OBJECTIVES: Approximately one-third of candidates for epilepsy surgery have no visible abnormalities on conventional magnetic resonance imaging. This is extremely discouraging, as these patients have a less favorable prognosis. We aimed to evaluate the utility of quantitative magnetic resonance imaging in patients with drug-resistant neocortical focal epilepsy and negative imaging. METHODS: A prospective study including 46 patients evaluated through individualized postprocessing of five quantitative measures: cortical thickness, white and gray matter junction signal, relaxation rate, magnetization transfer ratio, and mean diffusivity. Scalp video-electroencephalography was used to suggest the epileptogenic zone. A volumetric fluid-attenuated inversion recovery sequence was performed to aid visual inspection. A critical assessment of follow-up was also conducted throughout the study. RESULTS: In the subgroup classified as having an epileptogenic zone, individualized postprocessing detected abnormalities within the region of electroclinical origin in 9.7% to 31.0% of patients. Abnormalities outside the epileptogenic zone were more frequent, up to 51.7%. In five patients initially included with negative imaging, an epileptogenic structural abnormality was identified when a new visual magnetic resonance imaging inspection was guided by information gleaned from postprocessing. In three patients, epileptogenic lesions were detected after visual evaluation with volumetric fluid-attenuated sequence guided by video electroencephalography. CONCLUSION: Although quantitative magnetic resonance imaging analyses may suggest hidden structural lesions, caution is warranted because of the apparent low specificity of these findings for the epileptogenic zone. Conversely, these methods can be used to prevent visible lesions from being ignored, even in referral centers. In parallel, we need to highlight the positive contribution of the volumetric fluid-attenuated sequence.

ABSTRACT The purpose of this work was to evaluate the influence of the clinical profile on lamotrigine (LTG) plasma concentrations from patients with refractory epileptic seizures. In this cross-sectional study, therapeutic monitoring of LTG, and questionnaires with 75 patients with refractory epileptic seizures of a Hospital in Ribeirão Preto-SP-Brazil were performed. The multiple linear regression model was used to verify association between the LTG plasma concentrations and the independent variables. Covariance analysis was used to compare the mean LTG plasma concentration among the co-medication groups. The LTG plasma concentration was associated both with the LTG dosage (mg/kg/day) (p=0.0096) and with the use of first generation antiepileptic drugs (AED) (p<0.01), being carbamazepine (CBZ) and phenytoin (PHT), the AEDs showing the most prominent influence in reducing LTG plasma concentrations. Adverse events, adherence to the pharmacological treatment, and epileptic seizures frequency, did not show significant correlation with LTG plasma concentration values. The conclusion is that LTG plasma concentration is significantly influenced by the LTG dosage and by the concomitant use of a first generation AED.

Objetivos Status epilepticus (SE) está associado com morbidade e mortalidade importantes. Diversos estudos avaliaram determinantes de prognóstico relacionados com SE, havendo controvérsias neste sentido. O objetivo deste estudo foi avaliar mortalidade no SE e seus fatores determinantes. Método Estudo prospectivo, em Ribeirão Preto, incluiu 105 pacientes, entre fevereiro e dezembro de 2000. Mortalidade foi definida como óbito no período de internação hospitalar. Resultados O índice de mortalidade foi de 36.2%, superior ao verificado em estudos prévios. Em análise univariada, mortalidade foi associada com idade, antecedente de epilepsia, presença de crises focais complexas, etiologia, recorrência e refratariedade do SE, presença de complicações clínicas e classificação focal do SE. Em análise multivariada, a ocorrência de complicações clínicas relacionou-se significativamente com prognóstico. Conclusões Em nossa amostra, a mortalidade foi mais elevada do que previamente descrito na literatura, não relacionada com idade, etiologia ou duração do SE, mas, em análise multivariada, com complicações médicas durante o tratamento.

Objective Status epilepticus (SE) is associated with significant morbidity and mortality, and there is some controversy concerning predictive indicators of outcome. Our main goal was to determine mortality and to identify factors associated with SE prognosis. Method This prospective study in a tertiary-care university hospital, included 105 patients with epileptic seizures lasting more than 30 minutes. Mortality was defined as death during hospital admission. Results The case-fatality rate was 36.2%, which was higher than in previous studies. In univariate analysis, mortality was associated with age, previous epilepsy, complex focal seizures; etiology, recurrence, and refractoriness of SE; clinical complications, and focal SE. In multivariate analysis, mortality was associated only with presence of clinical complications. Conclusions Mortality associated with SE was higher than reported in previous studies, and was not related to age, specific etiology, or SE duration. In multivariate analysis, mortality was independently related to occurrence of medical complications.

