Hemispheric lateralization interrupted: material-specific memory deficits in temporal lobe epilepsy

Neuropsychiatry revisited: epilepsy as the borderland between neurology and psychiatry

Since epilepsy is often complicated by psychiatric symptoms, the contributions of psychiatry are indispensable for the care and improvement of the quality of life of individuals with epilepsy. Moreover, the existence of a bidirectional relationship between epilepsy and psychiatric symptoms was recently proposed, based on the evidence that not only are some psychiatric symptoms more likely than others to follow epilepsy, but also that psychiatric symptoms may precede the onset of epilepsy and the presence of psychiatric symptoms may influence the outcome of treatment for seizures. There has also been a gradual accumulation of neurobiological findings related to psychosis, depressive, and anxiety symptoms that are associated with epilepsy with respect to abnormalities in brain networks and neurotransmission. This mini-review focuses on the neuropsychiatric aspects of epilepsy and proposes that a reconsideration of neuropsychiatry in light of epilepsy findings could serve as a bridge between psychiatry and neurology.

Altered structural network in temporal lobe epilepsy with focal to bilateral tonic-clonic seizures

OBJECTIVES

This study aims to investigate whether alterations in white matter topological networks are associated with focal to bilateral tonic-clonic seizures (FBTCS) in temporal lobe epilepsy (TLE). Additionally, we investigated the variables contributing to memory impairment in TLE.

METHODS

This cross-sectional study included 88 unilateral people with TLE (45 left/43 right), and 42 healthy controls. Graph theory analysis was employed to compare the FBTCS (+) group (n = 51) with the FBTCS (-) group (n = 37). The FBTCS (+) group was subcategorized into current-FBTCS (n = 31) and remote-FBTCS (n = 20), based on the history of FBTCS within 1 year or longer than 1 year before scanning, respectively. We evaluated the discriminatory power of topological network properties by receiver operating characteristic (ROC) analysis. Generalized linear models (GLMs) were employed to investigate variables associated with memory impairment in TLE.

RESULTS

Global efficiency (Eg) was significantly reduced in the FBTCS (+) group, especially in the current-FBTCS subgroup. Greater disruption of regional properties in the ipsilateral occipital and temporal association cortices was observed in the FBTCS (+) group. ROC analysis revealed that Eg, normalized characteristic shortest path length, and nodal efficiency of the ipsilateral middle temporal gyrus could distinguish between FBTCS (+) and FBTCS (-) groups. Additionally, GLMs linked the occurrence of current FBTCS with poorer verbal memory outcomes in TLE.

INTERPRETATION

Our study suggests that abnormal networks could be the structural basis of seizure propagation in FBTCS. Strategies aimed at reducing the occurrence of FBTCS could potentially improve the memory outcomes in people with TLE.

Sex differences in the pre and postoperative neuropsychological function of epilepsy surgery candidates

Objective: As programs expand globally, epilepsy surgery is becoming increasingly available as an effective treatment for some people with medically intractable seizures. Prospective candidates require careful neuropsychological evaluation and follow-up. The aim of this study was to examine the sex differences in neuropsychological function in presurgical presentation and postoperative outcomes in people with temporal lobe epilepsy referred for epilepsy surgery. Methods: Three hundred and seventy-two patients (202 Female; 170 Male) with a homogenous underlying pathology (hippocampal sclerosis) underwent a preoperative assessment on tests of intellectual, language, and memory function and were followed up one year after undergoing a unilateral temporal lobe resection; n = 169 Right (RTL), n = 203 Left (LTL). Results: There was no impact of sex or laterality of surgery on seizure outcome; 84% of males and 80% of females were seizure free at follow-up. Before surgery, sex effects were evident on tests of verbal memory with females performing better than males. Declines in verbal memory function following surgery were greater in females than males. Being female had a stronger association with postoperative decline on immediate prose recall (partial eta squared η2 = 0.029), than side of surgery (η2 = 0.018) albeit with a small effect size. Conclusions: There are subtle but significant sex differences in the neuropsychological profiles of people with temporal lobe epilepsy, before and following surgery. Whilst females generally perform better than males on tests of verbal memory function before surgery they demonstrate greater post-operative declines on these measures following surgery.

Hippocampal and neocortical BRAF mutant non-expansive lesions in focal epilepsies

OBJECTIVE

Mesial Temporal Lobe Epilepsy-associated Hippocampal Sclerosis (MTLE-HS) is a syndrome associated with various aetiologies. We previously identified CD34-positive extravascular stellate cells (CD34+ cells) possibly related to BRAFV600E oncogenic variant in a subset of MTLE-HS. We aimed to identify the BRAFV600E oncogenic variants and characterise the CD34+ cells.

METHODS

We analysed BRAFV600E oncogenic variant by digital droplet Polymerase Chain Reaction in 53 MTLE-HS samples (25 with CD34+ cells) and nine non-expansive neocortical lesions resected during epilepsy surgery (five with CD34+ cells). Ex vivo multi-electrode array recording, immunolabelling, methylation microarray and single nuclei RNAseq were performed on BRAFwildtype MTLE-HS and BRAFV600E mutant non-expansive lesion of hippocampus and/or neocortex.

RESULTS

We identified a BRAFV600E oncogenic variant in five MTLE-HS samples with CD34+ cells (19%) and in five neocortical samples with CD34+ cells (100%). Single nuclei RNAseq of resected samples revealed two unique clusters of abnormal cells (including CD34+ cells) associated with senescence and oligodendrocyte development in both hippocampal and neocortical BRAFV600E mutant samples. The co-expression of the oncogene-induced senescence marker p16INK4A and the outer subventricular zone radial glia progenitor marker HOPX in CD34+ cells was confirmed by multiplex immunostaining. Pseudotime analysis showed that abnormal cells share a common lineage from progenitors to myelinating oligodendrocytes. Epilepsy surgery led to seizure freedom in eight of the 10 patients with BRAF mutant lesions.

INTERPRETATION

BRAFV600E underlies a subset of MTLE-HS and epileptogenic non-expansive neocortical focal lesions. Detection of the oncogenic variant may help diagnosis and open perspectives for targeted therapies.

Multifocal hypometabolic correlates to deficits of verbal memory in mesial temporal lobe epilepsy

BACKGROUND AND OBJECTIVES

Neuropsychological research on mesial temporal lobe epilepsy (MTLE) often highlights material-specific memory deficits, but a lesion-focused model may not accurately reflect the underlying networks that support episodic memory in these patients. Our study evaluated the pathophysiology behind verbal learning/memory deficits as revealed by hypometabolism quantified through 18-fluorodeoxyglucose positron emission tomography (FDG-PET).

METHODS

This retrospective study included thirty presurgical patients with intractable unilateral MTLE who underwent interictal FDG-PET and verbal memory assessment (12 females, mean age: 38.73 years). Fluorodeoxyglucose-positron emission tomography mapping was performed with voxel-based mapping of glucose utilization to a database of age-matched controls to derive regional Z-scores. Neuropsychological outcome variables included scores on learning and recall trials of two distinct verbal memory measures validated for use in epilepsy research. Pearson's correlations evaluated relationships between clinical variables and verbal memory. Linear regression was used to relate regional hypometabolism and verbal memory assessment. Post hoc analyses assessed areas of FDG-PET hypometabolism (threshold Z ≤ -1.645 below mean) where verbal memory was impaired.

