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1.  The evolution of epilepsy surgery between 1991 and 2011 in nine major epilepsy centers across the United States, Germany, and Australia 
Epilepsia  2015;56(10):1526-1533.
Summary
Objective
Epilepsy surgery is the most effective treatment for select patients with drug-resistant epilepsy. In this article, we aim to provide an accurate understanding of the current epidemiologic characteristics of this intervention, as this knowledge is critical for guiding educational, academic, and resource priorities.
Methods
We profile the practice of epilepsy surgery between 1991 and 2011 in nine major epilepsy surgery centers in the United States, Germany, and Australia. Clinical, imaging, surgical, and histopathologic data were derived from the surgical databases at various centers.
Results
Although five of the centers performed their highest number of surgeries for mesial temporal sclerosis (MTS) in 1991, and three had their highest number of MTS surgeries in 2001, only one center achieved its peak number of MTS surgeries in 2011. The most productive year for MTS surgeries varied then by center; overall, the nine centers surveyed performed 48% (95% confidence interval [CI] −27.3% to −67.4%) fewer such surgeries in 2011 compared to either 1991 or 2001, whichever was higher. There was a parallel increase in the performance of surgery for nonlesional epilepsy. Further analysis of 5/9 centers showed a yearly increase of 0.6 ± 0.07% in the performance of invasive electroencephalography (EEG) without subsequent resections. Overall, although MTS was the main surgical substrate in 1991 and 2001 (proportion of total surgeries in study centers ranging from 33.3% to 70.2%); it occupied only 33.6% of all resections in 2011 in the context of an overall stable total surgical volume.
Significance
These findings highlight the major aspects of the evolution of epilepsy surgery across the past two decades in a sample of well-established epilepsy surgery centers, and the critical current challenges of this treatment option in addressing complex epilepsy cases requiring detailed evaluations. Possible causes and implications of these findings are discussed.
doi:10.1111/epi.13116
PMCID: PMC5082694  PMID: 26250432
Epilepsy surgery; Mesial temporal sclerosis; Neocortical epilepsy; Invasive EEG
3.  Defects of mutant DNMT1 are linked to a spectrum of neurological disorders 
Brain  2015;138(4):845-861.
Baets et al. expand the clinical spectrum of hereditary sensory and autonomic neuropathy type 1E (HSAN1E) by studying nine newly identified kinships, and reveal a potential pathogenic mechanism for causative DNMT1 mutations. Mutant DNMT1 proteins form aggresomes in the cytoplasm, suggesting that aggresome-induced autophagy may contribute to disease pathogenesis.
We report a broader than previously appreciated clinical spectrum for hereditary sensory and autonomic neuropathy type 1E (HSAN1E) and a potential pathogenic mechanism for DNA methyltransferase (DNMT1) mutations. The clinical presentations and genetic characteristics of nine newly identified HSAN1E kinships (45 affected subjects) were investigated. Five novel mutations of DNMT1 were discovered; p.C353F, p.T481P, p.P491L, p.Y524D and p.I531N, all within the target-sequence domain, and two mutations (p.T481P, p.P491L) arising de novo. Recently, HSAN1E has been suggested as an allelic disorder of autosomal dominant cerebellar ataxia, deafness and narcolepsy. Our results indicate that all the mutations causal for HSAN1E are located in the middle part or N-terminus end of the TS domain, whereas all the mutations causal for autosomal dominant cerebellar ataxia, deafness and narcolepsy are located in the C-terminus end of the TS domain. The impact of the seven causal mutations in this cohort was studied by cellular localization experiments. The binding efficiency of the mutant DNMT proteins at the replication foci and heterochromatin were evaluated. Phenotypic characterizations included electromyography, brain magnetic resonance and nuclear imaging, electroencephalography, sural nerve biopsies, sleep evaluation and neuropsychometric testing. The average survival of HSAN1E was 53.6 years. [standard deviation = 7.7, range 43–75 years], and mean onset age was 37.7 years. (standard deviation = 8.6, range 18–51 years). Expanded phenotypes include myoclonic seizures, auditory or visual hallucinations, and renal failure. Hypersomnia, rapid eye movement sleep disorder and/or narcolepsy were identified in 11 subjects. Global brain atrophy was found in 12 of 14 who had brain MRI. EEGs showed low frequency (delta waves) frontal-predominant abnormality in five of six patients. Marked variability in cognitive deficits was observed, but the majority of patients (89%) developed significant cognitive deficit by the age of 45 years. Cognitive function decline often started with personality changes and psychiatric manifestations. A triad of hearing loss, sensory neuropathy and cognitive decline remains as the stereotypic presentation of HSAN1E. Moreover, we show that mutant DNMT1 proteins translocate to the cytoplasm and are prone to form aggresomes while losing their binding ability to heterochromatin during the G2 cell cycle. Our results suggest mutations in DNMT1 result in imbalanced protein homeostasis through aggresome-induced autophagy. This mechanism may explain why mutations in the sole DNA maintenance methyltransferase lead to selective central and peripheral neurodegeneration.
doi:10.1093/brain/awv010
PMCID: PMC5014076  PMID: 25678562
protein aggregation; sensory neuropathy; narcolepsy; REM sleep behaviour disorder; neurodegeneration
4.  Crowdsourcing reproducible seizure forecasting in human and canine epilepsy 
Brain  2016;139(6):1713-1722.
