- Neurology - Child Neurology
Board Certification: Epilepsy, American Board of Psychiatry and Neurology (2013)
Board Certification: Clinical Neurophysiology, American Board of Psychiatry and Neurology (2009)
Board Certification: Neurology - Child Neurology, American Board of Psychiatry and Neurology (2007)
Fellowship:Cleveland Clinic Foundation Clinical Neurophysiology Fellowship (2007) OH
Residency:Medical College of Georgia Child Neurology Residency (2006) GA
Internship:Medical College of Georgia Pediatric Residency (2003) GA
Fellowship, Seoul National University Hospital, Seoul, South Korea (1997)
Fellowship, Ewha Womans University Hospital, Seoul, South Korea (1996)
Residency, Asan Medical Center, Seoul, South Korea (1995)
Intership, Younsei University Severance Hospital, Seoul, South Korea (1991)
Medical Education, Ewha Womans University School of Medicine, Seoul, South Korea (1989)
New-onset lesional and nonlesional epilepsy in the US population: Patient characteristics and patterns of antiepileptic drug use.
2019; 157: 106210
PURPOSE: Describe treatment patterns in patients from the United States with new-onset epilepsy, comparing those with and without lesional epilepsy.METHODS: In this observational study we used Truven Health MarketScan databases derived from commercial health insurance, Medicare and Medicaid claims covering at least 5 years, commencing in 2008. We identified incident epilepsy cases based on International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating epilepsy or recurrent seizures, taking into account antiepileptic drug (AED) claims, consistent with International League Against Epilepsy Commission on Epidemiology recommendations. We identified patients with lesional epilepsy when associated diagnoses indicated central nervous system infection, neoplasm, traumatic brain injury, stroke, senile dementia and static encephalopathy. Lesional and nonlesional cohorts were matched 1:1 on baseline characteristics of age, sex and insurance type for group comparisons.RESULTS: In unmatched cohorts lesional epilepsy patients (N = 15,302) were more commonly older (mean age 48.7 years) compared with nonlesional epilepsy patients (N = 15,970; mean age 18.5 years). Among lesional patients <20 years of age, the leading putative etiology was static encephalopathy, while among ages ≥20 years and older, the leading putative etiology was stroke or cerebrovascular disease. In matched cohorts (7063 patients each), those with lesional epilepsy were significantly less likely to be untreated at 1 year versus those with nonlesional epilepsy (37.2% vs 56.1%). In children and adults among matched cohorts, levetiracetam was the most common AED prescribed for initial AED therapy for the lesional (39.5%) and nonlesional (32.1%) groups. Lesional epilepsy patients on monotherapy were only slightly less likely than nonlesional epilepsy patients to be on the same AED 1 year after treatment initiation (55.6% vs 59.7%).SIGNIFICANCE: Compared with patients with lesional epilepsy, a higher proportion of patients with nonlesional epilepsy remain untreated 1 year after diagnosis. There were differences in AED selection by epilepsy etiology; levetiracetam is the most commonly prescribed drug for both cohorts.
View details for DOI 10.1016/j.eplepsyres.2019.106210
View details for PubMedID 31605878
- Response to the Letter. Journal of child neurology 2019: 883073819876142
- Antiepileptic Drug Treatment Patterns in Women of Childbearing Age With Epilepsy JAMA NEUROLOGY 2019; 76 (7): 783–90
- Independent role of neonatal seizures in subsequent neurological outcomes: a population-based study DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY 2019; 61 (6): 661-+
Assessment and effect of a gap between new-onset epilepsy diagnosis and treatment in the US.
