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Original article
Focal cortical dysplasia. Clinical-radiological-pathological associations
Displasia cortical focal. Correlaciones clínico-radiológicas-patológicas
I. Pascual-Castroviejoa,
Corresponding author
, J.L. Hernández-Moneob, M.L. Gutiérrez-Molinac, J. Viañod, S.I. Pascual-Pascuala, R. Velazquez-Fraguaa, C. Moralesc, D. Quiñonesd
a Servicio de Neurología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Neurocirugía, Hospital Comarcal de la Mancha, Toledo, Spain
c Sección de Neuropatología, Hospital Universitario La Paz, Madrid, Spain
d Unidad de Imagen, Hospital del Rosario, Madrid, Spain
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anatomical and histological study of the surgical sample from the same patient shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46; &#40;A&#41; External appearance of the surgical sample shows severely deformed folds and sulci&#46; &#40;B&#41; Lateral slice of the surgical sample shows irregular cortical thickness with highly myelinated white matter&#46; &#40;C&#41; Histological preparation in which we observe isolated or grouped balloon cells in the cerebral cortex&#46; Masson&#39;s trichrome stain 200&#215;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term &#8216;focal cortical dysplasia&#8217; primarily refers to histological abnormalities found in the cortex of surgical specimens removed from the brains of subjects with drug-resistant epilepsy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> The histological description of such lesions is a collection of large&#44; strangely formed neurons with grotesque cells in some cases&#46; These collections are located in deep areas of the cortex and the underlying white matter&#46; Severity of FCD is related to its location&#44; its gross morphology&#44; and its histological characteristics&#46; The mildest form of FCD is known as microdysgenesis&#44; and some cases cannot be detected by neuroradiological imaging&#46; The lesions are most commonly found in autopsies of epilepsy patients&#46; They can now be found in epileptogenic zones in surgical specimens as well&#44; thanks to the highly sensitive diagnostic imaging techniques that are currently available&#46; The extension of FCD lesions varies&#59; some may be found only in part of a fold&#44; while others may affect an entire lobe&#46; When they are found throughout an entire hemisphere or in parts of both hemispheres&#44; the condition is called massive CD &#40;MCD&#41;&#46; Over the last few years&#44; the terms &#8216;focal cortical dysplasia&#8217;&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> &#8216;cortical dysgenesis&#8217;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the generic term &#8216;neuronal migration disorders&#8217;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> have become widely used&#46; Some authors believe that the term FCD is the best one to designate the histopathological changes occurring in this disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Scientific literature search engines such as PubMed often include tubers&#44; typical lesions of the cerebral or even cerebellar hemispheres that are concomitant with tuberous sclerosis complex &#40;TSC&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> among forms of cortical&#47;subcortical dysplasia&#46; Although these syndromes can be differentiated clinically due to the conditions of the skin and other organs exhibited by TSC patients&#44; MR imaging studies and histological characteristics for both FCD and TSC may be very similar in many cases&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main clinical symptoms caused by FCD are epilepsy&#44; focal neurological deficits&#44; intellectual disabilities&#44; delayed development of cognitive facets&#44; or deterioration of those facets&#46; For most focal-type cases&#44; seizures may begin at any age&#44; including during gestation&#44; and continue throughout the subject&#39;s life&#44; although they are more common in childhood&#46; Seizures may be partial simple&#44; partial complex&#44; or generalised&#44; depending on the FCD location and the patient&#39;s age&#46; FCD is gaining increasing recognition as a cause of epilepsy&#46; The lesion concomitant with FCD is rarely visible by computed tomography&#44; at least when using older equipment&#46; However&#44; high-resolution magnetic resonance and some of its specific sequences<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;20</span></a> often show cortical and subcortical lesions&#46; Lesions are very frequently associated with hypoplasia of the hemisphere in which they are located&#44; especially when they reach a certain size&#46; Early diagnosis of these cortical malformations results in the decision to remove them surgically as soon as possible in order to prevent the short-term and long-term consequences associated with suffering a lengthy series of seizures&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years&#44; diagnostic imaging techniques have been perfected&#44; and doctors are now able to identify dysgenic cortical or dysplastic epileptogenic tissue during surgical procedures&#46; As a result&#44; they can remove it more precisely and