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Solli E, Colwell NA, Markosian C, Johal AS, Houston R, Iqbal MO, Say I, Petrsoric JI, Tomycz LD. Underutilization of advanced presurgical studies and high rates of vagus nerve stimulation for drug-resistant epilepsy: a single-center experience and recommendations. Acta Neurochir (Wien) 2022; 164:565-573. [PMID: 34773497 DOI: 10.1007/s00701-021-05055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Epilepsy surgery continues to be profoundly underutilized despite its safety and effectiveness. We sought to investigate factors that may contribute to this phenomenon, with a particular focus on the antecedent underutilization of appropriate preoperative studies. METHODS We reviewed patient data from a pediatric epilepsy clinic over an 18-month period. Patients with drug-resistant epilepsy (DRE) were categorized according to brain magnetic resonance imaging (MRI) findings (lesional, MRI-negative, or multifocal abnormalities) and type of epilepsy diagnosis based on semiology and electroencephalography (EEG) (focal or generalized). We then analyzed the rates of diagnostic test utilization, surgical referral, and subsequent epilepsy surgery as well as vagus nerve stimulation (VNS). RESULTS Of the 249 patients with a diagnosis of epilepsy, 138 (55.4%) were found to have DRE. Excluding the 10 patients with DRE who did not undergo MRI, 76 patients (59.4%) were found to be MRI-negative (non-lesional epilepsy), 37 patients (28.9%) were found to have multifocal abnormalities, and 15 patients (11.7%) were found to have a single epileptogenic lesion on MRI (lesional epilepsy). Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) were each completed in nine patients (7.0%) and magnetoencephalography (MEG) in four patients (3.1%). Despite the low utilization rate of adjunctive studies, over half (56.3%) ultimately underwent VNS alone, and 8.6% ultimately underwent definitive intracranial resection or disconnection surgery. CONCLUSIONS The underutilization of appropriate non-invasive, presurgical testing in patients with focal DRE may in part explain the continued underutilization of definitive, resective/disconnective surgery. For patients without access to a high-volume, multidisciplinary surgical epilepsy center, adjunctive presurgical studies [e.g., PET, SPECT, MEG, electrical source imaging (ESI), EEG-functional magnetic resonance imaging (fMRI)], even when available, are rarely ordered, and this may contribute to excessive rates of VNS in lieu of definitive intracranial surgery.
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[Imaging in the presurgical evaluation of epilepsy]. DER NERVENARZT 2021; 93:592-598. [PMID: 34491376 PMCID: PMC9200687 DOI: 10.1007/s00115-021-01180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 11/19/2022]
Abstract
Während zwei Drittel der PatientInnen mit Epilepsie durch Medikamente anfallsfrei werden, ist die Erkrankung bei 30 % pharmakoresistent. Bei pharmakoresistenter fokaler Epilepsie bietet die Epilepsiechirurgie eine etwa 65 %ige Chance auf Anfallsfreiheit. Vorab muss der Anfallsfokus exakt eingegrenzt werden, wofür bildgebende Methoden unverzichtbar sind. In den letzten Jahren hat sich in der Prächirurgie der Anteil von PatientInnen mit unauffälliger konventioneller Magnetresonanztomographie (MRT) erhöht. Allerdings konnte die Sensitivität der MRT durch spezielle Aufnahmesequenzen und Techniken der Postprozessierung gesteigert werden. Die Quellenlokalisation des Signals von Elektro- und Magnetenzephalographie (EEG und MEG) verortet den Ursprung iktaler und interiktaler epileptischer Aktivität im Gehirn. Nuklearmedizinische Untersuchungen wie die interiktale Positronen-Emissions-Tomographie (PET) und die iktale Einzelphotonen-Emissionscomputertomographie (SPECT) detektieren chronische oder akute anfallsbezogene Veränderungen des Hirnmetabolismus und können auch bei nichtlokalisierendem MRT auf den epileptogenen Fokus hinweisen. Alle Befunde zusammengenommen werden zur Planung eventueller invasiver EEG-Ableitungen und letztlich der chirurgischen Operation eingesetzt. Konkordante Befunde sind mit besseren chirurgischen Ergebnissen assoziiert und zeigen auch im Langzeitverlauf signifikant höhere Anfallsfreiheitsraten.