OBJECTIVE: To estimate the treatment gap between a new epilepsy diagnosis and antiepileptic drug (AED) initiation in the United States.METHODS: Retrospective claims-based cohort study using Truven Health MarketScan databases (commercial and supplemental Medicare, calendar years 2010-2015; Medicaid, 2010-2014) and a validation study using PharMetrics Plus Database linked to LRx claims database (2009-2014). Persons met epilepsy diagnostic criteria, had an index date (first epilepsy diagnosis) with a preceding 2-year baseline (1 year for persons aged 1 to <2 years; none for persons <1 year), and continuous medical and pharmacy enrollment without epilepsy/seizure diagnosis or AED prescription during baseline. Outcomes included percentage of untreated persons (no AED prescription) up to 3 years' follow-up and comparative outcomes (incidence rate ratio: untreated persons/treated persons), including medical events and health care resource utilization.RESULTS: In the primary study, 59,970 persons met selection (or inclusion) criteria; 36.7% of persons with newly diagnosed epilepsy remained untreated up to 3 years after diagnosis. In the validation study (N = 30,890), 31.8% of persons remained untreated up to 3 years after diagnosis. Lack of AED treatment was associated with an adjusted incidence rate ratio (95% confidence interval) of 1.2 (1.2-1.3) for medical events, 2.3 (2.2-2.3) for hospitalizations, and 2.8 (2.7-2.9) for emergency department visits.CONCLUSIONS: One-third of newly diagnosed persons remain untreated up to 3 years after epilepsy diagnosis. The increased risk of medical events and health care utilization highlights the consequences of delayed treatment after epilepsy diagnosis, which might be preventable.
View details for PubMedID 30971487
Clinical Characteristics and Nonconvulsive Seizures in Young Children With Abusive Head Trauma.
Journal of child neurology
We aimed to evaluate putative predictors of symptoms and signs at admission for nonconvulsive seizure and to examine the impact of nonconvulsive seizures on short-term outcomes.We retrospectively collected consecutive abusive head trauma patients (<36 months of age) from the trauma registry at Children's Healthcare of Atlanta between 2009 and 2014. Multiple logistic regression was performed to assess the putative predictors for the occurrence of nonconvulsive seizures including clinical seizures, altered mental status, respiratory difficulty, and cardiac arrest at admission, while controlling for age, sex, and injury severity. The Mann-Whitney U test and the Fisher exact test were used to compare the short-term outcomes between patients with and without nonconvulsive seizures.Two hundred seventy patients with abusive head trauma were identified (male = 55.6%). The median age was 4 months (interquartile range = 2-8 months). Among 70 patients who underwent continuous electroencephalography (EEG), 40 had nonconvulsive seizures (57%) and 21 developed nonconvulsive status epilepticus (30%). Altered mental status at admission was associated with the occurrence of nonconvulsive seizures (odds ratio = 6.8, 95% confidence interval = 1.2-38.2, P = .03). Comparing patients with no seizures, those with nonconvulsive seizures were more likely to stay longer at hospital (9 days vs 14 days, P = .04) and to need rehabilitation (50.0% vs 63.2%, P = .03).Nonconvulsive seizures and nonconvulsive status epilepticus was highly prevalent in young pediatric patients with abusive head trauma. Presenting with altered mental status at admission was found to predict the occurrence of nonconvulsive seizures. Nonconvulsive seizures had an unfavorable impact on short-term outcomes.
View details for DOI 10.1177/0883073819853973
View details for PubMedID 31185789
Patient characteristics and treatment patterns in patients with newly diagnosed epilepsy: A US database analysis.
Epilepsy & behavior : E&B
2018; 85: 37–44
The objective of this study was to determine patient characteristics and antiepileptic drug (AED) treatment patterns in patients with newly diagnosed epilepsy in a United States (US) population followed for ≥180 days.In this retrospective cohort study, Commercial, Supplemental Medicare, and Medicaid insurance claims from US-based Truven Health MarketScan® claims database were analyzed for incident epilepsy cases (index date: January 2010-June 2013; prior baseline of 2 years [1 year for ages 1 to <2 years; none for those <1 year]). Cases met epilepsy criteria consistent with the International League Against Epilepsy diagnostic guidelines, with continuous medical and pharmacy enrollment without an epilepsy or seizure diagnosis or AED prescription during baseline. Treatment was classified as monotherapy (one AED for ≥90 continuous days), polytherapy (at least two AEDs for ≥90 days), or untreated (no AED claims but other pharmacy or healthcare claims). Treatment pattern comparisons used matched cohorts across seizure types.Of 58,757 incident cases, 50,838 had a follow-up of ≥180 days. The median (range) follow-up duration was 529 (180-1096) days. Patient characteristics were similar across seizure types (matched focal vs. generalized epilepsy, N = 9949 each). At 6 and 12 months post-index, 46.8% and 52.2% of patients, respectively, had received AED treatment. Of 29,226 patients receiving treatment, 74.7% and 1.6% received monotherapy and polytherapy for ≥90 days, respectively, as first-line treatment; remaining patients received AED for <90 days and were excluded. The probability of remaining on initial treatment after 1 year was 61.0% for monotherapy and 36.5% for polytherapy. The most common first-line AEDs were levetiracetam (44.4%), phenytoin (6.5%), valproic acid (6.4%), lamotrigine (6.3%), oxcarbazepine (5.7%), topiramate (5.5%), and gabapentin (5.3%).Although the majority of treated patients received AED monotherapy consistent with guidelines, suboptimal rates of AED treatment and persistence of first-line treatment after initial epilepsy diagnosis suggest that efforts are needed to improve patient care.
