventory (BDI-II).

Results: We identified a smaller ipsilateral amygdala volume (p = 0.04) in the MTLE-severe-MDD group when compared to the control group. Our results presented a reduced ipsilateral lateral orbitofrontal cortex (p = 0.02) in the MTLE-severe-MDD in comparison to the MTLE-mild-MDD group. We also identified a thinner ipsilateral fusiform gyrus (p < 0.01) in the MTLE-severe-MDD compared to both MTLE-without-MDD and control groups. A reduced CT of the contralateral superior frontal gyrus (p = 0.02) was observed in the MTLE-severe-MDD in comparison to the MTLE-mild-MDD group.

Conclusions: The identification of areas with reduced CT and atrophy of the ipsilateral amygdala in women with MTLE and MDD suggest that the cortical thinning in the network of the paralimbic system is related to the co-occurrence and intensity of depressive symptoms in this group.

Impact of resective surgery for pediatric drug-resistant epilepsy on emotional functioning

OBJECTIVE

The objective of the study was to evaluate emotional functioning following surgical and medical treatment in children with drug-resistant epilepsy (DRE; i.e., uncontrolled seizures despite treatment with ≥2 antiepileptic drugs [AED]).

METHOD

This prospective, longitudinal, multicenter study involved 128 children and adolescents (8-18 years) with DRE who were assessed for surgical candidacy; 48 went on to have surgery and 80 continued medical treatment. Participants completed child-validated self-report measures of anxiety and depression at baseline, 6, and 12 month follow-up. Standardized z-scores were calculated with higher scores indicative of greater symptoms.

RESULTS

At baseline, 16% and 22% of all patients reported elevated symptoms of depression and anxiety, respectively (i.e., z ≥ 1.00). Seizure freedom was higher in the surgical, compared with the medical, group at 6 (64 vs. 11%) and 12 month (77 vs. 24%) follow-up. Linear mixed effects models controlling for age found a main effect of time for both depression and anxiety; scores decreased over time for all patients. A main effect of seizure outcome was found for depression, but not anxiety; seizure freedom was associated with lower scores overall. There were no main effects of treatment or significant interactions. Multiple regression analyses found baseline mood predicted outcomes at 6 and 12 month follow-up; higher anxiety and depression scores at baseline were associated with higher scores at follow-up. Older age and greater number of AEDs at baseline was associated with higher depression scores at 12 month follow-up.

CONCLUSION

Overall, patients reported a reduction in anxiety and depressive symptoms over the first 12 months, irrespective of treatment, and baseline level of functioning was the best predictor of outcome. Despite more children achieving seizure freedom with surgery compared with medical treatment, surgery was not associated with better outcomes over time. It may be that changes in anxiety and depression require a longer time to emerge postsurgery; however, being seizure-free is associated with fewer depressive symptoms, irrespective of treatment type.

Cortical and subcortical changes in patients with premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is characterized by a series of emotional, physical and behavioral symptoms. Although PMS is related to dysfunctions of the central nervous system, the neuropathological mechanism of PMS still has not been clearly established. The aim of this study is to evaluate potential differences in both cortical thickness and subcortical volumes in PMS patients compared to healthy controls (HCs).

METHODS

Twenty PMS patients and twenty HCs underwent a structural magnetic resonance imaging scan and clinical assessment. Cortical thickness and subcortical volumes were computed using the FreeSurfer image analysis suite. Relationships between cortical thickness/subcortical volumes and the daily rating of severity of problems (DRSP) score were then measured in patients.

RESULTS

Compared to HCs, PMS patients exhibited reduced cortical thickness in the medial prefrontal cortex (MPFC), orbitofrontal cortex (OFC) and insula, and increased subcortical volumes of the amygdala, thalamus and pallidum. Furthermore, negative correlations were detected between the DRSP and cortical thickness in the anterior cingulate cortex and precuneus.

LIMITATIONS

The study is limited by a small sample size and narrow age range of participants.

CONCLUSIONS

Our findings indicate that the abnormal morphological changes are mainly implicated in emotional regulation and visceral perception in PMS patients. We hope that our study may contribute to a better understanding of PMS.