RESULTS

Verbal memory deficits correlated with hypometabolism in limbic structures ipsilateral to language dominance but also correlated with hypometabolism in networks involving the ipsilateral perisylvian cortex and contralateral limbic and nonlimbic structures.

DISCUSSION

We conclude that traditional models of verbal memory may not adequately capture cognitive deficits in a broader sample of patients with MTLE. This study has important implications for epilepsy surgery protocols that use neuropsychological data and FDG-PET to draw conclusions about surgical risks.

Hippocampal resection in temporal lobe epilepsy: Do we need to resect the tail?

INTRODUCTION

Anteromesial temporal lobe resection is the most common surgical technique used to treat drug-resistant mesial temporal lobe epilepsy, particularly when secondary to hippocampal sclerosis. Structural and functional imaging data suggest the importance of sparing the posterior hippocampus for minimising language and memory deficits. Recent work has challenged the view that maximal posterior hippocampal resection improves seizure outcome. This study was designed to assess whether resection of posterior hippocampal atrophy was associated with improved seizure outcome.

METHODS

Retrospective analysis of a prospective database of all anteromesial temporal lobe resections performed in individuals with hippocampal sclerosis at our epilepsy surgery centre, 2013-2021. Pre- and post-operative MRI were reviewed by 2 neurosurgical fellows to assess whether the atrophic segment, displayed by automated hippocampal morphometry, was resected, and ILAE seizure outcomes were collected at 1 year and last clinical follow-up. Data analysis used univariate and binary logistic regression.

RESULTS

Sixty consecutive eligible patients were identified of whom 70% were seizure free (ILAE Class 1 & 2) at one year. There was no statistically significant difference in seizure freedom outcomes in patients who had complete resection of atrophic posterior hippocampus or not (Fisher's Exact test statistic 0.69, not significant at p < .05) both at one year, and at last clinical follow-up. In the multivariate analysis only a history of status epilepticus (OR=0.2, 95%CI:0.042-0.955, p = .04) at one year, and pre-operative psychiatric disorder (OR=0.145, 95%CI:0.036-0.588, p = .007) at last clinical follow-up, were associated with a reduced chance of seizure freedom.

SIGNIFICANCE

Our data suggest that seizure freedom is not associated with whether or not posterior hippocampal atrophy is resected. This challenges the traditional surgical dogma of maximal posterior hippocampal resection in anteromesial temporal lobe resections and is a step further optimising this surgical procedure to maximise seizure freedom and minimise associated language and memory deficits.

Episodic memory network connectivity in temporal lobe epilepsy

OBJECTIVE

Temporal lobe epilepsy (TLE) affects brain networks and is associated with impairment of episodic memory. Temporal and extratemporal reorganization of memory functions is described in functional magnetic resonance imaging (fMRI) studies. Functional reorganizations have been shown at the local activation level, but network-level alterations have been underinvestigated. We aim to investigate the functional anatomy of memory networks using memory fMRI and determine how this relates to memory function in TLE.

METHODS

Ninety patients with unilateral TLE (43 left) and 29 controls performed a memory-encoding fMRI paradigm of faces and words with subsequent out-of-scanner recognition test. Subsequent memory event-related contrasts of words and faces remembered were generated. Psychophysiological interaction analysis investigated task-associated changes in functional connectivity seeding from the mesial temporal lobes (MTLs). Correlations between changes in functional connectivity and clinical memory scores, epilepsy duration, age at epilepsy onset, and seizure frequency were investigated, and between connectivity supportive of better memory and disease burden. Connectivity differences between controls and TLE, and between TLE with and without hippocampal sclerosis, were explored using these confounds as regressors of no interest.

RESULTS

Compared to controls, TLE patients showed widespread decreased connectivity between bilateral MTLs and frontal lobes, and increased local connectivity between the anterior MTLs bilaterally. Increased intrinsic connectivity within the bilateral MTLs correlated with better out-of-scanner memory performance in both left and right TLE. Longer epilepsy duration and higher seizure frequency were associated with decreased connectivity between bilateral MTLs and left/right orbitofrontal cortex (OFC) and insula, connections supportive of memory functions. TLE due to hippocampal sclerosis was associated with greater connectivity disruption within the MTL and extratemporally.

SIGNIFICANCE

Connectivity analyses showed that TLE is associated with temporal and extratemporal memory network reorganization. Increased bilateral functional connectivity within the MTL and connectivity to OFC and insula are efficient, and are disrupted by greater disease burden.

The challenge of neuropsychological assessment of visual/visuo-spatial memory: A critical, historical review, and lessons for the present and future

A proliferation of tests exists for the assessment of auditory-verbal memory processes. However, from a clinical practice perspective, the situation is less clear when it comes to the ready availability of reliable and valid tests for the evaluation of visual/visuo-spatial memory processes. While, at face value, there appear to be a wide range of available tests of visual/visuo-spatial memory, utilizing different types of materials and assessment strategies, a number of criticisms have been, and arguably should be, leveled at the majority of these tests. The criticisms that have been directed toward what are typically considered to be visual/visuo-spatial memory tests, such as (1) the potential for verbal mediation, (2) over-abstraction of stimuli, (3) the requirement of a drawing response, and (4) the lack of sensitivity to unilateral brain lesions, mean that, in reality, the number of readily available valid tests of visual/visuo-spatial memory is, at best, limited. This article offers a critical, historical review on the existing measures and resources for the neuropsychological assessment of visual/visuo-spatial memory, and it showcases some examples of newer tests that have aimed to overcome the challenges of assessing these important aspects of memory. The article also identifies new trends and examples of how technological advances such as virtual reality may add value to overcome previous obstacles to assessment, thereby offering professionals more reliable, accurate means to evaluate visual/visuo-spatial memory in clinical practice.

Accelerated long-term forgetting in children with temporal lobe epilepsy: A timescale investigation of material specificity and executive skills

Recently, children with temporal lobe epilepsy (TLE) were found to be at risk of accelerated long-term forgetting (ALF). In this study, we examined the temporal trajectory of ALF, while exploring the relationship between ALF, executive skills, and epilepsy variables. Fifty-one children, (23 with TLE and 28 typically developing) completed a battery of neuropsychological tests of verbal and visual memory, executive skills, and two experimental memory tasks (verbal and visual) involving recall after short (30-min) and extended (1-day and 2-week) delays. Side of seizure focus and hippocampal integrity were considered. On the visual task (Scene Memory), children with TLE performed comparably to typically developing children following a 30-min and 1-day delay, although worse than typically developing children at 2 weeks: ALF was observed in children with right TLE focus. The two groups did not differ on the experimental verbal memory task. Children with TLE also had worse performance than typically developing children on standardized verbal memory test and on tests of executive skills (i.e., verbal generativity, inhibition, working memory, complex attention). Only complex attention was associated with visual ALF. ALF was present for visuo-spatial materials in children with TLE at two weeks, and children with right TLE were most susceptible. A relationship was identified between complex attention and long-term forgetting. The findings extend our understanding of difficulties in long-term memory formation experienced by children with TLE.

