Publications by authors named "Michael Westerveld"

50 Publications

Intracranial EEG and laser interstitial thermal therapy in MRI-negative insular and/or cingulate epilepsy: case series.

J Neurosurg 2020 Dec 11:1-9. Epub 2020 Dec 11.

2Department of Neurosurgery, Neuroscience Institute, AdventHealth.

Objective: The goal of this study was to assess the success rate and complications of stereo-electroencephalogra-phy (sEEG) and laser interstitial thermal therapy (LITT) in the treatment of nonlesional refractory epilepsy in cingulate and insular cortex.

Methods: The authors retrospectively analyzed the treatment response in 9 successive patients who underwent insular or cingulate LITT for nonlesional refractory epilepsy at their center between 2011 and 2019. Localization of seizures was based on inpatient video-EEG monitoring, neuropsychological testing, 3-T MRI, PET scan, magnetoencephalography scan, and/or ictal SPECT scan. Eight patients underwent sEEG, and 1 patient had implantation of both sEEG electrodes and subdural grids for localization of epileptogenic zones. LITT was performed in 5 insular cases (4 left and 1 right) and 3 cingulate cases (all left-sided). One patient also underwent both insular and cingulate LITT on the left side. All of the patients who underwent insular LITT as well as 2 of the 3 who underwent cingulate LITT were right-hand dominant. The patient who underwent insular plus cingulate LITT was also right-hand dominant.

Results: Following LITT, 67% of the patients were seizure free (Engel class I) at follow-up (mean 1.35 years, range 0.6-2.8 years). All patients responded favorably to treatment (Engel class I-III). Two patients developed small intracranial hemorrhages during the sEEG implantation that did not require surgical management. One patient developed a large intracranial hemorrhage during an insular LITT procedure that did require surgical management. That patient experienced aphasia, incoordination, and hemiparesis, which resolved with inpatient rehabilitation. No permanent neurological deficits were noted in any of the patients at last follow-up. Neuropsychological status was stable in this cohort before and after LITT.

Conclusions: sEEG can be safely used to localize seizures originating from insular and cingulate cortex. LITT can successfully treat seizures arising from these deep-seated structures. The insula and cingulum should be evaluated more frequently for seizure onset zones.
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http://dx.doi.org/10.3171/2020.7.JNS201912DOI Listing
December 2020

Atypical language representation as a protective factor against verbal memory decline following epilepsy surgery.

Epilepsy Behav 2020 11 18;112:107451. Epub 2020 Sep 18.

Barrow Neurological Institute, United States of America. Electronic address:

Objective: An important role of neuropsychology in the preoperative evaluation of epilepsy surgery candidates is to assess risk for postoperative memory decline. One factor associated with postoperative verbal memory decline is surgery in the language-dominant temporal lobe (TL). The aim of the study was to determine whether atypical language representation has a protective effect against verbal memory decline following left temporal, frontotemporal, or hippocampal excision.

Methods: Data from 61 patients with medically refractory epilepsy, Wada testing, and pre- and postsurgical memory assessment from four comprehensive epilepsy surgery centers were gathered and examined for pre- to postsurgical memory change. Wada testing was used to determine language dominance (left vs. atypical [bilateral + right]). Postoperative memory change was examined at both the individual (using nonparametric analyses) and group (using parametric analyses) levels for the two language dominance groups.

Results: Significant postoperative verbal memory decline was observed in the left hemisphere language-dominant group, while the atypical language group showed verbal memory improvement. Individuals with left hemisphere language dominance were more likely to show postoperative declines in verbal memory, whereas individuals with atypical language dominance were significantly less likely to decline. As expected, there were no significant differences between language groups with regard to postoperative visuospatial memory outcome.

Conclusion: Patients with atypical language dominance had better verbal memory outcomes following left hemisphere resections than those with left hemisphere language dominance suggesting that typical memory substrates likely reorganized along with language. Thus, atypical cerebral organization of language may be considered a protective factor against verbal memory decline following epilepsy surgery involving the left TL.
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http://dx.doi.org/10.1016/j.yebeh.2020.107451DOI Listing
November 2020

Telehealth perceptions in patients with epilepsy and providers during the COVID-19 pandemic.

Epilepsy Behav 2020 11 12;112:107394. Epub 2020 Sep 12.

AdventHealth Epilepsy at Orlando, 615 E Princeton Street, Suite 540, Orlando, FL 32803, USA. Electronic address:

Coronavirus disease 2019 (COVID-19) has required novel solutions for issues that arise with social distancing. Telehealth has become one of those solutions in many clinics around the U.S. As we look beyond, the pandemic telehealth can be utilized as an important tool for clinics in the future. Patient satisfaction will most likely affect reimbursement, while provider perception will affect implementation. We see this as a valuable tool to many epilepsy clinics. The goal of our survey was to determine the perceptions and satisfaction of patients with intractable epilepsy and providers with telehealth during the COVID-19 pandemic; we surveyed patient and providers. We evaluated the first 111 patients who participated in our telehealth visits. We conducted telephone surveys with the first 68 patients who agreed to participate. We also conducted surveys by email with our providers who participated in these telehealth visits. We found that 66% of patients and 67% of providers would use a telehealth visit in the future if given the option. Review of our patients' and providers' comments provides valuable insights for building a long-term successful intractable epilepsy telehealth clinic.
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http://dx.doi.org/10.1016/j.yebeh.2020.107394DOI Listing
November 2020

Carotid Revascularization and Its Effect on Cognitive Function: A Prospective Nonrandomized Multicenter Clinical Study.

J Stroke Cerebrovasc Dis 2020 May 25;29(5):104702. Epub 2020 Feb 25.

