Introdução. As hemisferectomias são cirurgias utilizadas há décadas para se tratar epilepsias refratárias à medicação anticonvulsivante. Embora o controle das crises seja satisfatório, a morbidade, per e pós-operatória, ainda é considerada um importante fator limitante à sua utilização. Dessa maneira, compreender as complicações mais comuns do procedimento, e os fatores que as influenciam, é essencial para se estabelecer o melhor uso para a técnica. Métodos. Foram coletados dados de 30 pacientes, operados por seis cirurgiões no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período entre 1980 e 2003. Foram realizadas 11 hemisferectomias com a abordagem de Rasmussen, três hemisferectomias anatômicas, nove hemisferectomias funcionais extraventriculares e sete hemisferotomias. Foram estudados cinco grupo de pacientes de acordo com a fisiopatologia da doença de base: Dezesseis pacientes eram portadores de Síndrome de Rasmussen, dois da Síndrome de Sturge-Weber, quatro de malformações corticais, dois de lesões sequelares e seis de cistos porencefálicos. Os fatores de morbidade foram avaliados dentro de rês perspectivas: 1- da doença de base; 2- da técnica utilizada; e 3- do fator humano. Resultados. Nossos dados mostraram ausência de diferença estatisticamente significativa entre as técnicas cirúrgicas empregadas nos itens: tempo cirúrgico; tempo de internação na unidade de terapia intensiva; queda da hemoglobina; volume de hemoderivados transfundidos e febre no pós-operatório. Presença de leucograma acima de 15.000 leucócitos/mm3 no pós-operatório imediato foi associada a estadias mais longas na unidade de terapia intensiva A média diária de temperatura dos pacientes, mostrou temperaturas acima de 38º C entre o terceiro e sexto dia pós-operatório. Pacientes com hemimegalencefalia apresentaram temperaturas mais elevadas quando comparados com os portadores de cistos porencefálicos. Doenças com maior manto cortical contribuíram para aumentar o tempo cirúrgico, embora o fator humano tenha sido decisivo nesse item. Ao comparar nossos achados com os da literatura, vimos que os pacientes submetidos à hemisferectomia anatômica apresentaram no pós-operatório temperaturas mais elevadas e reação inflamatória liquórica mais intensa que os submetidos a técnicas de desconexão hemisférica, no entanto, a importância desse dado necessita ser estabelecida. Conclusões: O principal fator de morbidade nas hemisferectomias é a doença de base, assim, os dados presentes na literatura, incluindo nossa casuística, não nos permite concluir que uma técnica seja superior à outra ou que as técnicas desconectivas sejam melhores que as ressectivas / Hemispherectomy has been the treatment of choice in some sorts of refractory epilepsies for decades. Although surgery results in satisfactory control of seizures, its morbidity remains a major concern. Thus, understanding most common complications, as well as the factors that contribute to it, becomes an essential step to learn the limits on technique applications. Methods. Hospital charts from 30 patients operated on by six different surgeons at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo from 1980 to 2003 were reviewed. Eleven functional hemispherectomies using Rasmussen approach, three anatomical hemispherectomies, nine extraventricular functional hemispherectomies, and seven hemispherotomies were included in this study. Sixteen patients presented with Rasmussen Syndrome, two Sturge-Weber Syndrome, four cortical malformations, two hemispheric lesions, and six porencephalic cysts. Morbidity was evaluated from three different perspectives 1- background disease, 2- employed technique, and 3- human factor. Results: our data presented no statistical difference among the employed techniques regarding 1- surgical time, 2- intensive care unit time, 3- per and postoperative fall of hemoglobin, 4- blood transfusion volume, and 5- postoperative axilar temperature variation. Patients that presented over 15,000 leucocytes per mm3 stayed longer at the intensive care unit, regardless of the surgical technique employed. Daily average temperatures varied around 38 degrees Celsius from the third to the sixth postoperative day. Patients with hemimegalencephaly had higher postoperative axilar temperatures when compared to those with porencephaly. Thicker cortical mantle contributed to increase surgical time, though human factor also showed to be important in this item. Comparing data from this study and the literature disclosed that patients undergoing anatomical hemispherectomies presented an inflammatory response in the cerebrospinal fluid more evident than those submitted to cerebral disconnection, although the importance of this finding is still elusive. Conclusions: The main factors of morbidity in the hemispherectomy are the background disease and patient\'s peculiarities, therefore, it is not reasonable to infer that there is a superior technique or that hemisphere disconnection is better than removal

Optimizing of Epilepsy Surgery in Paediatric Patients Abstract Epilepsy surgery represents an effective treatment of intractable focal epilepsy. The presented work aims to describe the state of the art and enhance diagnostic and therapeutic algorithm in paediatric patients. The ultimate goal is to improve the outcome of surgeries. The work depicts the evolution of the paediatric epilepsy surgery program in Motol Epilepsy Center over the course of years 2000-2017. Complexity of patients (younger age, epileptogenic zone in proximity of eloquent cortex, multifocal MRI findings) and surgeries (hemispherotomy) alike increased over time. However, the outcomes in terms of postoperative seizure-freedom and complications remained stable. Cognitive abilities of patients improved by 9.1 IQ/DQ points one year after surgery. Patients with preexisting intellectual deficit reached the most significant increase. We developed a novel paradigm of intraoperative cortical electrical stimulation mapping. Furthermore, we introduced a technique employing visual detection of SEEG electrodes during the surgery. These procedures aim to achieve a complete resection while avoiding complications. We developed and standardized Czech versions of questionnaires IPES a QOLIE-AD-48 assessing quality of life in children with epilepsy. We...

