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Clinical features of neocoritcal temporal lobe epilepsy.

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Clinical Features of Neocortical Temporal
A
Lobe Epilepsy
Steven
~~
V. Pacia, MD,* Orrin Devinsky, MD,* Kenneth Perrine, PhD,* Lisa Ravdin, PhD,*
Daniel Luciano, MD,* Blanca Vazquez, MD,* and Werner K. Doyle, MDT
~~~
~~
~
~~
~
Few studies have examined the clinical features of neocortical temporal lobe epilepsy (NTLE) in carefully selected
patients. We reviewed records from 21 patients with NTLE, defined by intracranial electroencephalogram (EEG), who
have been seizure free for 1 year or more following temporal lobectomy. The mean age of onset at the time of first
seizure was 14 years (range, 1-41 years). Febrile seizures were reported in only 2 patients (9.5%). In contrast to prior
mesial temporal lobe epilepsy (MTLE) studies, seizure-free intervals between the initial cerebral insult or first seizure
and habitual seizures were uncommon. Possible or known risk factors for epilepsy were reported in 13 of 21 patients
(62%). Fifteen (71%)patients reported auras, with experiential phenomena being the most common type. Magnetic
resonance imaging was normal or nonspecific in 15 patients, revealed mild hippocampal atrophy in 2, tumors in 2, and
heterotopic gray matter and hippocampal atrophy in 1, and cortical dysgenesis in 1. Neuropsychological testing showed
deficits consistent with the seizure focus in 13 patients (62%),and Wada test showed ipsilateral memory deficits in 10
(48%). The most common behavioral manifestation was a motionless stare at ictal onset (48%). In contrast to prior
studies of MTLE, only 1 NTLE patient had frequent independent, contralateral temporal lobe epileptiform spikes on
scalp EEG.
Pacia SV, Devinsky 0, Perrine K, Ravdin L, Luciano D, Vazquez B, Doyle WK. Clinical features of
neocortical temporal lobe epilepsy. Ann Neurol 1996;40:724-730
Some investigators report a less favorable surgical outcome for patients with neocortical temporal lobe epilepsy (NTLE) than for those with mesial temporal lobe
epilepsy (MTLE) [ I , 21. A recent study attributes the
disparity to insufficient resection of the epileptogenic
zone when standard temporal lobe resections are performed in patients with NTLE [ 3 ] .Standard resections
often spare much of the inferolateral and posterior temporal neocortex, which may give rise to postoperative
seizures. More extensive lateral temporal resection may
be accomplished safely, after seizure localization with
careful intracranial electroencephalographic (EEG)
monitoring and cortical mapping to preserve functional
regions [4].
While our knowledge of the clinical characteristics,
imaging abnormalities, and EEG findings in MTLE
continues to grow 15-91, the clinical features of NTLE
remain poorly defined. Presumably, if a syndrome of
NTLE could be characterized, as in MTLE, improved
preoperative prediction of seizure localization within
the temporal lobe will aid in selecting patients that will
benefit from intracranial EEG monitoring and tailored
resections. This study reports the clinical and presurgi-
cal findings in a carefully selected group of patients
with neocortical temporal lobe seizures.
From the *Departments of Neurology and Neurosurgery, NYUI
HJD Comprehensive Epilepsy Center, and ?New York University
School of Medicine, Hospital for Joint Diseases, 301 East 17th
Street, New York, NY.
Received Feb 26, 1996, and in revised form Apr 16. Accepted for
publication May 22, 1936.
Patients and Methods
Patients
We reviewed intracranial EEG results from 67 patients at
our epilepsy center who had anteromedial temporal lobe resections for the treatment of inrractable seizures and who
have been seizure free, o r experiencing occasional auras only,
for at least 1 year. Of those 67 patients, 21 had intracranial
EEG monitoring studies, documenting seizure onsets in the
temporal neocortex without involvement of basomesial temporal or extratemporal structures at ictal onset.
Prior to intracranial electrode implantation, all patients
had presurgical evaluations that included audiovisual and
EEG monitoring of interictal and ictal activity, magnetic resonance imaging (MRI) with 3-mm coronal cuts through the
temporal lobes, a neuropsychological evaluation and angiogram-Wada testing. Patients were referred for intracranial
EEG monitoring after review of the presurgical evaluation
by a multidisciplinary epilepsy team.
