Focal extratemporal epilepsy: clinical features, EEG patterns, and surgical approach

doi:10.1016/S0022-510X(99)00107-0

Journal of the Neurological Sciences

Volume 166, Issue 1, 15 June 1999, Pages 1-15

https://doi.org/10.1016/S0022-510X(99)00107-0 Get rights and content

Abstract

The objective of this review is a summary of the clinical and electrographic findings in those forms of epilepsy to which the term ‘extratemporal’ (ExT) can be applied. They form a group that differs in many ways from the better known temporal lobe epilepsies. Seizure foci are difficult to localize by clinical semiology alone but modern imaging now often allows a precise definition of the epileptogenic area. The most common causes of ExT epilepsy are tumors and cortical dysgenesis. The concept of ‘dual pathology’ implies the coexistence of two or more distinct lesions, typically mesial temporal sclerosis and cortical dysplasia. Electroencephalography (EEG) and electrocorticography (ECoG) are valuable tests in the definition of the epileptogenic area beyond the structural lesion, and surgical removal must be guided by the nature of the lesion and the extent of the epileptogenic zone.

Introduction

Electroencephalography (EEG), neuroimaging, and long-term monitoring have aided in the characterization of many types of focal epilepsy. ‘Typical’ temporal lobe seizures originating in the hippocampi the parahippocampal gyri, and the amygdaloid nuclei constitute the majority of focal epilepsies and gain the most benefit from surgery [36]. In contrast, extratemporal (ExT) epilepsy constitutes a more heterogeneous group. Different types of focal ExT epilepsies manifest themselves by a wide range of epileptic seizures and show highly variable responses to therapy.

Extratemporal epilepsy can be classified according to the presumed site of seizure origin. Frontal, parietal, and occipital focal epilepsies exist, and multiple territorial overlaps may occur [96], [98]. The ExT epilepsies are common disorders. According to the National General Practice Study of Epilepsy [75] at the Chalfont Centre for Epilepsy in England, 26.9% of all patients with definite epilepsy had seizures of identifiable focal origin. Within this group 22.5% had frontal, 32.5% central, 5.6% frontotemporal, and 6.3% each parietal and occipital foci, with only 27% of the patients having temporal lobe abnormalities. A larger more recent study [109] at the Epilepsy Unit of the La Salpêtrière Hospital in Paris included 1369 patients with partial epilepsy of whom 814 had identifiable lesions by magnetic resonance imaging (MRI). One hundred and seventy-nine (22%) had frontal, 20 (2.5%) occipital, and 15 (2%) parietal epilepsies. It is not always clear how the type of epilepsy affects the outcome of medical or surgical therapy. This retrospective review attempts a correlation of clinical findings, EEG and electrocorticography (ECoG), and surgical success rates, and the goal is to guide the neurologist toward the most rational management in their patients with ExT epilepsy.

Section snippets

Clinical features

The manifestations of ExT epilepsy are variable, and localization by clinical signs alone remains difficult. A few types of ExT seizures are stereotypical and characteristic of certain epileptogenic sites. Generally, ictal semiology is diagnostic when seizures arise from a primary cortical area, such as the primary motor, visual, or sensory cortices.

Interictal EEG abnormalities

Several types of interictal patterns may be seen in patients with ExT epilepsy. They include: (1) focal interictal epileptiform discharges (IEDs) localized to the site of seizure origin; (2) regional, poorly localized, but lateralized IEDs; (3) falsely localizing focal IEDs; (4) multifocal IEDs; (5) bilateral or generalized, bilaterally synchronous IEDs; and (6) no IEDs. Different degrees of focal or diffuse non-epileptiform electrographic changes may also be present.

Causes of extratemporal epilepsy

Jackson [55] recognized that structural brain pathology, such as a tumor, may cause epilepsy. With progress in neuroimaging, the proportion of ExT epilepsy cases without an identifiable focal brain lesion decreased significantly and now constitutes probably 20–40% of all ExT epilepsy cases [34], [83]. Table 2 presents the rate of occurrence of different radiological and histopathological findings in ExT epilepsies. Brain tumors and developmental cortical disorders are the two largest