See Mormann and Andrzejak (doi:10.1093/brain/aww091) for a scientific commentary on this article.  
Seizures are thought to arise from an identifiable pre-ictal state. Brinkmann et al. report the results of an online, open-access seizure forecasting competition using intracranial EEG recordings from canines with naturally occurring epilepsy and human patients undergoing presurgical monitoring. The winning algorithms forecast seizures at rates significantly greater than chance.
See Mormann and Andrzejak (doi:10.1093/brain/aww091) for a scientific commentary on this article.  Seizures are thought to arise from an identifiable pre-ictal state. Brinkmann et al. report the results of an online, open-access seizure forecasting competition using intracranial EEG recordings from canines with naturally occurring epilepsy and human patients undergoing presurgical monitoring. The winning algorithms forecast seizures at rates significantly greater than chance.
See Mormann and Andrzejak (doi:10.1093/brain/aww091) for a scientific commentary on this article.  
Accurate forecasting of epileptic seizures has the potential to transform clinical epilepsy care. However, progress toward reliable seizure forecasting has been hampered by lack of open access to long duration recordings with an adequate number of seizures for investigators to rigorously compare algorithms and results. A seizure forecasting competition was conducted on kaggle.com using open access chronic ambulatory intracranial electroencephalography from five canines with naturally occurring epilepsy and two humans undergoing prolonged wide bandwidth intracranial electroencephalographic monitoring. Data were provided to participants as 10-min interictal and preictal clips, with approximately half of the 60 GB data bundle labelled (interictal/preictal) for algorithm training and half unlabelled for evaluation. The contestants developed custom algorithms and uploaded their classifications (interictal/preictal) for the unknown testing data, and a randomly selected 40% of data segments were scored and results broadcasted on a public leader board. The contest ran from August to November 2014, and 654 participants submitted 17 856 classifications of the unlabelled test data. The top performing entry scored 0.84 area under the classification curve. Following the contest, additional held-out unlabelled data clips were provided to the top 10 participants and they submitted classifications for the new unseen data. The resulting area under the classification curves were well above chance forecasting, but did show a mean 6.54 ± 2.45% (min, max: 0.30, 20.2) decline in performance. The kaggle.com model using open access data and algorithms generated reproducible research that advanced seizure forecasting. The overall performance from multiple contestants on unseen data was better than a random predictor, and demonstrates the feasibility of seizure forecasting in canine and human epilepsy.
doi:10.1093/brain/aww045
PMCID: PMC5022671  PMID: 27034258
epilepsy; intracranial EEG; refractory epilepsy; experimental models
5.  Gamma oscillations precede interictal epileptiform spikes in the seizure onset zone 
Neurology  2015;84(6):602-608.
Objective:
To investigate the generation, spectral characteristics, and potential clinical significance of brain activity preceding interictal epileptiform spike discharges (IEDs) recorded with intracranial EEG.
Methods:
Seventeen adult patients with drug-resistant temporal lobe epilepsy were implanted with intracranial electrodes as part of their evaluation for epilepsy surgery. IEDs detected on clinical macro- and research microelectrodes were analyzed using time-frequency spectral analysis.
Results:
Gamma frequency oscillations (30–100 Hz) often preceded IEDs in spatially confined brain areas. The gamma-IEDs were consistently observed 35 to 190 milliseconds before the epileptiform spike waveforms on individual macro- and microelectrodes. The gamma oscillations associated with IEDs had longer duration (p < 0.001) and slightly higher frequency (p = 0.045) when recorded on microelectrodes compared with clinical macroelectrodes. Although gamma-IEDs comprised only a subset of IEDs, they were strongly associated with electrodes in the seizure onset zone (SOZ) compared with the surrounding brain regions (p = 0.004), in sharp contrast to IEDs without preceding gamma oscillations that were often also detected outside of the SOZ. Similar to prior studies, isolated pathologic high-frequency oscillations in the gamma (30–100 Hz) and higher (100–600 Hz) frequency range, not associated with an IED, were also found to be associated with SOZ.
Conclusions:
The occurrence of locally generated gamma oscillations preceding IEDs suggests a mechanistic role for gamma in pathologic network activity generating IEDs. The results show a strong association between SOZ and gamma-IEDs. The potential clinical application of gamma-IEDs for mapping pathologic brain regions is intriguing, but will require future prospective studies.
doi:10.1212/WNL.0000000000001234
PMCID: PMC4335986  PMID: 25589669
6.  Lateralization and Localization of Epilepsy Related Hemodynamic Foci Using Presurgical fMRI 
Objective
The aim was to develop a method for the purpose of localizing epilepsy related hemodynamic foci for patients suffering intractable focal epilepsy using task-free fMRI alone.
Methods
We studied three groups of subjects: patients with intractable focal epilepsy, healthy volunteers performing motor tasks, and healthy volunteers in resting state. We performed spatial independent component analysis (ICA) on the fMRI alone data and developed a set of IC selection criteria to identify epilepsy related ICs. The method was then tested in the two healthy groups.
