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Article abstract-We performed functional MRI (FMRI) in 22 consecutive epilepsy patients undergoing intracarotid amobarbital (Wada) testing and compared language lateralization measures obtained with the two procedures. FMRI used a single-word semantic decision task previously shown to activate lateralized language areas in normal adults. Correlation between the two tests was highly significant (r = 0.96; 95% CIS 0.90 to 0.98; p < 0.0001). These results validate the FMRI technique and suggest that "active" areas observed with this semantic processing task correspond to those underlying hemispheric dominance for language. The strong correlation observed supports the view that language lateralization is a continuous rather than a dichotomous variable. In addition to lateralization information, FMRI consistently demonstrated focal regions of activity in lateral frontal and temporo-parieto-occipital cortex. These functional maps may be helpful in defining the boundaries of surgical excisions. NEUROLOGY 1996;46:978-984 Localization of cortical functions in patients undergoing excisional brain surgery is useful in three ways: to predict the general level of risk should the planned excision proceed, to guide the surgeon in limiting the boundaries of the excision, and to help determine the location of abnormal brain areas (e.g., seizure foci) preoperatively. One commonly used localization technique is the intracarotid amobarbital, or Wada, test, which measures the relative lateralization of language and memory functions across the two hemispheres. Preoperative determination of language lateralization is important in selecting patients for more invasive and specific localization procedures, such as intraoperative stimulation mapping." Determination of language lateralization is particularly important in the preoperative evaluation of epilepsy patients, because this population may have a higher incidence of atypical language dominance than does the normal p o p~l a t i o n .~?~ Although there are several alternative methods for determining language d~m i n a n c e ,~,~ the Wada test remains the only method used routinely for this purpose.The Wada test, although a proven measure of language lateralization, has several important limitations. First, the required angiographic procedure is invasive, with reported complication rates of up to 3%1.8 Second, the test measures only the relative distribution of language across the two hemispheres. More specific information about localization within a hemisphere, which might be useful for tailoring an excision, must be obtained by other means, such as intraoperative stimulation mapping. Third, validity of the test depends on demonstration of relatively separate and symmetric arterial supply routes for the two hemispheres. Thus, interpretation of the test may not be straightforward or possible in patients with azygous supply patterns or arterial crossflow.!' Other methodologic drawbacks of the Wada test are limitations on the time available for testing distinct functions during the ...

Summary:We propose an epileptic seizure classification based exclusively on ictal semiology. In this semiological seizure classification (SSC), seizures are classified as follows: The SSC identifies in detail the somatotopic distribution of the ictal semiology as well as the seizure evolution. The advantages of a pure SSC, as opposed to the current classification of the International League Against Epilepsy (ILAE), which is actually a classification of electroclinical syndromes, are discussed. Key Words: Seizure classification-Ictal semiology-Auras-Motor seizures-Paroxysmal events.The International League Against Epilepsy (ILAE) introduced a seizure classification in 1981 based on clinical semiology, interictal EEG findings, and ictal EEG patterns (1). The assumption behind such a classification, which is actually a classification of electroclinical features, is the existence of a strict one-to-one correlation between clinical-ictal semiology and interictalhctal EEG findings. Detailed analysis of clinical semiology and EEG findings shows, however, that this assumption is frequently incorrect (2), particularly for infants (3).

Seizures in some 30% to 40% of patients with epilepsy fail to respond to antiepileptic drugs or other treatments. While much has been made of the risks of new drug therapies, not enough attention has been given to the risks of uncontrolled and progressive epilepsy. This critical review summarizes known risks associated with refractory epilepsy, provides practical clinical recommendations, and indicates areas for future research. Eight international epilepsy experts from Europe, the United States, and South America met on May 4, 2013, to present, review, and discuss relevant concepts, data, and literature on the consequences of refractory epilepsy. While patients with refractory epilepsy represent the minority of the population with epilepsy, they require the overwhelming majority of time, effort, and focus from treating physicians. They also represent the greatest economic and psychosocial burdens. Diagnostic procedures and medical/surgical treatments are not without risks. Overlooked, however, is that these risks are usually smaller than the risks of long-term, uncontrolled seizures. Refractory epilepsy may be progressive, carrying risks of structural damage to the brain and nervous system, comorbidities (osteoporosis, fractures), and increased mortality (from suicide, accidents, sudden unexpected death in epilepsy, pneumonia, vascular disease), as well as psychological (depression, anxiety), educational, social (stigma, driving), and vocational consequences. Adding to this burden is neuropsychiatric impairment caused by underlying epileptogenic processes ("essential comorbidities"), which appears to be independent of the effects of ongoing seizures themselves. Tolerating persistent seizures or chronic medicinal adverse effects has risks and consequences that often outweigh risks of seemingly "more aggressive" treatments. Future research should focus not only on controlling seizures but also on preventing these consequences.

