14 Epilepsy C LINICAL N EUROLOGY N EWS • February 2007 MRI Reveals New Epilepsy Surgery Candidates

BY MICHELE G. SULLIVAN spherectomy a difficult Mid-Atlantic Bureau decision for both physi- cian and parent. emispherectomy or cortical resection may cure At a recent meeting of catastrophic epilepsy even in a child with gener- the Child Neurology So- alized seizures, with MRI rather than EEG iden- ciety, Dr. Wyllie reported H YLLIE tifying surgical candidates, according to Dr. Elaine Wyl- some preliminary find- W lie, director of the child neurology center at the Cleveland ings from a retrospective Clinic Children’s Hospital. study of 50 such children, LAINE . E R

Candidates for the surgery are children in whom the all of whom underwent D epileptogenic focus is a unilateral brain lesion that prob- functional hemispherec- ably occurred prenatally, perinatally, or during infancy. tomy or cortical resection “These extensive congenital or early-acquired unilateral at the Cleveland Clinic in brain lesions may produce generalized—or even con- 1999-2004. All had ictal or HOTOS COURTESY tralateral—maximum epileptiform discharge patterns on interictal epileptiform dis- P EEG,” she said in an interview. “Despite these EEG find- charges that were either Encephalomalacia from a perinatal infarction is shown on MRI (left); perioperative ings, you can still get favorable surgical results in some generalized or maximum interictal EEG in the same patient shows generalized slow spike-wave complexes (right). cases, if you have a clear unilateral brain lesion on MRI contralateral to the surgi- with side-appropriate semiology.” Children with this cal site, and early brain lesions that were unilateral or very ated from high school, and is now learning a trade.” clinical picture are typically turned away from surgery. strongly asymmetrical. Even though all of the children had Many of the other 49 patients with focal lesions and dif- In the 1990s, she said, a team from the University of Cal- an obvious focus for their seizures, their generalized EEG fuse EEGS had a similarly good outcome, she said. Her pre- ifornia, Los Angeles, began to report surgical cures of in- patterns had eliminated some of these patients as surgical liminary results, based on each patient’s last follow-up, fantile spasms and hypsarrhythmia—that is, seizure types candidates at other centers they had visited. showed that 72% had become seizure free since their with diffuse EEG patterns (Epilepsia 1993;34:764-71). Oth- One of her first such patients, a 12-year-old, was a prime surgery. Major improvements—resolution of catastroph- er centers, including the Cleveland Clinic, soon were repli- example, Dr. Wyllie said. His seizures began when he was ic epilepsy with some remaining seizures—occurred in sev- cating the results. “When a lesion occurs this early, it’s ac- 1 month old, and by the time he was 5 months old, he had eral of the other patients, with only 6 of the original 50 tually interacting with the time-locked processes of brain developed a right hemiparesis with no fine finger move- experiencing little or no improvement. The three wound development: the formation of the cortex, the migration ment. By 9 years of age, he had developed medically re- infections resolved with antibiotics and cranioplasty, one of neurons, the increase in synaptogenesis, and myelina- fractory epilepsy, with daily right arm tonic seizures. His hydrocephalus that required a shunt, and one late ex- tion,” Dr. Wyllie said. “And when the lesion interacts with MRI showed a middle cerebral artery infarct, which prob- panding cyst that required fenestration. The next step is to this dynamic process, you get the development of epilep- ably occurred between 34 weeks’ gestation and birth, with further define the best surgical candidates, she said. Her sy that looks different—electrically and clinically—from left-sided gliosis and cortical and subcortical encephalo- current work-up includes the following considerations: what you see when a fixed electrical brain system acquires malacia, all of which corresponded with his seizure semi- Ǡ Imaging must identify an extensive brain lesion that a lesion.” In fact, she said, the healthier side of the brain ology and neurologic exam. But his ictal and interictal probably occurred pre- or perinatally or during infancy. can sometimes express more pronounced epileptiform dis- EEGs showed generalized discharges, mainly in the right Ǡ The lesion must be capable of epileptogenesis. charges than does the injured side. hemisphere. “We had to ignore these features on EEG and Ǡ The lesion must be unilateral or strongly asymmetric. Although the EEG findings—considered in isolation— go with what we saw on the MRI, the exam, and the Ǡ Seizures must be medically refractory. may suggest that the child has generalized seizures, the seizure type,” she said. “He had a left functional hemi- Ǡ Hemispherectomy candidates must have side-appro- seizure semiology, motor deficits, and MRI all point to a spherectomy in 1999, and has been off all medications priate motor deficit that will not be worsened by surgery. focal source. This seeming contradiction makes hemi- since 2001. He hasn’t had any seizures since, has gradu- Ǡ A video EEG can be helpful in confirming seizures. ■ Patients’ Artwork Grants Insight Into Living With Epilepsy