Tufts University School of Medicine, Boston, Massachusetts. Electronic address:

Background: There is conflicting data on the effect of carotid revascularization on cognitive function.

Objective: To examine cerebral blood flow and cognitive function after carotid revascularization.

Methods: Patients with unilateral, asymptomatic hemodynamically significant carotid artery stenosis (80% by computed tomography angiography or magnetic resonance angiography) were eligible. Cerebral blood flow was measured preoperatively and 1 month postoperatively using quantitative phase contrast magnetic resonance angiography. Preoperative flow impairment was defined as ipsilateral flow at least 20% less than contralateral flow (ie, an ipsilateral and/or contralateral flow ratio ≤0.8). Significant improvement in blood flow was defined as at least a 0.15 increase in flow ratio from pre- to postoperative. A control group was managed medically. Four cognitive domains were assessed at baseline, 1 month, and 6-12 months postoperatively.

Results: Seventy-five patients were enrolled at 6 sites; 53 carotid endarterectomy, 11 carotid artery stenting, and 11 medical management only controls. Preoperative Trails B scores were similar between groups. Revascularization was associated with significant improvement in executive function (Trials B) while no improvement was observed in controls (P = .007). Of patients with improvement in middle cerebral artery (MCA) flow, 90% had improved Trails B scores compared to 46.5% of patients without MCA flow improvement (P = .01). Greater absolute improvement in mean Trails B scores was observed in patients with MCA flow improvement compared to those without (48 seconds versus 24.7 seconds, P = .001).

Conclusions: In a cohort of patient with asymptomatic carotid stenosis, improvement in MCA flow following carotid revascularization is associated with improvement in executive functioning.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104702DOI Listing
May 2020

American Academy of Clinical Neuropsychology consensus conference statement on uniform labeling of performance test scores.

Clin Neuropsychol 2020 04 10;34(3):437-453. Epub 2020 Feb 10.

Adventhealth Neuropsychology-Orlando, Adventhealth Medical Group, Adventhealth Children's Hospital, Orlando, FL, USA.

Descriptive labels of performance test scores are a critical component of communicating outcomes of neuropsychological and psychological evaluations. Yet, no universally accepted system exists for assigning qualitative descriptors to scores in specific ranges. In addition, the definition and use of the term "impairment" lacks specificity and consensus. Consequently, test score labels and the denotation of impairment are inconsistently applied by clinicians, creating confusion among consumers of neuropsychological services, including referral sources, trainees, colleagues, and the judicial system. To reduce this confusion, experts in clinical and forensic neuropsychological and psychological assessment convened in a consensus conference at the 2018 Annual Meeting of the American Academy of Clinical Neuropsychology (AACN). The goals of the consensus conference were to recommend (1) a system of qualitative labels to describe results from performance-based tests with normal and non-normal distributions and (2) a definition of impairment and its application in individual case determinations. The goals of the consensus conference were met resulting in specific recommendations for the application of uniform labels for performance tests and for the definition of impairment, which are described in this paper. In addition, included in this consensus statement is a description of the conference process and the rationales for these recommendations. This consensus conference is the first formal attempt by the professional neuropsychological community to make recommendations for uniform performance test score labels and to advance a consistent definition of impairment. Using uniform descriptors and terms will reduce confusion and enhance report comprehensibility by the consumers of our reports as well as our trainees and colleagues.
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http://dx.doi.org/10.1080/13854046.2020.1722244DOI Listing
April 2020

Autoimmune encephalitis and epilepsy: evolving definition and clinical spectrum.

Clin Exp Pediatr 2020 Aug 16;63(8):291-300. Epub 2019 Aug 16.

Comprehensive Epilepsy Center, AdventHealth for Children, Orlando, FL, USA.

Advances in autoimmune encephalitis studies in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to the disorder. The disorder or syndrome has been linked to a wide variety of pathologic processes associated with the neuron-specific autoantibodies targeting intracellular and plasma membrane antigens. However, current criteria for autoimmune encephalitis are quite dependent on antibody testing and responses to immunotherapy, which might delay the diagnosis. This form of encephalitis can involve the multifaceted presentation of seizures and unexpected behavioral changes. The spectrum of neuropsychiatric symptoms in children is less definitive than that in adults, and the incorporation of clinical, immunological, electrophysiological, and neuroradiological results is critical to the diagnostic approach. In this review, we document the clinical and immunologic characteristics of autoimmune encephalitis known to date, with the goal of helping clinicians in differential diagnosis and to provide prompt and effective treatment.
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http://dx.doi.org/10.3345/kjp.2019.00598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402981PMC
August 2020

Successful Intrathecal Rituximab Administration in Refractory Nonteratoma Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Case Report.

J Neurosci Nurs 2019 Aug;51(4):194-197

Questions or comments about this article may be directed to Maritsa Casares, BSN CNRN, at She is an Adult Clinical Coordinator, Florida Epilepsy Center, Florida Hospital, Orlando, FL. Holly J. Skinner, DO, is Epileptologist and Sleep Specialist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Elakkat D. Gireesh, MD, is Epileptologist, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Christina Wombles, ARNP, is Nurse Practitioner, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Josephine Schweitzer, MSW, is Social Worker, Florida Epilepsy Center, Florida Hospital, Orlando, FL. P. Gage Gwyn, PhD ARNP, is Nurse Practitioner, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Herbert B. Newton, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Sherif M. Makar, MD, is NeuroOncologist, Florida Hospital Medical Group, NeuroOncology Center, Orlando, FL. Kihyeong Lee, MD MSN, is Medical Director, Florida Epilepsy Center: Florida Hospital Medical Group, Florida Hospital, Orlando, FL. Michael Westerveld, PhD ABPP, is Director, Florida Hospital Medical Group, Florida Center for Neuropsychology, Orlando, FL.