Results
In seven out of the nine surgery patients, identified ICs were concordant with surgical resection. Our results were also consistent with presurgical evaluation of the remaining one patient without surgery and may explain why she was not suitable for resection treatment. In the motor task study of ten healthy subjects, our method revealed components with concordant spatial and temporal features as expected from the unilateral motor tasks. In the resting state study of seven healthy subjects, the method successfully rejected all components in four out of seven subjects as non-epilepsy related components.
Conclusion
These results suggest the lateralization and localization value of fMRI alone in presurgical evaluation for patients with intractable unilateral focal epilepsy.
Significance
The proposed method is noninvasive in nature and easy to implement. It has the potential to be incorporated in current presurgical workup for treating intractable focal epilepsy patients.
doi:10.1016/j.clinph.2014.04.011
PMCID: PMC4214895  PMID: 24856460
fMRI; ICA; epilepsy; lateralization; default mode network
7.  Lateralization of mesial temporal lobe epilepsy with chronic ambulatory electrocorticography 
Epilepsia  2015;56(6):959-967.
Objective
Patients with suspected mesial temporal lobe (MTL) epilepsy typically undergo inpatient video–electroencephalography (EEG) monitoring with scalp and/or intracranial electrodes for 1 to 2 weeks to localize and lateralize the seizure focus or foci. Chronic ambulatory electrocorticography (ECoG) in patients with MTL epilepsy may provide additional information about seizure lateralization. This analysis describes data obtained from chronic ambulatory ECoG in patients with suspected bilateral MTL epilepsy in order to assess the time required to determine the seizure lateralization and whether this information could influence treatment decisions.
Methods
Ambulatory ECoG was reviewed in patients with suspected bilateral MTL epilepsy who were among a larger cohort with intractable epilepsy participating in a randomized controlled trial of responsive neurostimulation. Subjects were implanted with bilateral MTL leads and a cranially implanted neurostimulator programmed to detect abnormal interictal and ictal ECoG activity. ECoG data stored by the neurostimulator were reviewed to determine the lateralization of electrographic seizures and the interval of time until independent bilateral MTL electrographic seizures were recorded.
Results
Eighty-two subjects were implanted with bilateral MTL leads and followed for 4.7 years on average (median 4.9 years). Independent bilateral MTL electrographic seizures were recorded in 84%. The average time to record bilateral electrographic seizures in the ambulatory setting was 41.6 days (median 13 days, range 0–376 days). Sixteen percent had only unilateral electrographic seizures after an average of 4.6 years of recording.
Significance
About one third of the subjects implanted with bilateral MTL electrodes required >1 month of chronic ambulatory ECoG before the first contralateral MTL electrographic seizure was recorded. Some patients with suspected bilateral MTL seizures had only unilateral electrographic seizures. Chronic ambulatory ECoG in patients with suspected bilateral MTL seizures provides data in a naturalistic setting, may complement data from inpatient video-EEG monitoring, and can contribute to treatment decisions.
doi:10.1111/epi.13010
PMCID: PMC4676303  PMID: 25988840
EEG monitoring; Electrocorticography; Ambulatory EEG; Intracranial EEG; Responsive stimulation; Localization
8.  Proceedings of the Fifth International Workshop on Advances in Electrocorticography 
Epilepsy & behavior : E&B  2014;0:183-192.
The Fifth International Workshop on Advances in Electrocorticography convened in San Diego, CA, on November 7–8, 2013. In the interval year since the last workshop, advancements in methodology, implementation, and commercialization across both research and clinical interests were the focus of the gathering. Electrocorticography (ECoG) is now firmly established as a preferred signal source for advanced research in functional, cognitive, and neuroprosthetic domains. Published output in ECoG fields has increased tenfold in the past decade. This proceedings attempts to summarize the state of the art.
doi:10.1016/j.yebeh.2014.09.015
PMCID: PMC4268064  PMID: 25461213
electrocorticography; brain-computer interface; high-frequency oscillations; brain mapping; seizure detection; gamma-frequency electroencephalography; neuroprosthetics; subdural grid; functional mapping; electrical stimulation mapping
9.  Forecasting Seizures Using Intracranial EEG Measures and SVM in Naturally Occurring Canine Epilepsy 
PLoS ONE  2015;10(8):e0133900.
Management of drug resistant focal epilepsy would be greatly assisted by a reliable warning system capable of alerting patients prior to seizures to allow the patient to adjust activities or medication. Such a system requires successful identification of a preictal, or seizure-prone state. Identification of preictal states in continuous long- duration intracranial electroencephalographic (iEEG) recordings of dogs with naturally occurring epilepsy was investigated using a support vector machine (SVM) algorithm. The dogs studied were implanted with a 16-channel ambulatory iEEG recording device with average channel reference for a mean (st. dev.) of 380.4 (+87.5) days producing 220.2 (+104.1) days of intracranial EEG recorded at 400 Hz for analysis. The iEEG records had 51.6 (+52.8) seizures identified, of which 35.8 (+30.4) seizures were preceded by more than 4 hours of seizure-free data. Recorded iEEG data were stratified into 11 contiguous, non-overlapping frequency bands and binned into one-minute synchrony features for analysis. Performance of the SVM classifier was assessed using a 5-fold cross validation approach, where preictal training data were taken from 90 minute windows with a 5 minute pre-seizure offset. Analysis of the optimal preictal training time was performed by repeating the cross validation over a range of preictal windows and comparing results. We show that the optimization of feature selection varies for each subject, i.e. algorithms are subject specific, but achieve prediction performance significantly better than a time-matched Poisson random predictor (p<0.05) in 5/5 dogs analyzed.