Children with focal intractable epilepsy caused by MCD, FCD and TSC are in a high risk of development of cognitive delay, as a result of both drug resistant epilepsy and genetically determined abnormal structure of the neuronal networks. Epilepsy surgery represents an established and safe treatment method of focal drug resistant epilepsy, and increases the chances for these patients to be rid of epileptic seizures, anti-epileptic medication and cognitive comorbidities. Current data on genetic background of focal MCD and FCD and their comorbidities provide space to expand the diagnostic process in epilepsy surgery candidates. However, available information on genetic causes of MCD and FCD do not allow us to infer prognostic estimates on chances of seizure freedom and optimal cognitive development. Future studies should elucidate these uncertainties.

Epilepsy, as the most common chronic neurological disease, affects a significant part of population (0.5-1%). Drug resistant epilepsy has a significant negative effect on the quality of life, psychiatric comorbidities, neurocognitive performance and the risk of SUDEP in children. Therefore, resective epilepsy surgery, the only curative treatment of this condition, can fundamentally reverse this unfavorable prognosis. An inevitable prerequisite for a good postoperative result is complete removal of the epileptogenic zone (EC) and preservation of eloquent areas (EC). At present, even with improving and new preoperative non-invasive methods, we don't have an exclusive diagnostic method for theirs delineation. The aim of this PhD study is to assess benefit of individual intraoperative electrophysiological (iEF) methods in pediatric patients with focal intractable epilepsy. The first study evaluates the importance of intraoperative electrocorticography (iECoG) in the localization of EZ. The study proved that iECoG serves as a reliable tool to guide surgical resection and may predict results of epilepsy surgery. iECoG-based modification of surgical plan is not associated with increased risk of significant complications. The second presented study analyzed the contribution of intraoperative electrical...

L'épilepsie constitue le désordre neurologique le plus fréquent après les maladies cérébrovasculaires. Bien que le contrôle des crises se fasse généralement au moyen d'anticonvulsivants, environ 30 % des patients y sont réfractaires. Pour ceux-ci, la chirurgie de l'épilepsie s'avère une option intéressante, surtout si l’imagerie par résonance magnétique (IRM) cérébrale révèle une lésion épileptogène bien délimitée. Malheureusement, près du quart des épilepsies partielles réfractaires sont dites « non lésionnelles ». Chez ces patients avec une IRM négative, la délimitation de la zone épileptogène doit alors reposer sur la mise en commun des données cliniques, électrophysiologiques (EEG de surface ou intracrânien) et fonctionnelles (tomographie à émission monophotonique ou de positrons). La faible résolution spatiale et/ou temporelle de ces outils de localisation se traduit par un taux de succès chirurgical décevant. Dans le cadre de cette thèse, nous avons exploré le potentiel de trois nouvelles techniques pouvant améliorer la localisation du foyer épileptique chez les patients avec épilepsie focale réfractaire considérés candidats potentiels à une chirurgie d’épilepsie : l’IRM à haut champ, la spectroscopie proche infrarouge (SPIR) et la magnétoencéphalographie (MEG). Dans une première étude, nous avons évalué si l’IRM de haut champ à 3 Tesla (T), présentant théoriquement un rapport signal sur bruit plus élevé que l’IRM conventionnelle à 1,5 T, pouvait permettre la détection des lésions épileptogènes subtiles qui auraient été manquées par cette dernière. Malheureusement, l’IRM 3 T n’a permis