N-methyl-D-aspartate receptor (NMDA-R) antibody encephalitis is an immune-mediated disorder characterized by the presence of anti-NMDA antibody in serum and cerebrospinal fluid, with a characteristic combination of psychological and neurological signs and symptoms. The scientific knowledge pertaining to the management of anti-NMDA-R encephalitis is growing. It is important that neuroscience nurses be aware of treatments as well as the newest novel treatment options available. Early aggressive intervention is imperative to recovery. The first line of treatment often includes high-dose steroids, intravenous immunoglobulin, and therapeutic plasma exchange. Second-line therapy for refractory NMDA-R encephalitis includes intravenous rituximab and cyclophosphamide. Even with these treatments, up to 25% of patients may be left with severe deficits or have a fatal outcome. It is well known that penetration of monoclonal anti-CD20 antibody therapy (rituximab) into the cerebrospinal fluid is 0.1% of that in the serum. Therefore, efficacy of rituximab in the treatment of NMDA encephalitis may be improved by intrathecal administration in selected cases with a poor response to intravenous rituximab. We present a case of anti-NMDA-R encephalitis that was refractory to first- and second-line therapies, who responded to intrathecal rituximab, to highlight a novel treatment that may be able to prevent long-term disability and improve clinical outcomes.
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http://dx.doi.org/10.1097/JNN.0000000000000450DOI Listing
August 2019

Epilepsy Surgery in Children versus Adults.

J Korean Neurosurg Soc 2019 May 1;62(3):328-335. Epub 2019 May 1.

Comprehensive Epilepsy Center, Advent Health for Children, Orlando, FL, USA.

Epilepsy is one of the most common chronic neurological disorder affecting 6-7 per 1000 worldwide. Nearly one-third of patients with newly diagnosed epilepsy continue to have recurrent seizures despite adequate trial of more than two anti-seizure drugs : drug-resistant epilepsy (DRE). Children with DRE often experience cognitive and psychosocial co-morbidities requiring more urgent and aggressive treatment than adults. Epilepsy surgery can result in seizure-freedom in approximately two-third of children with improvement in cognitive development and quality of life. Understanding fundamental differences in etiology, co-morbidity, and neural plasticity between children and adults is critical for appropriate selection of surgical candidates, appropriate presurgical evaluation and surgical approach, and improved overall outcome.
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http://dx.doi.org/10.3340/jkns.2019.0026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514317PMC
May 2019

Utility of the Behavior Rating Inventory of Executive Function - Preschool version (BRIEF-P) in young children with epilepsy.

Child Neuropsychol 2018 10 29;24(7):975-985. Epub 2017 Aug 29.

a Department of Neurology, Comprehensive Epilepsy Center , New York University , New York , NY , USA.

Executive functioning deficits are prominent in children with epilepsy. Although instruments, such as the Behavior Rating Inventory of Executive Function (BRIEF), are useful in detecting executive dysfunction in school-age children with epilepsy, little data are available for younger children. The present study evaluates the ability of the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P) to detect executive dysfunction in preschool-age children with epilepsy. Parents of 51 clinically referred children with epilepsy (age: M = 1.99 years, SD = 1.29 years, range = 2-5 years) completed the BRIEF-P. Using a cutoff t score of ≥65 as the threshold for impairment, the BRIEF-P's ability to detect executive dysfunction within this clinical population was established. Additionally, correlational analyses were used to assess the relations between epilepsy severity factors and BRIEF-P indices. Epilepsy severity variables that were significantly related to BRIEF-P indices were entered into a linear regression model to explore their predictive ability. Emergent metacognition (emergent metacognition index [EMI]; 59%) and the global executive composite (43%) were the most frequently elevated indices. The most commonly elevated subscales were working memory (65%), inhibition (37%), and planning/organization (35%). Age of seizure onset, seizure frequency, and number of antiepileptic drugs were not significantly correlated with BRIEF-P indices. However, children with lower intellectual ability were rated as having greater executive dysfunction, specifically with EMI (r = -.30). Still, intellectual functioning only accounted for a small percentage (9%) of the variance in EMI scores. The current pilot study demonstrates that the BRIEF-P shows promise in identifying executive dysfunction in preschool-age children with epilepsy.
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http://dx.doi.org/10.1080/09297049.2017.1365829DOI Listing
October 2018

The role of executive functioning in quality of life in pediatric intractable epilepsy.

Epilepsy Behav 2016 11 8;64(Pt A):37-43. Epub 2016 Oct 8.

Florida Hospital for Children, Comprehensive Epilepsy Center, 615 E. Princeton St., Orlando, FL 32803, USA; Boston Children's Hospital, Department of Neurology, Division of Epilepsy, 300 Longwood Ave., Fegan 9, Boston, MA 02115, USA. Electronic address:

Objective: Children with epilepsy are vulnerable to executive dysfunction, but the relationship between executive functioning (EF) and quality of life (QOL) in children with epilepsy is not fully delineated. This exploratory study elucidated the relationship between ecological EF and QOL in pediatric intractable epilepsy.

Method: Fifty-four consecutively referred pediatric epilepsy surgery candidates and their parents were administered IQ measures, the Behavior Rating Inventory of Executive Function (BRIEF), and the Quality of Life in Childhood Epilepsy (QOLCE) as part of a comprehensive neuropsychological evaluation.

Results: A significant difference was found in QOL between those with and without clinical impairments on the BRIEF [t(52)=3.93; p<.001]. That is, children with executive dysfunction had lower overall QOL. All seizure variables and BRIEF scales were associated with overall QOL [F(12, 40)=6.508; p=.001; R=.661]. Working memory from the BRIEF was the most frequently elevated scale in our sample (57%). Those with executive dysfunction had 9.7 times the risk of having poor QOL.