doi:10.1371/journal.pone.0133900
PMCID: PMC4524640  PMID: 26241907
10.  Advances in Radiofrequency Ablation of the Cerebral Cortex in Primates Using the Venous System: Improvements for Treating Epilepsy with Catheter Ablation Technology 
Epilepsy research  2014;108(6):1026-1031.
Background
Pharmacology frequently fails for the treatment of epilepsy. Although surgical techniques are effective, these procedures are highly invasive. We describe feasibility and efficacy of minimally invasive mapping and ablation for the treatment of epilepsy.
Methods
Mapping and radiofrequency ablations were performed via the venous system in eleven baboons and three dogs.
Results
Mapping in deep cerebral areas was obtained in all animals. High-frequency pacing was able to induce seizure activity of local cerebral tissue in 72% of our attempts. Cerebral activity could be seen during mapping. Ablative lesions were deployed at deep brain sites without steam pops or sudden impedance rise. Histologic analysis showed necrosis at the sites of ablation in all primates.
Conclusion
Navigation through the cerebral venous system to map seizure activity is feasible. Radiofrequency energy can be delivered transvenously or transcortically to successful ablate cortical tissue in this animal model using this innovative approach.
doi:10.1016/j.eplepsyres.2014.04.002
PMCID: PMC4454459  PMID: 24836846
epilepsy; catheter ablation; venous system; radiofrequency; cerebral cortex
11.  High frequency oscillations are associated with cognitive processing in human recognition memory 
Brain  2014;137(8):2231-2244.
High frequency oscillations have been associated with focal epilepsy, but their role in human cognition is less clear. During intracranial recordings in patients undergoing seizure monitoring, Kucewicz et al. detect high gamma, ripple and fast ripple oscillations that are induced by image processing, and modulated by memory encoding and recall.
High frequency oscillations are associated with normal brain function, but also increasingly recognized as potential biomarkers of the epileptogenic brain. Their role in human cognition has been predominantly studied in classical gamma frequencies (30–100 Hz), which reflect neuronal network coordination involved in attention, learning and memory. Invasive brain recordings in animals and humans demonstrate that physiological oscillations extend beyond the gamma frequency range, but their function in human cognitive processing has not been fully elucidated. Here we investigate high frequency oscillations spanning the high gamma (50–125 Hz), ripple (125–250 Hz) and fast ripple (250–500 Hz) frequency bands using intracranial recordings from 12 patients (five males and seven females, age 21–63 years) during memory encoding and recall of a series of affectively charged images. Presentation of the images induced high frequency oscillations in all three studied bands within the primary visual, limbic and higher order cortical regions in a sequence consistent with the visual processing stream. These induced oscillations were detected on individual electrodes localized in the amygdala, hippocampus and specific neocortical areas, revealing discrete oscillations of characteristic frequency, duration and latency from image presentation. Memory encoding and recall significantly modulated the number of induced high gamma, ripple and fast ripple detections in the studied structures, which was greater in the primary sensory areas during the encoding (Wilcoxon rank sum test, P = 0.002) and in the higher-order cortical association areas during the recall (Wilcoxon rank sum test, P = 0.001) of memorized images. Furthermore, the induced high gamma, ripple and fast ripple responses discriminated the encoded and the affectively charged images. In summary, our results show that high frequency oscillations, spanning a wide range of frequencies, are associated with memory processing and generated along distributed cortical and limbic brain regions. These findings support an important role for fast network synchronization in human cognition and extend our understanding of normal physiological brain activity during memory processing.
doi:10.1093/brain/awu149
PMCID: PMC4107742  PMID: 24919972
high frequency oscillations; cognitive processing; memory; gamma oscillations; neural networks
12.  Evidence for Consolidation of Neuronal Assemblies after Seizures in Humans 
The Journal of Neuroscience  2015;35(3):999-1010.
The establishment of memories involves reactivation of waking neuronal activity patterns and strengthening of associated neural circuits during slow-wave sleep (SWS), a process known as “cellular consolidation” (Dudai and Morris, 2013). Reactivation of neural activity patterns during waking behaviors that occurs on a timescale of seconds to minutes is thought to constitute memory recall (O'Keefe and Nadel, 1978), whereas consolidation of memory traces may be revealed and served by correlated firing (reactivation) that appears during sleep under conditions suitable for synaptic modification (Buhry et al., 2011). Although reactivation has been observed in human neuronal recordings (Gelbard-Sagiv et al., 2008; Miller et al., 2013), reactivation during sleep has not, likely because data are difficult to obtain and the effect is subtle. Seizures, however, provide intense and synchronous, yet sparse activation (Bower et al., 2012) that could produce a stronger consolidation effect if seizures activate learning-related mechanisms similar to those activated by learned tasks. Continuous wide-bandwidth recordings from patients undergoing intracranial monitoring for drug-resistant epilepsy revealed reactivation of seizure-related neuronal activity during subsequent SWS, but not wakefulness. Those neuronal assemblies that were most strongly activated during seizures showed the largest correlation changes, suggesting that consolidation selectively strengthened neuronal circuits activated by seizures. These results suggest that seizures “hijack” physiological learning mechanisms and also suggest a novel epilepsy therapy targeting neuronal dynamics during post-seizure sleep.