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Markosian C, Dodson V, Zhang HJ, Mahalingam RS, Geller EB, Tomycz LD. Total and partial posterior quadrant disconnection for medically refractory epilepsy: A systematic review. Seizure 2021; 91:66-71. [PMID: 34102378 DOI: 10.1016/j.seizure.2021.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Posterior quadrant disconnection (PQD) is a surgical procedure for medically refractory epilepsy (MRE) involving diffuse regions of the temporo-parieto-occipital lobes. We sought to compare factors and efficacy according to PQD extent. METHODS We performed a systematic review of the literature reporting the use of PQD since 2004. We analyzed various characteristics of pooled cases, including the role of preoperative studies in patient selection, intraoperative techniques, and outcomes. RESULTS Our review of 137 patients from nine studies revealed 66% undergoing total PQD and 34% undergoing partial PQD. Interictal electroencephalography (EEG) findings were predominantly characterized as lateralized for total PQD (56%) and localized within the ipsilateral posterior quadrant in patients undergoing partial PQD (53%). Metabolic functional studies [positron emission tomography (PET) or ictal single-photon emission computed tomography (SPECT)] played a role in surgical decision-making in 42% of patients who underwent total PQD. Wada and/or functional magnetic resonance imaging (fMRI) was more often utilized for partial PQD (22%) than total PQD (3%) as was intracranial electroencephalography (icEEG) (30% versus 13%, respectively). Overall, 75% of total PQD patients achieved seizure freedom [defined as Engel I or International League Against Epilepsy (ILAE) Class 1 outcome] in comparison to 63% of partial PQD patients (p = .078). New visual field deficits were seen in 12% and new or worsened hemiparesis in 6%. For patients in either cohort, concordance of interictal and ictal EEG findings was found to be predictive of seizure freedom (p = .048). CONCLUSION Both total and partial PQD represent effective alternatives for managing patients with MRE whose seizure onset zone (SOZ) involves a diffuse region within the posterior quadrant. While PET and/or SPECT frequently aided in the decision to proceed with total PQD, patients who underwent a tailored, partial multilobar resection were more likely to undergo Wada and/or fMRI testing as well as stage I icEEG studies.
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Affiliation(s)
- Christopher Markosian
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Vincent Dodson
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Helen J Zhang
- Division of Biology and Medicine, Brown University, Providence, Rhode Island, United States
| | - Rajeshwari S Mahalingam
- Institute of Neurology and Neurosurgery, Saint Barnabas Medical Center, Livingston, New Jersey, United States
| | - Eric B Geller
- Institute of Neurology and Neurosurgery, Saint Barnabas Medical Center, Livingston, New Jersey, United States
| | - Luke D Tomycz
- New Jersey Brain and Spine, Montclair, New Jersey, United States.
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Lorio S, Sedlacik J, So PW, Parkes HG, Gunny R, Löbel U, Li YF, Ogunbiyi O, Mistry T, Dixon E, Adler S, Cross JH, Baldeweg T, Jacques TS, Shmueli K, Carmichael DW. Quantitative MRI susceptibility mapping reveals cortical signatures of changes in iron, calcium and zinc in malformations of cortical development in children with drug-resistant epilepsy. Neuroimage 2021; 238:118102. [PMID: 34058334 PMCID: PMC8350142 DOI: 10.1016/j.neuroimage.2021.118102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Malformations of cortical development (MCD), including focal cortical dysplasia (FCD), are the most common cause of drug-resistant focal epilepsy in children. Histopathological lesion characterisation demonstrates abnormal cell types and lamination, alterations in myelin (typically co-localised with iron), and sometimes calcification. Quantitative susceptibility mapping (QSM) is an emerging MRI technique that measures tissue magnetic susceptibility (χ) reflecting it's mineral composition. We used QSM to investigate abnormal tissue composition in a group of children with focal epilepsy with comparison to effective transverse relaxation rate (R2*) and Synchrotron radiation X-ray fluorescence (SRXRF) elemental maps. Our primary hypothesis was that reductions in χ would be found in FCD lesions, resulting from alterations in their iron and calcium content. We also evaluated deep grey matter nuclei for changes in χ with age. METHODS QSM and R2* maps were calculated for 40 paediatric patients with suspected MCD (18 histologically confirmed) and 17 age-matched controls. Patients' sub-groups were defined based on concordant electro-clinical or histopathology data. Quantitative investigation of QSM and R2* was performed within lesions, using a surface-based approach with comparison to homologous regions, and within deep brain regions using a voxel-based approach with regional values modelled with age and epilepsy as covariates. Synchrotron radiation X-ray fluorescence (SRXRF) was performed on brain tissue resected from 4 patients to map changes in iron, calcium and zinc and relate them to MRI parameters. RESULTS Compared to fluid-attenuated inversion recovery (FLAIR) or T1-weighted imaging, QSM improved lesion conspicuity in 5% of patients. In patients with well-localised lesions, quantitative profiling demonstrated decreased χ, but not R2*, across cortical depth with respect to the homologous regions. Contra-lateral homologous regions additionally exhibited increased χ at 2-3 mm cortical depth that was absent in lesions. The iron decrease measured by the SRXRF in FCDIIb lesions was in agreement with myelin reduction observed by Luxol Fast Blue histochemical staining. SRXRF analysis in two FCDIIb tissue samples showed increased zinc and calcium in one patient, and decreased iron in the brain region exhibiting low χ and high R2* in both patients. QSM revealed expected age-related changes in the striatum nuclei, substantia nigra, sub-thalamic and red nucleus. CONCLUSION QSM non-invasively revealed cortical/sub-cortical tissue alterations in MCD lesions and in particular that χ changes in FCDIIb lesions were consistent with reduced iron, co-localised with low myelin and increased calcium and zinc content. These findings suggest that measurements of cortical χ could be used to characterise tissue properties non-invasively in epilepsy lesions.