View details for DOI 10.1016/j.yebeh.2018.05.019
View details for PubMedID 29906700
Use of an intraventricular strip electrode for mesial temporal monitoring in children with medically intractable epilepsy
JOURNAL OF NEUROSURGERY-PEDIATRICS
2017; 19 (4): 495-501
OBJECTIVE The objective of this study was to evaluate mesial temporal electroencephalographic (EEG) monitoring, using an intraventricular strip electrode (IVSE) along the ventricular surface of the hippocampus, in children with medically intractable epilepsy. METHODS The authors reviewed 10 consecutive cases in which subdural electrode placements and mesial temporal monitoring were recommended. The median age of the patients was 12.7 years (range 4.5-19.3 years). Both grids and IVSE were placed in all patients. The 4-contact IVSE was used in 5 cases, and the 6-contact IVSE in the other 5 cases. The median number of contacts, including IVSE contacts, was 122 (range 66-181). A total of 182 seizures were analyzed. RESULTS The IVSE localized seizure-onset zones in 8 patients. The seizure-onset zone was identified exclusively by IVSE in 3 patients and was simultaneous in IVSE and subdural electrodes in 5 patients. Among the 5 patients with simultaneous onset on both IVSE and subdural electrodes, 4 had basal temporal onset and one had orbitofrontal and lateral midtemporal onset. In the remaining 2 patients, the absence of IVSE seizure onset permitted sparing of mesial temporal structures. An Engel Class Ia outcome was achieved in 9 of 10 cases. No complication was associated with IVSE placement. CONCLUSIONS Intracranial monitoring using IVSE offers an alternative in terms of quality of EEG recording. IVSE was useful in children who already required open craniotomy for intracranial monitoring over an extensive network of hyper-excitability.
View details for DOI 10.3171/2016.10.PEDS16407
View details for Web of Science ID 000397355000015
View details for PubMedID 28156216
Comorbidities and risk factors associated with newly diagnosed epilepsy in the U.S. pediatric population.
Epilepsy & behavior : E&B
2017; 75: 230–36
Neurobehavioral comorbidities can be related to underlying etiology of epilepsy, epilepsy itself, and adverse effects of antiepileptic drugs. We examined the relationship between neurobehavioral comorbidities and putative risk factors for epilepsy in children with newly diagnosed epilepsy. We conducted a retrospective analysis of children aged ≤18years in 50 states and the District of Columbia, using the Truven Health MarketScan® commercial claims and encounters database from January 1, 2009 to December 31, 2013. The eligible study cohort was continuously enrolled throughout 2013 as well as enrolled for any days during a baseline period of at least the prior 2years. Newly diagnosed cases of epilepsy were defined by International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or recurrent seizures and evidence of prescribed antiepileptic drugs during 2013, when neither seizure codes nor seizure medication claims were recorded during baseline periods. Twelve neurobehavioral comorbidities and eleven putative risk factors for epilepsy were measured. More than 6 million children were analyzed (male, 51%; mean age, 8.8years). A total of 7654 children were identified as having newly diagnosed epilepsy (125 per 100,000, 99% CI=122-129). Neurobehavioral comorbidities were more prevalent in children with epilepsy than children without epilepsy (60%, 99% CI=58.1-61.0 vs. 23%, CI=23.1-23.2). Children with epilepsy were far more likely to have multiple comorbidities (36%, 99% CI=34.3-37.1) than those without epilepsy (8%, 99% CI=7.45-7.51, P<0.001). Preexisting putative risk factors for epilepsy were detected in 28% (99% CI=26.9-29.6) of children with epilepsy. After controlling for demographics, neurobehavioral comorbidities, family history of epilepsy, and other risk factors than primary interest, neonatal seizures had the strongest independent association with the development of epilepsy (OR=29.8, 99% CI=23.7-37.3, P<0.001). Compared with children with risk factors but no epilepsy, those with both epilepsy and risk factors were more likely to have intellectual disabilities (OR=13.4, 99% CI=11.9-15.0, P<0.001). The epilepsy and intellectual disabilities could share the common pathophysiology in the neuronal network.