de détecter qu’un faible nombre de lésions épileptogènes supplémentaires (5,6 %) d’où la nécessité d’explorer d’autres techniques. Dans les seconde et troisième études, nous avons examiné le potentiel de la SPIR pour localiser le foyer épileptique en analysant le comportement hémodynamique au cours de crises temporales et frontales. Ces études ont montré que les crises sont associées à une augmentation significative de l’hémoglobine oxygénée (HbO) et l’hémoglobine totale au niveau de la région épileptique. Bien qu’une activation contralatérale en image miroir puisse être observée sur la majorité des crises, la latéralisation du foyer était possible dans la plupart des cas. Une augmentation surprenante de l’hémoglobine désoxygénée a parfois pu être observée suggérant qu’une hypoxie puisse survenir même lors de courtes crises focales. Dans la quatrième et dernière étude, nous avons évalué l’apport de la MEG dans l’évaluation des patients avec épilepsie focale réfractaire considérés candidats potentiels à une chirurgie. Il s’est avéré que les localisations de sources des pointes épileptiques interictales par la MEG ont eu un impact majeur sur le plan de traitement chez plus des deux tiers des sujets ainsi que sur le devenir postchirurgical au niveau du contrôle des crises. / Epilepsy is the most common chronic neurological disorder after stroke. The major form of treatment is long-term drug therapy to which approximately 30% of patients are unfortunately refractory to. Brain surgery is recommended when medication fails, especially if magnetic resonance imaging (MRI) can identify a well-defined epileptogenic lesion. Unfortunately, close to a quarter of patients have nonlesional refractory focal epilepsy. For these MRI-negative cases, identification of the epileptogenic zone rely heavily on remaining tools: clinical history, video-electroencephalography (EEG) monitoring, ictal single-photon emission computed tomography (SPECT), and a positron emission tomography (PET). Unfortunately, the limited spatial and/or temporal resolution of these localization techniques translates into poor surgical outcome rates. In this thesis, we explore three relatively novel techniques to improve the localization of the epileptic focus for patients with drug-resistant focal epilepsy who are potential candidates for epilepsy surgery: high-field 3 Tesla (T) MRI, near-infrared spectroscopy (NIRS) and magnetoencephalography (MEG). In the first study, we evaluated if high-field 3T MRI, providing a higher signal to noise ratio, could help detect subtle epileptogenic lesions missed by conventional 1.5T MRIs. Unfortunately, we show that the former was able to detect an epileptogenic lesion in only 5.6% of cases of 1.5T MRI-negative epileptic patients, emphasizing the need for additional techniques. In the second and third studies, we evaluated the potential of NIRS in localizing the epileptic focus by analyzing the hemodynamic behavior of temporal and frontal lobe seizures respectively. We show that focal seizures are associated with significant increases in oxygenated haemoglobin (HbO) and total haemoglobin (HbT) over the epileptic area. While a contralateral mirror-like activation was seen in the majority of seizures, lateralization of the epileptic focus was possible most of the time. In addition, an unexpected increase in deoxygenated haemoglobin (HbR) was noted in some seizures, suggesting possible hypoxia even during relatively brief focal seizures. In the fourth and last study, the utility of MEG in the evaluation of nonlesional drug-refractory focal epileptic patients was studied. It was found that MEG source localization of interictal epileptic spikes had an impact both on patient management for over two thirds of patients and their surgical outcome.