A clinically applicable functional MRI memory paradigm for use with pediatric patients

OBJECTIVE

Clinically employable functional MRI (fMRI) memory paradigms are not yet established for pediatric patient epilepsy surgery workups. Seeking to establish such a paradigm, we evaluated the effectiveness of memory fMRI tasks we developed by quantifying individual activation in a clinical pediatric setting, analyzing patterns of activation relative to the side of temporal lobe (TL) pathology, and comparing fMRI and Wada test results.

METHODS

We retrospectively identified 72 patients aged 6.7-20.9 years with pathology (seizure focus and/or tumor) limited to the TL who had attempted memory and language fMRI tasks over a 9-year period as part of presurgical workups. Memory fMRI tasks required visualization of autobiographical memories in a block design alternating with covert counting. Language fMRI protocols involved verb and sentence generation. Scans were both qualitatively interpreted and quantitatively assessed for blood oxygenation level dependent (BOLD) signal change using region of interest (ROI) masks. We calculated the percentage of successfully scanned individual cases, compared 2 memory task activation masks in cases with left versus right TL pathology, and compared fMRI with Wada tests when available. Patients who had viable fMRI and Wada tests had generally concordant results.

RESULTS

Of the 72 cases, 60 (83%), aged 7.6-20.9 years, successfully performed the memory fMRI tasks and 12 (17%) failed. Eleven of 12 unsuccessful scans were due to motion and/or inability to perform the tasks, and the success of a twelfth was indeterminate due to orthodontic metal artifact. Seven of the successful 60 cases had distorted anatomy that precluded employing predetermined masks for quantitative analysis. Successful fMRI memory studies showed bilateral mesial temporal activation and quantitatively demonstrated: (1) left activation (L-ACT) less than right activation (R-ACT) in cases with left temporal lobe (L-TL) pathology, (2) nonsignificant R-ACT less than L-ACT in cases with right temporal lobe (R-TL) pathology, and (3) lower L-ACT plus R-ACT activation for cases with L-TL versus R-TL pathology. Patients who had viable fMRI and Wada tests had generally concordant results.

SIGNIFICANCE

This study demonstrates evidence of an fMRI memory task paradigm that elicits reliable activation at the individual level and can generally be accomplished in clinically involved pediatric patients. This autobiographical memory paradigm showed activation in mesial TL structures, and cases with left compared to right TL pathology showed differences in activation consistent with extant literature in TL epilepsy. Further studies will be required to assess outcome prediction.

Optimal Surgical Extent for Memory and Seizure Outcome in Temporal Lobe Epilepsy

OBJECTIVE

Postoperative memory decline is an important consequence of anterior temporal lobe resection (ATLR) for temporal lobe epilepsy (TLE), and the extent of resection may be a modifiable factor. This study aimed to define optimal resection margins for cognitive outcome while maintaining a high rate of postoperative seizure freedom.

METHODS

This cohort study evaluated the resection extent on postoperative structural MRI using automated voxel-based methods and manual measurements in 142 consecutive patients with unilateral drug refractory TLE (74 left, 68 right TLE) who underwent standard ATLR.

RESULTS

Voxel-wise analyses revealed that postsurgical verbal memory decline correlated with resections of the posterior hippocampus and inferior temporal gyrus, whereas larger resections of the fusiform gyrus were associated with worsening of visual memory in left TLE. Limiting the posterior extent of left hippocampal resection to 55% reduced the odds of significant postoperative verbal memory decline by a factor of 8.1 (95% CI 1.5-44.4, p = 0.02). Seizure freedom was not related to posterior resection extent, but to the piriform cortex removal after left ATLR. In right TLE, variability of the posterior extent of resection was not associated with verbal and visual memory decline or seizures after surgery.

INTERPRETATION

The extent of surgical resection is an independent and modifiable risk factor for cognitive decline and seizures after left ATLR. Adapting the posterior extent of left ATLR might optimize postoperative outcome, with reduced risk of memory impairment while maintaining comparable seizure-freedom rates. The current, more lenient, approach might be appropriate for right ATLR. ANN NEUROL 2021.

Histopathological validation and clinical correlates of hippocampal subfield volumetry based on T2-weighted MRI in temporal lobe epilepsy with hippocampal sclerosis

The objectives of this study were 1) to histologically validate the hippocampal subfield volumetry based on T2-weighted MRI, and 2) to explore its clinical impact on postsurgical memory function and seizure outcome in temporal lobe epilepsy (TLE) with hippocampal sclerosis (HS). We analyzed the cases of 24 patients with medial TLE (12 left, 12 right) and HS who were preoperatively examined with T2-weighted high-resolution MRI. The volume of each hippocampal subfield was calculated with an automatic segmentation of hippocampal subfields (ASHS) program. Hippocampal sclerosis patterns were determined pathologically, and the cross-sectional area and neuronal cell density of the CA1 and CA4 subfields were calculated using tissue specimens. Pre- and postoperative memory evaluations based on the Wechsler Memory Scale-Revised (WMS-R) were performed. We compared the presurgical MRI-based volumes with the pathological measurements in each subfield and then compared them with the change in the patients' neurocognitive function. As a result, there was a significant relationship between the presurgical MRI-based volume of CA4/dentate gyrus (DG) and the cross-sectional area of CA4 calculated with tissue specimens (Spearman's rs = 0.482, p = 0.023), and a similar trend-level correlation was observed in CA1 (rs = 0.455, p = 0.058). Some of MRI-based or pathology-based parameters in the subfields preliminarily showed relationships with the postsurgical memory changes. In conclusion, automated subfield volumetry for patients with hippocampal sclerosis moderately reflects their subfield atrophy and might be useful to predict the postsurgical change of memory function in these patients.

Whole-brain functional correlates of memory formation in mesial temporal lobe epilepsy

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Large study of encoding and subsequent memory for words, faces, and scenes.

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Less ipsilateral mesial temporal activity in mesial temporal lobe epilepsy (mTLE).

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Extra-mTL activity in mTLE only partly relevant for memory formation.

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Across materials contralateral mTL decisive to maintain intact memory in mTLE.

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Left frontal activation correlates with better verbal memory only in left mTLE.

The mesial temporal lobe is a key region for episodic memory. Accordingly, memory impairment is frequent in patients with mesial temporal lobe epilepsy. However, the functional relevance of potentially epilepsy-induced reorganisation for memory formation is still not entirely clear. Therefore, we investigated whole-brain functional correlates of verbal and non-verbal memory encoding and subsequent memory formation in 56 (25 right sided) mesial temporal lobe epilepsy patients and 21 controls. We applied an fMRI task of learning scenes, faces, and words followed by an out-of-scanner recognition test. During encoding of faces and scenes left and right mesial temporal lobe epilepsy patients had consistently reduced activation in the epileptogenic mesial temporal lobe compared with controls. Activation increases in patients were apparent in extra-temporal regions, partly associated with subsequent memory formation (left frontal regions and basal ganglia), and patients had less deactivation in regions often linked to the default mode and auditory networks. The more specific subsequent memory contrast indicated only marginal group differences. Correlating patients’ encoding activation with memory performance both within the paradigm and with independent clinical measures demonstrated predominantly increased contralateral mesio-temporal activation supporting intact memory performance. In left temporal lobe epilepsy patients, left frontal activation was also correlated with better verbal memory performance. Taken together, our findings hint towards minor extra-temporal plasticity in mesial temporal lobe epilepsy patients, which is in line with pre-surgical impairment and post-surgical memory decline in many patients. Further, data underscore the importance of particularly the contralateral mesial temporal lobe itself, to maintain intact memory performance.