View details for DOI 10.1016/j.yebeh.2017.07.040
View details for PubMedID 28844439
- Utility of gray-matter segmentation of ictal-Interictal perfusion SPECT and interictal 18F-FDG-PET in medically refractory epilepsy Epilepsy Res 2017; 130: 93-100
Estimating Epilepsy Incidence and Prevalence in the US Pediatric Population Using Nationwide Health Insurance Claims Data
JOURNAL OF CHILD NEUROLOGY
2016; 31 (6): 743-749
This study aims to determine prevalence and incidence of epilepsy in the US pediatric population. We analyzed commercial claims and Medicaid insurance claims data between 2008 and 2012. Over 8 million continuously enrolled lives aged 0 to 19 years were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified in subjects continuously enrolled for ≥2 years of which the first 2 years had no indication of epilepsy or seizures. The overall prevalence estimate for 2012 was 6.8 per 1,000 children. The overall incidence estimate for 2012 was 104 per 100,000 pediatric population. This study provides estimates of the prevalence and incidence of epilepsy in the US pediatric population, using large claims datasets from multiple US population sectors. The findings appear reasonably representative of the US-insured pediatric population.
View details for DOI 10.1177/0883073815620676
View details for Web of Science ID 000374327400011
View details for PubMedID 26719495
Seizure Recurrence in Developmentally and Neurologically Normal Children With a Newly Diagnosed Unprovoked Seizure
JOURNAL OF CHILD NEUROLOGY
2016; 31 (4): 421-425
This study aims to assess recurrence risk in developmentally and neurologically normal children with a newly diagnosed unprovoked seizure. The medical record was retrospectively reviewed in 393 children who had a newly diagnosed, unprovoked seizure. A total of 152 children met inclusion criteria. The relationship between seizure recurrence and variables was examined. Seventy cases had recurrent seizures. Total 113 cases had follow-up data and 70 cases of these (63.7%) experienced recurrent seizures. EEG was abnormal in 65 (44.8%): focal epileptiform abnormality in 34 cases (23.4%) and generalized epileptiform abnormality in 23 cases (15.9%). Brain MRI revealed any structural abnormality in 14 of 86 cases (16.3%). Neither EEG abnormality nor brain MRI abnormality was statistically significantly associated with increased seizure recurrence in this cohort. Further study is required to confirm the EEG and brain MRI findings in otherwise normal children with a newly diagnosed unprovoked seizure.
View details for DOI 10.1177/0883073815596616
View details for Web of Science ID 000370719900003
View details for PubMedID 26215392
Effect of EEG electrode number on epileptic source localization in pediatric patients
2015; 126 (3): 472-480
To investigate the relationship between EEG source localization and the number of scalp EEG recording channels.128 EEG channel recordings of 5 pediatric patients with medically intractable partial epilepsy were used to perform source localization of interictal spikes. The results were compared with surgical resection and intracranial recordings. Various electrode configurations were tested and a series of computer simulations based on a realistic head boundary element model were also performed in order to further validate the clinical findings.The improvement seen in source localization substantially decreases as the number of electrodes increases. This finding was evaluated using the surgical resection, intracranial recordings and computer simulation. It was also shown in the simulation that increasing the electrode numbers could remedy the localization error of deep sources. A plateauing effect was seen in deep and superficial sources with further increasing the electrode number.The source localization is improved when electrode numbers increase, but the absolute improvement in accuracy decreases with increasing electrode number.Increasing the electrode number helps decrease localization error and thus can more ably assist the physician to better plan for surgical procedures.
