Faculty Bibliography

Patients with temporal lobe epilepsy (TLE) often show increased cardiovascular sympathetic modulation during the interictal period, that decreases after epilepsy surgery. In this study, we evaluated whether temporal lobectomy changes autonomic modulation of cerebral blood flow velocity (CBFV) and cerebral autoregulation. We studied 16 TLE patients 3-4 months before and after surgery. We monitored heart rate (HR), blood pressure (BP), respiration, transcutaneous oxygen saturation (sat-O(2)), end-expiratory carbon dioxide partial pressure (pCO(2)) and middle cerebral artery CBFV. Spectral analysis was used to determine sympathetic and parasympathetic modulation of HR, BP and CBFV as powers of signal oscillations in the low frequency (LF) ranges from 0.04-0.15Hz (LF-power) and in the high frequency ranges from (HF) 0.15-0.5Hz (HF-power). LF-transfer function gain and phase shift between BP and CBFV were calculated as parameters of cerebral autoregulation. After surgery, HR, BP(mean), CBFV(mean), respiration, sat-O(2), pCO(2) and HF powers remained unchanged. LF-powers of HR, BP, CBFV and LF-transfer function gain had decreased while the phase angle had increased (p<0.05). The reduction of LF powers and LF-gain and the higher phase angle showed reduced sympathetic modulation and improved cerebral autoregulation. The enhanced cerebrovascular stability after surgery may improve autonomic balance in epilepsy patients

Tuberous sclerosis complex is associated with medically refractory seizures and developmental delay in children. These epilepsies are often resistant to antiepileptic drugs, can be quite severe, and usually have a negative impact on the child's neurologic and cognitive development. It is believed that functional outcome is improved if seizures can be controlled at an early age. The surgical treatment of intractable epilepsy in children and adults with tuberous sclerosis complex has gained significant interest in recent years. Previously published studies have shown a potential benefit from resection of single tubers, with most of the results noted in relatively older children. All of these reports support the idea that if a single primary epileptogenic tuber or region can be identified, then a surgical approach is appropriate. However, most children with tuberous sclerosis complex have multiple potentially epileptogenic tubers, rendering localization challenging, and they are therefore rejected as possible surgical candidates. We have used a novel surgical approach using invasive intracranial monitoring, which is typically multistaged and bilateral. This multistage surgical approach has been useful in identifying both primary and secondary epileptogenic zones in patients with tuberous sclerosis complex with multiple tubers. Multiple or bilateral seizure foci are not necessarily a contraindication to surgery in selected patients. Long-term follow-up will determine whether this approach has durable effects. We await better methods for identifying the epileptogenic zone, both noninvasive and invasive

There is no consensus for the type(s) of treatment(s) that may be effective or ineffective for psychological nonepileptic seizures (PNES). We provided an open-ended group psychotherapy program to 10 patients with PNES, including a disorder-specific psychoeducation treatment component in the first 10 weeks. Seizure frequency and questionnaire responses were examined pre- and posttreatment in all 7 of 10 individuals who completed the majority of the psychoeducational sessions. Four individuals experienced no change in seizure frequency; in three of these this was due to a cessation of events at treatment initiation. Two individuals experienced a decline; and one, an increase, in seizure frequency. Significant decreases were reported in posttraumatic (P=0.003) and dissociative (P=0.04) symptoms and emotionally based coping mechanisms (P=0.03). There was also a trend toward improved quality of life (P=0.07). Experience/expression of anger remained stable. Psychoeducation may be an effective method of treating PNES and may improve coping strategies and reduce PNES-associated psychopathology in some patients. Additional controlled studies on larger samples are needed