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Affiliation(s)
- Sara Lorio
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK; Wellcome EPSRC Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London SE1 7EH, UK
| | - Jan Sedlacik
- Biomedical Engineering Department, School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK; Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Po-Wah So
- Department of Neuroimaging, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Harold G Parkes
- Department of Neuroimaging, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Roxana Gunny
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ulrike Löbel
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Yao-Feng Li
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, University College London and Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Pathology Department, Tri-Service General Hospital and National Defence Medical Centre, Taipei, Taiwan, ROC
| | - Olumide Ogunbiyi
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, University College London and Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Talisa Mistry
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, University College London and Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Emma Dixon
- MRI Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Sophie Adler
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - J Helen Cross
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Torsten Baldeweg
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Thomas S Jacques
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, University College London and Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karin Shmueli
- MRI Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - David W Carmichael
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK; Wellcome EPSRC Centre for Medical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London SE1 7EH, UK.
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Assadsangabi R, Ozturk A, Kantamneni T, Azizi N, Asaikar SM, Hacein-Bey L. Neuroimaging of Childhood Epilepsy: Focal versus Generalized Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0040-1722301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractNeuroimaging plays an increasingly crucial role in delineating the pathophysiology, and guiding the evaluation, management and monitoring of epilepsy. Imaging contributes to adequately categorizing seizure/epilepsy types in complex clinical situations by demonstrating anatomical and functional changes associated with seizure activity. This article reviews the current status of multimodality neuroimaging in the pediatric population, including focal lesions which may result in focal epileptic findings, focal structural abnormalities that may manifest as generalized epileptiform discharges, and generalized epilepsy without evidence of detectable focal abnormalities.
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Affiliation(s)
- Reza Assadsangabi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Arzu Ozturk
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Trishna Kantamneni
- Department of Neurology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Nazarin Azizi
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Shailesh M. Asaikar
- Child & Adolescent Neurology Consultants, Sacramento, California, United States
| | - Lotfi Hacein-Bey
- Department of Neuroradiology, Radiology, University of California Davis School of Medicine, Sacramento, California, United States
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Juhász C, John F. Utility of MRI, PET, and ictal SPECT in presurgical evaluation of non-lesional pediatric epilepsy. Seizure 2019; 77:15-28. [PMID: 31122814 DOI: 10.1016/j.seizure.2019.05.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 02/12/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022] Open
Abstract
Children with epilepsy and normal structural MRI pose a particular challenge in localization of epileptic foci for surgical resection. Many of these patients have subtle structural lesions such as mild cortical dysplasia that can be missed by conventional MRI but may become detectable by optimized and advanced MRI acquisitions and post-processing. Specificity of objective analytic techniques such as voxel-based morphometry remains an issue. Combination of MRI with functional imaging approaches can improve the accuracy of detecting epileptogenic brain regions. Analysis of glucose positron emission tomography (PET) combined with high-resolution MRI can optimize detection of hypometabolic cortex associated with subtle cortical malformations and can also enhance presurgical evaluation in children with epileptic spasms. Additional PET tracers may detect subtle epileptogenic lesions and cortex with enhanced specificity in carefully selected subgroups with various etiologies; e.g., increased tryptophan uptake can identify epileptogenic cortical dysplasia in the interictal state. Subtraction ictal SPECT can be also useful to delineate ictal foci in those with non-localizing PET or after failed surgical resection. Presurgical delineation of language and motor cortex and the corresponding white matter tracts is increasingly reliable by functional MRI and DTI techniques; with careful preparation, these can be useful even in young and sedated children. While evidence-based pediatric guidelines are still lacking, the data accumulated in the last decade strongly indicate that multimodal imaging with combined analysis of MRI, PET, and/or ictal SPECT data can optimize the detection of subtle epileptogenic lesions and facilitate seizure-free outcome while minimizing the postsurgical functional deficit in children with normal conventional MRI.