Intracranial EEG Recording and EEG Review
Intracranial EEG studies were performed using a 64-contact
subdural grid of electrodes placed over the lateral temporal
Address correspondence
Dr Pacia,
of Neurology,
Hospital for Joint Diseases, 301 East 17th Street, New York. NY
10003.
724 Copyright 0 1996 by the American Neurological Association
and inferior frontoparietal convexity supplemented with two
or three niulticontact (4-8) subdural strip elecrrodes covering anterior and midposterior basal temporal cortex with
the most distal contacr of each strip underlying the parahippocanipal gyrus. Basomesial temporal coverage in all patients
was verified by MRI or skull x-rays. In addition, all patients
had subdural strip electrode coverage of frontopolar, orbitofrontal and parietooccipital cortex. Sixty-four channels of
digital EEG were recorded onto super VHS tape at a 200Hz sampling rate for all patients (Telefactor Beehive, Telefactor Corp, PA).
EEGs were reviewed in both bipolar and referential niontage formats (Telefactor Beekeeper). All patients had a minimum of three seizures recorded, all of which arose exclusively
from temporal neocorrex. Patients with ictal onsets revealing
simultaneous neocortical temporal and mesial (defined as any
involvement of the three most distal subtemporal subdural
strip electrodes covering basomesial temporal lobe) or extratemporal involvement were excluded. Intracranial EEG onset
was defined as an initial sustained localized or regional
change from the background activiry preceding behavioral
changes consistent with the patient's chronic seizure type.
These changes included low-voltage. high-frequency discharges and electrodecremental patterns in addition to typical ictal rhythms.
Siirgely and Pathology
Following intracranial EEG seizure localization and functional mapping of language for dominant temporal lobe patients, all patients had anterior and mesial temporal lobe
resections with complete resection of the amygdala and hippocanipus and variable extent of the lateral resection, depending on the location of ictal onset and its proximity to
language function. Six patients had multiple subpial transection procedures performed in posterior superior temporal
language areas in addition to a temporal lobectomy. A detailed gross and microscopic tissue analysis of neocortical and
mesial temporal structures was performed in 19 of the 21
cases.
Results
Table 1 summarizes the medical record review for the
21 patients in the study.
Histoly
Thirteen men a n d 8 women h a d intracranial EEG
studies demonstrating ictal oiisets within temporal neocortex. Seizures were left temporal in 1 8 a n d right temporal in 3. All patients met t h e criteria of Engel a n d
colleagues [ l o ] for class I outcome at a m i n i m u m follow-up period of 1 year (mean, 1 5 months). T h e age
of onset for habitual nonfebrile seizures ranged from 1
year to 41 years with a mean age of 13.7 years. Febrile
seizures were reported in 2 of the 21 patients (9.5%).
Neither patient had reported complicated febrile convulsions o r a documented central nervous system infection. O n l y 2 patients (3.5%) reported significant sei-
zure-free intervals prior to habitual seizures, occurring
7 a n d 8 years, after the onset of seizures.
Table 1 lists the frequency of risk factors for NTLE.
No risk factors for epilepsy were reported in 8 of the
21 patients (38%). T w o additional patients had histories significant only for minor head trauma, without a
loss of consciousness. The remaining 1 I patients had
significant neurologic histories that likely explained
their seizure disorders.
O n l y 6 of the 21 patients (29%0/0)failed to report an
aura prior to seizures. Table 2 lists the 23 auras reported by the remaining 1 5 patients. Eight patients
(38%) described more than one aura type. Experiential
phenomena including d&jivu, janiais vu, a n d depersonalization were the most frequent auras reported by
10 patients.
Presurgical Evaluation
IMAGING;.
M R I s were normal in 12 patients and
showed nonspecific white matter changes in 3 others.
Two patients had mass lesions. O n e had an inferolatera1 temporal cystic lesion and the other had a posterolateral temporal tumor. Mild hippocampal atrophy was
found o n the side of seizure onset in 2 patients. No
signal change was noted o n T2-weighted images for
either patient. O n e patient had marked hippocampal
atrophy b u t also had heterotopic gray matter in the
anterolateral temporal region. One patient lacked distinction of gray-white junction in the inferolateral
temporal lobe.
N E U R O P S Y C H O L O G I C A L T M T I N G ANL) 'X'AUA
'TESTING.