achieve better seizure control without increasing the size of the surgical lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The introduction of surgical treatment programmes&#44; especially those for FCD patients&#44; coincided with the policy of systematically performing 1&#46;5<span class="elsevierStyleHsp" style=""></span>T and 3<span class="elsevierStyleHsp" style=""></span>T MRI studies on patients with focal epileptic seizures&#46; Since that time&#44; we have studied 7 patients with FCD and drug-resistant epilepsy at the Paediatric Neurology Department at Hospital Universitario La Paz in Madrid&#46; Since about 1990&#44; more than 150 cases of neuronal migration and cortical organisation disorders have been identified&#46; The diseases causing these disorders were categorised mainly according to the characteristics displayed in the imaging studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7&#44;9&#44;10&#44;13&#44;15&#8211;17</span></a> Here&#44; we attempt to identify different entities using MRI studies with all of the sequences available to us&#44; including T1&#44; T2&#44; contrast enhancement&#44; inversion recovery &#40;FLAIR&#41;&#44; proton density&#44; 3D MRI&#44; diffusion-weighted MRI &#40;especially axial&#41;&#44; cortical surface reconstruction&#44; and at times&#44; MRI spectroscopy &#40;this last technique was only used when it was necessary to obtain data that could distinguish between a malformation and a tumour&#41;&#46; Functional imaging studies &#40;mainly SPECT and PET&#41; were also completed in some cases&#46; Patients were selected based on presence of focal seizures that were resistant to specific antiepileptic drugs &#40;administered in monotherapy&#44; bitherapy&#44; or even tritherapy in 1 case&#44; during sufficiently long periods and at high enough doses to be able to determine whether or not the treatment provided effective seizure control&#41;&#59; presence of focal epileptogenic activity whose location remained unchanged according to several EEG studies taken while doctors were attempting to control epileptic seizures&#59; and presence of cortical dysplasia revealed by different neuroimaging studies&#46; Regarding age&#44; 6 of the 7 patients are children&#44; and the seventh is a young adult who began suffering epileptic seizures in childhood&#46; No cases of TSC were included&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study focuses exclusively on 7 patients&#44; comprising 6 children &#40;2 males and 4 females&#41; aged between 6 months and 9 years &#40;mean age&#44; 34&#46;3 months&#41; and an adult aged 25 years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Imaging studies revealed FCD in all cases&#46; Onset of seizures occurred during the first year of life in 5 paediatric patients&#44; at the age of 5 years in the other child&#44; and at the age of 9 years in the adult&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical sign common to all cases was focal crises with different clinical expressions&#44; the most common of which was myoclonic movement in a specific region of the body &#40;lips&#44; an upper or lower limb&#44; etc&#46;&#41;&#46; In some cases&#44; movements lasted only briefly&#59; however&#44; on rare occasions&#44; they propagated to the entire side of the body without becoming generalised&#44; lasting only a few seconds without the patient&#39;s losing consciousness and resolving without antiepileptic drugs&#46; This occurred in our single adult patient &#40;case 2&#41;&#46; On other occasions&#44; they evolved to become infantile spasms brought on by focal seizures&#46; This occurred in case 6 in which simply administering an antiepileptic drug &#40;Keppra&#41; resolved the infantile spasms&#44; corrected the hypsarrhythmia in the EEG&#44; and controlled focal seizures&#46; Eight years after treatment&#44; seizures had not returned&#59; a focus in the dysplastic area was still apparent&#44; but the patient&#39;s neurological course was normal&#46; Case 7 presented frontal focal dysplasia with a superjacent arachnoid cyst and focal seizures that were controlled at one point with antiepileptic drugs&#44; but which became intractable in later years&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Seizures were more likely to appear during sleep in 2 patients&#44; during waking hours in 3&#44; and during either sleeping or waking hours in 2&#46; Well-delimited and operable FCD was found in cases 3&#44; 4&#44; and 5&#44; and the areas were extirpated completely&#46; In cases 3 and 4&#44; patients&#8217; partial seizures with secondary generalisation disappeared completely&#44; and these patients continued taking their previous antiepileptic medication during 2 years&#46; At the end of those 2 years&#44; doctors began to reduce medication&#44; suspending it completely 3 years after the surgery&#46; These patients have experienced no new seizures in the more than 10 years elapsed since that time&#46; In case 5&#44; seizure control was achieved by resecting the FCD&#59; the patient remained seizure-free until he was lost to follow-up 3 years after his surgery&#46; In case 1&#44; displaying a medium-sized but very active FCD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and a poor response to