The Pair Test: A computerised measure of learning and memory

There is increasing interest in the assessment of learning and memory in typically developing children as well as in children with neurodevelopmental disorders. However, neuropsychological assessments have been hampered by the dearth of standardised tests that enable direct comparison between distinct memory processes or between types of stimulus materials. We developed a tablet-based paired-associate learning paradigm, the Pair Test, based on neurocognitive models of learning and memory. The aims are to (i) establish the utility of this novel memory tool for use with children across a wide age range, and (ii) examine test validity, reliability and reproducibility of the construct. The convergent validity of the test was found to be adequate, and higher test reliability was shown for the Pair Test compared to standardised measures. Moderate test-retest reproducibility was shown, despite a long time interval between sessions (14 months). Moreover, the Pair Test is able to capture developmental changes in memory, and can therefore chart the developmental trajectory of memory and learning functions across childhood and adolescence. Finally, we used this novel instrument to acquire normative data from 130 typically developing children, aged 8-18 years. Age-stratified normative data are provided for learning, delayed recall and delayed recognition, for measures of verbal and non-verbal memory. The Pair Test thus provides measures of learning and memory accounting for encoding, consolidation and retrieval processes. As such, the standardised test results can be used to determine the status of learning and memory in healthy children, and also to identify deficits in paediatric patients at risk of damage to the neural network underlying mnemonic functions.

Critical area for memory decline after mesial temporal resection in epilepsy patients

OBJECTIVE

Mesial temporal lobe epilepsy (MTLE) surgery is associated with a risk of memory decline after surgery, but the effect of the extent and locus of temporal resection on postoperative memory function are controversial. The authors' aim in this study was to confirm if selective resection is effective in preserving memory function and identify critical areas for specific memory decline after temporal resection.

METHODS

In this single-center retrospective study, the authors investigated data from patients who underwent unilateral MTLE surgery between 2005 and 2015. Data from 74 MTLE patients (60.8% of whom were female; mean [SD] age at surgery 32 years [8.91 years] and duration of epilepsy 16 years [9.65 years]) with histologically proven hippocampal sclerosis were included. Forty-two patients underwent left-sided surgery. The resection area was manually delineated on each patient's postoperative T1-weighted images. Mapping was performed to see if the resected group, compared with the nonresected group, had worse postoperative memory in various memory domains, including verbal item, verbal associative, and figural memory.

RESULTS

Overall, 95.9% had a favorable epilepsy outcome. In verbal item memory, resection of the left lateral temporal area was related to postoperative decline in immediate and delayed recall scores of word lists. In verbal associative memory, resection of the anterior part of the left hippocampus, left parahippocampal area, and left lateral temporal area was related to postoperative decline in immediate recall scores of word pairs. Resection of the posterior part of the left hippocampus, left parahippocampal area, and left lateral temporal area was related to delayed recall scores of the same task. Similarly, in the figural memory, postoperative decline of immediate recall scores was associated with the resection of the anterior part of the right hippocampus, amygdala, parahippocampal area, and superior temporal area, and decline of delayed recall scores was related to resection of the posterior part of the right hippocampus and parahippocampal area.

CONCLUSIONS

Using voxel-based analysis, which accounts for the individual differences in the resection, the authors found a critical region for postoperative memory decline that is not revealed in the region-of-interest or groupwise comparison. Particularly, resection of the hippocampus was related to associative memory. In both verbal and visual memory, resection of the anterior part of the hippocampus was associated with immediate recall, and resection of the posterior part of the hippocampus was associated with delayed recall. Therefore, the authors' results suggest that selective resection may be effective in preserving postoperative memory decline.

Visuo-verbal distinction revisited: new insights from a study on temporal lobe epilepsy patients in the debate over the lateralization of material-specific and process-specific aspects of memory

Introduction: The automatic interaction between a cue and a memory trace can give rise to the vivid recollection of a purely sensory past experience. But are humans able to reach back intentionally to purely sensory experiences in the absence of any exogenous or endogenous cue? In the present study, we propose an alternative hypothesis, claiming that the retrieval of associated semantic memories, stored in the left hemisphere and acting as endogenous cues, is a prerequisite for intentionally recollecting sensory experience stored in the right hemisphere during mental time travels (MTT). Methods: To investigate this issue, we administered an MTT task to 26 epileptic patients (16 males and 10 females) who had undergone right or left temporal lobectomy and to 28 age and education matched controls. The task was devised so as to require the recollection of purely visual memories in the absence of external cues. Participants also performed two conventional recognition tasks with visual and verbal materials. The three between-subjects memory tasks were analyzed separately with the Kruskal-Wallis test and the Wilcoxon rank-sum test in order to investigate differences across groups. According to our hypothesis, we expected side asymmetries in the patients' performance on the two recognition tasks but not the MTT task. Results: While patients showed the well-known hemispheric asymmetry for visual and verbal material in the (external-cue dependent) recognition tasks, no side asymmetries emerged in the purely visual MTT task. Conclusions: In keeping with the view that visual memories cannot be targeted directly by a strategic search process, the lack of any side asymmetry in our MTT task can be interpreted as a trade-off between left-sided strategic search for associated semantic memories and right-sided storage of visual ones.

How predictable is cognitive performance in Brazilian patients with pharmacoresistant mesial temporal lobe epilepsy?

OBJECTIVE

The objective of the study was to investigate the independent association between clinical, demographic, psychiatric, radiologic, electrophysiological, and pharmacologic variables and cognitive performance of Brazilian patients with pharmacoresistant mesial temporal lobe epilepsy (MTLE).

METHODS

Ninety-three patients with pharmacoresistant MTLE related to hippocampal sclerosis (HS) were included in the study. Multiple linear regressions were done to identify predictor variables for 24 cognitive tests. Independent variables analyzed were sex, hand dominance, age, years of education, marital status, work activity, history for an initial precipitant injury (IPI), family history of epilepsy, lesion side, antiseizure medication (ASM) treatment type, ASM serum levels, benzodiazepine (BDZ) treatment, age at epilepsy onset, disease duration, monthly frequency of seizures, and Hospital Anxiety and Depression Scale (HADS) scores.

RESULTS

Years of education was an independent and positive predictor in 22 of the 24 cognitive tests evaluated. Male sex was also a positive predictor of one cognitive test. Variables negatively associated with cognitive performance were left side lesion (10 tests), disease duration (5 tests), polytherapy (3 tests), ASM serum levels (3 tests), and BDZ treatment or not working (1 test each). The regression model explained between 6% and 44% of the cognitive test scores variation.

