Diffusion-weighted MRI (DWI) and perfusion MRI (PI) have been mainly applied in acute stroke, but may provide information in the peri-ictal phase in epilepsy patients. Both transient reductions of brain water diffusion, namely a low apparent diffusion coefficient (ADC), and signs of hyperperfusion have been reported in experimental and human epilepsy case studies. We studied 10 patients with complex partial status epilepticus (CPSE) with serial MRI including DWI and PI. All patients showed regional hyperintensity on DWI, and a reduction of the ADC in (i) the hippocampal formation and the pulvinar region of the thalamus (six out of 10 patients), (ii) the pulvinar and cortical regions (two out of 10), (iii) the hippocampal formation only (one out of 10), and (iv) the hippocampal formation, the pulvinar and the cortex (one out of 10). In all patients a close spatial correlation of focal hyperperfusion with areas of ADC/DWI change was present. In two patients hyperperfusion was confirmed in additional SPECT (single photon emission computed tomography) studies. All patients received follow-up MRI examinations showing partial or complete resolution of diffusion and perfusion abnormalities depending on the length of the follow-up interval. The clinical course, EEG and SPECT results all indicate that MRI detected changes related to prolonged epileptic activity. Combined PI and DWI can visualize haemodynamic and tissue changes after CPSE in the hippocampus, thalamus and affected cortical regions.

To evaluate the effects of a daily patient reminder on seizure documentation accuracy.Design: Randomized controlled trial.Setting: Monitoring unit of an academic department of epileptology.Patients: Consecutive sample of 91 adult inpatients with focal epilepsies undergoing video-electroencephalographic monitoring.Intervention: While all patients were asked to document seizures at the beginning of the monitoring period, patients from the experimental group were reminded each day to document seizures. Main Outcome Measure: Documentation accuracy (percentage of documented seizures).Results: A total of 582 partial seizures were recorded. Patients failed to document 55.5% of all recorded sei-zures, 73.2% of complex partial seizures, 26.2% of simple partial seizures, 41.7% of secondarily generalized tonicclonic seizures, 85.8% of all seizures during sleeping, and 32.0% of all seizures during the awake state. The group medians of individual documentation accuracies for overall seizures, simple partial seizures, complex partial seizures, and secondarily generalized tonic-clonic seizures were 33.3%, 66.7%, 0%, and 83.3%, respectively. Neither the patient reminder nor cognitive performance affected documentation accuracy. A left-sided electroencephalographic focus or lesion, but not the site (frontal or temporal), contributed to documentation failure.Conclusions: Patient seizure counts do not provide valid information. Documentation failures result from postictal seizure unawareness, which cannot be avoided by reminders. Unchanged documentation accuracy is a prerequisite for the use of patient seizure counts in clinical trials and has to be demonstrated in a subsample of patients undergoing electroencephalographic monitoring.

Summary:Purpose: To evaluate the long-term outcome of medication-reduction/discontinuation trials after epilepsy surgery in pediatric patients.Methods: Of the total Bonn pediatric surgical sample (1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001); n = 251), we were able to obtain postsurgical follow-up data for 232 patients. We surveyed 140 of these patients by using a standardized telephone interview that addressed medicationreduction/discontinuation trials.Results: Of the 140 surveyed patients, 102 completely discontinued medication. Seven of these patients had recurring seizures that were controlled again after restarting the medication. Of 102 patients, 101 were completely seizure free during the 3 months before the survey. Postsurgical epileptic events before the trial significantly increased the risk for recurring epileptic events after the trial. Two surveyed patients lost postsurgical seizure freedom after medication reduction. We were also able to identify from the records another nine patients with complete medication discontinuation and seven patients with medication reduction. Two of these latter patients lost postsurgical seizure freedom despite restarting their medication. The total rate of patients with medication-reduction/discontinuation trials was 55%. The seizure recurrence rate in these patients was 10%. Recurring seizures could not be controlled by restarted medication in 3% of the trials. Currently, 90% of patients with discontinuation trials were seizure free without medication.Conclusions: The reduction/withdrawal of anticonvulsant medication after successful epilepsy surgery has a low risk of seizure recurrence for pediatric patients in long-term follow-up, particularly in cases of complete postsurgical seizure freedom before the trial. Key Words: Epilepsy surgery in childrenMedication withdrawal-Anticonvulsants.Epilepsy surgery is acknowledged as a highly effective therapeutic intervention for children and adults with pharmacoresistant focal seizures. Earlier studies with relatively short outcome periods are now being compared with long-term outcome (≥5 years seizure free) (1). The postoperative long-term outcome in pediatric and adult samples is similar, with 60-70% (2-6) of patients experiencing a complete relief from seizures. A recent review (7) raised the issue as to whether successful epilepsy surgery may be regarded as "curative" (i.e., sustained seizure freedom without medication). According to Schmidt et al. (7), only 40-60% of the seizure-free adult patients risk a medication-discontinuation trial. About one third of these patients experience a recurrence of epileptic events after the withdrawal trial as compared with 7-17% of postsurgical patients under continued medication. those patients who experience seizure recurrence does not guarantee complete seizure relief. The authors hypothesize as to whether the outcome of the discontinuation trials might be advantageous in pediatric samples. They refer to a preliminary poster abstract (8) [higher...

No abstract

No abstract