Richard Kaplan Sandra Koffler Greg J. Neuropsychology of Epilepsy and Epilepsy Surgery Gregory P. The Business of Neuropsychology Mark T. Adult Learning Disabilities and ADHD Robert L. Board Certification in Clinical Neuropsychology. Mild Traumatic Brain Injury and Post-Concussion Syndrome Michael A. Ethical Decision Making in Clinical Neuropsychology Shane S. NEUROPSYCHOLOGY OF EPILEPSY AND EPILEPSY SURGERY. Library of Congress Cataloging-in-Publication Data Lee, Gregory P. Neuropsychology of epilepsy and epilepsy surgery / by Gregory P. Oxford workshop series).
Psychologists in North America have been studying the cognitive and behavioral consequences of epilepsy surgery since the technique was introduced more than three-quarters of a century ago. Short descriptions of less common epilepsies are found in the Quick Reference Appendix. The day-to-day work of a comprehensive epilepsy surgery program depends on a multitude of healthcare professionals, including epileptologists, neurosurgeons, neuropsychologists, nurses, EEG technicians and various support staff, and I have had the privilege of working among them for the past 24 years at the Medical College of Georgia.
The epilepsy surgery program at the Medical College of Georgia was founded in 1981 by Dr. I am grateful to all the neuropsychology staff at the Medical College of Georgia for their patience and assistance with this project, including Dr.
NEUROPSYCHOLOGISTS
- Classification of Epilepsy Disorders 13
- Epilepsy Syndromes 39
- Diagnostic Tests in Epilepsy 65 Electroencephalography 65
- Medical Treatment of Epilepsy 73
- Neuropsychological Assessment in Epilepsy 95
- Psychological and Psychiatric Disorders in Epilepsy 133
- Psychogenic Nonepileptic Seizures 151 Diagnosis 151
3-Hz spike and wave pattern 69 Multiple spike and wave pattern 69 Slow spike and wave pattern 69 Generalized paroxysmal fast activity 70 Structural neuroimaging in epilepsy 71. Antiepileptic drugs in women 79 Pregnancy and teratogenic effects 80 Antiepileptic drug treatment in children 81 Adverse effects of antiepileptic drugs in children 82 Cognitive and behavioral effects of antiepileptic drugs. Adult Quality of Life in Epilepsy Measures 120 Pediatric Quality of Life in Epilepsy Measures 122 Quality of Life in Adolescents in Epilepsy Measures 124 Driving Problems in Epilepsy 125.
PART TWO SURGICAL TREATMENT OF EPILEPSY Chapter 9 Neuropsychological Assessment in Epilepsy
Other Neuropsychological Procedures in Epilepsy Surgery 183
Language recovery after amobarbital injection 186 Mixed or atypical language presentation 186 Clinical implications of language Wada.
Medical Aspects of Epilepsy Surgery 211 Criteria for Surgical Evaluation 211
Adverse Effects of Vagus Nerve Stimulation 227 Current Status of Vagus Stimulation 227 Anterior Temporal Lobectomy 227 .
Traditional Classification of Epileptic Seizures
Classification of Epilepsy Syndromes: Description of Seizure Syndromes Not Covered in Body of Text 257
Seizures in the precentral frontal lobe 264 Seizures in the premotor frontal lobe 264 Seizures in the supplementary motor area 265 Seizures in the dorsolateral prefrontal lobe 265 Seizures in the orbitofrontal 265. Seizures in the postcentral gyrus 266 Seizures in the superior parietal lobe 267 Seizures in the inferior parietal lobe 267 Seizures in the paracentral parietal lobe 268. Idiopathic generalized epilepsy syndromes 268 Benign Neonatal familial convulsions 268 Benign neonatal convulsions (non-familial) 268 Benign myoclonic epilepsy of childhood 268 Juvenile myoclonic epilepsy 269.
Epilepsy with tonic-clonic (generalized tonic-clonic) seizures after awakening 270 Cryptogenic or symptomatic generalized epilepsy.
Wada Assessment Procedures and Rating Criteria at the Medical College of Georgia 273
The American Academy of Clinical Neuropsychology (AACN) is offering continuing education (CE) through its book series with Oxford University Press, Oxford Workshop Series: American Academy of Clinical Neuropsychology (Workshop Series). Each licensed psychologist who reads a volume in the Workshop series can earn up to three CE credits by completing an online quiz about the volume's content. A fee of $20 per credit ($15 for AACN members), payable online by credit card, will be charged for participation in this event.
Go online to the CE Quiz at the AACN website (www.theaacn.org), register for the specific workshop book for which you would like to receive CE credit, and answer all questions on the quiz. The AACN is approved by the American Psychological Association to sponsor continuing education for psychologists. To download materials from the author's workshop presentation, such as PowerPoints, visit www.AACNWorkshopSeries/Lee.