Structural Neuroimaging and Neuropsychologic Signatures in Children With Vertically Acquired HIV

BACKGROUND

Children with vertically acquired HIV exhibit persistent cognitive impairments, yet the corresponding neuroimaging signature of vertical infection remains unclear.

METHODS

Fifty healthy control children and 51 vertically infected children were included in the study. The HIV-infected group consisted of survivors who had not received antiretroviral therapy at birth. The HIV-infected group averaged 11.4 (2.5) years of age, with a median CD4 count of 683 cells/mm(3). Most (71%) of the HIV-infected children were on antiretroviral therapy for a median of 34 months (range: 33-42) with HIV RNA <40 copies/mL in 89% of the sample. The HIV-uninfected group averaged 10.6 (2.6) years of age. Magnetic resonance imaging was acquired to determine volumes of the caudate, putamen, thalamus, pallidum, hippocampus, nucleus accumbens, total white matter, total gray matter and cortical gray matter. Correlational analyses examined the degree of shared variance between brain volumes and both cognitive performances and laboratory markers of disease activity (T cells and plasma viral load).

RESULTS

HIV-infected children exhibited larger volumes of the caudate, nucleus accumbens, total gray matter and cortical gray matter when compared with the controls. Volumetric differences were predominately evident in children under 12 years of age. HIV-infected children performed worse than controls on most neuropsychologic tests, though neither cognitive performances nor laboratory markers corresponded to brain volumes in the HIV-infected children.

CONCLUSIONS

Outcomes of the present study suggest abnormal brain maturation among HIV-infected pediatric survivors. Longitudinal studies of brain integrity and related resilience factors are needed to determine the impact of neuroimaging abnormalities on psychosocial function in pediatric HIV.

Cortical Thickness and Subcortical Gray Matter Volume in Pediatric Anxiety Disorders

Perturbations in the prefrontal cortex (PFC), hippocampus, and amygdala are implicated in the development of anxiety disorders. However, most structural neuroimaging studies of patients with anxiety disorders utilize adult samples, and the few studies in youths examine small samples, primarily with volume-based measures. This study tested the hypothesis that cortical thickness of PFC regions and gray matter volume of the hippocampus and amygdala differ between pediatric anxiety disorder patients and healthy volunteers (HVs). High-resolution 3-Tesla T1-weighted MRI scans were acquired in 151 youths (75 anxious, 76 HV; ages 8-18). Analyses tested associations of brain structure with anxiety diagnosis and severity across both groups, as well as response to cognitive-behavioral therapy in a subset of 53 patients. Cortical thickness was evaluated both within an a priori PFC mask (small-volume corrected) and using an exploratory whole-brain-corrected (p<0.05) approach. Anxious relative to healthy youths exhibited thicker cortex in the left ventromedial PFC (vmPFC) and left precentral gyrus. Both anxiety diagnosis and symptom severity were associated with smaller right hippocampal volume. In patients, thinner cortex in parietal and occipital cortical regions was associated with worse treatment response. Pediatric anxiety was associated with structural differences in vmPFC and hippocampus, regions implicated in emotional processing and in developmental models of anxiety pathophysiology. Parietal and occipital cortical thickness were related to anxiety treatment response but not baseline anxiety.

Psychiatric comorbidity with hypothalamic hamartoma: Systematic review for predictive clinical features

OBJECTIVE

We conducted a systematic review of the English-language literature to identify clinical features associated with a higher risk of psychiatric symptoms (aggression and rage behaviors) in patients with hypothalamic hamartoma (HH) and epilepsy.

METHODS

Two publicly-accessible databases (PubMed and Cochrane Library) were searched for Hypothalamic Hamartoma AND Epilepsy. We identified peer-reviewed original research publications (case reports or clinical series; N=19) in which clinical data was provided on an individual basis. Subjects were cohorted into those with (N=51) and without (N=68) behavioral aggression. Multiple clinical features were collated and subjected to univariate analysis to determine possible differences between these two cohorts.