Conclusions: Poor EF control according to behavior ratings is significantly related to QOL in intractable pediatric epilepsy. Identification of executive dysfunction in home environments is an essential component of presurgical evaluations and target for intervention, which may improve QOL.
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http://dx.doi.org/10.1016/j.yebeh.2016.08.018DOI Listing
November 2016

CortiQ-based Real-Time Functional Mapping for Epilepsy Surgery.

J Clin Neurophysiol 2015 Jun;32(3):e12-22

*g.tec Medical Engineering GmbH, Graz, Austria; †Johannes Kepler University, Linz, Austria; ‡Milena's Functional Brain Mapping and Brain-Computer Interface Lab, Florida Hospital for Children, Orlando, Florida, U.S.A.; §MEG Lab, Florida Hospital for Children, Orlando, Florida, U.S.A.; ‖Comprehensive Pediatric Epilepsy Center, Florida Hospital for Children, Orlando, Florida, U.S.A.; ¶Division of Neuropsychology, Florida Hospital for Children, Orlando, Florida, U.S.A.; and #Department of Radiology, Florida Hospital, Orlando, Florida, U.S.A.

Purpose: To evaluate the use of the cortiQ-based mapping system (g.tec medication engineering GmbH, Austria) for real-time functional mapping (RTFM) and to compare it to results from electrical cortical stimulation mapping (ESM) and functional magnetic resonance imaging (fMRI).

Methods: Electrocorticographic activity was recorded in 3 male patients with intractable epilepsy by using cortiQ mapping system and analyzed in real time. Activation related to motor, sensory, and receptive language tasks was determined by evaluating the power of the high gamma frequency band (60-170 Hz). The sensitivity and specificity of RTFM were tested against ESM and fMRI results.

Results: "Next-neighbor" approach demonstrated [sensitivity/specificity %] (1) RTFM against ESM: 100.00/79.70 for hand motor; 100.00/73.87 for hand sensory; -/87 for language (it was not identified by the ESM); (2) RTFM against fMRI: 100.00/84.4 for hand motor; 66.70/85.35 for hand sensory; and 87.85/77.70 for language.

Conclusions: The results of the quantitative "next-neighbor" RTFM evaluation were concordant to those from ESM and fMRI. The RTFM correlates well with localization of hand motor function provided by ESM and fMRI, which may offer added localization in the operating room and guidance for extraoperative ESM mapping. Real-time functional mapping correlates with fMRI language activation when ESM findings are negative. It has fewer limitations than ESM and greater flexibility in activation paradigms and measuring responses.
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http://dx.doi.org/10.1097/WNP.0000000000000131DOI Listing
June 2015

The American Board of Clinical Neuropsychology and American Academy of Clinical Neuropsychology: updated milestones 2005-2014.

Clin Neuropsychol 2014 12;28(6):889-906. Epub 2014 Aug 12.

a Department of Psychiatry & Psychology , Mayo Clinic , Jacksonville , FL , USA.

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http://dx.doi.org/10.1080/13854046.2014.935484DOI Listing
November 2014

Real-time functional mapping: potential tool for improving language outcome in pediatric epilepsy surgery.

J Neurosurg Pediatr 2014 Sep 4;14(3):287-95. Epub 2014 Jul 4.

Functional Brain Mapping and Brain-Computer Interface Lab, Center for Pediatric Research and Outcomes and Comprehensive Pediatric Epilepsy Center;

Accurate language localization expands surgical treatment options for epilepsy patients and reduces the risk of postsurgery language deficits. Electrical cortical stimulation mapping (ESM) is considered to be the clinical gold standard for language localization. While ESM affords clinically valuable results, it can be poorly tolerated by children, requires active participation and compliance, carries a risk of inducing seizures, is highly time consuming, and is labor intensive. Given these limitations, alternative and/or complementary functional localization methods such as analysis of electrocorticographic (ECoG) activity in high gamma frequency band in real time are needed to precisely identify eloquent cortex in children. In this case report, the authors examined 1) the use of real-time functional mapping (RTFM) for language localization in a high gamma frequency band derived from ECoG to guide surgery in an epileptic pediatric patient and 2) the relationship of RTFM mapping results to postsurgical language outcomes. The authors found that RTFM demonstrated relatively high sensitivity (75%) and high specificity (90%) when compared with ESM in a "next-neighbor" analysis. While overlapping with ESM in the superior temporal region, RTFM showed a few other areas of activation related to expressive language function, areas that were eventually resected during the surgery. The authors speculate that this resection may be associated with observed postsurgical expressive language deficits. With additional validation in more subjects, this finding would suggest that surgical planning and associated assessment of the risk/benefit ratio would benefit from information provided by RTFM mapping.
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http://dx.doi.org/10.3171/2014.6.PEDS13477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405165PMC
September 2014

360 Degree advocacy: a model for high impact advocacy in a rapidly changing healthcare marketplace.

Clin Neuropsychol 2014 17;28(2):167-80. Epub 2014 Feb 17.

a Delegate to the Inter Organizational Practice Committee.

In an era of rapid changes in the healthcare marketplace the specialty of clinical neuropsychology faces a substantial increase in advocacy challenges. These include maintaining both access to services and a favorable practice climate as new healthcare structures and payment models evolve. The issue of regional variability complicates an effective response to these challenges from national professional organizations. One response to the challenge of regional variability is to strengthen our national organizations' capacity to engage in coordinated and effective advocacy, and to partner with state and regional neuro/psychological associations. The Inter-Organizational Practice Committee (IOPC) was formed in 2012 to meet this need. The IOPC has developed a model of 360 Degree Advocacy that coordinates local, regional, and national resources for high-impact, efficient advocacy. This paper describes the 360 Degree Advocacy model, and walks readers through an example of the model in action, successfully responding to a threat to patient access and practice climate with a regional Medicare carrier.
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http://dx.doi.org/10.1080/13854046.2014.885087DOI Listing
May 2014

Influence of anxiety on memory performance in temporal lobe epilepsy.