Comprehensive neuropsychological testing lateralized
abnormalities consistent with the hemisphere of ictal
onset in 13 of the 21 patients (62%). I n 3 patients
neuropsychological findings were discordanr with side
of seizure onset. T w o of the patients with right temporal seizure foci had testing consistent with dominant
temporal lobe dysfunction, while 1 patient with left
temporal lobe seizures was lateralized to the right. T w o
patients had n o significant abnormalities and 3 others
had abnormal findings bilaterally with n o lateralized
predominance. T h e details of the testing results are the
subject of a future article.
The W a d a test lateralized language to the left hemisphere in 19 of 2 1 patients. T w o patients had evidence
of language function in both hemispheres. Memory
was adequate in both hemispheres in 10 of the 21 patients. T e n patients had impaired memory in the affected hemisphere. O n e patient with left temporal seizures had better memory in the left hemisphere than
the right.
ICTAL BEHAVIORAL FEATUKES. Table 1 lists the stereotyped behavioral features of multiple seizures recorded
in each patient during long-term audiovisual and EEG
Pacia et al: Neocorticd Temporal Lobe Epilepsy 725
Table I . Historical Features and Preswgical Finding5
I’ntienr
No.
Typical
Febrile
Seizure
Age of
Onscr
(yr)
Wada
bailure
MRI Findings
Ncuropsychological
Testing Abnormal
(LIR)
St.ILure-
Presumed
Etiology
free
Interval
LIR
1
2
Encephalitis
No
NSWM
L
I.
2
G
?
No
L anr temp
R
No
L
L
Semiology
(l’romincnt
Features)
Interictal
EEC
Ictal EEG
l’athology
Repetitive
phrases,
BHA,
OA
MS, LHA
BT
LT
SG, N M D
LAT
LAT
N /A
MS, mure,
R face
clonic
MS, chanr
Ing,
BHA,
OA
MS, RHA,
laugh,
LT LFC
SHP
I 7’
Low-grade glioma
RAT,
RM?‘
RAT
RMT
SG, diffuse gliosis
LM-l’T,
rai e
LT
Diffuse gliosis
Most
LAT,
SG
loss of
3
-
I2
Tumor
No
GIW, high
T2 signal
mesial LT
lnferotemporal
lesion, cysric
4
-
13
?
5
-
17
Minor
HI‘
NO
NL
L
R
No
NL
L
L
rare
6
-
11
?
No
NL
I.
No
LHA
LHA
RT
LAT,
rare
RAT
some
BT, 1
RT
7
38
8
10
9
21
HT/LOC
Tumor
No
No
H T / I .OC
No
NSWM
Tumor
NL
Unlat
NL
L
No
NO
L
MS, OA
MS, mute,
R face
clonic
MS, OA,
RHA
LAT
L-1’
[“AT
LAT
Diffuse gliosis
Ganglioneurocyroma
LAT,
LAT or
BT
Diffuse gliosis
LAT,
Mild diffuse gliosis
rare
RA-r
10
20
HTILOC
No
NL
L
No
BHA
LT
LMT
11
41
Minor HT
No
NSWM
L
R
Head L
RT
RAT,
RMT
SG
12
14
?
8 Y‘
L
NO
Turns R
LAT
LAT
N M D , SG
13
4
Meningitis
No
Mild L hippocampal
atrophy
NL
L
L
LHA, head
ro R,
LMT
LT, unlat
Diffuse gliosis
LAT
LT
SG, diffuse gliosis
LAT
LT
SG, diffuse gliosis
LAT
LAT,
LPT
Neuronal loss in
Somer‘s sector of
hc
LT, F T
LT, F T
OA,
14
9
?
No
NL
L
No
15
9
?
7 Y‘
NL
L
No
16
1
Posrop hypoxia
No
NL
? L
L
blinking
Head R, R
arm
tonic
MS, OA,
RHA
OA, iiirns
head R,
LHA,
RUE
17
4
Eucephaliris
NO
NL
Unlat
NO
dystonia
Rocking
18
14
Heterotopia
No
NL
R
MS
LT
LT
19
4
?
No
R T hereroropia, R h i p
pocampal
arrophy
NL
NMD, SG, diffuse
gliosis
NIA
L
No
OA, BHA
LAT
LAT
Cortical dysplasia
20
13
Meningitis
No
? L hippocam-
Bilateral
I~
LA, RUE
posrure,
LAT
LT
SG
LMT,
LPT
LPT
Sc,
pal atrophy
R face
21
24
>
No
NI.