RESULTS

The presence of aggression significantly correlated with 1) male gender, 2) younger age at time of first seizure onset, 3) the presence of intellectual disability, and 4) the presence of multiple seizure types (versus gelastic seizures only). For those patients undergoing surgical treatment, aggression also correlated with younger age at the time of surgical intervention.

CONCLUSION

Possible predictive clinical features for the presence of aggression and rage behaviors in patients with hypothalamic hamartoma and epilepsy are identified. These results may contribute to the complex treatment decisions that are unique to this population.

WONOEP appraisal: Biomarkers of epilepsy-associated comorbidities

Neurologic and psychiatric comorbidities are common in patients with epilepsy. Diagnostic, predictive, and pharmacodynamic biomarkers of such comorbidities do not exist. They may share pathogenetic mechanisms with epileptogenesis/ictogenesis, and as such are an unmet clinical need. The objectives of the subgroup on biomarkers of comorbidities at the XIII Workshop on the Neurobiology of Epilepsy (WONOEP) were to present the state-of-the-art recent research findings in the field that highlighting potential biomarkers for comorbidities in epilepsy. We review recent progress in the field, including molecular, imaging, and genetic biomarkers of comorbidities as discussed during the WONOEP meeting on August 31-September 4, 2015, in Heybeliada Island (Istanbul, Turkey). We further highlight new directions and concepts from studies on comorbidities and potential new biomarkers for the prediction, diagnosis, and treatment of epilepsy-associated comorbidities. The activation of various molecular signaling pathways such as the "Janus Kinase/Signal Transducer and Activator of Transcription," "mammalian Target of Rapamycin," and oxidative stress have been shown to correlate with the presence and severity of subsequent cognitive abnormalities. Furthermore, dysfunction in serotonergic transmission, hyperactivity of the hypothalamic-pituitary-adrenocortical axis, the role of the inflammatory cytokines, and the contributions of genetic factors have all recently been regarded as relevant for understanding epilepsy-associated depression and cognitive deficits. Recent evidence supports the utility of imaging studies as potential biomarkers. The role of such biomarker may be far beyond the diagnosis of comorbidities, as accumulating clinical data indicate that comorbidities can predict epilepsy outcomes. Future research is required to reveal whether molecular changes in specific signaling pathways or advanced imaging techniques could be detected in the clinical settings and correlate with epilepsy-associated comorbidities. A reliable biomarker will allow a more accurate diagnosis and improved treatment of epilepsy-associated comorbidities.

Disruptions in cortico-subcortical covariance networks associated with anxiety in new-onset childhood epilepsy

Anxiety disorders represent a prevalent psychiatric comorbidity in both adults and children with epilepsy for which the etiology remains controversial. Neurobiological contributions have been suggested, but only limited evidence suggests abnormal brain volumes particularly in children with epilepsy and anxiety. Since the brain develops in an organized fashion, covariance analyses between different brain regions can be investigated as a network and analyzed using graph theory methods. We examined 46 healthy children (HC) and youth with recent onset idiopathic epilepsies with (n = 24) and without (n = 62) anxiety disorders. Graph theory (GT) analyses based on the covariance between the volumes of 85 cortical/subcortical regions were investigated. Both groups with epilepsy demonstrated less inter-modular relationships in the synchronization of cortical/subcortical volumes compared to controls, with the epilepsy and anxiety group presenting the strongest modular organization. Frontal and occipital regions in non-anxious epilepsy, and areas throughout the brain in children with epilepsy and anxiety, showed the highest centrality compared to controls. Furthermore, most of the nodes correlating to amygdala volumes were subcortical structures, with the exception of the left insula and the right frontal pole, which presented high betweenness centrality (BC); therefore, their influence in the network is not necessarily local but potentially influencing other more distant regions. In conclusion, children with recent onset epilepsy and anxiety demonstrate large scale disruptions in cortical and subcortical brain regions. Network science may not only provide insight into the possible neurobiological correlates of important comorbidities of epilepsy, but also the ways that cortical and subcortical disruption occurs.