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Affiliation(s)
- Csaba Juhász
- Department of Pediatrics, Wayne State University, PET Center and Translational Imaging Laboratory, Children's Hospital of Michigan, 3901 Beaubien St., Detroit, Michigan, 48201, USA; Departments of Neurology and Neurosurgery, Wayne State University, 4201 St. Antoine St., Detroit, Michigan, 48201, USA.
| | - Flóra John
- Department of Pediatrics, Wayne State University, PET Center and Translational Imaging Laboratory, Children's Hospital of Michigan, 3901 Beaubien St., Detroit, Michigan, 48201, USA; Department of Neurology, University of Pécs, H-7623, Rét u. 2., Pécs, Hungary.
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18F-FDG in the presurgical evaluation of epilepsies: a pictorial essay. Clin Transl Imaging 2019. [DOI: 10.1007/s40336-019-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Parsons MS, Sharma A, Hildebolt C. Using Correlative Properties of Neighboring Pixels to Enhance Contrast-to-Noise Ratio of Abnormal Hippocampus in Patients With Intractable Epilepsy and Mesial Temporal Sclerosis. Acad Radiol 2019; 26:e1-e8. [PMID: 29907398 DOI: 10.1016/j.acra.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 10/14/2022]
Abstract
RATIONALE AND OBJECTIVES To test whether an image-processing algorithm can aid in visualization of mesial temporal sclerosis on magnetic resonance imaging by selectively increasing contrast-to-noise ratio (CNR) between abnormal hippocampus and normal brain. MATERIALS AND METHODS In this Institutional Review Board-approved and Health Insurance Portability and Accountability Act-compliant study, baseline coronal fluid-attenuated inversion recovery images of 18 adults (10 females, eight males; mean age 41.2 years) with proven mesial temporal sclerosis were processed using a custom algorithm to produce corresponding enhanced images. Average (Hmean) and maximum (Hmax) CNR for abnormal hippocampus were calculated relative to normal ipsilateral white matter. CNR values for normal gray matter (GM) were similarly calculated using ipsilateral cingulate gyrus as the internal control. To evaluate effect of image processing on visual conspicuity of hippocampal signal alteration, a neuroradiologist masked to the side of hippocampal abnormality rated signal intensity (SI) of hippocampi on baseline and enhanced images using a five-point scale (definitely abnormal to definitely normal). Differences in Hmean, Hmax, GM, and SI ratings for abnormal hippocampi on baseline and enhanced images were assessed for statistical significance. RESULTS Both Hmean and Hmax were significantly higher in enhanced images as compared to baseline images (p < 0.0001 for both). There was no significant difference in the GM between baseline and enhanced images (p = 0.9375). SI ratings showed a more confident identification of abnormality on enhanced images (p = 0.0001). CONCLUSION Image-processing resulted in increased CNR of abnormal hippocampus without affecting the CNR of normal gray matter. This selective increase in conspicuity of abnormal hippocampus was associated with more confident identification of hippocampal signal alteration.
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Jain RS, Khan I, Nagpal K. Identification of structural lesion using a 3-Tesla MRI in partial onset epilepsy with a normal CT scan: A perspective of a tertiary centre in Northern India. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2018. [DOI: 10.1016/j.injms.2018.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dirik MA, Sanlidag B. Magnetic Resonance Imaging and Interictal Electroencephalography Findings in Newly Diagnosed Epileptic Children. J Clin Med 2018; 7:E134. [PMID: 29865192 PMCID: PMC6025345 DOI: 10.3390/jcm7060134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Epilepsy is one of the most frequently diagnosed chronic neurological disorders in children. Diagnosis is often based on seizure history and electroencephalography (EEG) assessment. Magnetic resonance imaging (MRI) is recommended for etiologic workup and intervention requirements. We aimed to detect by MRI if focal structural abnormalities are present in the brain in relation to interictal epileptiform discharges (IED). MATERIAL AND METHODS The study was designed retrospectively. The data were collected from patients admitted to Near East University, Department of Pediatric Neurology, who were aged between 3 months and 18 years and who were diagnosed with epilepsy. The cases considered in the current study, however, were patients that had an EEG record prior to initiating treatment and an MRI within the first six months following diagnosis. RESULTS Among 222 patients, 212 (95.5%) had IED, and 92 (41.4%) had abnormal MRI results. The most frequently seen abnormalities detected by MRI were encephalomalacia, hydrocephaly, and atrophy. Among patients who had IED, the ones with multifocal IED were documented to have a statistically significant higher rate of abnormalities in MRI scans. In other patients, IED had no significant correlation with structural lesions detected by MRI. CONCLUSION IED can be unrelated to MRI findings. Focal IED were not statistically concordant with the structural lesions detected by MRI. However, for the cases with multifocal discharges revealed by interictal EEG, the rate of abnormalities detected using MRI was 68%. Therefore, the likelihood of detecting abnormalities using MRI in patients with multifocal IED does support the necessity of the use of MRI in early diagnosis stages.