The prevalence of psychogenic non-epileptic seizures is difficult to estimate. We propose an estimate based on a calculation. We used the following data, which are known or have been estimated, and are generally accepted. A prevalence of epilepsy of 0.5-1%; a proportion of intractable epilepsy of 20-30%; a percentage of these referred to epilepsy centers of 20-50%; and a percentage of patients referred to epilepsy centers that are psychogenic non-epileptic seizures: 10-20%. Using the low estimates, the prevalence of psychogenic non-epileptic seizures would be 1/50 000. Using the high estimates, the prevalence of psychogenic non-epileptic seizures would be 1/3000. The prevalence of psychogenic non-epileptic seizures is somewhere between 1/50 000 and 1/3000, or 2 to 33 per 100 000, making it a significant neurologic condition.

Summary:Purpose: When seizures do not respond to medications, video-EEG monitoring is the best available diagnostic tool and is the principal activity of epilepsy centers. The purpose of this study was to analyze the eventual disposition of patients who undergo video-EEG monitoring at a typical referral epilepsy center.Methods: We reviewed the diagnoses and dispositions of all patients (adults and children) who underwent inpatient video-EEG monitoring (≥24 h) at our center (University of South Florida-Tampa General Hospital) over a 1-year period (2002).Results: In total, 251 inpatient video-EEG monitoring sessions were performed. Nonepileptic seizures were diagnosed in 75 (30%); 58 (23%) were found to be surgical candidates; seven were implanted with the vagus nerve stimulator. In 47 (19%) patients, seizures were recorded, and the diagnosis of epilepsy was confirmed and clarified (symptomatic/cryptogenic generalized epilepsy, seven; localization-related epilepsy, 35; idiopathic generalized epilepsy, five). Conclusions:The eventual outcome of video-EEG monitoring is diverse. The largest groups, as expected, are psychogenic nonepileptic seizures (30%), and surgery (23%). Key Words: Video-EEG-Psychogenic-Nonepileptic seizure.Epilepsy affects 1% of the population, and ∼20 to 30% of patients with epilepsy are medically intractable (1,2). This means that the prevalence of medically intractable epilepsy is ∼0.2 to 0.3%, comparable to the overall prevalence of multiple sclerosis. For patients whose seizures do not respond to medications, video-EEG monitoring is the best available diagnostic tool and the starting point to evaluate treatment options (1). Video-EEG monitoring allows (a) making a diagnosis of epilepsy versus nonepileptic events; (b) correctly diagnosing the seizure type and epilepsy syndrome; and (c) if the seizures are focal, localizing the area of seizure onset. As a result, it is then possible to examine therapeutic options (1). Thus video-EEG monitoring is the principal activity of epilepsy centers.The purpose of this study was to describe the eventual disposition of patients who undergo video-EEG monitoring at a typical referral epilepsy center.

Background: Pseudoseizures may occur as a somatoform disorder in children and adolescents as well as adults. However, few data are available about psychiatric features or outcome in pediatric patients.

The proportion of patients with psychogenic nonepileptic seizures (PNES) who also have epilepsy has been reported to vary from 10% to over 50%. The authors reviewed all 32 patients diagnosed with PNES in our EEG-video monitoring unit over a period of 1 year, and only 3 (9.4%) had interictal epileptiform discharges to support a coexisting diagnosis of epilepsy. Thus, the authors believe that only a small proportion of patients with PNES have coexisting epilepsy.