Cortical thickness asymmetries and surgical outcome in neocortical epilepsy

PURPOSE

We evaluated if cortical thickness measures were associated with surgical outcome in patients with non-lesional neocortical epilepsy.

METHODS

Twenty-one young patients (age: 2.4-19.7years) with epilepsy of neocortical origin and normal MRI underwent two-stage epilepsy surgery with subdural EEG monitoring. Cortical thickness was measured on presurgical volumetric MRI using the FreeSurfer software. The prognostic value of hemispheric and lobar/regional cortical thickness measures for 1-year and 2-year post-surgical seizure outcome has been analyzed.

RESULTS

At one-year follow-up, 14 patients (67%) were seizure-free. Hemispheric and frontal lobe cortical thickness showed no/minimal asymmetry in seizure-free patients but thinner cortex ipsilateral to the seizure focus in those with recurrent seizures (p=0.02). More robust differences were found in patients≥6years of age (p=0.006 for frontal asymmetries), whose cortical thickness asymmetries remained prognostic for 2-year post-surgical outcome (p=0.007). By using an optimal cutoff threshold based on a receiver operating characteristic analysis, mean hemispheric asymmetry predicted one-year seizure freedom with 93% sensitivity and 71% specificity in the whole group, and with 100% sensitivity and 92% specificity in patients≥6years of age.

CONCLUSION

In patients with neocortical epilepsy and normal MRI, neocortical thinning in the epileptic hemisphere, particularly in frontal cortex, is associated with poor surgical outcome. Although these results require validation in a larger cohort prospectively, these data suggest that presurgical evaluation of cortical thickness may assist in identification of patients at high risk for surgical failure.

Cortical thickness and sulcal depth: insights on development and psychopathology in paediatric epilepsy

BACKGROUND

The relationship between cortical thickness (CThick) and sulcal depth (SDepth) changes across brain regions during development. Epilepsy youth have CThick and SDepth abnormalities and prevalent psychiatric disorders.

AIMS

This study compared the CThick-SDepth relationship in children with focal epilepsy with typically developing children (TDC) and the role played by seizure and psychopathology variables.

METHOD

A surface-based, computational high-resolution three-dimesional (3D) magnetic resonance image analytic technique compared regional CThick-SDepth relationships in 42 participants with focal epilepsy and 46 TDC (6-16 years) imaged in a 1.5 Tesla scanner. Psychiatric interviews administered to each participant yielded psychiatric diagnoses. Parents provided seizure-related information.

RESULTS

The TDC group alone demonstrated a significant negative medial fronto-orbital CThick-SDepth correlation. Focal epilepsy participants with but not without psychiatric diagnoses showed significant positive pre-central and post-central CThick-SDepth associations not found in TDC. Although the history of prolonged seizures was significantly associated with the post-central CThick-SDepth correlation, it was unrelated to the presence/absence of psychiatric diagnoses.

CONCLUSIONS

Abnormal CThick-SDepth pre-central and post-central associations might be a psychopathology biomarker in paediatric focal epilepsy.

DECLARATION INTEREST

None.

COPYRIGHT AND USAGE

© 2015 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Structural Image Analysis of the Brain in Neuropsychology Using Magnetic Resonance Imaging (MRI) Techniques

Magnetic resonance imaging (MRI) of the brain provides exceptional image quality for visualization and neuroanatomical classification of brain structure. A variety of image analysis techniques provide both qualitative as well as quantitative methods to relate brain structure with neuropsychological outcome and are reviewed herein. Of particular importance are more automated methods that permit analysis of a broad spectrum of anatomical measures including volume, thickness and shape. The challenge for neuropsychology is which metric to use, for which disorder and the timing of when image analysis methods are applied to assess brain structure and pathology. A basic overview is provided as to the anatomical and pathoanatomical relations of different MRI sequences in assessing normal and abnormal findings. Some interpretive guidelines are offered including factors related to similarity and symmetry of typical brain development along with size-normalcy features of brain anatomy related to function. The review concludes with a detailed example of various quantitative techniques applied to analyzing brain structure for neuropsychological outcome studies in traumatic brain injury.