SIGNIFICANCE

In Brazilian patients with pharmacoresistant MTLE-HS, up to 44% of cognitive test scores variation is predictable by clinical, demographic, psychiatric, radiologic, electrophysiology, and pharmacological variables. The identification of predictors of cognitive performance may be helpful for better planning of patient care.

The Medial Temporal Lobe Is Critical for Spatial Relational Perception

The medial temporal lobe (MTL) is traditionally considered to be a system that is specialized for long-term memory. Recent work has challenged this notion by demonstrating that this region can contribute to many domains of cognition beyond long-term memory, including perception and attention. One potential reason why the MTL (and hippocampus specifically) contributes broadly to cognition is that it contains relational representations-representations of multidimensional features of experience and their unique relationship to one another-that are useful in many different cognitive domains. Here, we explore the hypothesis that the hippocampus/MTL plays a critical role in attention and perception via relational representations. We compared human participants with MTL damage to healthy age- and education-matched individuals on attention tasks that varied in relational processing demands. On each trial, participants viewed two images (rooms with paintings). On "similar room" trials, they judged whether the rooms had the same spatial layout from a different perspective. On "similar art" trials, they judged whether the paintings could have been painted by the same artist. On "identical" trials, participants simply had to detect identical paintings or rooms. MTL lesion patients were significantly and selectively impaired on the similar room task. This work provides further evidence that the hippocampus/MTL plays a ubiquitous role in cognition by virtue of its relational and spatial representations and highlights its important contributions to rapid perceptual processes that benefit from attention.

Reduced Brain Electric Activity and Functional Connectivity in Bipolar Euthymia: An sLORETA Source Localization Study

Bipolar disorder (BD) is a chronic illness with a relapsing and remitting time course. Relapses are manic or depressive in nature and intermitted by euthymic states. During euthymic states, patients lack the criteria for a manic or depressive diagnosis, but still suffer from impaired cognitive functioning as indicated by difficulties in executive and language-related processing. The present study investigated whether these deficits are reflected by altered intracortical activity in or functional connectivity between brain regions involved in these processes such as the prefrontal and the temporal cortices. Vigilance-controlled resting state EEG of 13 euthymic BD patients and 13 healthy age- and sex-matched controls was analyzed. Head-surface EEG was recomputed into intracortical current density values in 8 frequency bands using standardized low-resolution electromagnetic tomography. Intracortical current densities were averaged in 19 evenly distributed regions of interest (ROIs). Lagged coherences were computed between each pair of ROIs. Source activity and coherence measures between patients and controls were compared (paired t tests). Reductions in temporal cortex activity and in large-scale functional connectivity in patients compared to controls were observed. Activity reductions affected all 8 EEG frequency bands. Functional connectivity reductions affected the delta, theta, alpha-2, beta-2, and gamma band and involved but were not limited to prefrontal and temporal ROIs. The findings show reduced activation of the temporal cortex and reduced coordination between many brain regions in BD euthymia. These activation and connectivity changes may disturb the continuous frontotemporal information flow required for executive and language-related processing, which is impaired in euthymic BD patients.

A Functional MRI Paradigm Suitable for Language and Memory Mapping in Pediatric Temporal Lobe Epilepsy

Functional Magnetic Resonance Imaging (fMRI) is a technique frequently used to determine the territories of eloquent tissue that serve critical functions, such as language. This can be particularly useful as part of the pre-surgical assessment for temporal lobe epilepsy (TLE) in order to predict cognitive outcome and guide surgical decision-making. Whereas language fMRI is widely used, memory fMRI is less frequently employed in adult TLE, and lacking in childhood TLE. We have developed a combined language/memory fMRI paradigm that is suitable for children, to provide clinically useful information for surgical planning in pediatric TLE. We evaluated this paradigm in 28 healthy children, aged 8 to 18 years. The advantages of this paradigm are: (a) it examines the functional mapping of language and memory networks within one scanning session, (b) provides assessment of both memory encoding- and retrieval-related neural networks, (c) examines recall-based retrieval to engage hippocampal involvement compared to recognition-based retrieval, and (d) provides overt verbal responses to monitor in-scanner memory performance. This novel fMRI paradigm was designed for language and memory mapping in pediatric TLE and could provide clinically useful information for surgical planning. Finally, parallel versions of the paradigm allow the comparison of brain activations pre- and post-surgical intervention.

A Guide to Designing a Memory fMRI Paradigm for Pre-surgical Evaluation in Temporal Lobe Epilepsy

There has been increasing interest in the clinical and experimental use of memory functional Magnetic Resonance Imaging (fMRI). The 2017 American Academy of Neurology practice guidelines on the use of pre-surgical cognitive fMRI suggests that verbal memory fMRI could be used to lateralize memory functions in people with Temporal Lobe Epilepsy (TLE) and should be used to predict post-operative verbal memory outcome. There are however technical and methodological considerations, to optimize both the sensitivity and specificity of this imaging modality. Below we discuss these constraints and suggest recommendations to consider when designing a memory fMRI paradigm.

Neural basis of episodic memory in the intermediate term after medial temporal lobe resection

OBJECTIVE

How the brain supports intermediate-term preservation of memory in patients who have undergone unilateral medial temporal lobe resection (MTLR) has not yet been demonstrated. To understand the neural basis of episodic memory in the intermediate term after surgery for temporal lobe epilepsy (TLE), the authors investigated the relationship between the activation of the hippocampus (HIP) during successful memory encoding and individual memory capacity in patients who had undergone MTLR. They also compared hippocampal activation with other parameters, including structural volumes of the HIP, duration of illness, and age at seizure onset.

METHODS

Thirty-five adult patients who had undergone unilateral MTLR at least 1 year before recruiting and who had a favorable seizure outcome were enrolled (17 left MTLR, 18 right MTLR; mean follow-up 6.31 ± 2.72 years). All patients underwent a standardized neuropsychological examination of memory function and functional MRI scanning with a memory-encoding paradigm of words and figures. Activations of the HIP during successful memory encoding were calculated and compared with standard neuropsychological memory scores, hippocampal volumes, and other clinical variables.

RESULTS

Greater activation in the HIP contralateral to the side of the resection was related to higher postoperative memory scores and greater postoperative memory improvement than the preoperative baseline in both patient groups. Specifically, postoperative verbal memory performance was positively correlated with contralateral right hippocampal activation during word encoding in the left-sided surgery group. In contrast, postoperative visual memory performance was positively correlated with contralateral left hippocampal activation during figure encoding in the right-sided surgery group. Activation of the ipsilateral remnant HIP was not correlated with any memory scores or volumes of the HIP; however, it had a negative correlation with the seizure-onset age and positive correlation with the duration of illness in both patient groups.

CONCLUSIONS

For the first time, a neural basis that supports effective intermediate-term episodic memory after unilateral MTLR has been characterized. The results provide evidence that engagement of the HIP contralateral rather than ipsilateral to the side of resection is responsible for effective memory function in the intermediate term (> 1 year) after surgery in patients who have undergone left MTLR and right MTLR. Engagement of the material-specific contralesional HIP, verbal memory in the left-sided surgery group, and visual memory in the right-sided surgery group were observed.