all types of antiepileptic drugs and numerous drug combinations&#44; the family refused surgical treatment&#46; When he was lost to follow-up at the age of 6&#44; the child presented moderate psychomotor delays&#44; restless personality&#44; and uncontrolled seizures&#46; Case 2&#44; a 25-year-old male with a university degree&#44; experienced 1 or 2 short rolandic seizures daily during sleep which did not cause either loss of consciousness or waking&#46; Complete control could not be achieved using any of the drug combinations employed&#46; He presented a small FCD in the rolandic area &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and has been scheduled for surgical treatment&#46; Case 6 also has a small frontal FCD and his seizures have been controlled with antiepileptic drugs for the last 8 years&#46; The patient is neurologically normal and his EEG shows foci&#46; The MRI study shows well-delimited images of the FCD with good uptake of the paramagnetic contrast agents that show the size of the dysplasia precisely &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">There was a high degree of correlation between neuroradiological images of the FCD and the anatomical appearance of the surgical specimen &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>&#41;&#46; The MRI showed local cortical and subcortical signal changes which were generally small or medium-sized&#44; with poor delimitation of cortical grey matter and subcortical white matter&#46; Excised tissue specimens from the 3 cases treated surgically had the following dimensions&#58; 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;8<span class="elsevierStyleHsp" style=""></span>cm&#44; weighing 20<span class="elsevierStyleHsp" style=""></span>g &#40;case 3&#41;&#59; 5&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>cm&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#44; weighing 33<span class="elsevierStyleHsp" style=""></span>g&#59; &#40;case 4&#41; and 6<span class="elsevierStyleHsp" style=""></span>nm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>nm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>nm &#40;case 5&#41;&#46; Examination of some of these tissue samples reveals that at least 1 of the folds is larger and has a firmer consistency than the others&#46; Multi-slice imaging of this larger fold shows an indistinct cortex&#47;white matter junction caused by thickening of the cerebral cortex&#44; which could be as much as 1<span class="elsevierStyleHsp" style=""></span>cm thick&#46; The demarcation between the cortex and the white matter is only blurred at certain points&#46; The histological descriptions of the surgical specimens from each of the 3 patients are quite similar and a summary appears below&#46; Their most remarkable feature is the presence of large atypical neurons grouped together in multiple foci and which disrupt the pattern of the normal laminar structure of the cortex&#46; These neurons display morphological variations in their cytoplasm and frequently show signs of chromatolysis&#46; Their distribution was also irregular&#46; Other large cells with globoid nuclei and astroglial histogenesis were also present&#46; Observation of the white matter showed both isolated heterotopic cells and cell clusters representing the 2 types of cell described above&#46; They were also present in the molecular layer of the cortex&#44; where clear marginal gliosis could be observed&#46; White matter adjacent to the cortical changes described above explains the abnormally thick folds that could be observed macroscopically&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Definitive control over seizures was achieved by surgery in all 3 cases treated surgically &#40;antiepileptic drugs were provided for 2 years&#44; after which they were discontinued&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cortical malformations&#44; which frequently cause drug-resistant epilepsy&#44; have been described under a number of names&#46; The generic term &#8216;cortical dysplasia&#8217; is frequently used to describe malformations of cortical development that include heterotopias&#44; polymicrogyria&#44; and FCD&#46; The best-known form of FCD is that described by Taylor&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and it is characterised by the presence of balloon cells&#46; This type of cortical anomaly is therefore known as Taylor&#39;s FCD or balloon-cell subtype&#46; Different types and subtypes of FCD have been described based on histological changes in the cortex of patients who have undergone surgical treatment for intractable epilepsy&#46; Each one can be distinguished from the others due to histological particularities corresponding to either FCD type II or Taylor&#39;s FCD&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Children with Taylor&#39;s FCD experience early-onset intractable epilepsy with mild neurological comorbidities&#46; The condition responds well to antiepileptic drugs&#44; but patients with the FCD subtype that is not accompanied by balloon cells display a more severe phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Categories based on imaging&#44; which several authors described a few years ago under the less precise name &#8216;malformations