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Dynamic Preictal Discharges in Patients With Mesial Temporal Lobe Epilepsy

Chen, Jia*; Li, Liping*; Wu, Dongyan; Li, Xiaoxuan; Xue, Qing*; Wang, Liying; Du, Jialin*; Wang, Di*; Hu, Minjing*; Ren, Liankun*; Wang, Yuping*

Journal of Clinical Neurophysiology: September 2018 - Volume 35 - Issue 5 - p 381–387
doi: 10.1097/WNP.0000000000000486
Original Research

Purpose: It has been challenging to detect early changes preceding seizure onset in patients with epilepsy. This study investigated the preictal discharges (PIDs) by intracranial electroencephalogram of 11 seizures from 7 patients with mesial temporal lobe epilepsy.

Methods: The EEG segments consisting of 30 seconds before ictal onset and 5 seconds after ictal onset were selected for analysis. After PID detection, the amplitude and interval were measured. According to the timing of PID onset, the 30-second period preceding seizure onset was divided into two stages: before PID stage and PID stage. The autocorrelation coefficients during the two stages were calculated and compared.

Results: Preictal discharge amplitude progressively increased, while PID interval gradually decreased toward seizure onset. The autocorrelation coefficients of PID channels were significantly higher during PID stage than before PID stage. There was an overlap between channels with PIDs and seizure onset channels (80.77%).

Conclusions: Preictal discharges emerge prior to ictal event, with a dynamic change and a spatial correlation with seizure onset zone. These findings deepen our understanding of seizure generation and help early prediction and localization of seizure onset zone.

*Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, Beijing, China;

Department of Neurology, China-Japan Friendship Hospital, Beijing, China; and

Department of Neurology, Jiaozhou Central Hospital of Qingdao, Shandong, China.

Address correspondence and reprint requests to Liankun Ren, MD, Department of Neurology, Beijing Key Laboratory of Neuromodulation, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China; e-mail:

The authors have no funding or conflicts of interest to disclose.

J. Chen and L. Li contributed equally to this work.

Ethical Publication Statement: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

An epileptic seizure is a transient and intrinsic dynamic phenomenon. Despite considerable studies on the ictogenesis, our knowledge on the initiation of seizures is still limited. Epileptic seizures are assumed to be an abrupt onset resulting from hypersynchrony of the populations of neurons. The existence of preictal period, however, has been supported by previous observations, including the increase in cerebral blood flow,1,2 the alterations in heart rate,3,4 and the changes in blood oxygen level prior to seizure onset.5 In particular, the firing of neurons and multiunit activities preceding seizures indicate that preictal EEG changes are detectable.6–8 Various biomarkers have been proposed to identify preictal stage. For example, abnormally intensified gamma rhythms,2,9,10 high-frequency oscillations,11 and the power imbalance between spike-related high-frequency oscillations and postspike slow waves12–14 correlated with the transition to seizures.

Recently, preictal discharges (PIDs) were described to be characterized by higher amplitude and faster propagation speed than interictal discharges (IIDs) and prior to ictal events,15–18 suggesting an imbalance of the interaction between excitement and inhibition. In this study, we aimed to provide new insights into seizure prediction by investigating the dynamics of PIDs with intracranial EEG (iEEG) recordings in drug-resistant epileptic patients who underwent the presurgical evaluation.

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Patient Selection

This study was approved by the institutional review board. Total 334 patients with focal drug-resistant epilepsy who were implanted with intracranial electrodes for presurgical evaluation were recruited at the Epilepsy Surgery Center in Xuanwu Hospital between December 2012 and January 2015. Before invasive EEG recording, all patients underwent noninvasive evaluations including clinical history, neurological examination, neuroimaging, and long-term scalp EEG recording. Electrode grids and strips were implanted subdurally, and the sites of electrode placement were individually determined according to noninvasive data in each patient. The diameter of the subdural electrode was 2 mm, and the center-to-center electrode distance was 10 mm. The EEG signals were sampled at 200 Hz or 1,000 Hz, low-pass filtered at 70 Hz or 300 Hz, and recorded using NIHON KOHDEN EEG-1200C (NIHON KOHDEN Inc., Tokyo, Japan). Among them, 112 patients (33.5%) were diagnosed as having mesial temporal lobe epilepsy (MTLE). The decision to proceed with iEEG recording before surgical resection was made in 21 patients (18.8%). The surgical resection was performed after removal of intracranial electrodes. Postoperatively, 12 of these 21 patients (57.1%) attained seizure free (International League Against Epilepsy class I) in the first year according to the International League Against Epilepsy classification.19 The iEEG recordings of these 12 patients were reviewed by two electroencephalographers (EEGs) to identify the ictal onset and PIDs. Only if the two observers got an agreement, the activities would be identified as PIDs. There were 30 seizures recorded for the 12 patients, however, PIDs were noted in 11 seizures (36.7%) from 7 patients.