Improving cognitive task in kindled rats by using low frequency stimulation during epileptogenesis

Numerous studies indicate that one of the bad effects of epilepsy is cognitive impairment. In this study we focused on the effect of LFS as a potential anticonvulsant agent, during epileptogenesis on cognitive impairments induced by amygdala kindling in rat. Twenty-one adult rats were divided into 3 groups including control (n = 7), kindled (n = 7), and Kindled+LFS (KLFS) (n = 7). Animals in the kindled group received kindling stimulation in a rapid kindling manner (a 3 s train of 50 Hz monophasic pulses of 1 ms duration, 12 times a day) in amygdala whereas control animals had no stimulation. Four packages of LFS (each package consisting of 200 monophasic square pulses, 0.1 ms pulse duration at 1 Hz) were applied daily after termination of kindling stimulation in KLFS group. Spatial memory of all animals was tested using radial arm maze after termination of stimulation on acquisition trial days and 14 days after the final acquisition trial test. Epileptogenesis process significantly increased working and reference memory error compared to control groups whereas application of LFS immediately after kindling stimulation prevented this impairment in 8 arm radial maze and there was no significant difference between KLS and control groups. Our results indicated that application of LFS during kindling acquisition suppresses memory impairment in epileptogenesis by kindling stimulation.

Revealing the Dynamic Modulations That Underpin a Resilient Neural Network for Semantic Cognition: An fMRI Investigation in Patients With Anterior Temporal Lobe Resection

One critical feature of any well-engineered system is its resilience to perturbation and minor damage. The purpose of the current study was to investigate how resilience is achieved in higher cognitive systems, which we explored through the domain of semantic cognition. Convergent evidence implicates the bilateral anterior temporal lobes (ATLs) as a conceptual knowledge hub. While bilateral damage to this region produces profound semantic impairment, unilateral atrophy/resection or transient perturbation has a limited effect. Two neural mechanisms might underpin this resilience to unilateral ATL damage: 1) the undamaged ATL upregulates its activation in order to compensate; and/or 2) prefrontal regions involved in control of semantic retrieval upregulate to compensate for the impoverished semantic representations that follow from ATL damage. To test these possibilities, 34 postsurgical temporal lobe epilepsy patients and 20 age-matched controls were scanned whilst completing semantic tasks. Pictorial tasks, which produced bilateral frontal and temporal activation, showed few activation differences between patients and control participants. Written word tasks, however, produced a left-lateralized activation pattern and greater differences between the groups. Patients with right ATL resection increased activation in left inferior frontal gyrus (IFG). Patients with left ATL resection upregulated both the right ATL and right IFG. Consistent with recent computational models, these results indicate that 1) written word semantic processing in patients with ATL resection is supported by upregulation of semantic knowledge and control regions, principally in the undamaged hemisphere, and 2) pictorial semantic processing is less affected, presumably because it draws on a more bilateral network.

New clinicopathological associations and histoprognostic markers in ILAE types of hippocampal sclerosis

Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) is a heterogeneous syndrome. Surgery results in seizure freedom for most pharmacoresistant patients, but the epileptic and cognitive prognosis remains variable. The 2013 International League Against Epilepsy (ILAE) histopathological classification of hippocampal sclerosis (HS) has fostered research to understand MTLE-HS heterogeneity. We investigated the associations between histopathological features (ILAE types, hypertrophic CA4 neurons, granule cell layer alterations, CD34 immunopositive cells) and clinical features (presurgical history, postsurgical outcome) in a monocentric series of 247 MTLE-HS patients treated by surgery. NeuN, GFAP and CD34 immunostainings and a double independent pathological examination were performed. 186 samples were type 1, 47 type 2, 7 type 3 and 7 samples were gliosis only but no neuronal loss (noHS). In the type 1, hypertrophic CA4 neurons were associated with a worse postsurgical outcome and granule cell layer duplication was associated with generalized seizures and episodes of status epilepticus. In the type 2, granule cell layer duplication was associated with generalized seizures. CD34+ stellate cells were more frequent in the type 2, type 3 and in noHS. These cells had a Nestin and SOX2 positive, immature neural immunophenotype. Patients with nodules of CD34+ cells had more frequent dysmnesic auras. CD34+ stellate cells in scarce pattern were associated with higher ratio of normal MRI and of stereo-electroencephalographic studies. CD34+ cells were associated with a trend for a better postsurgical outcome. Among CD34+ cases, we proposed a new entity of BRAF V600E positive HS and we described three hippocampal multinodular and vacuolating neuronal tumors. To conclude, our data identified new clinicopathological associations with ILAE types. They showed the prognostic value of CA4 hypertrophic neurons. They highlighted CD34+ stellate cells and BRAF V600E as biomarkers to further decipher MTLE-HS heterogeneity.

The Roles of Left Versus Right Anterior Temporal Lobes in Semantic Memory: A Neuropsychological Comparison of Postsurgical Temporal Lobe Epilepsy Patients

The presence and degree of specialization between the anterior temporal lobes (ATLs) is a key issue in debates about the neural architecture of semantic memory. Here, we comprehensively assessed multiple aspects of semantic cognition in a large group of postsurgical temporal lobe epilepsy (TLE) patients with left versus right anterior temporal lobectomy (n = 40). Both subgroups showed deficits in expressive and receptive verbal semantic tasks, word and object recognition, naming and recognition of famous faces and perception of faces and emotions. Graded differences in performance between the left and right groups were secondary to the overall mild semantic impairment; primarily, left resected TLE patients showed weaker performance on tasks that required naming or accessing semantic information from a written word. Right resected TLE patients were relatively more impaired at recognizing famous faces as familiar, although this effect was observed less consistently. These findings unify previous partial, inconsistent results and also align directly with fMRI and transcranial magnetic stimulation results in neurologically intact participants. Taken together, these data support a model in which the 2 ATLs act as a coupled bilateral system for the representation of semantic knowledge, and in which graded hemispheric specializations emerge as a consequence of differential connectivity to lateralized speech production and face perception regions.

Memory Rehabilitation in Patients with Epilepsy: a Systematic Review

Memory failure is a common clinical concern of patients with epilepsy and is associated with significant functional impairments. Thus, memory rehabilitation is of critical clinical importance. In this article, we aimed to systematically evaluate the efficacy of memory rehabilitation in patients with epilepsy. The Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to guide searches, extraction and reporting of data in this review. PsycINFO, Medline and PsychBITE searches yielded 95 studies. Twelve papers met inclusion criteria, reporting outcomes of cognitive or behavioural interventions that specifically targeted the rehabilitation of memory in patients with epilepsy. Methodological rigour was rated using the Single-Case Experimental Design (SCED) scale for single-case studies and a modified version of the Downs and Black checklist for group studies. Twelve prospective studies, nine group (six pre-post design, one waitlist crossover, two randomised controlled trials) and three single-case studies were identified. Eleven of the studies included adults, eight of which involved adults with temporal lobe epilepsy (TLE). One paediatric study was identified. The quality of group studies ranged from 36% (poor) to 72% (good), using the modified Downs and Black checklist. Single-case studies were assessed using the SCED scale and assessed to range in quality from four to seven out to 11. Overall, memory rehabilitation was associated with improved memory function in all studies. Verbal memory outcomes were most commonly examined and associated with improvements. This review found that the level of evidence available to support rehabilitation of memory in patients with epilepsy was generally weak and inconsistent. Nevertheless, studies conducted to date, albeit of limited methodological quality, offer preliminary evidence that memory rehabilitation is associated with improvements in verbal memory in patients with temporal lobe epilepsy. Little is known about the efficacy of memory rehabilitation in patients with non-TLE, children, and other aspects of memory difficulties. Guidelines for future research are proposed.