L'épilepsie constitue le désordre neurologique le plus fréquent après les maladies cérébrovasculaires. Bien que le contrôle des crises se fasse généralement au moyen d'anticonvulsivants, environ 30 % des patients y sont réfractaires. Pour ceux-ci, la chirurgie de l'épilepsie s'avère une option intéressante, surtout si l’imagerie par résonance magnétique (IRM) cérébrale révèle une lésion épileptogène bien délimitée. Malheureusement, près du quart des épilepsies partielles réfractaires sont dites « non lésionnelles ». Chez ces patients avec une IRM négative, la délimitation de la zone épileptogène doit alors reposer sur la mise en commun des données cliniques, électrophysiologiques (EEG de surface ou intracrânien) et fonctionnelles (tomographie à émission monophotonique ou de positrons). La faible résolution spatiale et/ou temporelle de ces outils de localisation se traduit par un taux de succès chirurgical décevant. Dans le cadre de cette thèse, nous avons exploré le potentiel de trois nouvelles techniques pouvant améliorer la localisation du foyer épileptique chez les patients avec épilepsie focale réfractaire considérés candidats potentiels à une chirurgie d’épilepsie : l’IRM à haut champ, la spectroscopie proche infrarouge (SPIR) et la magnétoencéphalographie (MEG). Dans une première étude, nous avons évalué si l’IRM de haut champ à 3 Tesla (T), présentant théoriquement un rapport signal sur bruit plus élevé que l’IRM conventionnelle à 1,5 T, pouvait permettre la détection des lésions épileptogènes subtiles qui auraient été manquées par cette dernière. Malheureusement, l’IRM 3 T n’a permis de détecter qu’un faible nombre de lésions épileptogènes supplémentaires (5,6 %) d’où la nécessité d’explorer d’autres techniques. Dans les seconde et troisième études, nous avons examiné le potentiel de la SPIR pour localiser le foyer épileptique en analysant le comportement hémodynamique au cours de crises temporales et frontales. Ces études ont montré que les crises sont associées à une augmentation significative de l’hémoglobine oxygénée (HbO) et l’hémoglobine totale au niveau de la région épileptique. Bien qu’une activation contralatérale en image miroir puisse être observée sur la majorité des crises, la latéralisation du foyer était possible dans la plupart des cas. Une augmentation surprenante de l’hémoglobine désoxygénée a parfois pu être observée suggérant qu’une hypoxie puisse survenir même lors de courtes crises focales. Dans la quatrième et dernière étude, nous avons évalué l’apport de la MEG dans l’évaluation des patients avec épilepsie focale réfractaire considérés candidats potentiels à une chirurgie. Il s’est avéré que les localisations de sources des pointes épileptiques interictales par la MEG ont eu un impact majeur sur le plan de traitement chez plus des deux tiers des sujets ainsi que sur le devenir postchirurgical au niveau du contrôle des crises. / Epilepsy is the most common chronic neurological disorder after stroke. The major form of treatment is long-term drug therapy to which approximately 30% of patients are unfortunately refractory to. Brain surgery is recommended when medication fails, especially if magnetic resonance imaging (MRI) can identify a well-defined epileptogenic lesion. Unfortunately, close to a quarter of patients have nonlesional refractory focal epilepsy. For these MRI-negative cases, identification of the epileptogenic zone rely heavily on remaining tools: clinical history, video-electroencephalography (EEG) monitoring, ictal single-photon emission computed tomography (SPECT), and a positron emission tomography (PET). Unfortunately, the limited spatial and/or temporal resolution of these localization techniques translates into poor surgical outcome rates. In this thesis, we explore three relatively novel techniques to improve the localization of the epileptic focus for patients with drug-resistant focal epilepsy who are potential candidates for epilepsy surgery: high-field 3 Tesla (T) MRI, near-infrared spectroscopy (NIRS) and magnetoencephalography (MEG). In the first study, we evaluated if high-field 3T MRI, providing a higher signal to noise ratio, could help detect subtle epileptogenic lesions missed by conventional 1.5T MRIs. Unfortunately, we show that the former was able to detect an epileptogenic lesion in only 5.6% of cases of 1.5T MRI-negative epileptic patients, emphasizing the need for additional techniques. In the second and third studies, we evaluated the potential of NIRS in localizing the epileptic focus by analyzing the hemodynamic behavior of temporal and frontal lobe seizures respectively. We show that focal seizures are associated with significant increases in oxygenated haemoglobin (HbO) and total haemoglobin (HbT) over the epileptic area. While a contralateral mirror-like activation was seen in the majority of seizures, lateralization of the epileptic focus was possible most of the time. In addition, an unexpected increase in deoxygenated haemoglobin (HbR) was noted in some seizures, suggesting possible hypoxia even during relatively brief focal seizures. In the fourth and last study, the utility of MEG in the evaluation of nonlesional drug-refractory focal epileptic patients was studied. It was found that MEG source localization of interictal epileptic spikes had an impact both on patient management for over two thirds of patients and their surgical outcome.

No description available.