doi:10.1523/JNEUROSCI.3019-14.2015
PMCID: PMC4300336  PMID: 25609617
consolidation; epilepsy; learning; memory; neural assemblies; seizures
13.  Pathologic brain network activity 
Neurology  2013;81(1):12-13.
doi:10.1212/WNL.0b013e318297ef3c
PMCID: PMC4490898  PMID: 23685930 CAMSID: cams4872
14.  Noninvasive Imaging of the High Frequency Brain Activity in Focal Epilepsy Patients 
High frequency (HF) activity represents a potential biomarker of the epileptogenic zone in epilepsy patients, the removal of which is considered to be crucial for seizure-free surgical outcome. We proposed a high frequency source imaging (HFSI) approach to noninvasively image the brain sources of scalp recorded high frequency EEG activity. Both computer simulation and clinical patient data analysis were performed to investigate the feasibility of using the HFSI approach to image the sources of HF activity from noninvasive scalp EEG recordings. The HF activity was identified from high-density scalp recordings after high-pass filtering the EEG data and the EEG segments with HF activity were concatenated together to form repetitive HF activity. Independent component analysis was utilized to extract the components corresponding to the HF activity. Noninvasive EEG source imaging using realistic geometric boundary element head modeling was then applied to image the sources of the pathological HF brain activity. Five medically intractable focal epilepsy patients were studied and the estimated sources were found to be concordant with the surgical resection or intracranial recordings of the patients. The present study demonstrates, for the first time, that source imaging from the scalp HF activity could help to localize the seizure onset zone (SOZ) and provide a novel noninvasive way of studying the epileptic brain in humans. This study also indicates the potential application of studying HF activity in the pre-surgical planning of medically intractable epilepsy patients.
doi:10.1109/TBME.2013.2297332
PMCID: PMC4123538  PMID: 24845275
Source imaging; High frequency activity; Epileptogenic zone; Scalp EEG; Epilepsy
15.  Diagnostic Outcome of Surgical Revision of Intracranial Electrode Placements for Seizure Localization 
Purpose
We aimed to determine the yield of revising intracranially implanted electrodes and the factors contributing to the yield.
Methods
Patients were identified from the Mayo Clinic Epilepsy Surgery Database between 1997 and 2010. Twenty patients had revision of intracranial electrode placements because initial implantation did not localize seizure onset adequately.
Results
Seizures were captured in 18 of 20 patients who underwent intracranial electrode revision, of which 10 (55.6%) showed localized seizure onset that led to a surgical resection. Seizures were improved in 9 of 10 patients who underwent resection; of these, 5were seizure free. The only factors found to be statistically significant in localizing ictal onset zone after revised implantation were prior focal scalp interictal discharges and an initial intracranial EEG showing ictal onset at the edge of the electrode grid. No permanent complication was associated with revised implantation, but 1 patient had transient apraxia of the right foot.
Conclusion
Revised implantation could be useful in selected patients with inadequate seizure localization on initial intracranial EEG. Resective surgery was performed in 50% of patients who underwent revision of intracranial electrodes, with the majority of these patients experiencing an improvement in seizure control.
doi:10.1097/WNP.0000000000000047
PMCID: PMC4049195  PMID: 24887601
epilepsy surgery; intracranial EEG monitoring; seizure
16.  Electrophysiological Biomarkers of Epilepsy 
Neurotherapeutics  2014;11(2):334-346.
In patients being evaluated for epilepsy and in animal models of epilepsy, electrophysiological recordings are carried to capture seizures to determine the existence of epilepsy. Electroencephalography recordings from the scalp, or sometimes directly from the brain, are also used to locate brain areas where seizure begins, and in surgical treatment help plan the area for resection. As seizures are unpredictable and can occur infrequently, ictal recordings are not ideal in terms of time, cost, or risk when, for example, determining the efficacy of existing or new anti-seizure drugs, evaluating potential anti-epileptogenic interventions, or for prolonged intracerebral electrode studies. Thus, there is a need to identify and validate other electrophysiological biomarkers of epilepsy that could be used to diagnose, treat, cure, and prevent epilepsy. Electroencephalography recordings in the epileptic brain contain other interictal electrophysiological disturbances that can occur more frequently than seizures, such as interictal spikes (IIS) and sharp waves, and from invasive studies using wide bandwidth recording and small diameter electrodes, the discovery of pathological high-frequency oscillations (HFOs) and microseizures. Of IIS, HFOs, and microseizures, a significant amount of recent research has focused on HFOs in the pathophysiology of epilepsy. Results from studies in animals with epilepsy and presurgical patients have consistently found a strong association between HFOs and epileptogenic brain tissue that suggest HFOs could be a potential biomarker of epileptogenicity and epileptogenesis. Here, we discuss several aspects of HFOs, as well as IIS and microseizures, and the evidence that supports their role as biomarkers of epilepsy.
