gary mathern

OBJECTIVE: We aimed to measure parent-reported barriers to timely receipt of pediatric epilepsy surgery. BACKGROUND: Although shorter time to pediatric resective epilepsy surgery is most strongly associated with greater disease severity, other non-clinical diagnostic and sociodemographic factors play a role. METHODS: We conducted 37 interviews of parents of children who previously had resective epilepsy surgery at UCLA (2006-2011); parents were recruited purposively oversampling those with longer times to surgery. Interviews were audio-recorded, transcribed and systematically coded using thematic analysis by two independent coders and subsequently checked for agreement. Clinical data, including ‘time to surgery’ (age of epilepsy onset to age of surgery, mean 5.3 years, SD=3.8), and type of surgery (32[percnt] hemispherectomy, 43[percnt] lobar/focal, 24[percnt] multilobar), were abstracted from medical records. RESULTS: The more arduous and longer aspect of the journey to surgery was perceived to be experienced prior to presurgical referral. The time from second anti-epileptic drug failure to presurgical referral was 蠅1 year in 64[percnt] of children. Thematic analysis revealed four themes along the journey to surgery (with subthemes): (1) recognition: “something is wrong” (unfamiliarity with epilepsy, identification of medical emergency), (2) searching and finding: “a circuitous journey” (information seeking, finding the right doctors, multiple medications, insurance obstacles, parental stress) (3) surgery is a viable option: “the right spot” (surgery as last resort, surgery as best option, hoping for candidacy), (4) life now: “we took the steps we needed to” (a new life, giving back). CONCLUSIONS: Parents perceive a spectrum of parent-, provider- and health-system based barriers that influence the ease of getting to and the timeliness of receipt of pediatric epilepsy surgery. Multi-pronged interventions targeting parent-, provider- and system-based barriers prior to presurgical referral are needed to improve access to subspecialty care for children with medically refractory epilepsy and eligible for surgery. Epilepsy Foundation Grant 20111278 Disclosure: Dr. Baca has nothing to disclose. Dr. Pieters has nothing to disclose. Dr. Iwaki has nothing to disclose. Dr. Mathern has nothing to disclose. Dr. Vickrey has received personal compensation for activities with EMD Serono as a consultant.

The present study examined the relationship between the patterns and densities of glutamate AMPA receptor sub-units GluR1 and GluR2/3 in the molecular layer of the fascia dentata and aberrant mossy fiber neoinnervation in human and kainate rat hippocampal epilepsy. Because AMPA sub-units modulate the fast glutamate synaptic transmission, we hypothesized that the AMPA receptor densities would be related to the glutamate-secreting mossy fibers, which could then contribute to seizure generation. In human hippocampal epilepsy, we found that the immunocytochemical labeling of GluR1 and GluR2/3 dendrites was positively related to the densities and spatial locations of the densest, aberrant neo-Timm stained supragranular mossy fibers. We used quantitative densitometry for the mossy fibers. However, the relatively faint and punctate immunocytochemical staining of the receptors did not allow true quantitative densitometry of the dendritic trees because in human epilepsy granule cell densities were decreased on average 50% of normal. Nevertheless, visual observations did confirm spatial relations between dense fascia dentata inner molecular layer mossy fibers and dense AMPA receptor staining. In the outer molecular layer, the mossy fibers were present only in the lower portion, were not densely-stained, and the AMPA receptors were only faintly-labeled. Nevertheless, outer molecular layer AMPA receptor densities were usually present more distally than were the mossy fibers. Experiments were done using intrahippocampal kainate epileptic rats to test the time courses for the changes in mossy fibers and AMPA receptors. The upregulation of inner and outer molecular layer AMPA receptors occurred maximally within 5 days post-kainate injection, prior to any mossy fiber supragranular ingrowth. One hundred and eighty days after ipsilateral kainate the AMPA receptors were increased bilaterally in the inner and outer molecular layers despite the fact that the contralateral aberrant supragranular mossy fibers were minor in comparison to the dense ipsilateral mossy fiber hyperinnervation. These results suggest that in hippocampal epilepsy AMPA receptor numbers increase throughout the length of the molecular layer dendrites; however the AMPA receptor densities are greater in rough relation to the greatest aberrant mossy fiber presynaptic inputs. Interestingly, the receptor upregulation precedes the mossy fiber ingrowth and may play a role in initiating axonal sprouting or in maintaining the aberrant mossy fiber synapses.