View details for DOI 10.1016/j.clinph.2014.05.038
View details for Web of Science ID 000349616700009
View details for PubMedID 25088733
View details for PubMedCentralID PMC4289666
Magnetic source imaging (MSI) in children with neocortical epilepsy: Surgical outcome association with 3D post-resection analysis
2013; 106 (1-2): 164-172
To investigate the validity of magnetic source imaging (MSI) to localize seizure-onset zone using 3D analysis of pre-operative MSI source imaging coregistered to post-resection MRI following neocortical epilepsy surgery.Twenty-two children who had MSI and epilepsy surgery were studied (median age=11 years, 1 year 2 months-22 years). Only seven (31.8%) had localized lesions on pre-operative conventional brain MRIs. Sixteen (72.7%) underwent intracranial EEG monitoring. Mean post-operative follow-up was 4.7 years (1 year 3 months-8 years 2 months). Fifteen patients (68%) were seizure-free. MEG spike dipole sources were superimposed onto post-operative MRIs. The number and proportion of spike dipoles within resection volume were calculated and compared between seizure free and non-free groups.Both number of dipole clusters and proportion of dipoles in resection volume were not associated with seizure-free outcome (p>0.05). In seven cases with MRI lesions, six of these with a ≥70% dipoles within the resection margin were seizure-free, while one with the proportion <70% was not seizure-free. Further, among the 15 cases with non-localized or normal MRI, five with both the proportion <70% and multiple dipoles clusters were post-operatively seizure free.Number and density of clustered spike dipole sources within the surgical resection volume is not associated with postoperative seizure-free outcome. MSI successfully localized the perilesional epileptogenic zone in cases with localized MRI lesions, but not in cases with normal MRI in this study. Even if MEG localizes spikes to a single focal region, confirmation of epilepsy localization with intracranial EEG is still recommended in cases with non-lesional MRI.
View details for DOI 10.1016/j.eplepsyres.2013.04.004
View details for Web of Science ID 000324665600018
View details for PubMedID 23689013
Major white matter fiber changes in medically intractable neocortical epilepsy in children: A diffusion tensor imaging study
2013; 103 (2-3): 211-220
This study aimed to investigate the extent of microstructural changes in the major white matter fibers and to evaluate whether diffusion tensor imaging (DTI) adds any lateralizing information in children with medically intractable neocortical epilepsy secondary to focal cortical dysplasia. Patient group included twenty-three consecutively enrolled patients with medically intractable focal neocortical epilepsy and focal cortical dysplasia histopathologically confirmed. Thirteen patients (56.5%) had no visible lesion on the conventional magnetic resonance imaging (MRI). Fractional anisotropy (FA) was measured for regions of interest (ROIs) in each major white matter fiber. FA in patients was compared with eighteen age-matched healthy controls. Patient group had lower FA values at corpus callosum, bilateral inferior frontooccipital fasciculus (IFO), bilateral inferior longitudinal fasciculus (ILF) and left superior longitudinal fasciculus (SLF) compared to controls (p<0.05). In the left-side surgery group, the left SLF FA value was lower than controls, while in the right-side surgery group, the right SLF FA values were lower than controls (p<0.05). In the patient group as a whole, ipsilateral SLF FA was significantly lower than the contralateral SLF (p<0.05). Widespread decrease in FA values in the patients compared with the controls suggests that the pathologic changes extend diffusely to most major white matter tracts. In the patient group, the ipsilateral SLF to the seizure focus had greater change compared to the contralateral SLF. These data suggest that the detection of DTI abnormality has an added value to lateralization.