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Affiliation(s)
- Mehmet Alp Dirik
- Faculty of Medicine, Department of Radioloy, Suat Gunsel University, Kyrenia 99138, North Cyprus.
| | - Burcin Sanlidag
- Faculty of Medicine, Department of Pediatrics Division of Pediatric Neurology, Near East University, Nicosia 99138, North Cyprus.
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Crocker CE, Pohlmann-Eden B, Schmidt MH. Role of neuroimaging in first seizure diagnosis. Seizure 2017; 49:74-78. [DOI: 10.1016/j.seizure.2016.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/17/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022] Open
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Bruno V, Klein JP, Nidup D, Nirola DK, Tshering L, Deki S, Clark SJ, Linn KA, Shinohara RT, Dorji C, Pokhrel DR, Dema U, Mateen FJ. Yield of Brain MRI in Clinically Diagnosed Epilepsy in the Kingdom of Bhutan: A Prospective Study. Ann Glob Health 2017; 83:415-422. [PMID: 29221514 DOI: 10.1016/j.aogh.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND People with epilepsy (PWE) in low- and middle-income countries may not access the health resources that are considered optimal for epilepsy diagnosis. The diagnostic yield of magnetic resonance imaging (MRI) has not been well studied in these settings. OBJECTIVES To report the diagnostic yield of brain MRI and identify clinical associations of abnormal MRI findings among PWE in a neurocysticercosis-endemic, resource-limited setting and to identify the proportion and putative structural brain causes of drug-resistant epilepsy. METHODS PWE were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan (2014-2015). Each participant completed clinical questionnaires and a 1.5-Tesla brain MRI. Each MRI was reviewed by at least 1 radiologist and neurologist in Bhutan and the United States. A working definition of drug-resistant epilepsy for resource-limited settings was given as (a) seizures for >1 year, (b) at least 1 seizure in the prior year, and (c) presently taking 2 or more antiepileptic drugs (AEDs). Logistic regression models were constructed to test the cross-sectional association of an abnormal brain MRI with clinical variables. FINDINGS A total of 217 participants (125 [57%] female; 54 [25%] < 18 years old; 199 [92%] taking AEDs; 154 [71%] with a seizure in the prior year) were enrolled. There was a high prevalence of abnormal brain MRIs (176/217, 81%). Mesial temporal sclerosis was the most common finding (n = 115, 53%, including 24 children), exceeding the number of PWE with neurocysticercosis (n = 26, 12%, including 1 child) and congenital/perinatal abnormalities (n = 29, 14%, including 14 children). The number of AEDs (odds ratio = .59, P = .03) and duration of epilepsy (odds ratio = 1.11, P = .02) were significantly associated with an abnormal MRI. Seizure in the prior month was associated with the presence of mesial temporal sclerosis (odds ratio = .47, P = .01). A total of 25 (12%) participants met our definition of drug-resistant epilepsy, with mesial temporal sclerosis (n = 10), congenital malformations (n = 5), and neurocysticercosis (n = 4) being the more common findings. CONCLUSIONS The prevalence of abnormalities on brain MRI for PWE in resource-limited settings is high as a result of a diffuse range of etiologies, most commonly mesial temporal sclerosis. Drug-resistant epilepsy accounted for 12% of the referral population in a conservative estimation.