Whether hippocampal neuron loss and/or hippocampal sclerosis is the 'cause' or 'consequence' of seizures has been a fundamental question in human epilepsy studies for over a century. To address this question, this study examined hippocampal specimens from temporal lobe epilepsy patients (TLE; n = 572) and those with extra-temporal seizures and pathologies (n = 73) for qualitative signs of hippocampal sclerosis and quantitative neuron loss using cell counting techniques. Patients were additionally classified based on pathological substrate, and history of an initial precipitating injury (IPI). Results showed that: (1) Hippocampal sclerosis was strongly linked with an IPI in both TLE and extra-temporal seizure patients. (2) In TLE cases, IPIs showed an early age preference and often involved seizures, but IPIs were not age dependent and older IPI cases showed sclerosis that was indistinguishable from younger IPI patients. (3) In TLE patients, longer seizure durations were associated with decreased neuronal densities in all hippocampal subfields. The decrease was independent of the neuron loss linked with IPIs, it occurred in all pathological groups, it occurred over 30 years or more, and was not a consequence of aging. (4) Intractable seizures in the young human hippocampus were not associated with neuronal damage, but were linked with decreased postnatal granule cell development and aberrant axon sprouting. These results support the concept that hippocampal sclerosis is likely an acquired pathology, and most of the neuronal loss occurs with the IPI. In addition, there is progressive hippocampal damage from intractable TLE regardless of pathology. Hence, hippocampal neuron loss can be the 'consequence' of repeated limbic seizures over 30 years or more, but is unlikely to 'cause' hippocampal sclerosis unless there is also an IPI.

This study determined neuron losses, mossy fiber sprouting, and interictal spike frequencies in adult rats following intrahippocampal kainic acid (KA) injections during postnatal (PN) development. KA (0.4 micrograms/0.2 microliters; n = 64) was injected into one hippocampus and saline into the contralateral side between PN 7 to 30 days. Animals were sacrificed 28 to 256 days later, along with age-matched naive animals (controls; n = 20). Hippocampi were studied for: (1) Fascia dentata granule cell, hilar, and CA3c neuron counts; (2) neo-Timm's stained supragranular mossy fiber sprouting; and (3) hippocampal and intracerebral interictal spike densities (n = 13). Mossy fiber sprouting was quantified as the gray value differences between the inner and outer molecular layer. Statistically significant results (p < 0.05) showed the following: (1) Compared to controls, CA3c and hilar neuron counts were reduced in KA-hippocampi with injections at PN 7-10 and PN 12-14 respectively and counts decreased with older PN injections. Granule cell densities on the KA-side and saline injected hippocampi were not reduced compared to controls. (2) In adult rats, supragranular mossy fiber sprouting was observed in 2 of 7 PN 7 injected animals. Compared to controls, increased gray value differences, indicating mossy fiber sprouting, were found on the KA-side beginning with injuries at PN 12-14 and increasing with older PN injections. On the saline-side only PN 30 animals showed minimal sprouting. (3) Mossy fiber sprouting progressively increased on the KA-side with longer survivals in rats injured after PN 15. Sprouting correlated positively with later PN injections and longer post-injection survival intervals, and not with reduced hilar or CA3c neuron counts. (4) On the KA-side, mossy fiber gray value differences correlated positively with in vivo intrahippocampal interictal spike densities. These results indicate that during postnatal rat development intrahippocampal kainate excitotoxicity can occur as early as PN 7 and increases with older ages at injection. This rat model reproduces many of the pathologic, behavioral, and electrophysiologic features of human mesial temporal lobe epilepsy, and supports the hypothesis that hippocampal sclerosis can be the consequence of focal injury during early postnatal development that progressively evolves into a pathologic and epileptic focus.

This study determined in temporal lobe epilepsy patients and rats injected with intrahippocampal kainate (KA) whether fascia dentata molecular layer mossy fiber sprouting was associated with increases in NMDAR2 immunoreactivity (IR). Patients with hippocampal sclerosis (n = 11) were compared with those with temporal mass lesions (n = 7) and material obtained at autopsies (n = 4); and unilateral KA-injected rat hippocampi (n = 7) were compared with the contralateral saline-injected side and non-lesioned animals (n = 7; control). Hippocampi were studied for neo-Timm's stained mossy fiber sprouting and NMDAR2 IR. The staining was quantified as gray values (GV) using computer image analysis. Hippocampal sclerosis patients and KA-injected rats showed the greatest inner molecular layer (IML) mossy fiber sprouting and NMDAR2 staining. Compared with autopsies and patients with mass lesions, hippocampal sclerosis patients had greater IML neo-Timm's (p = 0.0018) and NMDAR2 staining (p = 0.0063). Similarly, compared with controls and saline-injected rats, KA-injected hippocampi showed greater IML mossy fiber sprouting and NMDAR2 IR (p = 0.0001). Furthermore, IML mossy fiber sprouting positively correlated with greater IML NMDAR2 staining in both human and experimental rat groups (p < 0.0099). These results support the hypothesis that in severely damaged hippocampi abnormal mossy fiber sprouting and concordant increases in IML NMDAR2 receptor staining may contribute or partially explain granule cell hyperexcitability and the pathophysiology of hippocampal epilepsy.