Electronic supplementary material
The online version of this article (doi:10.1007/s13311-014-0259-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s13311-014-0259-0
PMCID: PMC3996122  PMID: 24519238
High frequency oscillation; Interictal spike; Microseizure; Epileptogenicity; Epileptogenesis; Ictogenesis
17.  Statistical SPECT processing in MRI-negative epilepsy surgery 
Neurology  2014;82(11):932-939.
Objective:
To evaluate the benefit of statistical SPECT processing over traditional subtraction methods, we compared ictal–interictal SPECT analyzed by statistical parametric mapping (SPM) (ISAS), statistical ictal SPECT coregistered to MRI (STATISCOM), and subtraction ictal–interictal SPECT coregistered with MRI (SISCOM) in patients with MRI-negative focal temporal lobe epilepsy (nTLE) and extratemporal lobe epilepsy (nETLE).
Methods:
We retrospectively identified 49 consecutive cases of drug-resistant focal epilepsy that had a negative preoperative MRI and underwent interictal and ictal SPECT prior to resective epilepsy surgery. Interictal and ictal SPECT scans were analyzed using SISCOM, ISAS, and STATISCOM to create hyperperfusion and hypoperfusion maps for each patient. Reviewers blinded to clinical data and the SPECT analysis method marked the site of probable seizure origin and indicated their confidence in the localization.
Results:
In nTLE and nETLE, the hyperperfusions detected by STATISCOM (71% nTLE, 57% nETLE) and ISAS (67% nTLE, 53% nETLE) were more often colocalized with surgery resection site compared to SISCOM (38% nTLE, 36% nETLE). In nTLE, localization of the hyperperfusion to the region of surgery was associated with an excellent outcome for STATISCOM (p = 0.005) and ISAS (p = 0.027), but not in SISCOM (p = 0.071). This association was not present in nETLE for any method.
Conclusion:
In an unselected group of patients with normal MRI and focal epilepsy, SPM-based methods of SPECT processing showed better localization of SPECT hyperperfusion to surgical resection site and higher interobserver agreement compared to SISCOM. These results show the benefit of statistical SPECT processing methods and further highlight the challenge of nETLE.
doi:10.1212/WNL.0000000000000209
PMCID: PMC3963002  PMID: 24532274
18.  Long-term treatment with responsive brain stimulation in adults with refractory partial seizures 
Neurology  2015;84(8):810-817.
Objective:
The long-term efficacy and safety of responsive direct neurostimulation was assessed in adults with medically refractory partial onset seizures.
Methods:
All participants were treated with a cranially implanted responsive neurostimulator that delivers stimulation to 1 or 2 seizure foci via chronically implanted electrodes when specific electrocorticographic patterns are detected (RNS System). Participants had completed a 2-year primarily open-label safety study (n = 65) or a 2-year randomized blinded controlled safety and efficacy study (n = 191); 230 participants transitioned into an ongoing 7-year study to assess safety and efficacy.
Results:
The average participant was 34 (±11.4) years old with epilepsy for 19.6 (±11.4) years. The median preimplant frequency of disabling partial or generalized tonic-clonic seizures was 10.2 seizures a month. The median percent seizure reduction in the randomized blinded controlled trial was 44% at 1 year and 53% at 2 years (p < 0.0001, generalized estimating equation) and ranged from 48% to 66% over postimplant years 3 through 6 in the long-term study. Improvements in quality of life were maintained (p < 0.05). The most common serious device-related adverse events over the mean 5.4 years of follow-up were implant site infection (9.0%) involving soft tissue and neurostimulator explantation (4.7%).
Conclusions:
The RNS System is the first direct brain responsive neurostimulator. Acute and sustained efficacy and safety were demonstrated in adults with medically refractory partial onset seizures arising from 1 or 2 foci over a mean follow-up of 5.4 years. This experience supports the RNS System as a treatment option for refractory partial seizures.
Classification of evidence:
This study provides Class IV evidence that for adults with medically refractory partial onset seizures, responsive direct cortical stimulation reduces seizures and improves quality of life over a mean follow-up of 5.4 years.
doi:10.1212/WNL.0000000000001280
PMCID: PMC4339127  PMID: 25616485
19.  What is the importance of abnormal “background” activity in seizure generation? 
Investigations of interictal epileptiform spikes and seizures have played a central role in the study of epilepsy. The background EEG activity, however, has received less attention. In this chapter we discuss the characteristic features of the background activity of the brain when individuals are at rest and awake (resting wake) and during sleep. The characteristic rhythms of the background EEG are presented, and the presence of 1/f β behavior of the EEG power spectral density is discussed and its possible origin and functional significance. The interictal EEG findings of focal epilepsy and the impact of interictal epileptiform spikes on cognition are also discussed.
doi:10.1007/978-94-017-8914-1_3
PMCID: PMC4276130  PMID: 25012365
Electroencephalogram; Epilepsy; Local Field Potential Oscillations; High Frequency Oscillations; Sleep
20.  Two-year seizure reduction in adults with medically intractable partial onset epilepsy treated with responsive neurostimulation: Final results of the RNS System Pivotal trial 
Epilepsia  2014;55(3):432-441.