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Affiliation(s)
- Veronica Bruno
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Joshua P Klein
- Harvard Medical School, Boston, MA; Department of Neurology, Brigham & Women's Hospital, Boston, MA; Department of Radiology, Brigham & Women's Hospital, Boston, MA
| | - Dechen Nidup
- Department of Radiology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Damber K Nirola
- Department of Radiology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Lhab Tshering
- Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Sonam Deki
- Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Sarah J Clark
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | | | | | - Chencho Dorji
- Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Dili Ram Pokhrel
- Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Ugyen Dema
- Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Liao WH, Wu HM, Wu HY, Tu TY, Shiao AS, Castillo M, Hung SC. Revisiting the relationship of three-dimensional fluid attenuation inversion recovery imaging and hearing outcomes in adults with idiopathic unilateral sudden sensorineural hearing loss. Eur J Radiol 2016; 85:2188-2194. [PMID: 27842665 DOI: 10.1016/j.ejrad.2016.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/02/2016] [Accepted: 10/07/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Three-dimensional fluid attenuation inversion recovery (3D FLAIR) may demonstrate high signal in the inner ears of patients with idiopathic sudden sensorineural hearing loss (ISSNHL), but the correlations of this finding with outcomes are still controversial. Here we compared 4 3D MRI sequences with the outcomes of patients with ISSNHL. MATERIALS AND METHODS 77 adult patients with ISSNHL underwent MRI with pre contrast FLAIR, fast imaging employing steady-state acquisition images (FIESTA-C), post contrast T1WI and post contrast FLAIR. The extent and degree of high signal in both cochleas were evaluated in all patients, and asymmetry ratios between the affected ears and the normal ones were calculated. The relationships among MRI findings, including extent and asymmetry of abnormal cochlear high signals, degree of FLAIR enhancement, and clinical information, including age, vestibular symptoms, baseline hearing loss, and final hearing outcomes were analyzed. RESULTS 54 patients (28 men; age, 52.1±15.5years) were included in our study. Asymmetric cochlear signal intensities were more frequently observed in pre contrast and post contrast FLAIR (79.6% and 68.5%) than in FIESTA-C (61.1%) and T1WI (51.9%) (p<0.001). Age, baseline hearing loss, extent of high signal and asymmetry ratios of pre contrast and post contrast FLAIR were all correlated with final hearing outcomes. In multivariate analysis, age and the extent of high signals were the most significant predictors of final hearing outcomes. CONCLUSION 3D FLAIR provides a higher sensitivity in detecting the asymmetric cochlear signal abnormality. The more asymmetric FLAIR signals and presence of high signals beyond cochlea indicated a poorer prognosis.
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Affiliation(s)
- Wen-Huei Liao
- School of Medicine, National Yang Ming University, Taipei, 11221, Taiwan; Department of Otolaryngology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming University, Taipei, 11221, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - Hung-Yi Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - Tzong-Yang Tu
- School of Medicine, National Yang Ming University, Taipei, 11221, Taiwan; Department of Otolaryngology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - An-Suey Shiao
- School of Medicine, National Yang Ming University, Taipei, 11221, Taiwan; Department of Otolaryngology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - Mauricio Castillo
- Department of Radiology, University of North Carolina, Chapel Hill, NC, 27599-7510, USA
| | - Sheng-Che Hung
- School of Medicine, National Yang Ming University, Taipei, 11221, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei, 11221, Taiwan.
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15
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Bagić A. Look back to leap forward: The emerging new role of magnetoencephalography (MEG) in nonlesional epilepsy. Clin Neurophysiol 2015; 127:60-66. [PMID: 26055337 DOI: 10.1016/j.clinph.2015.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 05/02/2015] [Accepted: 05/08/2015] [Indexed: 11/25/2022]
Abstract
This review considers accumulating evidence for a new role of MEG/MSI in increasing the diagnostic yield of supposedly negative MRIs, and suggests changes in the use of MEG/MSI in presurgical epilepsy evaluations. Specific alterations in practice protocols for both the MEG practitioner (i.e. physician magnetoencephalographer) and MEG user (i.e. referring physician) are proposed that should further enhance the overall value of MEG/MSI. Although advances in MEG analysis methods will likely become increasingly assisted by computers, interpretive competency and prudent clinical judgment remain irreplaceable.
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Affiliation(s)
- Anto Bagić
- University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), UPMC MEG Epilepsy Program, Department of Neurology, University of Pittsburgh Medical School, Suite 811, Kaufmann Medical Building, 3471 Fifth Ave, Pittsburgh, PA 15213, USA.