Epilepsy Behav 2014 Feb 26;31:19-24. Epub 2013 Nov 26.

Department of Neurology, Yale University, New Haven, CT, USA. Electronic address:

This study examined the degree to which anxiety contributed to inconsistent material-specific memory difficulties among 243 patients with temporal lobe epilepsy from the Multisite Epilepsy Study. Visual memory performance on the Rey Complex Figure Test (RCFT) was poorer for those with high versus low levels of anxiety but was not found to be related to the TLE side. The verbal memory score on the California Verbal Learning Test (CVLT) was significantly lower for patients with left-sided TLE than for patients with right-sided TLE with low anxiety levels but equally impaired for those with high anxiety levels. These results suggest that we can place more confidence in the ability of verbal memory tests like the CVLT to lateralize to left-sided TLE for those with low anxiety levels, but that verbal memory will be less likely to produce lateralizing information for those with high anxiety levels. This suggests that more caution is needed when interpreting verbal memory tests for those with high anxiety levels. These results indicated that RCFT performance was significantly affected by anxiety and did not lateralize to either side, regardless of anxiety levels. This study adds to the existing literature which suggests that drawing-based visual memory tests do not lateralize among patients with TLE, regardless of anxiety levels.
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http://dx.doi.org/10.1016/j.yebeh.2013.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3946774PMC
February 2014

The effect of carotid endarterectomy on cerebral blood flow and cognitive function.

J Stroke Cerebrovasc Dis 2013 Oct 2;22(7):1029-37. Epub 2012 May 2.

Wallace Trials Center, Greenwich Hospital, Greenwich, Connecticut; Department of Neurosurgery, Lahey Clinic, Burlington, Massachusetts. Electronic address:

Background: The effect of carotid endarterectomy on cognitive function is not fully understood. This study aims to characterize changes in cerebral blood flow after carotid endarterectomy and to determine if patients with improvement in cerebral blood flow have improved cognitive function after endarterectomy.

Methods: Cerebral blood flow was measured preoperatively and 1 month postoperatively using phase contrast magnetic resonance angiography. Preoperative flow impairment was defined as ipsilateral flow at least 20% less than contralateral flow. Improvement in flow was defined as an absolute increase of at least 0.10 in flow ratio from pre- to postoperative assessments. Patients underwent cognitive testing preoperatively and at 1, 6, and 12 months postoperatively.

Results: Twenty-four patients with unilateral carotid stenosis were enrolled from 3 sites. Preoperative internal carotid artery (ICA) and middle cerebral artery (MCA) flow impairment was observed in 50% and 22% of patients, respectively. Patients with preoperative flow impairment had an average of 0.25 and 0.16 absolute improvement in flow ratio in the ICA and MCA vessels, respectively; this was statistically significant for patients with baseline ICA flow impairment (P < .01). One hundred percent of patients with improvement in MCA flow had a significant improvement in attention compared to 56% of patients without MCA flow improvement (P = .06). Clinically significant improvements in all 4 cognitive domains were observed at 1 year (P < .01).

Conclusions: Patients with baseline impairment of MCA blood flow were more likely to experience improvement in flow after revascularization. Improvement in MCA blood flow was associated with greater cognitive improvement in attention and executive functioning.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2012.03.016DOI Listing
October 2013

Pediatric neuropsychology: toward subspecialty designation.

Clin Neuropsychol 2011 Aug;25(6):1075-86

Independent Practice, Potomac, MD 20854-2173, USA.

Clinical neuropsychology is a rapidly expanding field of study in the psychological sciences whose practitioners are expert in the assessment, treatment, and research of individuals with known or suspected central nervous system disease or disorder. Pediatric neuropsychology has emerged as a distinct subspecialty area with related education, training, and clinical expertise for a growing number of neuropsychologists. This paper details the numerous steps taken by two affiliated organizations, the American Board of Clinical Neuropsychology and its membership organization, the American Academy of Clinical Neuropsychology, in the interest of the larger pediatric neuropsychology community and in pediatric neuropsychology subspecialty development.
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http://dx.doi.org/10.1080/13854046.2011.594455DOI Listing
August 2011

Neuropsychological assessment: a valuable tool in the diagnosis and management of neurological, neurodevelopmental, medical, and psychiatric disorders.

Cogn Behav Neurol 2011 Sep;24(3):107-14

Wheaton Franciscan Healthcare, Racine, WI, USA.

For both children and adults with neurological, neurodevelopmental, medical, or psychiatric disorders, neuropsychological assessment can be a valuable tool in determining diagnosis, prognosis, and functional abilities as well as informing clinical management. This review summarizes the contributions of neuropsychological assessment to clinical care across diagnostic categories, with the goal of helping clinicians determine its utility for individual patients.
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http://dx.doi.org/10.1097/WNN.0b013e3182351289DOI Listing
September 2011

The contribution of neuropsychology to diagnostic assessment in epilepsy.

Epilepsy Behav 2010 May 14;18(1-2):3-12. Epub 2010 May 14.

Montreal Neurological Institute, McGill University, Montreal, QC, Canada.