Objective
To demonstrate the safety and effectiveness of responsive stimulation at the seizure focus as an adjunctive therapy to reduce the frequency of seizures in adults with medically intractable partial onset seizures arising from one or two seizure foci.
Methods
Randomized multicenter double-blinded controlled trial of responsive focal cortical stimulation (RNS System). Subjects with medically intractable partial onset seizures from one or two foci were implanted, and 1 month postimplant were randomized 1:1 to active or sham stimulation. After the fifth postimplant month, all subjects received responsive stimulation in an open label period (OLP) to complete 2 years of postimplant follow-up.
Results
All 191 subjects were randomized. The percent change in seizures at the end of the blinded period was −37.9% in the active and −17.3% in the sham stimulation group (p = 0.012, Generalized Estimating Equations). The median percent reduction in seizures in the OLP was 44% at 1 year and 53% at 2 years, which represents a progressive and significant improvement with time (p < 0.0001). The serious adverse event rate was not different between subjects receiving active and sham stimulation. Adverse events were consistent with the known risks of an implanted medical device, seizures, and of other epilepsy treatments. There were no adverse effects on neuropsychological function or mood.
Significance
Responsive stimulation to the seizure focus reduced the frequency of partial-onset seizures acutely, showed improving seizure reduction over time, was well tolerated, and was acceptably safe. The RNS System provides an additional treatment option for patients with medically intractable partial-onset seizures.
doi:10.1111/epi.12534
PMCID: PMC4233950  PMID: 24621228
Cortical stimulation; Partial seizures; Focal seizures; Responsive stimulation; Neurostimulator
21.  Interictal Scalp Electroencephalography and Intraoperative Electrocorticography in Magnetic Resonance Imaging–Negative Temporal Lobe Epilepsy Surgery 
JAMA neurology  2014;71(6):702-709.
IMPORTANCE
Scalp electroencephalography (EEG) and intraoperative electrocorticography (ECoG) are routinely used in the evaluation of magnetic resonance imaging–negative temporal lobe epilepsy (TLE) undergoing standard anterior temporal lobectomy with amygdalohippocampectomy (ATL), but the utility of interictal epileptiform discharge (IED) identification and its role in outcome are poorly defined.
OBJECTIVES
To determine whether the following are associated with surgical outcomes in patients with magnetic resonance imaging–negative TLE who underwent standard ATL: (1) unilateral-only IEDs on preoperative scalp EEG; (2) complete resection of tissue generating IEDs on ECoG; (3) complete resection of opioid-induced IEDs recorded on ECoG; and (4) location of IEDs recorded on ECoG.
DESIGN, SETTING, AND PARTICIPANTS
Data were gathered through retrospective medical record review at a tertiary referral center. Adult and pediatric patients with TLE who underwent standard ATL between January 1, 1990, and October 15, 2010, were considered for inclusion. Inclusion criteria were magnetic resonance imaging–negative TLE, standard ECoG performed at the time of surgery, and a minimum follow-up of 12 months. Univariate analysis was performed using log-rank time-to-event analysis. Variables reaching significance with log-rank testing were further analyzed using Cox proportional hazards.
MAIN OUTCOMES AND MEASURES
Excellent or nonexcellent outcome at time of last follow-up. An excellent outcome was defined as Engel class I and a nonexcellent outcome as Engel classes II through IV.
RESULTS
Eighty-seven patients met inclusion criteria, with 48 (55%) achieving an excellent outcome following ATL. Unilateral IEDs on scalp EEG (P = .001) and complete resection of brain regions generating IEDs on baseline intraoperative ECoG (P = .02) were associated with excellent outcomes in univariate analysis. Both were associated with excellent outcomes when analyzed with Cox proportional hazards (unilateral-only IEDs, relative risk = 0.31 [95% CI, 0.16-0.64]; complete resection of IEDs on baseline ECoG, relative risk = 0.39 [95% CI, 0.20-0.76]). Overall, 25 of 35 patients (71%) with both unilateral-only IEDs and complete resection of baseline ECoG IEDs had an excellent outcome.
CONCLUSIONS AND RELEVANCE
Unilateral-only IEDs on preoperative scalp EEG and complete resection of IEDs on baseline ECoG are associated with better outcomes following standard ATL in magnetic resonance imaging–negative TLE. Prospective evaluation is needed to clarify the use of ECoG in tailoring temporal lobectomy.
doi:10.1001/jamaneurol.2014.585
PMCID: PMC4183227  PMID: 24781216
22.  Feasibility Study of a Caregiver Seizure Alert System in Canine Epilepsy 
Epilepsy research  2013;106(3):456-460.