View details for DOI 10.1016/j.eplepsyres.2012.07.017
View details for Web of Science ID 000315372600010
View details for PubMedID 22917916
Safety and utility of supplemental depth electrodes for localizing the ictal onset zone in pediatric neocortical epilepsy Clinical article
JOURNAL OF NEUROSURGERY-PEDIATRICS
2011; 8 (1): 49-56
Depth electrodes provide a better sampling of sulci and regions of cortex that lie tangential to the plane of subdural electrodes. The aim of this study was to evaluate the utility of supplemental depth electrodes in the surgical treatment of pediatric patients with neocortical epilepsy.Cases involving 12 consecutive pediatric patients (mean age [SD] 10.9 ± 4.4 years) were reviewed. Focal resective surgery (in 9 cases) or functional hemispherectomy (in 3 cases) was performed after intracranial monitoring. The mean total number of electrodes was 118 ± 29; the mean numbers of grid, strip, and depth electrodes were 95 ± 27, 10 ± 6, and 13 ± 5, respectively The most common pathological condition was focal cortical dysplasia.In 4 cases, depth electrodes demonstrated the ictal onset zone in an area not easily accessible by grids or strips (in the basal temporal region in 3 cases and the upper opercular region in 1 case). In 3 of these 4 cases, the ictal onset zone was defined exclusively by the depth electrodes. In each of these 3 cases, the surface electrodes (on grids or strips) demonstrated early propagation but not ictal onset. In 9 cases, the depth electrodes also demonstrated the early propagation zone. The information about the ictal onset zone and the early propagation zone helped to provide additional information that affected the extent (in 7 cases) or depth (in 3 cases) of the resection. The proportion of the electrodes involved in resection relative to the total number of implanted electrodes was low (mean ± SD, 0.26 ± 0.09). Nine patients (75.0%) became seizure free (Engel class IA outcome) after surgery (mean duration of follow-up 25.7 ± 4.29 months). There were no surgical complications related to intracranial electroencephalography monitoring.Most patients (75.0%) became seizure free after extensive monitoring and more limited resection of seizure-onset regions. Supplemental depth electrodes contribute to improved outcome by providing information about the ictal onset zone that is not accessible by grid or strip electrodes in some cases. The supplemental depth electrodes conferred an extra dimension of depth to the analysis, which allowed for successful outcome with more limited resection.
View details for DOI 10.3171/2011.4.PEDS10519
View details for Web of Science ID 000292005000009
View details for PubMedID 21721889
Long-term neuropsychological follow-up of a child with Klaver-Bucy syndrome
EPILEPSY & BEHAVIOR
2010; 19 (4): 643-646
We describe the case of a 10-year-old girl who developed behavioral changes consistent with Klüver-Bucy Syndrome following Listeria meningoencephalitis at 2½ years of age. MRI at age 4 revealed evidence of diffuse brain atrophy with predominant temporal lobe involvement. Electroencephalograpy at 9½ years of age showed abnormal electrical discharges from the left temporal area. Follow-up MRI with volumetric analysis of the mesial temporal structures at 9 years of age demonstrated decreased hippocampal volume bilaterally. Consistent with the morphological abnormalities, serial neuropsychological evaluations demonstrated expressive and receptive language impairment and an amnestic syndrome that significantly decreased her ability to make new declarative memories and maintain adequate academic progress.
View details for DOI 10.1016/j.yebeh.2010.09.003
View details for Web of Science ID 000285657100019
View details for PubMedID 20926352
Language assessment in Wada test: Comparison of methohexital and amobarbital
SEIZURE-EUROPEAN JOURNAL OF EPILEPSY
2009; 18 (9): 656-659
Methohexital has replaced amobarbital during Wada testing at many centers. The objective of our study was to compare the use of methohexital and amobarbital during Wada testing regarding language and memory lateralization quotients as well as speech arrest times.A chart review of 582 consecutive patients undergoing 1041 Wada-procedures was performed (left=60, right=63, bilateral=459). Language lateralization was calculated based on duration of speech arrest using a laterality index, defined as (L-R)/(L+R). Memory lateralization was expressed as percentage of retained objects and laterality quotient.Language and memory lateralization revealed a similar distribution with amobarbital and methohexital. Speech arrest after left and right-sided injection was significantly longer in the amobarbital group as compared to the methohexital group. Language lateralization did not differ in the two groups. Percentage of retained memory items was higher in the methohexital group and there were fewer presented test items in the methohexital group.Language and memory testing during the Wada test can successfully be performed with methohexital instead of amobarbital. The shorter half-life of methohexital allows repeated injections and shorter interhemispheric testing intervals, but also shortens the testing window.