L’épilepsie insulaire (ÉI) est une forme rare d’épilepsie focale qui, en raison des défis liés à son diagnostic, est difficilement cernable. De plus, la prise en charge des patients avec ÉI s’avère complexifiée par le fait que cette pathologie est fréquemment résistante aux médicaments anti-crises. Pour ces cas médico-réfractaires, la chirurgie insulaire est une option viable. Cela dit, les patients subissant une telle intervention développent fréquemment des déficits neurologiques postopératoires; heureusement, la grande majorité de ceux-ci récupèrent complètement et rapidement. Or, le mécanisme sous-tendant ce singulier rétablissement fonctionnel demeure à ce jour mal compris. Deux modalités modernes d’IRM structurelle, soit l’analyse d’épaisseur corticale et la tractographie, ont permis, dans les dernières années, de décrire les altérations architecturales caractéristiques et potentiellement diagnostiques de divers types d’épilepsie ainsi que de caractériser les remodelages plastiques qui suivent la chirurgie de l’épilepsie extra-insulaire. Cependant, à ce jour, aucune étude ne s’est encore penchée sur le cas de l’ÉI. De ce fait, les études qui constituent cette thèse exploitent l’IRM structurelle afin, d’une part, de dépeindre les altérations d’épaisseur du cortex et de connectivité de matière blanche associées à l’ÉI et, d’autre part, de définir les réarrangements de connectivité subséquents à la chirurgie insulaire pour contrôle épileptique. Les deux premières études de cette thèse ont révélé que l’ÉI était associée à un pattern majoritairement ipsilatéral d’atrophie corticale et d’hyperconnectivité impliquant principalement des sous-régions insulaires et des régions connectées à l’insula. De manière intéressante, la topologie de ces changements correspondait, au moins en partie, à celle du réseau épileptique de l’ÉI. Ensuite, la troisième étude visait à décrire, par le biais d’une méta-analyse, l’histoire naturelle postopératoire des patients subissant une chirurgie pour ÉI. Cette analyse a, entre autres, confirmé que cette chirurgie était efficace (66.7% de disparition des crises) et qu’elle était fréquemment accompagnée de complications neurologiques (42.5%) qui, dans la plupart des cas, étaient transitoires (78.7% des complications) et récupéraient entièrement dans les trois mois postopératoires (91.6% des complications transitoires). Finalement, la quatrième étude a révélé que la chirurgie pour ÉI était suivie d’altérations de connectivité diffuses et bilatérales. Notamment, les connexions présentant une augmentation de connectivité concernaient particulièrement des régions localisées soit près de la cavité chirurgicale ou dans l’hémisphère controlatéral à l’intervention. De plus, la majorité de ces renforcements structurels se sont produits dans les six premiers mois suivant la chirurgie, un délai comparable à celui durant lequel la majeure partie de la récupération fonctionnelle postopératoire a été observée dans notre méta-analyse. En somme, nos résultats suggèrent que les altérations morphologiques en lien avec l’ÉI peuvent correspondre à son réseau épileptique sous-jacent. La topologie de ces changements pourrait constituer un biomarqueur structurel diagnostique qui aiderait à la reconnaissance de l’ÉI et, concomitamment, favoriserait possiblement un traitement chirurgical plus adapté et plus efficace. De plus, les augmentations de connectivité postopératoires pourraient correspondre à des réponses neuroplastiques permettant de prendre en charge les fonctions altérées par la chirurgie. Nos constats ont ainsi contribué à la caractérisation des mécanismes étayant la singulière récupération fonctionnelle accompagnant la chirurgie pour ÉI. À plus grande échelle, nos travaux offrent un aperçu du potentiel de l’IRM structurelle à assister au diagnostic de l’épilepsie focale ainsi qu’à participer à la description des changements plastiques subséquents à une résection neurochirurgicale. / Insular epilepsy (IE) is a rare type of focal epilepsy that is difficult to diagnose. In addition to the challenging nature of IE detection, management of patients with this condition is complicated by the tendency of insular seizures to be resistant to anti-seizure medications. For such medically refractory cases, insular surgery constitutes a viable and long-lasting therapeutic option. That said, patients who undergo an insular resection for seizure control frequently develop postoperative neurological deficits; fortunately, most of these impairments recover fully and rapidly. While