of cortical development&#8217;&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;23&#8211;25</span></a> are more generalised and include numerous types of cortical abnormalities&#59; under these criteria&#44; FCD is grouped with another type of malformations that are similar to one another&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The 2 types of FCD&#44; Taylor&#39;s FCD and non-Taylor&#39;s FCD&#44; can normally be distinguished from one another by MR imaging&#46; Characteristics suggesting Taylor&#39;s FCD include focal cortical thickening and indistinct grey&#47;white matter junction that frequently tapers towards the ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The lesion is generally extratemporal in Taylor&#39;s FCD and temporal in non-Taylor&#39;s FCD&#46; The latter is frequently associated with hippocampal sclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Identifying some types of FCD using low-resolution MRI was not easy&#44; and small lesions sometimes went undiagnosed a few years ago&#46; This rarely occurs now&#44; as the fluid attenuated inversion recovery pulse sequence &#40;FLAIR&#41; detects most such lesions&#46; However&#44; some small lesions may still go undetected&#44; and very large lesions may have indistinct edges&#46; Because of this&#44; in cases of suspected FCD&#44; we recommend using as many MRI sequences as possible&#44; especially 3D-FLAIR&#44; proton-density weighted sequence &#40;PD&#41;&#44; and high resolution T2-weighted sequence for transverse slices&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Using these techniques and a 3T MRI machine &#40;if available&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; we are able to diagnose FCD more accurately and identify its type and size&#44; enabling us to plan safer surgical procedures&#46; As imaging techniques evolve&#44; there are fewer cases of focal epilepsy of unknown aetiology and more cases of successful surgical treatment among patients with drug-resistant seizures&#46; Since the introduction of new imaging techniques&#44; we have learned that between 20&#37; and 25&#37; of patients with focal epilepsy have FCD<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a> and 76&#37; of them experience drug-resistant seizures&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The 2 types of FCD can now be distinguished from one another either by their histological characteristics &#40;presence or absence of balloon cells&#41; or by their innate&#44; adapted immune characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> While these findings are not necessary for a diagnosis of FCD&#44; they do allow us to categorise types of cells after diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Not all patients with focal seizures caused by FCD are candidates for surgery&#59; in some cases the seizures can be controlled with drugs&#44; at least for a few years&#46; In others&#44; including a patient in our series&#44; critical external manifestations are mild&#46; However&#44; surgery is the option offering the best outlook for most FCD patients&#44; especially those with intractable seizures&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Prior to the arrival of high-definition diagnostic methods&#44; including a number of functional imaging techniques in the area of nuclear medicine&#44; a lengthy list of MRI sequences&#44; and the combination of different methods&#44; cortical dysplasia was listed in large series among the rarer types of malformations of cortical development&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Nevertheless&#44; imaging and histopathological studies with better technical equipment&#44; which have recently been carried out in patients with drug-resistant epilepsy&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;39</span></a> have increased the possibility of detecting both very small lesions and large lesions with indistinct areas&#46; It has also become easier to distinguish between arrays of FCD-type anomalies and those pertaining to mesial temporal sclerosis or benign tumours&#44; even when 2 of these entities may be present in the same patient&#46; Functional images must be obtained prior to surgery if we are to generate a cortical map in order to prevent post-operative neurological deficits&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> This is almost always successful according to the results of our series&#46; FCD&#39;s ability to provoke seizures is related to excitatory and inhibitory neurotransmission abnormalities&#44; according to immunological and histochemical findings from histological tissue specimens from patients suffering from various types of seizures&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The incidence of FCD in series of patients who undergo surgery for epilepsy ranges between 12&#37; and 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;42&#8211;44</span></a> Seizure control is achieved in 63&#37; to 80&#37; of all cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34&#44;45&#44;46</span></a> In the case of the rolandic variant of FCD&#44; which requires increased precautions to be taken during surgery so as not to leave lesions that could result in motor or sensory