Neuropsychology plays a vital role in the treatment of epilepsy, providing information on the effects of seizures on higher cortical functions through the measurement of behavioral abilities and disabilities. This is accomplished through the design, administration and interpretation of neuropsychological tests, including those used in functional neuroimaging or cortical mapping and in intracarotid anesthetic procedures. The objective of this paper is to define and summarize in some detail the role and methods of neuropsychologists in specialized epilepsy centers. Included are information and recommendations regarding basic ingredients of a thorough neuropsychological assessment in the epilepsy setting, as well as suggestions for an abbreviated alternative exam when needed, with emphasis on functions associated with specific brain regions. The paper is intended for novice and experienced neuropsychologists to enable them to develop or evaluate their current practices, and also for other clinicians, who seek a better understanding of the methodology underlying the neuropsychological input to their work.
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http://dx.doi.org/10.1016/j.yebeh.2010.02.019DOI Listing
May 2010

Visual memory in patients after anterior right temporal lobectomy and adult normative data for the Brown Location Test.

Epilepsy Behav 2010 Feb 6;17(2):215-20. Epub 2010 Jan 6.

Department of Neurosurgery, Yale University, School of Medicine, New Haven, CT, USA.

Several large meta-analytic studies have failed to support a consistent relationship between visual or "nonverbal" memory deficits and right mesial temporal lobe changes. The Brown Location Test (BLT), a recently developed dot location learning and memory test, uses a nonsymmetrical array and provides control over many of the confounding variables (e.g., verbal influence and drawing requirements) inherent in other measures of visual memory. In the present investigation, we evaluated the clinical utility of the BLT in patients who had undergone left or right anterior mesial temporal lobectomy. We also provide normative data of 298 healthy adults for standardized scores. Results revealed significantly worse performance on the BLT in the right as compared to the left lobectomy group and the healthy adult normative sample. The present findings support a role for the right anterior mesial temporal lobe in dot location learning and memory.
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http://dx.doi.org/10.1016/j.yebeh.2009.11.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825669PMC
February 2010

Language lateralization in epilepsy patients: fMRI validated with the Wada procedure.

Epilepsia 2009 Oct 1;50(10):2225-41. Epub 2009 Jun 1.

Department of Diagnostic Radiology, Yale University, New Haven, Connecticut 06520, USA.

Purpose: This work examines the efficacy of functional magnetic resonance imaging (fMRI) for language lateralization using a comprehensive three-task language-mapping approach. Two localization methods and four different metrics for quantifying activation within hemisphere are compared and validated with Wada testing. Sources of discordance between fMRI and Wada lateralization are discussed with respect to specific patient examples.

Methods: fMRI language mapping was performed in patients with epilepsy (N = 40) using reading sentence comprehension, auditory sentence comprehension, and a verbal fluency task. This was compared with the Wada procedure using both whole-brain and midline exclusion-based analyses. Different laterality scores were examined as a function of statistical threshold to investigate the sensitivity to threshold effects.

Results: For the lateralized patients categorized by Wada, fMRI laterality indices (LIs) were concordant with the Wada procedure results in 83.87% patients for the reading task, 83.33% patients for the auditory task, 76.92% patients for the verbal fluency task, and in 91.3% patients for the conjunction analysis. The patients categorized as bilateral via the Wada procedure showed some hemispheric dominance in fMRI, and discrepancies between the Wada test findings and the functional laterality scores arose for a range of reasons.

Discussion: Discordance was dependent upon whether whole-brain or midline exclusion method-based lateralization was calculated, and in the former case the inclusion of the occipital and other midline regions often negatively influenced the lateralization scores. Overall fMRI was in agreement with the Wada test in 91.3% of patients, suggesting its utility for clinical use with the proper consideration given to the confounds discussed in this work.
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http://dx.doi.org/10.1111/j.1528-1167.2009.02136.xDOI Listing
October 2009

State of multicultural neuropsychological assessment in children: current research issues.

Neuropsychol Rev 2008 Sep 25;18(3):214-22. Epub 2008 Sep 25.

Department of Pathology, The Mount Sinai School of Medicine, New York, NY 10029, USA.

Scientific attention to cultural considerations in child neuropsychological assessment has not developed parallel to the focus these issues have received in adult and elderly neuropsychological assessment. There are limited data on the presence, magnitude, etiology, and implications of culture-related differences in cognitive test performance among children. This preliminary report reviews the available empirical literature on the current state of multicultural neuropsychological assessment in children. The review identified articles by searching PubMed and PsycINFO databases, and the tables of contents of Developmental Neuropsychology and Child Neuropsychology from 2003-2008. Of the 1,834 abstracts reviewed, ten papers met inclusion criteria for the review. Five studies were completed in America; four of these compared performance between ethnic groups while the fifth examined neighborhood level poverty indicators exclusively within African-American children. Of the five international studies, all established local normative data and/or were exploratory investigations of neuropsychological functions in specific cultural groups, including Taiwanese infants, South African youth, and bilingual British children. Taken together, the results yield important clinical and research data that begin to inform many of the complex and fascinating mechanisms by which ethnic identity and culture impact cognitive development and the neuropsychological assessment of children. A critique of the existing literature and directions for future research are provided.
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http://dx.doi.org/10.1007/s11065-008-9065-yDOI Listing
September 2008

Residual cognitive effects of uncomplicated idiopathic and cryptogenic epilepsy.

Epilepsy Behav 2008 Nov 19;13(4):614-9. Epub 2008 Aug 19.

Department of Biology, Northern Illinois University, DeKalb, IL 60115, USA.