Because epilepsy in children can lead to untoward developmental consequences, the key notion is that children with therapy-resistant epilepsy should be diagnosed early and referred to a pediatric epilepsy center so that they may receive a comprehensive evaluation by an interdisciplinary team experienced in treating this disorder. The diagnosis of therapy-resistant epilepsy should be entertained after the child has failed two antiepileptic drugs. Of all children diagnosed with treatment-resistant epilepsy, up to 33% may be eligible for ...

BACKGROUND: It is unclear whether long-term seizure outcomes in children are similar to those in adult epilepsy surgery patients. OBJECTIVE: To determine 5-year outcomes and antiepilepsy drug (AED) use in pediatric epilepsy surgery patients from a single institution. METHODS: The cohort consisted of children younger than 18 years of age whose 5-year outcome data would have been available by 2010. Comparisons were made between patients with and without 5-year data (n = 338), patients with 5-year data for seizure outcome (n = 257), and seizure-free patients on and off AEDs (n = 137). RESULTS: Five-year data were available from 76% of patients. More seizure-free patients with focal resections for hippocampal sclerosis and tumors lacked 5-year data compared with other cases. Of those with 5-year data, 53% were continuously seizure free, 18% had late seizure recurrence, 3% became seizure free after initial failure, and 25% were never seizure free. Patients were more likely to be continuously seizure free if their surgery was performed during the period 2001 to 2005 (68%) compared with surgery performed from 1996 to 2000 (61%), 1991 to 1995 (36%), and 1986 to 1990 (46%). More patients had 1 or fewer seizures per month in the late seizure recurrence (47%) compared with the not seizure-free group (20%). Four late deaths occurred in the not seizure-free group compared with 1 in the seizure-free group. Of patients who were continuously seizure free, 55% were not taking AEDs, and more cortical dysplasia patients (74%) had stopped taking AEDs compared with hemimegalencephaly patients (18%). CONCLUSION: In children, 5-year outcomes improved over 20 years of clinical experience. Our results are similar to those of adult epilepsy surgery patients despite mostly extratemporal and hemispheric operations for diverse developmental etiologies.

To design useful experimental models of epilepsy, it is necessary to clearly understand the known clinical-pathologic features of the disease process. Studies of mesial temporal lobe epilepsy (MTLE) patients have identified several distinctive clinical and pathophysiologic characteristics and many of these can be analyzed in experimental models. For example, patients with typical MTLE have medical histories that often contain an initial precipitating injury (IPI), are likely to have hippocampal sclerosis in the surgical specimen, and have better seizure outcomes than patients with typical idiopathic temporal seizures (i.e. cryptogenic). Hippocampal from children as young as age 1 year with IPI histories also demonstrate neuron damage similar to adults with hippocampal sclerosis. Compared to IPI patients without seizures (i.e. trauma, hypoxia, etc.), IPI cases with severe seizures showed younger ages at the IPI, shorter latent periods, and longer durations of habitual MTLE. Hippocampal damage is often bilateral, however, the epileptogenic side shows hippocampal sclerosis and the opposite side usually shows only mild neuron losses. Moreover, MTLE patients show declines in hippocampal neuron densities with very long histories of habitual seizures (15 to 20 years), however, the additional neuron loss adds to the template of hippocampal sclerosis and occurs in limited subfields (granule cells, CA1 and prosubiculum). Hippocampal axon and synaptic reorganization is another pathologic feature of MTLE, and involves granule cell mossy fibers and axons immunoreactive for neuropeptide upsilon, somatostatin, and glutamate decarboxylase (which synthesizes GABA). Finally, MTLE patients with hippocampal sclerosis show increased granule cell mRNA levels for brain derived neurotropic factor, nerve growth factor, and neurotrophin-3 that correlate with mossy fiber sprouting or with declines in Ammon's horn neuron densities. Taken together, our data support the following concepts: (1) The pathogenesis of MTLE is associated with IPI histories that probably injure the hippocampus at some time prior to habitual seizure onsets, (2) most of the damage seems to occur with the IPI, (3) there can be additional neuron loss associated with long histories, (4) another pathologic feature of MTLE is axon reorganization of surviving fascia dentata and hippocampal neurons, and (5) reorganized axon circuits probably contribute to seizure or propagation.