Objetivo Avaliar o perfil de utilização de fármacos antiepilépticos em uma população de pacientes adultos com epilepsia refratária atendidos em um centro terciário. Método Análises descritivas dos dados obtidos dos registros médicos de 112 pacientes. Também foram consideradas as características clínicas e demográficas. Resultados Foram prescritas politerapias com ≥3 antiepilépticos a 60,7% dos pacientes. Em relação aos fármacos de primeira geração, carbamazepina e clobazam foram os mais frequentemente prescritos (a 72,3% e 58,9% dos pacientes, respectivamente). Dentre os novos antiepilépticos, a lamotrigina foi o mais prescrito (36,6% dos pacientes). Ao menos um antiepiléptico de primeira geração foi encontrado em 103 das 104 politerapias; ao menos um novo antiepiléptico foi prescrito a 70,5% da população. A combinação mais prevalente foi carbamazepina+clobazan+lamotrigina. A carga média de antiepilépticos foi 3.3 (0.4 a 7.7). Conclusão O padrão de utilização de antiepilépticos, embora concordante com guias atuais, é fortemente influenciado pelo sistema público de saúde.

Objective To evaluate the utilization profile of antiepileptic drugs in a population of adult patients with refractory epilepsy attending a tertiary center. Method Descriptive analyses of data were obtained from the medical records of 112 patients. Other clinical and demographic characteristics were also registered. Results Polytherapies with ≥3 antiepileptic drugs were prescribed to 60.7% of patients. Of the old agents, carbamazepine and clobazam were the most commonly prescribed (72.3% and 58.9% of the patients, respectively). Among the new agents, lamotrigine was the most commonly prescribed (36.6% of the patients). At least one old agent was identified in 103 out of the 104 polytherapies, while at least one new agent was prescribed to 70.5% of the population. The most prevalent combination was carbamazepine + clobazam + lamotrigine. The mean AED load found was 3.3 (range 0.4–7.7). Conclusion The pattern of use of individual drugs, although consistent with current treatment guidelines, is strongly influenced by the public health system.

RESUMO OBJETIVOS: Pacientes com epilepsia do lobo temporal (ELT) e esclerose hipocampal (EH) unilateral acentuada podem apresentar início ictal contralateral à EH no registro com eletrodos de superfície. Esta situação foi recentemente chamada de "burned-out hippocampus", que pode corresponder a uma entidade rara. Nesse estudo, nós relatamos os casos de quatro pacientes com EH unilateral marcada e início ictal contralateral à EH nas crises registradas com eletrodos de escalpo. Nós discutimos a importância desses casos na avaliação pré-cirúrgica de pacientes com ELT, bem como as possíveis estratégias utilizadas na avaliação desses pacientes. PACIENTES E MÉTODOS: Nós revisamos os dados de todos os pacientes com ELT submetidos a avaliação pré-cirúrgica, que incluiu ressonância magnética (RM) de encéfalo de alta definição e monitorização prolongada com vídeo-eletroencefalograma (vídeo-EEG) com eletrodos de superfície, em um período de 3 anos (2002-2004). Procuramos por pacientes que apresentaram apenas crises com início ictal contralateral ao lado da EH. RESULTADOS: Quatro pacientes preencheram os critérios acima. Dois desses pacientes foram submetidos a monitorização semi-invasiva com eletrodos de forame oval (FO), que mostraram crises com origem no lobo temporal com o hipocampo atrófico, confirmando assim a falsa lateralização no EEG com os eletrodos de superfície. Esses pacientes foram submetidos a tratamento cirúrgico e apresentaram prognóstico pós-operatório favorável com relação ao controle das crises. CONCLUSÃO: "Burned-out hippocampus" pode não ser tão raro quanto se acreditava antes. Mais estudos serão necessários antes que seja possível afirmar que pacientes com EH unilateral e crises com início ictal contralateral à EH no registro com eletrodos de superfície podem ser operados sem confirmação da zona epileptogência através de monitorização invasiva. Nesses pacientes, a monitorização semi-invasiva com eletrodos de FO pode ser uma alternativa.

ABSTRACT OBJECTIVES: Patients with temporal lobe epilepsy (TLE) and unilateral severe hippocampal sclerosis (HS) may have contralateral temporal scalp ictal onset. This has recently been called "burned-out hippocampus", which is believed to be a rare entity. In this study we report four patients with unilateral hippocampal sclerosis and contralateral ictal onset registered by scalp electrodes. We discuss the importance of such cases in presurgical evaluation of patients with TLE, as well as possible strategies used for evaluation of these particular cases. PATIENTS AND METHODS: We reviewed charts from all patients with TLE submitted to pre-surgical evaluation, which included high resolution MRI and prolonged video-electroencephalogram (video-EEG) monitoring with scalp and sphenoidal electrodes, during a three-year period (2002-2004). We looked for patients who only had seizures that were clearly contralateral in location to the atrophic hippocampus. RESULTS: Four patients fulfilled the criteria above. Two of these patients had semi-invasive video-EEG monitoring with foramen ovale (FO) electrodes, which revealed seizures originating from the temporal lobe with the atrophic hippocampus, hence confirming false lateralization in the scalp-sphenoidal EEG. These patients were submitted to surgical treatment and had favorable prognosis after surgery. CONCLUSIONS: Burned-out hippocampus syndrome may not be as rare as it was previously believed. Further studies will be necessary before one can affirm that patients with unilateral HS and scalp ictal EEG showing contralateral ictal onset may be operated without confirmation of the epileptogenic zone by invasive monitoring. In these patients, semi-invasive monitoring with FO electrodes might be an interesting alternative.