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16
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Ramli N, Rahmat K, Lim KS, Tan CT. Neuroimaging in refractory epilepsy. Current practice and evolving trends. Eur J Radiol 2015; 84:1791-800. [PMID: 26187861 DOI: 10.1016/j.ejrad.2015.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 03/09/2015] [Accepted: 03/21/2015] [Indexed: 11/16/2022]
Abstract
Identification of the epileptogenic zone is of paramount importance in refractory epilepsy as the success of surgical treatment depends on complete resection of the epileptogenic zone. Imaging plays an important role in the locating and defining anatomic epileptogenic abnormalities in patients with medically refractory epilepsy. The aim of this article is to present an overview of the current MRI sequences used in epilepsy imaging with special emphasis of lesion seen in our practices. Optimisation of epilepsy imaging protocols are addressed and current trends in functional MRI sequences including MR spectroscopy, diffusion tensor imaging and fusion MR with PET and SPECT are discussed.
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Affiliation(s)
- N Ramli
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Malaysia
| | - K Rahmat
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Malaysia.
| | - K S Lim
- Neurology Unit, Department of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - C T Tan
- Neurology Unit, Department of Medicine, University Malaya, Kuala Lumpur, Malaysia
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17
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Wilmshurst JM, Berg AT, Lagae L, Newton CR, Cross JH. The challenges and innovations for therapy in children with epilepsy. Nat Rev Neurol 2014; 10:249-60. [PMID: 24709890 DOI: 10.1038/nrneurol.2014.58] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Major advances have been made in the diagnosis, evaluation and management of children with epilepsy over the past 15 years. There has been a marked increase in genetic diagnoses of a number of key childhood-onset epilepsy syndromes, such as Dravet syndrome, which has been linked to mutations in the SCN1A gene. The reorganization and reclassification of epilepsies, devised by the International League Against Epilepsy, has stimulated specialists to reassess their diagnostic practices; however, many studies have not addressed the global issues in treating children with epilepsy-specifically, the challenges of diagnosis through to optimal, and appropriate, therapeutic management. Also, Class I evidence-based data that are needed as a foundation for the development of treatment guidelines worldwide are lacking. Epilepsy is common, and the impact of this disease crosses age ranges and should be managed at all levels of care from community to quaternary care. In this Review, existing data and new therapeutic management approaches are discussed with the aim of highlighting the incidence of standard practices that may not be based on clinical evidence.
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Affiliation(s)
- Jo M Wilmshurst
- Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch 7700, South Africa
| | - Anne T Berg
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611, USA
| | - Lieven Lagae
- Department of Pediatric Neurology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Charles R Newton
- Centre for Geographic Medicine Research-Coast, Kenya Medical Research Institute, PO Box 230, Kilifi 80108, Kenya
| | - J Helen Cross
- UCL Institute of Child Health, 4/5 Long Yard, London WC1N 3LU, UK
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18
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Neuroimaging of epilepsy: lesions, networks, oscillations. Clin Neuroradiol 2014; 24:5-15. [PMID: 24424576 DOI: 10.1007/s00062-014-0284-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/03/2014] [Indexed: 10/25/2022]
Abstract
While analysis and interpretation of structural epileptogenic lesion is an essential task for the neuroradiologist in clinical practice, a substantial body of epilepsy research has shown that focal lesions influence brain areas beyond the epileptogenic lesion, across ensembles of functionally and anatomically connected brain areas. In this review article, we aim to provide an overview about altered network compositions in epilepsy, as measured with current advanced neuroimaging techniques to characterize the initiation and spread of epileptic activity in the brain with multimodal noninvasive imaging techniques. We focus on resting-state functional magnetic resonance imaging (MRI) and simultaneous electroencephalography/fMRI, and oppose the findings in idiopathic generalized versus focal epilepsies. These data indicate that circumscribed epileptogenic lesions can have extended effects on many brain systems. Although epileptic seizures may involve various brain areas, seizure activity does not spread diffusely throughout the brain but propagates along specific anatomic pathways that characterize the underlying epilepsy syndrome. Such a functionally oriented approach may help to better understand a range of clinical phenomena such as the type of cognitive impairment, the development of pharmacoresistance, the propagation pathways of seizures, or the success of epilepsy surgery.