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Segmentation of PIDs

Preictal discharges were observed preceding 11 seizure events in iEEG recordings of 7 patients (Table 1). Ictal onset was defined as the presence of typical iEEG changes prior to clinical seizure, including low-voltage fast activities, the flattening of background activity, or a slow potential or sustained, rhythmic bursts.20–22 The time and zone of seizure onset were identified with traditional visual inspection by experienced neurophysiologists. The PIDs occurred 6 to 25 seconds before seizure onset in our series. To include all the PIDs, the EEG segment comprising 30 seconds before ictal onset and 5 seconds after ictal onset was extracted from unfiltered iEEG of all implanted electrodes.



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Data Analysis

All the EEG data were processed with EEGLAB and custom MATLAB (Mathworks, Natick, MA) code. Selected EEG segments of PIDs were band-pass filtered (Butterworth filter) from 1 to 70 Hz. Then, PIDs were detected automatically and the amplitude and timing of each detected PID were measured. The time from the first discharge to the last discharge of PIDs was defined as PID duration, and the interval between two adjacent discharges was calculated. To evaluate the variation tendency of the amplitude and interval of PIDs, linear fitting was performed. For the patients who have more than one seizure with PIDs, linear fitting coefficients of different seizures were averaged.

Furthermore, we computed the normalized autocorrelation coefficients (ACCs) of each channel for selected EEG segments with a sliding window (window, 1 second; overlap, 0.25 seconds; lag, 0.1 seconds). All the channels were classified as PID channels or non-PID channels based on whether PIDs emerged. The 30-second period preceding seizure onset was divided into two stages: before PID stage and PID stage, according to the timing of PID onset. The ACCs of PID channels and non-PID channels during the two stages were individually averaged for each patient.

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All the numerical results are reported as mean ± SD unless specified. Analysis of samples was performed with either Student t-test (if normal distribution condition was satisfied) or Wilcoxon rank-sum test. A two-sided P value of <0.05 was considered statistically significant. Exact P values are given unless P < 0.001. All statistical tests were conducted with SPSS 17.0 (IBM Corp, Armonk, NY).

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Dynamics of PIDs

The duration, number, and rate of PIDs were measured for each patient. For the patients who had more than one seizure with PIDs, these measurements were defined as the average value of multiple seizure events. The mean number of PIDs per patient was 11.90 ± 4.01 (95% confidence interval, 8.20–15.61), and the mean PID duration per patient was 15.39 ± 6.00 seconds (95% confidence interval, 9.84–20.93). The PID rate ranged from 0.60 to 1.40 per second, with the mean of 0.84 ± 0.29 per second (95% confidence interval, 0.57–1.11; Fig. 1G).

FIG. 1

FIG. 1

Next, we measured the amplitudes and intervals of PIDs. As illustrated in the representative patient, the amplitude increased while the interval decreased gradually (Figs. 1C and 1D). The linear fitting regression confirmed the observed changes of amplitude and interval in the representative patient (Figs. 1E and 1F). The similar increasing tendency of PID amplitude over time was shown in most patients (n = 6), and PID interval represented a decreasing trend in all the patients (n = 7; Figs. 1H and 1I).

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Autocorrelation Analysis During the Transition to Ictal Activity

Next, we performed a continuous analysis of autocorrelation with a sliding window as mentioned above. As shown in a representative patient, the ACCs in PID channels increased immediately upon PID onset, whereas the ACCs in non-PID channels remained unchanged (Fig. 2E). The distinction between two groups of channels persisted even after ictal initiation.

FIG. 2

FIG. 2

The mean ACCs of PID channels were higher during PID stage than that before PID stage in all the seven patients individually (Fig. 2F). For non-PID channels, the mean ACC showed no obvious change between before PID stage and PID stage. In addition, the average of mean ACCs of PID channels in seven patients was significantly higher during PID stage than that before PID stage (p = 0.04), whereas there was no significant change between the mean ACCs of non-PID channels during the two stages (p = 0.98).

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Spatial Distribution of PID Region and Seizure Onset Zone

Finally, we examined whether the region with PIDs matched seizure onset zone (SOZ). The PID channels and channels within SOZ were taken as a whole, and the channels with both PIDs and seizure onset discharges accounted for 80.77% (Fig. 3). The rest 19.23% were divided into two groups: channels in SOZ without PIDs (11.54%) and PID channels beyond SOZ (7.69%).

FIG. 3

FIG. 3

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The unpredictability of seizure occurrence causes the enhanced risk of injury and sudden death in epilepsy patients. Increasing evidence suggests the existence of a preictal state, which can be detected by different measures.2,23,24 Identifying definite preictal EEG changes is important to provide new opportunities for predicting impending seizures and improving the life quality of patients.