LT
R
chic
MS
MR1 = magnetic rcsonance imaging: EEC
elccrroencrphalogram; N L
innrmal; K = right; I = left; RT = right temporal; LT = left temporal; RAT = right anrerior
tmiporal; LAT = Icft anrerior tempor.il; RPT = right frontotemporal; LFT = left frontotemporal; RMT = righr midtemporal; L M T = left midremporal; KPT = right
postcrior ceniporal: LPT = Irfi poirrrior temporal; FC = fronmcentral; NSWM = nonspecific white rnarter changes: G/W = gray/white; MS = motionless starc; OA =
oral autoniatism\; BHA = bilateral h m d autoniarisms; SG = superficial gliosis (Chaslin iype): NML) = neuronal migration defect; LHA = left-hand automatisms; RHA
= nght-h.ind d u i i ~ n i d i i ~ mI ~
M-I’T
;
= lcfr mid-posrciior teniporal; RT = hircmporal; unlat = unlareralized; F T = fwnroremporal; hc = hippocampnl.
7
Table 2.Auras
Aura Type
Number of Patients
None
6
6
3
D&jivu
Depersonalization
Jamais vu
Fear
OraUthroat sensation
Abdominal sensation
Tinnitus
Heart racing
Unusual taste
Unusual smell
1
2
3
4
1
1
1
1
monitoring. The most common clinical manifestation
at seizure onset was a motionless stare, occurring in
10 patients. Other common features included upper
extremity automatisms ipsilateral to the seizure focus
in 5 patients, 2 of which were accompanied by dystonic
posturing of the contralateral arm. Four patients had
bilateral upper extremity automatisms and 2 had upper
extremity automatisms contralateral to the side of seizure origin. Contralateral tonic or clonic activity of the
face or extremities was never an early ictal behavioral
manifestation but was a prominent feature in 4 patients
as the seizure progressed.
INTERICTAL AND ICTAL EEG. The interictal EEG in the
awake and asleep state during long-term audio and
video monitoring was appropriately lateralized in all
20 patients, although 3 patients had rare contralateral
temporal discharges. The remaining patient had frequent independent bitemporal epileptiform discharges.
The ictal EEG was lateralized to the appropriate temporal lobe for all seizures recorded during audiovisual
and scalp-sphenoidal EEG monitoring in 18 patients.
Of the remaining 3 patients, all had a majority of seizures localized to the appropriate temporal region;
however, all 3 had seizures with bilateral rhythmic temporal buildup that could not be lateralized. One of the
patients also had one seizure clearly lateralized to the
temporal region contralateral to the eventual site of sur-
gery.
PATHOLOGY.
Gross and microscopic examination of
surgical specimens was performed in 19 of the 21 patients. Table l lists these findings. Diffuse or superficial
gliosis (Chaslin-type) was the most common finding
in 12 of 19 patients (63%). Four patients (21%) had
neuronal migration defects or dysgenic cortex. Of the
2 patients with tumors seen on MRI, 1 had a lowgrade glioma and the other had a ganglioneurocytoma.
The patient who suffered a hypoxic event at an early
age had neuronal loss in Somer’s sector of the hippo-
campus. Pathological examination of the neocortical
and mesial temporal lobe was performed on surgical
specimens from 2 of the 3 patients with mild hippocampal atrophy on MRI. Netther study revealed mesial
temporal sclerosis.
Discussion
In two recent studies of temporal lobe epilepsy, NTLE
was diagnosed in 25% and 67% of patients with temporal lobe seizures [3, 111. However, commonly performed surgical procedures such as amygdalohippocampectomy and standard anteromesial temporal
resections may not eliminate seizures in many NTLE
patients. As a result, many epilepsy centers advocate
tailored temporal lobe resections guided by functional
mapping to remove as much epileptogenic temporal
neocortex as possible [3, 121. Because this surgical approach to NTLE patients requires invasive EEG monitoring and functional mapping, a better understanding
of the clinical features of NTLE is necessary to improve
operative planning.
In contrast to NTLE, the clinical syndrome of
MTLE has been well described. French and Williamson and colleagues [7, 81 reported on 67 patients with
MTLE, documented by intracranial EEG monitoring,
who became seizure free after temporal lobectomy. A
high incidence of complicated febrile seizures, a seizure-free interval between the presumed cerebral insult
and habitual seizures, seizure onset during or shortly
after the first decade of life, and rare convulsive and
nonconvulsive status epilepticus characterized this population. Presurgical evaluation in the MTLE group revealed frequent bilateral interictal epileptiform activity,
a lateralized ictal EEG buildup in 80%, lateralizing
neuropsychological testing abnormalities in 73%, lateralized memory disturbance on Wada test in 63%, and
a high incidence of mesial temporal lobe abnormalities
on MRI.