We assessed residual cognitive deficits in young people with idiopathic and cryptogenic epilepsy. In the setting of an ongoing prospective study, we invited participants initially diagnosed and enrolled in the cohort 8-9 years earlier to undergo standardized neuropsychological assessment. Sibling controls were invited when available. We analyzed 143 pairs in which cases had idiopathic or cryptogenic epilepsy and both case and control had normal intelligence. Compared with that for siblings, the Full Scale IQ for cases was 3.3 points lower (P=0.01) mainly due to slower processing speed, which was 5.6 points lower (P=0.0004). Word reading (P=0.04) and spelling (P=0.01), but not other scores, were also lower in cases. Remission status and drug use did not influence findings. In young people of normal intelligence with idiopathic or cryptogenic childhood-onset epilepsy, substantial residual effects of epilepsy appear to be confined largely to slower processing speed.
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http://dx.doi.org/10.1016/j.yebeh.2008.07.007DOI Listing
November 2008

Differential neuropsychological test sensitivity to left temporal lobe epilepsy.

J Int Neuropsychol Soc 2008 May;14(3):394-400

Department of Neurology, University of Florida, Gainesville, Florida 32610, USA.

We examined the sensitivity of the Rey Auditory Verbal Learning Test (AVLT), California Verbal Learning Test (CVLT), Boston Naming Test (BNT), and Multilingual Aphasia Examination Visual Naming subtest (MAE VN) to lateralized temporal lobe epilepsy (TLE) in patients who subsequently underwent anterior temporal lobectomy. For the AVLT (n = 189), left TLE patients performed more poorly than their right TLE counterparts [left TLE = 42.9 (10.6), right TLE = 47.7 (9.9); p < .002 (Cohen's d = .47)]. Although statistically significant, the CVLT group difference (n = 212) was of a smaller magnitude [left LTE = 40.7 (11.1), right TLE = 43.8 (9.9); (p < .03, Cohen's d = .29)] than the AVLT. Group differences were also present for both measures of confrontation naming ability [BNT: left LTE = 43.1 (8.9), right TLE = 48.1 (8.9); p < .001 (Cohen's d = .56); MAE VN: left TLE = 42.2, right TLE = 45.6, p = .02 (Cohen's d = .36)]. When these data were modeled in independent logistic regression analyses, the AVLT and BNT both significantly predicted side of seizure focus, although the positive likelihood ratios were modest. In the subset of 108 patients receiving both BNT and AVLT, the AVLT was the only significant predictor of seizure laterality, suggesting individual patient variability regarding whether naming or memory testing may be more sensitive to lateralized TLE.
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http://dx.doi.org/10.1017/S1355617708080582DOI Listing
May 2008

Cognitive outcomes after carotid revascularization: the role of cerebral emboli and hypoperfusion.

Neurosurgery 2008 Feb;62(2):385-95; discussion 393-5

Wallace Clinical Trials Center, Greenwich Hospital, Greenwich, Connecticut 06830, USA.

Objective: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are currently being compared in ongoing randomized, controlled trials using postprocedural 30-day stroke rate, myocardial infarction, and mortality as primary endpoints. Recent data suggest that cognitive function may decline after CEA. Understanding the mechanisms that affect cognitive outcomes after carotid revascularization will be important in the design of future comparative studies of CAS and CEA incorporating cognitive outcome as an endpoint.

Summary Of Review: The effects of carotid revascularization procedures on cognitive outcome are unclear. Several factors contribute to the difficulty in interpreting cognitive data, including patient heterogeneity, variability of surgical techniques, and the differences in neuropsychological testing methodology. Mechanisms underlying cognitive effects during CEA have emerged, including the potential detrimental effect of procedural emboli and the beneficial effect of improved cerebral hemodynamics. The emergence of CAS as an alternative to CEA for treating carotid stenosis again raises questions about cognitive outcomes. Despite the use of distal protection devices, CAS is associated with a higher burden of microemboli. CAS does not, however, require the extent of temporary vessel occlusion associated with CEA. Quantifying microemboli and changes in cerebral hemodynamics along with standardization of neuropsychological testing may lead to meaningful comparisons of cognitive data for patients undergoing carotid revascularization procedures.

Conclusion: As use of CAS increases, it is important for randomized, controlled trials comparing CAS with CEA to include cognitive outcomes assessments. Furthermore, understanding the key mechanisms resulting in cognitive impairment during carotid revascularization procedures might limit injury.
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http://dx.doi.org/10.1227/01.neu.0000316005.88517.60DOI Listing
February 2008

Global cognitive function in children with epilepsy: a community-based study.

Epilepsia 2008 Apr 6;49(4):608-14. Epub 2007 Dec 6.

Department of Biology, Northern Illinois University, DeKalb, Illinois 60115, USA.

Purpose: To determine the frequency and determinants of subnormal global cognitive function in a representative, community-based sample of children prospectively identified at the time of initial diagnosis of epilepsy.

Methods: In children enrolled with newly diagnosed epilepsy and followed a median of 10.5 years, level of cognitive function (within normal, borderline, mild, moderate to severe mental retardation (MR), neurologically devastated, and impaired but not further classified (NFC)) was determined based upon neurologists' and school records, repeated parental interviews, and, in over half the participants, standardized neuropsychological testing. For multivariable analyses, subnormal cognitive function was designated as consistent with a full scale IQ < 80.

Results: Global cognitive function was considered within normal, N = 451 (73.6%), borderline, N = 31 (5.1%), mild MR, N = 21 (3.4%), more severe MR, N = 45 (7.3%), devastated, N = 29 (4.7%), and impaired-NFC, N = 36 (5.9%). Age at onset <5 years, symptomatic etiology, epileptic encephalopathy, remission status and current AED treatment were each strongly associated with level of cognitive function (all p-values <0.0001). In a multivariable logistic regression model, all variables except remission status independently contributed to subnormal global cognitive function.