this favorable postoperative course contributes to improving the outcome of IE surgery, the mechanism underlying the functional recovery remains unknown. Two contemporary structural MRI modalities, namely cortical thickness analysis and tractography, have recently been used to describe characteristic structural alterations of focal epilepsies and to elucidate the postoperative plastic remodeling associated with surgery for extra-insular epilepsy. While these analyses added to our understanding of several localization-related epilepsies, none specifically studied IE. In this thesis, we exploit structural MRI techniques to, first, depict the alterations of cortical thickness and white matter connectivity in IE and, second, define the progressive rearrangements that follow insular surgery for epilepsy. The first two studies of the current thesis showed that IE is associated with a primarily ipsilateral pattern of cortical thinning and hyperconnectivity that mainly involves insular subregions and insula-connected regions. Interestingly, the topology of these changes corresponded, at least in part, to the epileptic network of IE. Furthermore, the third study aimed to describe, via a meta-analysis, the postoperative outcome of patients undergoing surgery for IE. Among other findings, the analysis revealed that insular surgery was effective (66.7% seizure freedom rate) but was associated with a significant risk of neurological complications (42.5%) which, in most cases, were transient (78.7% of all complications) and recovered fully within three months (91.6% of transient complications). Finally, the fourth study showed that surgery for IE was followed by a diffuse pattern of bilateral structural connectivity changes. Notably, connections exhibiting an increase in connectivity were specifically located near the surgical cavity and in the contralateral healthy hemisphere. In addition, the majority of the structural strengthening occurred in the first six months following surgery, a time course that is consistent with the short delay during which most of the postoperative functional recovery was observed in our meta-analysis. Our results suggest that the morphological alterations in IE may reflect its underlying epileptic network. The topology of these changes may constitute a structural biomarker that could help diagnose IE more readily and, concomitantly, potentially enable a more targeted and more effective surgical treatment. Moreover, the postoperative increases in connectivity may be compatible with compensatory neuroplastic responses, a process that arose to recoup the functions of the injured insular cortex. Our findings have therefore contributed to the characterization of the driving process that supports the striking functional recovery seen following surgery for IE. On a larger scale, our work provides insights into the potential of structural MRI to assist in the diagnosis of focal epilepsy and to describe plastic changes following neurosurgical resections.

Made available in DSpace on 2014-12-17T15:28:53Z (GMT). No. of bitstreams: 1 AndersonBS_DISSERT.pdf: 4240084 bytes, checksum: 0331343a1aab5e54d0d9cb6baeccb72d (MD5) Previous issue date: 2013-12-13 / Epilepsies are neurological disorders characterized by recurrent and spontaneous seizures due to an abnormal electric activity in a brain network. The mesial temporal lobe epilepsy (MTLE) is the most prevalent type of epilepsy in adulthood, and it occurs frequently in association with hippocampal sclerosis. Unfortunately, not all patients benefit from pharmacological treatment (drug-resistant patients), and therefore become candidates for surgery, a procedure of high complexity and cost. Nowadays, the most common surgery is the anterior temporal lobectomy with selective amygdalohippocampectomy, a procedure standardized by anatomical markers. However, part of patients still present seizure after the procedure. Then, to increase the efficiency of this kind of procedure, it is fundamental to know the epileptic human brain in order to create new tools for auxiliary an individualized surgery procedure. The aim of this work was to identify and quantify the occurrence of epilepticform activity -such as interictal spikes (IS) and high frequency oscillations (HFO) - in electrocorticographic (ECoG) signals acutely recorded during the surgery procedure in drug-resistant patients with MTLE. The ECoG recording (32 channels at sample rate of 1 kHz) was performed in the surface of temporal lobe in three moments: without any