View details for DOI 10.1016/j.seizure.2009.08.002
View details for Web of Science ID 000272116700011
View details for PubMedID 19800265
Secondary white matter degeneration of the corpus callosum in patients with intractable temporal lobe epilepsy: A diffusion tensor imaging study
2008; 81 (2-3): 136-142
Imaging changes in patients with focal epilepsy are not only seen in areas where seizures arise but often also in remote locations. The mechanism for such changes is unknown. We aimed to investigate whether patients with temporal lobe epilepsy (TLE) have microstructural changes involving the posterior portion of the corpus callosum (CC), where it links the temporal lobes, using presurgical diffusion tensor imaging (DTI) sequences. Ten patients with medically intractable TLE (two mesial TLE, eight neocortical TLE) who had seizure-free surgical outcomes were compared with 10 healthy controls. The regions of interest were outlined at each Witelson region (WR). Fractional anisotropy (FA), apparent diffusion coefficient (ADC) and three principal diffusivity values (lambda1, lambda2, lambda3) were determined in each WR. We performed tractography originating at each WR. In the TLE patients, the FA values were lower at the splenium of the corpus callosum (WR 7) compared to controls (p<0.05). Analysis of Eigen values in that location revealed that lambda1 values were decreased while lambda2 and lambda3 values were increased (p<0.05). Tractography revealed the connection between both temporal lobes via WR 7. In conclusion, decreased FA values with decreased lambda1 and increased lambda2 and lambda3 at the splenium of CC suggest that the pathologic changes, Wallerian degeneration, extend to the corpus callosum in TLE patients. Seizure-induced damage may cause secondary white matter degeneration along the tapetum and through the splenium of the corpus callosum, a potential pathway of spread in temporal lobe seizures.
View details for DOI 10.1016/j.eplepsyres.2008.05.005
View details for Web of Science ID 000261021000006
View details for PubMedID 18572387
Advances in intracranial monitoring
2008; 25 (3)
Intracranial monitoring using electroencephalography (IC-EEG) continues to play a critical role in the assessment of patients with medically intractable localization-related epilepsy. There has been minimal change in grid or electrode design in the last 15-20 years, and the surgical approaches for implantation are unchanged. Intracranial monitoring using EEG allows detailed definition of the region of ictal onset and defines the epileptogenic zone, particularly with regard to adjacent potentially eloquent tissue. Recent developments of IC-EEG include the coregistration of functional imaging data such as magnetoencephalography to the frameless navigation systems. Despite significant inherent limitations that are often overlooked, IC-EEG remains the gold standard for localization of the epileptogenic cortex. Intracranial electrodes take a variety of different forms and may be placed either in the subdural (subdural strips and grids, depth electrodes) or extradural spaces (sphenoidal, peg, and epidural electrodes). Each form has its own advantages and shortcomings but extensive subdural implantation of electrodes is most common and is most comprehensively discussed. The indications for intracranial electrodes are reviewed.
View details for DOI 10.3171/FOC/2008/25/9/E18
View details for Web of Science ID 000258823500018
View details for PubMedID 18759619
Do observer and self-reports of ictal eye closure predict psychogenic nonepileptic seizures?
2008; 49 (5): 898-904
Diagnostic delay in distinguishing psychogenic nonepileptic seizures (PNES) from epileptic seizures may result in unnecessary therapeutic interventions and higher health care costs. Previous studies demonstrated that video-recorded eye closure is associated with PNES. The present study prospectively assessed whether observer or self-report of eye closure could predict PNES, prior to video-EEG monitoring.Adults referred to an epilepsy monitoring unit (EMU) were prospectively enrolled into the study. At baseline, self-report of eye closure was assessed by questionnaire, and observer report was obtained by interview. Physicians viewed video clips independent of EEG tracings and determined the duration of eye closure during PNES and epileptic seizures. We evaluated whether video-recorded eye closure identified an episode as PNES using random effects models that accounted for episode clustering by subject. The utility of observer and self-report of eye closure in predicting a diagnosis of PNES was tested using logistic regression.Of 132 enrolled subjects, 112 met study criteria during EMU stay for either PNES (n = 43, 38.4%) or epilepsy (n = 84, 75.0%). Fifteen of the 43 PNES subjects (34.9%) had coexisting epilepsy. Self and observer reports of eye closure were neither sensitive nor specific for the diagnosis of PNES. Self-report of eye closure more accurately predicted actual video-recorded eye closure than observer report. Video-recorded eye closure was 92% specific, but only 64% sensitive for PNES identification.Neither observer nor self-report of eye closure, prior to VEEG monitoring, predicts PNES. Video-recorded eye closure may not be as sensitive an indicator of PNES as previously reported.
View details for DOI 10.1111/j.1528-1167.2007.01456.x
View details for Web of Science ID 000255480500017
View details for PubMedID 18070093
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