Discussion: Evidence of subnormal global cognitive function is apparent in approximately one of four children with epilepsy. Young age at onset, symptomatic cause, epileptic encephalopathy, and continued treatment, despite their strong intercorrelations, are independently associated with this outcome.
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http://dx.doi.org/10.1111/j.1528-1167.2007.01461.xDOI Listing
April 2008

Cognitive/behavioral teratogenetic effects of antiepileptic drugs.

Epilepsy Behav 2007 Nov;11(3):292-302

Department of Neurology, University of Florida, Gainesville, FL, USA.

The majority of children of mothers with epilepsy are normal, but they are at increased risk for developmental delay. Antiepileptic drugs (AEDs) appear to play a role. Our current knowledge is reviewed, including research design issues and recommendations for future research. In animals, exposure of the immature brain to some AEDs can produce widespread neuronal apoptosis and behavioral deficits. The risks of AEDs in humans are less clear, but recent studies raise concerns, especially for valproate. There is a critical need for well-designed systematic research to improve our understanding of AED effects on the fetal brain.
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http://dx.doi.org/10.1016/j.yebeh.2007.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2713059PMC
November 2007

Impact of smoking abstinence on working memory neurocircuitry in adolescent daily tobacco smokers.

Psychopharmacology (Berl) 2007 Sep 16;193(4):557-66. Epub 2007 May 16.

Department of Psychiatry, Yale University School of Medicine, 2 Church Street South, Suite 207, New Haven, CT 06519, USA.

Rationale: Efficient function of neurocircuitry that supports working memory occurs within a narrow range of dopamine neurotransmission. Work in rodents has shown that exposure to nicotine during adolescence leads to nicotine withdrawal emergent alterations in cortical and subcortical dopamine neurotransmission.

Objectives: To test for evidence that the efficiency of neurocircuitry supporting working memory is altered during acute smoking abstinence in adolescent daily tobacco smokers.

Materials And Methods: Fifty-five adolescent daily tobacco smokers were compared with 38 nonsmokers using functional magnetic resonance imaging while subjects performed a verbal working memory task. Smokers were studied during smoking and after 24 h of abstinence from tobacco use.

Results: Performance of a task with high working memory load in the context of smoking abstinence was associated with greater activation of components of the verbal working memory neurocircuit, including left ventrolateral prefrontal cortex and left inferior parietal lobe, among smokers relative to nonsmokers. During smoking abstinence, smokers failed to exhibit increases in functional connectivity between components of the working memory neurocircuit with increasing working memory load observed in nonsmoking adolescents and in prior studies of adults.

Conclusions: Smoking abstinence in adolescent smokers is associated with reductions in the efficiency of working memory neurocircuitry and alterations in the functional coordination between components of the working memory neurocircuit. These alterations may stem from effects of nicotine exposure on catecholaminergic systems during adolescent development.
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http://dx.doi.org/10.1007/s00213-007-0797-9DOI Listing
September 2007

The Verbal IQ/Performance IQ discrepancy as a sign of seizure focus laterality in pediatric patients with epilepsy.

Epilepsy Behav 2007 Feb 13;10(1):84-8. Epub 2006 Nov 13.

St. Louis Children's Hospital, St. Louis, MO, USA.

A large Verbal IQ (VIQ)/Performance IQ (PIQ) discrepancy has been viewed as a sign of lateralized brain dysfunction. The current study was conducted to determine if the presence of a large VIQ/PIQ discrepancy (15 points) would accurately predict laterality of seizure foci in pediatric patients with epilepsy. A discrepancy score (VIQ-PIQ) was calculated for 130 children (mean age=12.25) undergoing presurgical epilepsy evaluations. Patients were grouped on the basis of language mediation confirmed through the intracarotid amobarbital procedure. Large discrepancies were noted in 34% of the group with typical language and 24% of the children with atypical language organization. When present, this discrepancy accurately lateralized seizure focus for 79% of those with typical and 57% of those with atypical language organization. The presence of the discrepancy was unrelated to seizure control following surgery for the atypical language group. In the typical language group, 85% of children with discrepancies, but only 63% of children without discrepancies, achieved seizure control. Results suggest that the presence of a large discrepancy is not effective, by itself, in lateralizing seizure foci, but may contribute to refining predictions of surgical outcome.
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http://dx.doi.org/10.1016/j.yebeh.2006.10.001DOI Listing
February 2007

Functional correlates of verbal memory deficits emerging during nicotine withdrawal in abstinent adolescent cannabis users.

Biol Psychiatry 2007 Jan 21;61(1):31-40. Epub 2006 Apr 21.

Department of Psychiatry, Yale University School of Medicine, Connecticut 06519, USA.

Background: Cannabis remains the most widely used illicit substance by adolescents and is typically consumed by this population in the context of ongoing tobacco use. Human studies have shown that both cannabis and tobacco exert effects on cognitive function; however, little is known about possible interacting effects of these drugs on brain function and cognition during adolescent development.

Methods: Verbal learning and memory were assessed in 20 adolescent users of tobacco and cannabis and 25 adolescent tobacco users with minimal history of cannabis use. Functional magnetic resonance imaging was used to examine brain function and functional connectivity while a subset of these subjects performed a verbal working memory task.

Results: Delayed recall of verbal stimuli deteriorated during nicotine withdrawal among cannabis users but not among comparison subjects. During high verbal working memory load, nicotine withdrawal selectively increased task-related activation of posterior cortical regions and was associated with disruption of frontoparietal connectivity in adolescent cannabis users relative to comparison subjects.

Conclusions: These observations suggest that cannabis use during adolescent development may disrupt neurocircuitry supporting verbal memory formation and that deficits associated with disruption of these neurocircuits are unmasked during nicotine withdrawal.
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http://dx.doi.org/10.1016/j.biopsych.2006.02.014DOI Listing
January 2007