Few studies have reported historical or clinical features in a similarly well-defined group of patients with
NTLE. Burgerman and colleagues [3] recently compared 37 patients with MTLE with a group of 11 patients with NTLE. The two groups were identified by
intracranial EEG findings. No significant difference
was found with respect to risk factors for epilepsy, age
of first risk for epilepsy, surface interictal EEG findings,
or likelihood of seizure free-outcome, although patients
with mesial temporal lobe seizures were more likely to
demonstrate lateralized memory impairment on Wada
testing than those with NTLE. O n e possible explanation for the study’s negative results is the inclusion of
patients in the NTLE group that had simultaneous ictal EEG onsets in amygdalohippocampal and neocortical structures. It may be preferable to study this group
separately from patients with isolated mesial temporal
or neocortical seizures, as they may have clinical fea-
I’acia et a]: Neocortical Temporal Lobe Epilepsy
727
tures consistent with dysfunction of both mesial and
lateral teniporal lobe. In addition. not all the patients
studied were seizure free after surgery, raising the possibility o f a second seizure focus, and therefore a more
complex patient group.
In contrast to the study by Burgerman and colleagues [3], we included only patients with inferolateral
or lateral neocortical temporal seizures and excluded all
patients with basomesial temporal lobe seizures. All the
patients had extensive lateral temporal coverage with
subdural grid electrodes and basomesial coverage with
multiple subtemporal subdural strip electrodes. Prior
studies using simultaneous depth and subdural strip
electrode recordings of h ippocanipal seizures have consistently shown involvement of basomesial temporal regions alone or simultaneous with temporal neocortex
when seizures spread outside of the hippocampus [ 131.
Therefore, we excluded all patients demonstrating basomesial temporal involvement alone or simultaneous
with inferolateral temporal involvement. W e excluded
any patients wirh continued seizures postoperatively to
ensure that these patients did not have extratemporal
or biteniporal seizures.
We elected to remove the arnygdala and hippocampus despite the lack of involvement of the niesiobasal
temporal regions at ictal onset. This was done because
of the rapid spread of seizures into mesial temporal
regions i n many patients with neocortical foci and because of data from animal studies revealing the hippocampus to be a pacemaker or amplifier o f seizures beginning in the temporal lobe [14]. In addition, all our
patients demonstrated adequate Wada memory in the
contralateral temporal lobe. Whether NTLE patients
experience greater postoperative modality-specific
memory deficits than MTLE patients undergoing anteromesial temporal lobe resections is the subject of an
ongoing study.
Several historical features distinguish our NTLE patients from MTLE patients. Most important, febrile
seizures, which have been reported in up to 67% of
patients with proven MTLE were reported in only
9.5% of our patients [7, 151. This relative infrequency
of febrile convulsions in our NTLE patients is only
slightly higher than that reported for the general population [I6]. T h e age of onset for habitual seizures in
our group averaged 13.7 years, slightly older than the
mean age of onset reported for MTLE. However, more
important, the infrequency of a seizure-free interval between the first seizure or presumed etiologic insult, and
the development of habitual seizures, distinguishes our
patients from previous series of MTLE [7, 171.
Auras were reported by 71% of our patients. However, auras most commonly associated with the temporal neocortex such as vertigo and auditory phenomena
occurred infrequently i n our series [18]. This may have
been a result of our patient selection criteria. Patients
728 Annals of Neiirology
Vol 40
No 5
November i396
with these auras may have had posterolateral temporal
seizure foci and may not have had class I outcomes.
This may be particularly true for patients with dominant temporal lobe foci who may have had seizures
involving language areas and, therefore, could not have
complete resections. In contrast, many patients had
auras commonly associated with mesial temporal lobe
or insular activation, including visceral sensations and
fear [18, 191. Whether this is due to seizure spread
from lateral to mesial temporal structures or due to
ictal involvement of neocortical structures alone is unclear. Psychical or experiential phenomena were the
most commonly reported auras by our patients, occurring i n nearly one-half. Using electrical stimulation,
Penfield and Perot (201 localized these phenomena to
lateral teniporal structures. This finding was later challenged by Gloor and colleagues [19] after depth electrode stimulation of mesial temporal structures produced psychical auras. A more recent study reporting
on a patient with a left temporal neocortical focus concluded that experiential phenomena required involvement of both neocortical and mesial structures [21].