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19
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Mellerio C, Labeyrie MA, Chassoux F, Roca P, Alami O, Plat M, Naggara O, Devaux B, Meder JF, Oppenheim C. 3T MRI improves the detection of transmantle sign in type 2 focal cortical dysplasia. Epilepsia 2013; 55:117-22. [PMID: 24237393 DOI: 10.1111/epi.12464] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Type 2 focal cortical dysplasia (FCD2) is one of the main causes of refractory partial epilepsy, but often remains overlooked by MRI. This study aimed to elucidate whether 3T MRI offers better detection and characterization of FCD2 than 1.5T, using similar coils and acquisition time. METHODS Two independent readers reviewed the 1.5T and 3T MR images of 25 patients with histologically proven FCD2. For both magnetic fields, the ability to detect a lesion was analyzed. We compared the identification of each of the five criteria typical of FCD2 (cortical thickening, blurring, cortical signal changes, subcortical signal changes, and "transmantle" sign) and artifacts, using a four-point scale (0-3). Interobserver reliability for lesion detection was calculated. KEY FINDINGS Seventeen lesions (68%) were detected at 3T, two of which were overlooked at 1.5T. Interobserver reliability was better at 3T (κ = 1) than at 1.5T (κ = 0.83). The transmantle sign was more clearly identified at 3T than 1.5T (mean visualization score: 1.72 vs. 0.56; p = 0.002). SIGNIFICANCE The use of 3T MRI in patients suspected of type 2 FCD improves the detection rate and the lesion characterization owing to the transmantle sign being more clearly seen at 3T. This point is of interest, since this feature is considered as an MR signature of FCD2.
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Affiliation(s)
- Charles Mellerio
- Department of Neuroimaging, Sainte-Anne Hospital Center, Paris Descartes Sorbonne Paris Cité University, Paris, France
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20
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Wellmer J, Quesada CM, Rothe L, Elger CE, Bien CG, Urbach H. Proposal for a magnetic resonance imaging protocol for the detection of epileptogenic lesions at early outpatient stages. Epilepsia 2013; 54:1977-87. [DOI: 10.1111/epi.12375] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2013] [Indexed: 01/04/2023]
Affiliation(s)
- Jörg Wellmer
- Ruhr-Epileptology; Department of Neurology; University Hospital Knappschaftskrankenhaus; Bochum Germany
| | - Carlos M. Quesada
- Department of Epileptology & Life and Brain Institute; University Hospital Bonn; Bonn Germany
| | - Lars Rothe
- Ruhr-Epileptology; Department of Neurology; University Hospital Knappschaftskrankenhaus; Bochum Germany
| | - Christian E. Elger
- Department of Epileptology & Life and Brain Institute; University Hospital Bonn; Bonn Germany
| | | | - Horst Urbach
- Department of Neuroradiology; University Hospital Freiburg; Freiburg Germany
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21
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Berg AT, Baca CB, Loddenkemper T, Vickrey BG, Dlugos D. Priorities in pediatric epilepsy research: improving children's futures today. Neurology 2013; 81:1166-75. [PMID: 23966254 PMCID: PMC3795602 DOI: 10.1212/wnl.0b013e3182a55fb9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/26/2013] [Indexed: 11/15/2022] Open
Abstract
The Priorities in Pediatric Epilepsy Research workshop was held in the spirit of patient-centered and patient-driven mandates for developing best practices in care, particularly for epilepsy beginning under age 3 years. The workshop brought together parents, representatives of voluntary advocacy organizations, physicians, allied health professionals, researchers, and administrators to identify priority areas for pediatric epilepsy care and research including implementation and testing of interventions designed to improve care processes and outcomes. Priorities highlighted were 1) patient outcomes, especially seizure control but also behavioral, academic, and social functioning; 2) early and accurate diagnosis and optimal treatment; 3) role and involvement of parents (communication and shared decision-making); and 4) integration of school and community organizations with epilepsy care delivery. Key factors influencing pediatric epilepsy care included the child's impairments and seizure presentation, parents, providers, the health care system, and community systems. Care was represented as a sequential process from initial onset of seizures to referral for comprehensive evaluation when needed. We considered an alternative model in which comprehensive care would be utilized from onset, proactively, rather than reactively after pharmacoresistance became obvious. Barriers, including limited levels of evidence about many aspects of diagnosis and management, access to care--particularly epilepsy specialty and behavioral health care--and implementation, were identified. Progress hinges on coordinated research efforts that systematically address gaps in knowledge and overcoming barriers to access and implementation. The stakes are considerable, and the potential benefits for reduced burden of refractory epilepsy and lifelong disabilities may be enormous.
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Affiliation(s)
- Anne T Berg
- From the Ann & Robert H. Lurie Children's Hospital of Chicago (A.T.B.), Epilepsy Center, and Northwestern Memorial Feinberg School of Medicine, Department of Pediatrics, Chicago, IL; Department of Neurology (C.B.B., B.G.V.), University of California Los Angeles; Department of Neurology (C.B.B., B.G.V.), VA Greater Los Angeles Health Care System, Los Angeles, CA; Division of Epilepsy and Clinical Neurophysiology (T.L.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Pediatric Regional Epilepsy Program (D.D.), The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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