Epileptogenic lesions have higher concentrations of sodium than does normal brain tissue. Such lesions are palpably recognized by a surgeon and then excised in order to eliminate epileptic seizures with their associated abnormal electrical behavior. Here, we study the frequency-dependent electrical conductivities of lesion-laden tissues excised from the brains of epilepsy patients. The low-frequency (<1000 Hz) conductivity of biological tissue primarily probes extracellular solvated sodium-cations traveling parallel to membranes within regions bounded by blockages. This conductivity rises monotonically toward saturation as the frequency surpasses the rate with which diffusing solvated sodium cations encounter blockages. We find that saturation occurs at dramatically higher frequencies in excised brain tissue containing epileptogenic lesions than it does in normal brain tissue. By contrast, such an effect is not reported for tumors embedded in other excised biological tissue. All ...

We study the effect of lesions on our four-electrode measurements of the ionic conductivity of (∼1 cm3) samples of human brain excised from patients undergoing pediatric epilepsy surgery. For most (∼94%) samples, the low-frequency ionic conductivity rises upon increasing the applied frequency. We attributed this behavior to the long-range (∼0.4 mm) diffusion of solvated sodium cations before encountering intrinsic impenetrable blockages such as cell membranes, blood vessels, and cell walls. By contrast, the low-frequency ionic conductivity of some (∼6%) brain-tissue samples falls with increasing applied frequency. We attribute this unusual frequency-dependence to the electric-field induced liberation of sodium cations from traps introduced by the unusually severe pathology observed in samples from these patients. Thus, the anomalous frequency-dependence of the ionic conductivity indicates trap-producing brain lesions.

The electrical conductivities of freshly excised brain tissues from 24 patients were measured. The diffusion-MRI of the hydrogen nuclei of water molecules from regions that were subsequently excised was also measured. Analysis of these measurements indicates that differences between samples' conductivities are primarily due to differences of their densities of solvated sodium cations. Concomitantly, the sample-to-sample variations of their diffusion constants are relatively small. This finding suggests that non-invasive in-vivo measurements of brain tissues' local sodium-cation density can be utilized to estimate its local electrical conductivity.

We analyze the transient-dc and frequency-dependent electrical conductivities between blocking electrodes. We extend this analysis to measurements of ions' transport in freshly excised bulk samples of human brain tissue whose complex cellular structure produces blockages. The associated ionic charge-carrier density and diffusivity are consistent with local values for sodium cations determined non-invasively in brain tissue by MRI (NMR) and diffusion-MRI (spin-echo NMR). The characteristic separation between blockages, about 450 microns, is very much shorter than that found for sodium-doped gel proxies for brain tissue, >1 cm.

This chapter discusses studies on the properties of abnormal cells and synaptic circuits in pediatric cortical dysplasia (CD). It provides a working hypothesis concerning how CD tissue may be able to generate epileptic discharges. CD pathogenesis probably involves partial failure of events occurring during later phases of corticogenesis resulting in incomplete cortical development. The timing of these events during cortical development would explain the different forms of CD. Developmental alterations during the late second or early third trimester would account for severe CD with numerous dysmorphic and cytomegalic cells (CDII Type A and B), whereas events occurring closer to birth after the subplate has nearly degenerated would explain mild CD (CD Type I). As a consequence, subplate and radial glial degeneration and transformation would be prevented, giving the appearance of abnormal dysmorphic cells in the postnatal human brain. Failure of late cortical maturation could explain t...

To compare hemispherectomy patients with different pathologic substrates for hospital course, seizure, developmental, language, and motor outcomes. The authors compared hemispherectomy patients (n = 115) with hemimegalencephaly (HME; n = 16), hemispheric cortical dysplasia (hemi CD; n = 39), Rasmussen encephalitis (RE; n = 21), infarct/ischemia (n = 27), and other/miscellaneous (n = 12) for differences in operative management, postsurgery seizure control, and antiepilepsy drug (AED) usage. In addition, Vineland Adaptive Behavior Scale (VABS) developmental quotients (DQ), language, and motor assessments were performed pre- or postsurgery, or both. Surgically, HME patients had the greatest perioperative blood loss, and the longest surgery time. Fewer HME patients were seizure free or not taking AEDs 1 to 5 years postsurgery, but the differences between pathologic groups were not significant. Postsurgery, 66% of HME patients had little or no language and worse motor scores in the paretic limbs. By contrast, 40 to 50% of hemi CD children showed near normal language and motor assessments, similar to RE and infarct/ischemia cases. VABS DQ scores showed +5 points or more improvement postsurgery in 57% of patients, and hemi CD (+12.7) and HME (+9.1) children showed the most progress compared with RE (+4.6) and infarct/ischemia (-0.6) cases. Postsurgery VABS DQ scores correlated with seizure duration, seizure control, and presurgery DQ scores. The pathologic substrate predicted pre- and postsurgery differences in outcomes, with hemimegalencephaly (but not hemispheric cortical dysplasia) patients doing worse in several domains. Furthermore, shorter seizure durations, seizure control, and greater presurgery developmental quotients predicted better postsurgery developmental quotients in all patients, irrespective of pathology.