PART ONE
MEDICAL ASPECTS OF EPILEPSY FOR NEUROPSYCHOLOGISTS
The role of the neuropsychologist in the evaluation of patients with epilepsy is essentially the same as in any other neurological disease. Cycling or foot pedaling can be seen in complex partial seizures arising from the frontal lobe, most commonly in mesial frontal regions (Kotagal and Loddenkemper, 2006). Generalized seizure disorders can be convulsive or nonconvulsive and vary greatly depending on the severity of the epilepsy.
The first decision is whether the EEG seizure onset is focal or generalized. For example, in the most common neurodegenerative disorder, Alzheimer's disease, the risk of epilepsy is 10 times higher than in healthy older individuals. Thus, symptomatic (or secondary) epilepsy is the result of an acquired postnatal lesion; idiopathic epilepsy is genetic or familial; and cryptogenic epilepsy is the result of a prenatal or intrauterine acquired (developmental) condition of the brain.
Careful selection of the appropriate antiepileptic drug (AED) regimen is important, as drugs effective in partial epilepsies may be ineffective in idiopathic generalized epilepsy (Panayiotopoulos, 2005). Febrile convulsions usually occur early in the course of the infectious disease, as the temperature curve rises. In many cases, there may be no clear clinical manifestations of the abnormal electrical discharges.
Most of the cognitive and behavioral AED adverse effects are dose-dependent (less adverse cognitive effects at lower doses). There have been few studies of the ketogenic diet in adults or among patients with complex partial seizures. It largely depends on the age of the patient when the attacks started.
A standard interpretation of the reason for failure of a specific test can often be inaccurate for patients with epilepsy. Focal cortical excision of the epileptic focus, especially in the temporal lobe, can also cause recent memory deficits. These deficits depend on the etiology of the seizures and the severity of the epilepsy disorder.
This suggests that a patient's mood may be one of the most powerful predictors of quality of life. They also suggest that anhedonia is an excellent barometer of the severity of depression in the medically ill. There are no double-blind, placebo-controlled studies of the antianxiety drugs in patients with epilepsy and comorbid anxiety disorders.
Cragar, Berry, Fakhoury, and colleagues (2002) have detailed a number of tools that can be useful in the diagnostic process of PNES.
PART TWO
SURGICAL TREATMENT OF EPILEPSY
In addition, most epilepsy surgery neuropsychologists also perform the cognitive assessment portion of the intracarotid amobarbital (Wada) procedure; design, monitor and help interpret the results of cognitive testing performed during functional magnetic resonance imaging (fMRI); and plan and perform the sensorimotor and cognitive evaluations during electrocortical stimulation mapping both extraoperatively and intraoperatively. Before going into the details of the cognitive assessment procedures, it is important to see where these procedures fit within the overall scheme of the epilepsy surgery decision-making process (Fig. 9.1). One of the most important reasons to obtain preoperative neuropsychological testing is to aid in the lateralization and localization of the seizure focus (Kneebone, 2001).
Although the pattern of neuropsychological deficits is more sensitive to the brain damage causing the epilepsy than it is to the presence of the seizure focus itself, the lesion and epileptogenic focus often (but not always) overlap. This is thought to be due to early intractable seizures that disrupt the normal acquisition of a wide range of cognitive functions, regardless of the site of seizure onset (Chelune, 1994). The risks that have been studied the most and occupy the majority of the neuropsychologist's time center around memory and language in temporal lobectomy candidates.
Thus, the neuropsychological test patterns indicating a possible risk for global memory loss include impairments in both verbal and nonverbal memory, implying bilateral hippocampal dysfunction, and material-specific memory impairments in the opposite direction to what is expected based on expectations. seizure focus (e.g. verbal memory deficits in patients with right mesial temporal lobe seizures). This usually consists of selected subtests from one or more of the comprehensive aphasia batteries, such as the Boston Diagnostic Aphasia Examination (BDAE), Multilingual Aphasia Examination (MAE), or Western Aphasia Battery (WAB). Although refractory patients considered for epilepsy surgery almost universally have experienced significant disruption to daily life as a result of their epilepsy disorder, one purpose of a preoperative neuropsychological assessment is to help evaluate and quantify this impact.
These tests, in conjunction with cognitive measures, attempt to characterize the impact of seizures on the patient's life to help determine whether the epileptic disorder is of sufficient severity to warrant surgery. Postoperative neuropsychological assessment will help identify the cause(s) of postoperative changes, which in turn will determine appropriate treatment recommendations. This more generalized dysfunction may be due to widespread structural and physiological effects of repeated seizures on the brain.
Results over the past 20 years have consistently found that patients who have cognitive deficits limited to the area of proposed surgery are more likely to benefit from surgery (Rausch, 1987). Patients, families, and involved health care professionals should be aware of the type and severity of any postoperative cognitive deficits. This is followed by a spell and lip smacking, with deviation of the eyes and head to the left side, and tremors of the left arm that evolve Neuropsychological Evaluation in Epilepsy Surgery 173 .