Surgical outcome

Long-term outcome after surgery for ExT seizures depends on many factors. Generally, the benefit of surgical treatment for ExT epilepsy is less impressive than operations for medial temporal epilepsy. However, recent studies in pediatric epilepsy did not find a statistical difference between the outcomes after surgical treatment of temporal and ExT epilepsy [33], [134]. Seizure-free outcome rates were 10% for selected temporo-parietal and occipital cases [38], 26% in a large retrospective

Conclusion

Epilepsy is no longer a single clinical entity because it shows a perplexing abundance of clinical symptoms and signs and abnormal electrophysiological and radiological features. Extratemporal epilepsy stands out as a fairly well-circumscribed disorder. However, it may be further divided into subtypes based on the site of seizure origin and the presence of etiological factors. Clinical semiology of the seizures may be helpful in establishing the type of epilepsy but is not always reliable. A

Acknowledgements

The author wishes to acknowledge the assistance of Dr A. Koeppen, review editor, in the completion of the manuscript.

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Citation Excerpt :
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ReviewFocal extratemporal epilepsy: clinical features, EEG patterns, and surgical approach

Abstract

Introduction

Section snippets

Clinical features

Interictal EEG abnormalities

Causes of extratemporal epilepsy

Surgical outcome

Conclusion

Acknowledgements

Clin Neurol Neurosurg

Epilepsy Res

Mayo Clin Proc

Mayo Clin Proc

Electroencephalogr Clin Neurophysiol

Electroencephalogr Clin Neurophysiol

Neurosurg Clin N Am

Electroencephalogr Clin Neurophysiol

Electroencephalogr Clin Neurophysiol

Epilepsy Res

Hum Pathol

Clinical ictal patterns and electrographic data in cases of partial seizures of frontal-central-parietal origin

Surgical outcome in computer assisted stereotactic resection of intra-axial cerebral lesions for partial epilepsy

Stereotact. Funct. Neurosurg.

Clinical and electroencephalographic evidence for sites of origin of seizures with diffuse electrodecremental pattern

Epilepsia

Surgical management and seizure outcome in patients with tuberous sclerosis

J Neurosurg

Surgical outcome in occipital lobe epilepsy: implications for pathophysiology

Ann Neurol

Clinical semiology of frontal lobe seizures

Sublobar dysplasia: a new malformation of cortical development

Neurology

EEG findings in frontal lobe epilepsies

Neurology

Nocturnal temporal lobe epilepsy

Neurology

Occipital lobe epilepsies

Electrographic and clinical correlates of secondary bilateral synchrony

Epilepsia

Type I/II complex partial seizures: no correlation with surgical outcome

Epilepsia

Low-grade glial neoplasms and intractable partial epilepsy: efficacy of surgical treatment

Epilepsia

Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalographic results

Epilepsia

Extratemporal cortical resections and lesionectomies for partial epilepsy: complications of surgical treatment

Epilepsia

Frequency and characteristics of dual pathology in patients with lesional epilepsy

Neurology

Identification of dual pathology in patients with lesional epilepsy

Epilepsia

Secondary bilateral synchrony in unilateral pial angiomatosis: successful surgical treatment

J Neurol Neurosurg Psychiatry

Surgical treatment of epilepsy: the problem of lesion/focus incongruence

Surg Neurol

Seizure outcome after lesionectomy for cavernous malformations

J Neurosurg

Semiological value of adversive epilepsy

Epilepsia

The relationship between sleep and epilepsy in frontal and temporal lobe epilepsies: practical and physiopathologic considerations

Epilepsia

Posttraumatic frontal lobe epilepsy with structural changes: excellent results after cortical resection

Can J Neurol Sci

Dysembrioplastic neuroepithelial tumours

Brain Pathol

Complex partial seizures on closed-circuit television and EEG: a study of 691 attacks in 79 patients

Ann Neurol

Type I complex partial seizures of hippocampal origin: excellent results of anterior temporal lobectomy

Neurology

Bilateral periventricular nodular heterotopia with mental retardation and syndactyly in boys: a new X-linked mental retardation syndrome

Neurology

Periventricular and subcortical nodular heterotopia. A study of 33 patients

Brain

Prognostic significance of presurgical variables on outcome of focal resections in preadolescent children with intractable partial epilepsy

Epilepsia

Imaging and epilepsy

Brain

Outcome with respect to epileptic seizures

Frontal epileptogenic foci and their clinical correlations

Review
Focal extratemporal epilepsy: clinical features, EEG patterns, and surgical approach