Using a targeted transcriptomics approach, we have analyzed resected brain tissue from a cohort of 53 pediatric epilepsy surgery cases, and have found that there is a spectrum of involvement of both the innate and adaptive immune systems as evidenced by the differential expression of immune-specific genes in the affected brain tissue. The specimens with the highest expression of immune-specific genes were from two Rasmussen encephalitis cases, which is known to be a neuro-immunological disease, but also from tuberous sclerosis complex (TSC), focal cortical dysplasia, and hemimegalencephaly surgery cases. We obtained T cell receptor (TCR) Vβ chain sequence data from brain tissue and blood from patients with the highest levels of T cell transcripts. The clonality indices and the frequency of the top 50 Vβ clonotypes indicated that T cells in the brain were clonally restricted. The top 50 Vβ clonotypes comprised both public and private (patient specific) clonotypes, and the TCR Vβ chai...

In 1997, Jean AICARDI, one of the most brilliant child neurologists of our era, commented on "How the view has changed" in the field of pediatric epilepsy surgery: "Surgery for epilepsy has now become a realistic therapeutic option for selected children and the field is likely to increase in the near future. It is now realised that procrastination, in the hope that new antiepileptic drugs will become efficacious, is not justified for some forms of epilepsy that can often be recognised from onset or after a relatively short course. It is also becoming clear that surgery is not reserved for a highly selected population of patients with normal intelligence and focal seizures, but may also help a proportion of more severe epilepsies if a realistic view of the problem and perspectives is taken by the partners". Twenty years later, the most obvious and probably still the strongest reasons against epilepsy surgery in children are cultural and psychological. This book, written by members of the ad hoc ILAE Task Force for pediatric epilepsy surgery and experts in the field, is the result of continued collaborative working between pediatric epilepsy surgery centres over the years. Authors critically review all available data and set out the key elements of presurgical evaluation, the specific electro-clinical presentations per etiology, the range of outcomes to be monitored, and the surgical techniques used today. What becomes obvious when reviewing all available data is that the key to optimized outcome in children with epilepsy is early appropriate recognition of possible surgical candidates and timely referral to centres with expertise.

Background: In cases of intractable epilepsy resistant to drug therapy, hemispherectomy is often the only treatment option to mitigate seizures; however, the true long-term subjective visual outcomes are relatively unexplored. In this study, we sought to determine and characterize patient-reported visual function years after hemispherectomy. Methods: This was an observational study conducted on a large cohort of children with seizure disorder treated with cerebral hemispherectomy. An online survey was sent to parents with questions to assess subjective visual function with a variety of questions from presence of visual field defects after hemispherectomy, to improvement over time, compensatory mechanisms used, and development of strabismus. Results: This survey was emailed to 248 parents of previously evaluated children who agreed to be re-surveyed, 48 (20%) of which responded. The average age at hemispherectomy was approximately 5 (±4) years, and the average time after hemispherect...

OBJECTIVERasmussen encephalitis (RE) is a rare inflammatory neurological disorder typically involving one hemisphere and resulting in drug-resistant epilepsy and progressive neurological decline. Here, the authors present seizure outcomes in children who underwent epilepsy surgery for RE at a single institution.METHODSThe records of consecutive patients who had undergone epilepsy surgery for RE at the UCLA Mattel Children’s Hospital between 1982 and 2018 were retrospectively reviewed. Basic demographic information, seizure history, procedural notes, and postoperative seizure and functional outcome data were analyzed.RESULTSThe cohort included 44 patients, 41 of whom had sufficient data for analysis. Seizure freedom was achieved in 68%, 48%, and 22% of the patients at 1, 5, and 10 years, respectively. The median time to the first seizure for those who experienced seizure recurrence after surgery was 39 weeks (IQR 11–355 weeks). Anatomical hemispherectomy, as compared to functional he...