cortical resection, after anterior temporal lobectomy and after amygdalohippocampectomy (mean duration of each record: 10 min; N = 17 patients; ethic approval #1038/03 in Research Ethic Committee of Federal University of S?o Paulo). The occurrence of IS and HFO was quantified automatically by MATLAB routines and validated manually. The events rate (number of events/channels) in each recording time was correlated with seizure control outcome. In 8 hours and 40 minutes of record, we identified 36,858 IS and 1.756 HFO. We observed that seizure-free outcome patients had more HFO rate before the resection than non-seizure free, however do not differentiate in relation of frequency, morphology and distribution of IS. The HFO rate in the first record was better than IS rate on prediction of seizure-free patients (IS: AUC = 57%, Sens = 70%, Spec = 71% vs HFO: AUC = 77%, Sens = 100%, Spec = 70%). We observed the same for the difference of the rate of pre and post-resection (IS: AUC = 54%, Sens = 60%, Spec = 71%; vs HFO: AUC = 84%, Sens = 100%, Spec = 80%). In this case, the algorithm identifies all seizure-free patients (N = 7) with two false positives. To conclude, we observed that the IS and HFO can be found in intra-operative ECoG record, despite the anesthesia and the short time of record. The possibility to classify the patients before any cortical resection suggest that ECoG can be important to decide the use of adjuvant pharmacological treatment or to change for tailored resection procedure. The mechanism responsible for this effect is still unknown, thus more studies are necessary to clarify the processes related to it / As epilepsias s?o dist?rbios neurol?gicos caracterizados por crises espont?neas e recorrentes, resultantes de uma atividade el?trica anormal de uma rede neural. Dentre os diferentes tipos de epilepsia, a epilepsia mesial do lobo temporal (EMLT) ? a mais observada em adultos, sendo frequentemente associada ? esclerose hipocampal. Infelizmente, nem todos os pacientes s?o beneficiados pelo tratamento farmacol?gico (pacientes f?rmaco-resistentes). Para estes sujeitos, uma alternativa ? a realiza??o de cirurgia, um procedimento de alta complexidade e elevado custo. Atualmente, o procedimento mais realizado ? a lobectomia temporal anterior com amigdalo-hipocampectomia seletiva, uma cirurgia padronizada por marcos anat?micos. Entretanto, uma parcela dos pacientes continua a apresentar crises incapacitantes ap?s o tratamento cir?rgico. Desta forma, para aumentar a efici?ncia deste tipo de tratamento, ? fundamental a compreens?o do enc?falo humano epil?ptico com vistas a se criar ferramentas que auxiliem na realiza??o de procedimentos individualizados. O objetivo do presente trabalho foi identificar e quantificar a ocorr?ncia de atividade epileptiforme - esp?culas interictais (EI) e oscila??es de alta frequ?ncia (OAF) - em registros eletrocorticogr?ficos (ECoG) realizados durante procedimento cir?rgico em pacientes com EMLT refrat?ria ao tratamento farmacol?gico. Registros ECoG (32 canais a uma taxa de amostragem de 1 kHz) foram realizados na superf?cie do lobo temporal em 3 momentos cir?rgicos: no c?rtex intacto, ap?s lobectomia temporal anterior e ap?s amigdalo-hipocampectomia (dura??o m?dia de cada um desses registros: 10 min; N=17 pacientes). A ocorr?ncia de EI e OAF foi quantificada automatica-mente, por meio de rotinas em MATLAB, e validadas manualmente. A taxa de ocorr?ncia em cada um dos tempos cir?rgicos foi correlacionada com o resultado cir?rgico quanto ao controle das crises, num seguimento de 2 anos. De um total de 8 h e 40 min de registro, identificamos 36.858 EI e 1.756 OAF. Observamos que os pacientes que ficaram livres de crises no p?s-operat?rio apresentaram maior quanti-dade de OAF antes da cirurgia do que aqueles que continuaram a ter crises; por?m, n?o diferiram quanto a frequ?ncia, morfologia e distribui??o de EI. A ocorr?ncia de OAF no registro basal apresentou melhor desempenho que as EI na previs?o do controle total das crises no p?s-operat?rio (EI: AUC = 57%, S = 71% , E = 70% vs OAF: AUC = 77%, S = 100%, E=70%). O mesmo foi observado com a varia??o da ocorr?ncia entre os momentos pr?- e p?s-ressec??o (EI: AUC = 54%, S = 71%, E = 60% vs OAF: AUC = 84%, S = 100%, E = 80%). Nesse caso, o classificador foi capaz de identificar todos os pacientes livres de crises (N = 7) , apresentando apenas dois falsos positivos. Desta forma, podemos concluir que as OAF, juntamente com as EI, podem ser encontradas no registro ECoG intra-operat?rio, mesmo na presen?a de anest?sicos e em uma curta sess?o de registro. Al?m disso, a observa??o de que a ocorr?ncia desses eventos no in?cio da cirurgia permite classificar o paciente quanto ao progn?stico cir?rgico abre caminho para aplicar o ECoG intra-operat?rio, por exemplo, na decis?o sobre o uso de tratamento farmacol?gico adjuvante ou da convers?o para ressec??es individualizadas. No entanto, o mecanismo respons?vel por esse efeito ainda ? desconhecido, logo novos estudos s?o necess?rios para melhor esclarec?-lo