A Functional MRI-Based Model for Individual Memory Assessment in Patients Eligible for Anterior Temporal Lobe Resection

Title:

A functional (f) MRI-based model for individual memory assessment in patients eligible for temporal lobe resection.

Aim:

To investigate if pre-operative fMRI memory paradigms, add predictive information with regard to post-surgical memory deficits.

Methods:

Fourteen pharmacoresistant Temporal Lobe Epilepsy (TLE) patients accepted for Anterior Temporal Lobe Resection (ATLR) were included. A clinical risk assessment score (RAS 0-3) was constructed from structural MRI, neuropsychological testing and hemisphere dominance. fMRI lateralization indices (LIs) over frontal language and medial temporal regions were calculated. Predictive value from clinical risk scoring and added value from fMRI LIs were correlated to post-surgical memory change scores (significant decline -1 SD). Verbal memory outcome was classified either as expected (RAS 2-3 and post-operative decline; RAS 0-1 and intact post-operative verbal memory) or as unexpected (RAS 2-3 and intact post-operative verbal memory post-surgery; RAS 0-1 and post-operative decline).

Results:

RAS for verbal memory decline exhibited a specificity of 67% and a sensitivity of 75%. Significant correlations were found between frontal language LIs and post-operative verbal memory (r = -0.802; p = 0.017) for left (L) TLE and between medial temporal lobe LIs and visuospatial memory (r = 0.829; p = 0.021), as well as verbal memory (r = 0.714; p = 0.055) for right (R) TLE. Ten patients had expected outcome and four patients had an unexpected outcome. In two MRI-negative RTLE patients that suffered significant verbal memory decline post-operatively, fMRI identified bilateral language and right lateralized medial temporal verbal encoding. In two LTLE patients with MRI pathology and verbal memory dysfunction, neither RAS nor fMRI identified the risk for aggravated verbal memory decline following ATLR.

Conclusion:

fMRI visualization of temporal-frontal network activation may add value to the pre-surgical work-up in epilepsy patients eligible for ATLR. Frontal language patterns are important for prediction in both L and RTLE. Strong left lateralized language in LTLE, as well as bilateral language combined with right lateralized encoding in RTLE, seems to indicate an increased risk for post-operative verbal memory decline.

The new approach to classification of focal epilepsies: Epileptic discharge and disconnectivity in relation to cognition

The new classification of epilepsy stratifies the disease into an acute level, based on seizures, and an overarching chronic level of epileptic syndromes (Berg et al., 2010). In this new approach, seizures are considered either to originate and evolve in unilateral networks or to rapidly encompass both hemispheres. This concept extends the former vision of focal and generalized epilepsies to a genuine pathology of underlying networks. These key aspects of the new classification can be linked to the concept of cognitive curtailing in focal epilepsy. The present review will discuss the conceptual implications for acute and chronic cognitive deficits with special emphasis on transient and structural disconnectivity. Acute transient disruption of brain function is the hallmark of focal seizures. Beyond seizures, however, interictal epileptic discharges (IEDs) are increasingly recognized to interfere with physiological brain circuitry. Both concomitant EEG and high-precision neuropsychological testing are necessary to detect these subtle effects, which may concern task-specific or default-mode networks. More recent data suggest that longstanding IEDs may affect brain maturation and eventually be considered as a biomarker of pathological wiring. This brings us to the overarching level of chronic cognitive and behavioral comorbidity. We will discuss alterations in structural connectivity measured with diffusion-weighted imaging and tractography. Among focal epilepsies, much of our current insights are derived from temporal lobe epilepsy and its impact on neuropsychological and psychiatric functioning. Structural disconnectivity is maximal in the temporal lobe but also concerns widespread language circuitry. Eventually, pathological wiring may contribute to the clinical picture of cognitive dysfunction. We conclude with the extrapolation of these concepts to current research topics and to the necessity of establishing individual patient profiles of network pathology with EEG, high-precision neuropsychological testing, and state-of-the-art neuroimaging. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".

Material specificity of memory deficits in children with temporal tumors and seizures: A case series

In adults, left temporal lobe pathology is typically associated with verbal memory deficits, whereas right temporal lobe pathology is thought to produce visual memory deficits in right-handed individuals. However, in children and adolescents with temporal lobe pathology, conclusions regarding material specificity of memory deficits remain unclear. The goal of the present case series is to examine the profile of verbal and visual memory impairment in children with temporal lobe tumors. Three patients with identified right temporal tumors and three patients with left temporal tumors are included. The Wide Range Assessment of Memory and Learning-Second Edition (WRAML-2) was administered as part of a larger neuropsychological battery. As anticipated, participants with right temporal lesions showed impaired visual memory relative to intact verbal memory. Interestingly, although the discrepancies between verbal and visual indices were less extreme, those with left temporal lesions showed a similar memory profile. These seemingly counterintuitive findings among left temporal tumor patients likely reflect less hemispheric specialization in children in comparison to adults and the fact that early developmental lesions in the left hemisphere may lead to functional reorganization of language-based skills.

Clinical utility of the Wechsler Memory Scale - Fourth Edition (WMS-IV) in patients with intractable temporal lobe epilepsy

INTRODUCTION

The Wechsler Memory Scale (WMS) is one of the most widely used test batteries to assess memory functions in patients with brain dysfunctions of different etiologies. This study examined the clinical validation of the Dutch Wechsler Memory Scale - Fourth Edition (WMS-IV-NL) in patients with temporal lobe epilepsy (TLE).

METHOD

The sample consisted of 75 patients with intractable TLE, who were eligible for epilepsy surgery, and 77 demographically matched healthy controls. All participants were examined with the WMS-IV-NL.

RESULTS

Patients with TLE performed significantly worse than healthy controls on all WMS-IV-NL indices and subtests (p<.01), with the exception of the Visual Working Memory Index including its contributing subtests, as well as the subtests Logical Memory I, Verbal Paired Associates I, and Designs II. In addition, patients with mesiotemporal abnormalities performed significantly worse than patients with lateral temporal abnormalities on the subtests Logical Memory I and Designs II and all the indices (p<.05), with the exception of the Auditory Memory Index and Visual Working Memory Index. Patients with either a left or a right temporal focus performed equally on all WMS-IV-NL indices and subtests (F(15, 50)=.70, p=.78), as well as the Auditory-Visual discrepancy score (t(64)=-1.40, p=.17).

CONCLUSION

The WMS-IV-NL is capable of detecting memory problems in patients with TLE, indicating that it is a sufficiently valid memory battery. Furthermore, the findings support previous research showing that the WMS-IV has limited value in identifying material-specific memory deficits in presurgical patients with TLE.