BY DOUG BRUNK League Against Epilepsy. Dr. Schachter periences during their seizures. One artist where they feel the safest is their home or San Diego Bureau has collected more than 1,200 paintings, says during her seizures her world seems bedroom, which is a common theme in photographs, and other works of art by 52 very unreal, he said. “She feels like she’s the art,” Dr. Schachter said. S AN D IEGO — Artwork created by per- artists with epilepsy from around the walking in a dreamlike state. Her art rep- Ǡ Non–epilepsy related. There are many sons with epilepsy can help others gain in- world. “I often show the art when I’m see- resents this experience.” artists with epilepsy “whose art has no os- sight to the experiences of patients with ing other patients to help them verbalize For many epilepsy patients, “the postic- tensible connection to their epilepsy at the condition, Dr. Steven C. Schachter feelings,” he said. tal state is their only clue that they’ve had all,” he said. Such works serve to destig- said at the annual meetings of the Amer- Many of the works in his collection ap- a seizure. It can be a period of time with matize epilepsy, “to emphasize that people ican Epilepsy Society and the Canadian pear in “Vision: Artists Living With Epilep- very intense emotional symptoms.” One with epilepsy ... can be creative and con- sy” (Elsevier Science and Technology, artist told Dr. Schachter that after having tribute to society. It’s art for art’s sake.” 2003), a book edited by Dr. Schachter. All a seizure she “has an overwhelming sense The presentation was part of the AES royalties from sales of the book support that everything she knows to be present in Annual Course, a program supported by the Epilepsy Foundation. her world is actually distant in time and an educational grant from Abbott Labo- Studying the art of people with epilep- space. With that comes a powerful sense ratories, Cyberonics, and GlaxoSmithKline sy serves to recognize their contributions of anguish, pain, and loneliness.” Pharmaceuticals. ■ to society, but it also raises certain research Ǡ Psychiatric comorbidities. Themes questions, said Dr. Schachter, professor of that reflect anxiety and depression also are neurology at Harvard Medical School, common in the artwork, and the preva- National Walk for Boston, and director of neurotechnology lence of these conditions may be higher in at the Center for Integration of Medicine people with epilepsy than in the general Epilepsy in March and Innovative Technology, Boston. “For population. The fear of the next seizure example, are people with epilepsy partic- and the fear of dying “are all common anx- he Epilepsy Foundation is hosting ularly likely to engage in artistic activities?” ieties people with epilepsy have,” he said. Tthe first National Walk for Epilep- he asked. “Is there a link between epilep- One of his patients likened the beginning sy on March 31 in Washington, D.C. sy and creativity? If so, what are the epilep- of a seizure to being “in front of an on- The 5K walk, sponsored by Ortho-Mc- sy-specific variables that are involved?” coming train with no way to escape.” Psy- Neil Neurologics, should help raise $1

ALL While he did not offer answers to those chosis also occurs in patients with epilep- million to support programs “to elim- H questions during his presentation, he did sy, perhaps as a function of severity. inate stigma and raise awareness of discuss four general themes that emerge Ǡ Psychosocial aspects of epilepsy. epilepsy,” according to the Foundation, ENNIFER

J in the artwork in his collection: These include themes of isolation from so- which expects 5,000 people to partici- Dr. Schachter has collected over 1,200 Ǡ Seizures and the postictal state. Many ciety, stigma, and reminders of living with pate. More information is available at: works such as ‘Transcending’ (above). works represent the artists’ conscious ex- epilepsy. “For some patients, the place www.walkforepilepsy.org. ■