Nach dem Prinzip synchronisierter Reimwörter wurde ein deutscher dichotischer Hörtest entwickelt und erprobt (Fused Words, FW10b). Die Reliabilitätskennwerte lagen für die innere Konsistenz bei alpha=0,89 und für die Re-Test-Reliabilität im Bereich von r-tt=0,67 bis r-tt=0,87. Der dichotische Test korrelierte hoch mit einem Paralleltest (r=.73, FW12k). In mehreren Untersuchungen fand sich keine Assoziation des dichotischen Lateralisationsergebnisses mit dem Hormonzyklus bei Frauen. Zwischen der Klassifikation im Wada-Test und der Klassifikation im dichotischen Test wurde eine hohe prozentuale Übereinstimmung beobachtet (91%). Auch in einer externen Studie wurde eine hohe Konkordanz mit einem fMRT Paradigma gefunden (97%, Hund-Georgiadis et al 2002). Unter Rechtshändern hatten 70% einen Rechts-Ohr-Vorteil, 23% einen Links-Ohr-Vorteil; bei 7% wurde kein Ohr-Vorteil beobachtet. Es bestand eine hohe Assoziation zwischen dem Lateralitätsquotient der Händigkeit und dem Lateralitätsindex Lambda aus dem dichotischen Test (R=0,76, r=0,72). Bei epilepsiechirurgischen Kandidaten mit links- oder rechtsseitigen Temporallappenläsionen, die alle durch einen Wada-Test als unilateral links-hemisphärisch sprachdominant kategorisiert worden waren, wurden Läsionseffekte analysiert (Hippocampus-Sklerose vs. extra-hippocampale Läsionen). Wie erwartet ergaben sich massive Läsionseffekte für die Patienten mit den Läsionen in der linken sprachdominanten Hemisphäre. In der linken extra-hippocampalen Untergruppe kam es zu einer signifikanten Abnahme der Rechts-Ohr-Punkte und gleichzeitig zu einem signifikanten Anstieg der Links-Ohr-Punkte. Die Einbeziehung von neokortikalen und anderen extra-hippocampalen Strukturen in die temporalen Läsionen war von entscheidender Bedeutung für die Unterdrückung der Antworten vom kontralateralen (rechtsseitigen) Ohr. Die Zunahme der Links-Ohr-Punkte in der Gruppe mit linksseitigen extra-hippocampalen Läsionen deutet eine kompensatorische Verlagerung von Sprachfunktionen auf die rechte Hemisphäre an, die durch den Wada Test nicht erfasst wurde. / Following the principle of synchronized rhyming words a German dichotic listening test was developed and tested (fused words, FW10b). Reliability coefficients for the inner consistency were at alpha=0,89 and for the re-test-reliability between r-tt=0,67 and r-tt=0,87. The dichotic test FW10b was highly correlated with a parallel test (r=.73, FW12k). None of several studies did show any association between the dichotic language lateralization and the hormonal cycle in women. A high percentage of agreement was observed between the Wada classification and the classification by the dichotic test (91%). Furthermore Hund-Georgiadis et al. (2002) found a high percentage of concordance with the lateralization by a fMRI paradigm in an external study (97%). Among right-handers 70% showed a right ear advantage, 23% had a left ear advantage, and 7% had no ear advantage. There was a high association between the laterality quotient of the handedness inventory and the laterality index Lambda of the dichotic listening test FW10b (R=0.76, r=0.72). Lesion effects were analyzed in epilepsy surgical candidates with left and right temporal lobe lesions (hippocampus sclerosis vs. extra-hippocampal lesions), who were all categorized as left-hemispheric language dominant by a Wada-test. As expected, massive lesion effects were apparent in those patients who had their lesions in the left language dominant hemisphere. In the subgroup with left extra-hippocampal lesions there was a significant decrease of right-ear-points and at the same time a significant increase of left-ear-points. The involvement of neocortex and other extra-hippocampal structures in temporal lobe lesions were of crucial importance for the suppression of contralateral (right) ear responses. The elevation of left-ear-points in the left-lateral group indicated a partial compensational shift of language functions to the right hemisphere, which was not detected by the Wada procedure.