Hurt but still alive: Residual activity in the parahippocampal cortex conditions the recognition of familiar places in a patient with topographic agnosia

The parahippocampal cortex (PHC) participates in both perception and memory. However, the way perceptual and memory processes cooperate when we navigate in our everyday life environment remains poorly understood. We studied a stroke patient presenting a brain lesion in the right PHC, which resulted in a mild and quantifiable topographic agnosia, and allowed us to investigate the role of this structure in overt place recognition. Photographs of personally familiar and unfamiliar places were displayed during functional magnetic resonance imaging (fMRI). Familiar places were either recognized or unrecognized by the patient and 6 age- and education-matched controls in a visual post-scan recognition test. In fMRI, recognized places were associated with a network comprising the fusiform gyrus in the intact side, but also the right anterior PHC, which included the lesion site. Moreover, this right PHC showed increased connectivity with the left homologous PHC in the intact hemisphere. By contrasting recognized with unrecognized familiar places, we replicate the finding of the joint involvement of the retrosplenial cortex, occipito-temporal areas, and posterior parietal cortex in place recognition. This study shows that the ability for left and right anterior PHC to communicate despite the neurological damage conditioned place recognition success in this patient. It further highlights a hemispheric asymmetry in this process, by showing the fundamental role of the right PHC in topographic agnosia.

Visuo-spatial memory deficits following medial temporal lobe damage: A comparison of three patient groups

The contributions of the hippocampal formation and adjacent regions of the medial temporal lobe (MTL) to memory are still a matter of debate. It is currently unclear, to what extent discrepancies between previous human lesion studies may have been caused by the choice of distinct patient models of MTL dysfunction, as disorders affecting this region differ in selectivity, laterality and mechanisms of post-lesional compensation. Here, we investigated the performance of three distinct patient groups with lesions to the MTL with a battery of visuo-spatial short-term memory tasks. Thirty-one subjects with either unilateral damage to the MTL (postsurgical lesions following resection of a benign brain tumor, 6 right-sided lesions, 5 left) or bilateral damage (10 post-encephalitic lesions, 10 post-anoxic lesions) performed a series of tasks requiring short-term memory of colors, locations or color-location associations. We have shown previously that performance in the association task critically depends on hippocampal integrity. Patients with postsurgical damage of the MTL showed deficient performance in the association task, but performed normally in color and location tasks. Patients with left-sided lesions were almost as impaired as patients with right-sided lesions. Patients with bilateral post-encephalitic lesions showed comparable damage to MTL sub-regions and performed similarly to patients with postsurgical lesions in the association task. However, post-encephalitic patients showed additional impairments in the non-associative color and location tasks. A strikingly similar pattern of deficits was observed in post-anoxic patients. These results suggest a distinct cerebral organization of associative and non-associative short-term memory that was differentially affected in the three patient groups. Thus, while all patient groups may provide appropriate models of medial temporal lobe dysfunction in associative visuo-spatial short-term memory, additional deficits in non-associative memory tasks likely reflect damage of regions outside the MTL. Importantly, the choice of a patient model in human lesion studies of the MTL significantly influences overall performance patterns in visuo-spatial memory tasks.

Different effects of anterior temporal lobectomy and selective amygdalohippocampectomy on verbal memory performance of patients with epilepsy

The advantage of selective amygdalohippocampectomy (SAH) over anterior temporal lobectomy (ATL) for the treatment of temporal lobe epilepsy (TLE) remains controversial. Because ATL is more extensive and involves the lateral and medial parts of the temporal lobe, it may be predicted that its impact on memory is more important than SAH, which involves resection of medial temporal structures only. However, several studies do not support this assumption. Possible explanations include task-specific factors such as the extent of semantic and syntactic information to be memorized and failure to control for main confounders. We compared preoperative vs. postoperative memory performance in 13 patients with SAH with 26 patients who underwent ATL matched on side of surgery, IQ, age at seizure onset, and age at surgery. Memory function was assessed using the Logical Memory subtest from the Wechsler Memory Scales - 3rd edition (LM-WMS), the Rey Auditory Verbal Learning Test (RAVLT), the Digit Span subtest from the Wechsler Adult Intelligence Scale, and the Rey-Osterrieth Complex Figure Test. Repeated measures analyses of variance revealed opposite effects of SAH and ATL on the two verbal learning memory tests. On the immediate recall trial of the LM-WMS, performance deteriorated after ATL in comparison with that after SAH. By contrast, on the delayed recognition trial of the RAVLT, performance deteriorated after SAH compared with that after ATL. However, additional analyses revealed that the latter finding was only observed when surgery was conducted in the right hemisphere. No interaction effects were found on other memory outcomes. The results are congruent with the view that tasks involving rich semantic content and syntactical structure are more sensitive to the effects of lateral temporal cortex resection as compared with mesiotemporal resection. The findings highlight the importance of task selection in the assessment of memory in patients undergoing TLE surgery.

Neuropsychological Testing in Interventional Cardiology Staff after Long-Term Exposure to Ionizing Radiation

This study aimed at comparing neuropsychological test scores in 83 cardiologists and nurses (exposed group, EG) working in the cardiac catheterization laboratory, and 83 control participants (non exposed group, nEG), to explore possible cognitive impairments. The neuropsychological assessment was carried out by means of a battery called "Esame Neuropsicologico Breve." EG participants showed significantly lower scores on the delayed recall, visual short-term memory, and semantic lexical access ability than the nEG ones. No dose response could be detected. EG participants showed lower memory and verbal fluency performances, as compared with nEG. These reduced skills suggest alterations of some left hemisphere structures that are more exposed to IR in interventional cardiology staff. On the basis of these findings, therefore, head protection would be a mandatory good practice to reduce effects of head exposure to ionizing radiation among invasive cardiology personnel (and among other exposed professionals).

Neuroimaging of drug resistance in epilepsy

PURPOSE OF REVIEW

Drug resistance is an important clinical problem: it is associated with higher rates of somatic and psychiatric comorbidities and cognitive/memory decline, with seizures being just the 'tip of the iceberg'. This review summarizes recent developments in imaging research, focusing specifically on the functional consequence of chronic epilepsies and mechanisms of drug resistance, restricted to work published in 2013.

RECENT FINDINGS

Functional imaging approaches reliably identify underlying specific networks in patients with different epileptic syndromes, show specific responses to certain antiepileptic drugs and differentiate between responder and nonresponder. Functional MRI (fMRI) and the intracarotid amobarbital test (IAT) are generally congruent, but fMRI may be more sensitive than IAT to right hemisphere language processing. In addition, memory fMRI supports the functional adequacy of ipsilateral structures rather than functional reserve of the contralateral hemisphere. There is further evidence from group analysis of fMRI data for a node within the ipsilateral piriform cortex to be important for seizure modulation in focal refractory epilepsies of different cortical origin. Molecular imaging with verapamil-PET identifies P-glycprotein overexpression as a mechanism contributing to drug resistance in individual patients.

SUMMARY

Neuroimaging in epilepsy has progressed from correlations with demographic, semiologic, neuropsychological and other observational data primarily in patients undergoing presurgical investigations to imaging network connectivity changes in epilepsy syndromes, and testing specific mechanisms underlying drug-resistant epilepsy.