Cingulate epilepsy: report of 3 electroclinical subtypes with surgical outcomes

Authors: Alkawadri R, So NK, Van Ness PC, Alexopoulos AV

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Abstract

Importance  The literature on cingulate gyrus epilepsy in the magnetic resonance imaging era is limited to case reports and small case series. To our knowledge, this is the largest study of surgically confirmed epilepsy arising from the anterior or posterior cingulate region.

Objective  To characterize the clinical and electrophysiological findings of epilepsies arising from the anterior and posterior cingulate gyrus.

Design, Setting, and Participants  We studied consecutive cingulate gyrus epilepsy cases identified retrospectively from the Cleveland Clinic and University of Texas Southwestern Medical Center epilepsy databases from 1992 to 2009. Participants included 14 consecutive cases of cingulate gyrus epilepsies confirmed by restricted magnetic resonance image lesions and seizure freedom or marked improvement following lesionectomy.

Main Outcomes and Measures  The main outcome measure was improvement in seizure frequency following surgery. The clinical, video electroencephalography, neuroimaging, pathology, and surgical outcome data were reviewed.

Results  All 14 patients had cingulate epilepsy confirmed by restricted magnetic resonance image lesions and seizure freedom or marked improvement following lesionectomy. They were divided into 3 groups based on anatomical location of the lesion and corresponding seizure semiology. In the posterior cingulate group, all 4 patients had electroclinical findings suggestive of temporal origin of the epilepsy. The anterior cingulate cases were divided into a typical (Bancaud) group (6 cases with hypermotor seizures and infrequent generalization with the presence of fear, laughter, or severe interictal personality changes) and an atypical group (4 cases presenting with simple motor seizures and a tendency for more frequent generalization and less-favorable long-term surgical outcome). All atypical cases were associated with an underlying infiltrative astrocytoma.

Conclusions and Relevance  Posterior cingulate gyrus epilepsy may present with electroclinical findings that are suggestive of temporal lobe epilepsy and can be considered as another example of pseudotemporal epilepsies. The electroclinical presentation and surgical outcome of lesional anterior cingulate epilepsy is possibly influenced by the underlying pathology. This study highlights the difficulty in localizing seizures arising from the cingulate gyrus in the absence of a magnetic resonance image lesion.

 Representation of the magnetic resonance image lesions and corresponding distribution of interictal and ictal electroencephalographic findings on scalp. The interictal maps show electrodes with involvement greater than 50% of the maximum amplitude of the epileptiform discharges. The darker color, when present, marks the subset of electrodes that consistently exhibit maximal amplitude of the interictal activity. The highlighted ictal electrodes represent the ones with greater than 50% of maximum amplitude. The darker red color marks regions/electrodes with relatively localized and faster ictal rhythms (the most prominent ictal rhythm is in the left upper corner of the ictal map). Interictal maps have been left blank in patients who had no identifiable interictal discharges on scalp. Ictal maps have been left blank in patients whose scalp ictal rhythms were obscured. PF indicates paroxysmal fast activity.

Representation of the magnetic resonance image lesions and corresponding distribution of interictal and ictal electroencephalographic findings on scalp. The interictal maps show electrodes with involvement greater than 50% of the maximum amplitude of the epileptiform discharges. The darker color, when present, marks the subset of electrodes that consistently exhibit maximal amplitude of the interictal activity. The highlighted ictal electrodes represent the ones with greater than 50% of maximum amplitude. The darker red color marks regions/electrodes with relatively localized and faster ictal rhythms (the most prominent ictal rhythm is in the left upper corner of the ictal map). Interictal maps have been left blank in patients who had no identifiable interictal discharges on scalp. Ictal maps have been left blank in patients whose scalp ictal rhythms were obscured. PF indicates paroxysmal fast activity.