Summary
A device capable of detecting seizures and alerting caregivers would be a major advance for epilepsy management, and could be used to guide early intervention and prevent seizure-related injuries. The objective of this work was to evaluate a seizure advisory system (SAS) that alerts caregivers of seizures in canines with naturally occurring epilepsy. Four dogs with epilepsy were implanted with a SAS that wirelessly transmits continuous intracranial EEG (iEEG) to an external device embedded with a seizure detection algorithm and the capability to alert caregivers. In this study a veterinarian was alerted by automated text message if prolonged or repetitive seizures occurred, and a rescue therapy protocol was implemented. The performance of the SAS caregiver alert was evaluated over the course of 8 weeks. Following discontinuation of antiepileptic drugs, the dogs experienced spontaneous unprovoked partial seizures that secondarily generalized. Three prolonged or repetitive seizure episodes occurred in 2 of the dogs. On each occasion, the SAS caregiver alert successfully alerted an on call veterinarian who confirmed the seizure activity via remote video-monitoring. A rescue medication was then administered and the seizures were aborted. This study demonstrates the feasibility of a SAS caregiver alert for prolonged or repetitive seizures, and enabling rescue medications to be delivered in a timely manner. The SAS may improve the management of human epilepsy by alerting caregivers of seizures, enabling early interventions, and potentially improving outcomes and quality of life of patients and caregivers.
doi:10.1016/j.eplepsyres.2013.06.007
PMCID: PMC3903427  PMID: 23962794
epilepsy; seizure management; seizure advisory; caregiver alert; EEG; device
23.  Electrocortical source imaging of intracranial EEG data in epilepsy 
Here we report first results of numerical methods for modeling the dynamic structure and evolution of epileptic seizure activity in an intracranial subdural electrode (iEEG, ECoG) recording from a patient with partial refractory epilepsy. A 15-min dataset containing two seizures was decomposed using up to five competing adaptive mixture ICA (AMICA) models. Multiple models modeled early or late ictal, or pre-or post-ictal periods in the data, respectively. To localize sources, a realistic Boundary Element Method (BEM) head model was constructed for the patient with custom open skull and plastic (non-conductive) electrode holder features. Source localization was performed using Sparse Bayesian Learning (SBL) on a dictionary of overlapping multi-scale cortical patches constructed from 80,130 dipoles in gray matter perpendicular to the cortical surface. Remaining mutual information among seizure-model AMICA components was dominated by two dependent component subspaces with largely contiguous source domains localized to superior frontal gyrus and precentral gyrus; these accounted for most of the ictal activity. Similar though much weaker dependent subspaces were also revealed in pre-ictal data by the associated AMICA model. Electrocortical source imaging appears promising both for clinical epilepsy research and for basic cognitive neuroscience research using volunteer patients who must undergo invasive monitoring for medical purposes.
doi:10.1109/IEMBS.2011.6090971
PMCID: PMC4135517  PMID: 22255194
24.  Modeling Cortical Source Dynamics and Interactions During Seizure 
Mapping the dynamics and spatial topography of brain source processes critically involved in initiating and propagating seizure activity is critical for effective epilepsy diagnosis, intervention, and treatment. In this report we analyze neuronal dynamics before and during epileptic seizures using adaptive multivariate autoregressive (VAR) models applied to maximally-independent (ICA) sources of intracranial EEG (iEEG, ECoG) data recorded from subdural electrodes implanted in a human patient for evaluation of surgery for epilepsy. We visualize the spatial distribution of causal sources and sinks of ictal activity on the cortical surface (gyral and sulcal) using a novel combination of multivariate Granger-causal and graph-theoretic metrics combined with distributed source localization by Sparse Bayesian Learning applied to a multi-scale patch basis. This analysis reveals and visualizes distinct, seizure stage-dependent shifts in inter-component spatiotemporal dynamics and connectivity including the clinically-identified epileptic foci.
doi:10.1109/IEMBS.2011.6090332
PMCID: PMC4136461  PMID: 22254582
25.  Network oscillations modulate interictal epileptiform spike rate during human memory 
Brain  2013;136(8):2444-2456.
Eleven patients being evaluated with intracranial electroencephalography for medically resistant temporal lobe epilepsy participated in a visual recognition memory task. Interictal epileptiform spikes were manually marked and their rate of occurrence compared between baseline and three 2 s periods spanning a 6 s viewing period. During successful, but not unsuccessful, encoding of the images there was a significant reduction in interictal epileptiform spike rate in the amygdala, hippocampus, and temporal cortex. During the earliest encoding period (0–2000 ms after image presentation) in these trials there was a widespread decrease in the power of theta, alpha and beta band local field potential oscillations that coincided with emergent focal gamma frequency activity. Interictal epileptiform spike rate correlated with spectral band power changes and broadband (4–150 Hz) desynchronization, which predicted significant reduction in interictal epileptiform spike rate. Spike-triggered averaging of the field potential power spectrum detected a burst of low frequency synchronization 200 ms before the interictal epileptiform spikes that arose during this period of encoding. We conclude that interictal epileptiform spikes are modulated by the patterns of network oscillatory activity that accompany human memory offering a new mechanistic insight into the interplay of cognitive processing, local field potential dynamics and interictal epileptiform spike generation.
doi:10.1093/brain/awt159
PMCID: PMC3722348  PMID: 23803305
interictal epileptiform spikes; epilepsy; memory

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