However, the high frequency o f these auras in our
study and the relative infrequency reported for the
MTLE patients in the study by French and co-workers
[7] supports a neocortical localization of experiential
phenomena.
Because of the rapid spread of seizures within and
outside the temporal lobe, the reliability of semiology
for precise anatomic localization suffers from the same
uncertainty as the interpretation of auras. T h e most
common behavioral manifestation at ictal onset in our
patients was staring and behavioral arrest. This behavior has been a consistent early finding i n prior studies
of both mesial and neocortical temporal lobe seizures
[22-24]. However, in contrast to MTLE, contralateral
or bilateral upper extremity automatisms occurred
more frequently at seizure onset than ipsilateral automatisms. Other common behavioral manifestations in
our patients, such as head turning and oral automatisms, d o not distinguish NTLE from MTLE [23, 251.
I n contrast to the prominent hippocampal atrophy
seen in most patients with MTLE due to mesial temporal sclerosis [8], most of our patients had normal
MRIs or nonspecific abnormalites. Mild hippocampal
atrophy, seen in 3 of our patients, was not diagnosed
as mesial temporal sclerosis on tissue examination. T h e
mesial temporal atrophy may have been commensurate
with neocortical temporal lobe atrophy, although
quantitative MRI analysis was not performed.
T h e Wada test demonstrated adequate memory on
the side of seizure onset in nearly one-half of our patients. However, Williamson and associates [8] reported that 37% of their MTLE patients had Wada
studies that revealed adequate memory on the side of
seizure onset, indicating that this test may have limited
predictive value for seizure localization within the temporal lobe. T h e trend toward better memory function
with NTLE than MTLE in the hemisphere of seizure
onset may be significant if examined in a larger population. Significantly impaired Wada memory in approximately one-half of our NTLE patients probably reflects
variable dysfunction of lateral [4], and mesial [26],
temporal structures that contribute to short-term memory. Also, NTLE foci may cause secondary dysfunction
of mesial structures with which they have direct connections [26, 271. Neuropsychological testing showed
abnormalities consistent with the side of the seizure
focus in 62% of our patients. While the frequency of
correct and incorrect lateralization does not appear to
differ significantly from prior studies of MTLE [26],
further study of neuropsychological testing results in
carefully controlled groups of MTLE and NTLE patients is necessary to determine whether any subtests
have predictive value for either temporal lobe seizure
type.
A high frequency of bitemporal interictal epileptiform abnormalities in MTLE has been well described
[8, 15, 281. Only 1 of our patients with NTLE had
frequent independent bitemporal epileptiform activity
despite long-term EEG monitoring in all patients. Preselection bias does not completely explain this low frequency of contralateral interictal abnormalities, because
bitemporal interictal spikes do not preclude unilateral
intracranial EEG studies at our center when the preponderance of presurgical localization data supports a
unilateral focus. In addition, bitemporal abnormalities
are frequent even in MTLE patients with unilateral
temporal seizures who have had excellent surgical outcomes [8]. Therefore, the difference in frequency of
bitemporal interictal epileptiform abnormalities more
likely reflects a different pathogenesis for the two syndromes. Whether this is etiology-specific or an agerelated phenomenon is unclear [9]. As expected, most
ictal EEGs in our series lateralized seizures to the temporal lobe later resected. Ictal EEG is considered at our
center to be an important selection criteria for unilateral subdural grid placement, and therefore, patients
with ambiguous seizure localization are often referred
for bilateral intracranial EEG evaluations or are not
referred at all. O n e recent study demonstrates that
analysis of the spatial distribution, morphology, and
frequency of temporal lobe seizures recorded from the
scalp may provide valuable localizing data distinguishing MTLE from NTLE [ 1 11.
While no single clinical feature is diagnostic of
NTLE, the constellation of findings common to this
carefully selected population of patients should allow
better presurgical prediction of mesial and neocortical
temporal lobe seizure foci. In particular, the absence
of both a history of febrile seizures and a seizure-free
interval between the initial cerebral injury or first sei-
zure and habitual seizures, in the presence of an MRI
that fails to show hippocampal atrophy, along with a
well-lateralized interictal EEG abnormality, is suggestive of NTLE. In addition, the high frequency of psychical auras in our patients supports a prominent role
for the temporal neocortex in the generation of these
phenomena.
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