In this study, we recorded the occurrence of PIDs prior to seizure onset in MTLE patients with iEEG recordings, which were observed previously by Huberfeld et al.16 Then, we analyzed the dynamic changes of PIDs toward seizure initiation: (1) the PID amplitude progressively increased, whereas the interval gradually decreased approaching ictal onset, (2) the ACC in PID channels increased simultaneously with PID occurrence, while the ACC in non-PID channels remained unchanged, and (3) the region where PIDs generated from had a big overlap with SOZ. Our data demonstrate that PIDs are premonitory electrophysiological activities of seizure onset with the characteristic changing pattern, revealing the dynamic tempospatial processes that lead to seizures.

Several studies reported that during the preictal period, there were markedly increased glutamatergic excitatory post synaptic potentials, accompanied by the decrease of inhibitory GABAergic inhibitory post synaptic potentials.16,18,25 However, other studies found the excitation of GABAergic inputs preceding ictal initiation, indicating that inhibitory networks contribute to the interictal–ictal transition.6,7,26 Recently, a study on epileptic rats revealed that different hippocampal subregions exhibited different preictal changes.8 These inconsistent findings may be due to the differences in experimental conditions, seizure onset region, and methods.

Previous studies have shown that PIDs are fundamentally different from IIDs. Both glutamatergic and GABAergic networks are involved in IIDs,27–34 and interneurons firing induces IIDs.16,35 Interictal discharges frequency does not increase before the onset of an ictal event in human epileptic patients and in models of focal epilepsy36–38; thus, it is proposed that the after inhibition produced by IIDs protects against the emergence of ictal discharges.39 In contrast, PIDs occur just before ictal events and have different pharmacologic responsiveness from IIDs.16 Preictal discharges seem to depend on principal cells firing rather than interneurons firing and are mediated by glutamatergic activity, which is suggestive of excitatory networks activation.16,40

Based on the classical theory that spike is considered as the excitatory component and the slow wave is considered as the inhibitory component,41 the changes of PID amplitude and interval observed in our study provide support for a prominent role of excitatory effect during the transition to ictal activity. The shape of the autocorrelation function is determined by the frequency composition and the degree of predictability in the signal.42 High ACC reveals a high degree of interdependence between adjacent signals, representing high predictability.43,44 The elevated ACC on PID channels during PID stage indicates that the preictal activities are self-dependent, and PIDs tend to cluster together. Therefore, we hypothesize that during the preictal period, the excitatory effect gradually prevails over inhibitory effect, suggestive of an extension of epileptogenicity until seizure onset.

A series of studies have confirmed that cortical region that generates IIDs (irritative area) is not coincident and is usually larger than SOZ.17,21,39 Compared with IIDs, PIDs have more restricted spatial distribution, and the spatial distribution in situ is in line with SOZ.16 Our data suggest that the region of PIDs largely overlaps with SOZ, which may aid in the localization of SOZ in the presurgical evaluation. However, why PIDs and ictal discharges activate the same region of neurons remains to be unclear. An alternative hypothesis proposed that PIDs are an integral part of ictal event considering their consistent and reproducible emergence at the seizure onset.17 Preictal discharges may actually be the earliest electrographic change of seizure onset, and thus, the sites with the emergence of PIDs should be classified as SOZ. Future investigations on whether PIDs have the same cellular and network mechanism with ictal discharges could help determine these discharges as preictal or ictal.

All seven of the individuals in our study are patients with MTLE and PIDs emerged from the unilateral mesial temporal formation, consistent with previous studies.16,45 A study on the onset of limbic seizures in patients with MTLE reported that PIDs-like events always emerged in seizures derived from the hippocampus but barely in seizures with entorhinal cortex onset.46 Further studies are needed to determine the causal significance of PIDs in seizures originating from different regions.

As stated above, distinct PIDs could be used as a potential biomarker predicting seizure onset. Although the number of patients in this study is limited, the dynamic changes during PID period have been manifested. These characters could help detect preictal period and provide insights into how seizures generate. Given the correlation of spatial distribution between PIDs and ictal onset discharges, identifying PIDs may improve the localization of SOZ. Nevertheless, further large-scale studies are necessary to confirm our conclusions.

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In summary, our study characterized the PIDs based on iEEG recordings from patients with MTLE and demonstrated the dynamic electrophysiological process of PIDs toward seizure onset. Preictal discharges emerge preceding the ictal event, with a progressive increase in the amplitude and decrease in the interval. The autocorrelation coefficients of PID channels are significantly higher during PID stage than those before PID stage. The PID onset region has a correlation with SOZ. These findings deepen our understanding of seizure onset and provide help for seizure prediction and the localization of epileptogenic zone.

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This work was supported by National Natural Science Foundation of China (No. 81271447 and 81571271) and Brain Science & Brain Program of Beijing Municipal Commission of Science and Technology (Z161100002616001).

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Seizure prediction; Seizure onset zone; Intracranial EEG; Autocorrelation coefficient; Preictal period

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