sequelae&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> 59&#37; of such cases are seizure-free after surgery&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">One factor predicting favourable prognosis is total resection of the FCD according to the map of the lesion obtained by neuroimaging and electro-anatomical mapping techniques&#46; The factor predicting the poorest outcome and seizure recurrence is incomplete resection of the lesion&#46; For all varieties and locations of FCD&#44; exacerbation of seizures can be observed in the immediate postoperative period&#44; predominantly in the rolandic area&#46; This is due to the increased difficulty of completely extirpating lesions at this location&#46; Status epilepticus immediately following surgical resection of the lesion has been observed in 20&#37; to 37&#37; of cases with balloon-cell subtype FCD<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;47&#44;48</span></a> at any location&#46; Some suggest that this condition could arise due to balloon cells in the FCD lesion playing an inhibitory role&#46; When they are resected&#44; it could trigger a release of excitatory factors contained in the tissue surrounding any remaining epileptogenic cortex and cause seizure self-limiting mechanisms to fail&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> We have also observed onset of status epilepticus immediately following the extraction of epileptogenic tubers in 2 cases of tuberous sclerosis complex &#40;not included in this study&#41;&#46; This is logical when we consider that the histopathological structure of cortical tubers may be indistinguishable from that observed in some forms of FCD&#59; both diseases show large&#44; strangely formed neurons&#44; atypical astrocytes&#44; and subpial fibrillary gliosis&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The aetiology of type 1 FCD remains unknown&#46; Some authors believe that it arises due to exogenous lesions&#44; such as those left by hypoxia&#44; infections during gestation&#44; or perinatal trauma&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#8211;52</span></a> but this theory has not been demonstrated conclusively&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Some types of neurological sequelae are common during the postoperative period&#46; They include dysarthria&#44; hemiparesis&#44; monoparesis&#44; specific intellectual deficiencies&#44; and behaviour peculiar to attention deficit hyperactivity disorder &#40;ADHD&#41;&#44; as we have observed in certain cases in this series&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">We selected a group of 7 patients with onset of focal seizures during childhood&#44; very active foci in the EEG that did not change over time&#44; and an image of cortical dysplasia from an imaging study employing multiple MRI techniques&#46; Full surgical resection of the dysplasia resulted in seizure control and discontinuation of antiepileptic drugs in the 3 cases in which that technique was employed&#46; Histological studies of the excised tissue samples revealed findings compatible with Taylor-type FCD&#46; In 2 cases&#44; seizure control was achieved after several attempts with different drug regimens&#46; One patient with severely intractable seizures refused surgical treatment&#59; another&#44; now an adult in good neurological condition but with poor seizure control&#44; has been scheduled for surgery&#46; Drug-resistant seizures and signs of FCD in neuroimaging studies are crucial indicators of surgical treatment&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Balloon cells"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The term focal cortical dysplasia &#40;FCD&#41; describes a particular migration disorder with a symptomatology mainly characterised by drug-resistant epileptic seizures&#44; typical neuroradiological images&#44; and histological characteristics&#44; as well as a very positive response to surgical treatment in the majority of cases&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 7 patients were studied&#44; comprising 6 children with a mean age of 34&#46;3 months and one 25-year-old male with very persistent focal seizures and MRI images that showed FCD&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Three of the patients &#40;all girls&#41; were operated on while very young&#44; with extirpation of the FCD and the surrounding area&#59; with the histopathology study showed agreement between the MRI images and the macroscopic study of the slices&#46; The histology study showed findings typical of a Taylor-type FCD &#40;poor differentiation between the cortical grey matter and the subcortical white matter&#44; and balloon cells&#41;&#46; Three years after the FCD extirpation&#44; the same 3 patients remained seizure-free with no anti-epilepsy medication&#46; Two others have seizure control with medication&#44; another &#40;the adult&#41; is on the surgical waiting list&#44; and the remaining patient refused the operation&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Taylor-type FCD is associated with a high percentage of all drug-resistant focal seizures&#44; and it needs to be identified and extirpated as soon as possible&#46; Well planned and well-performed surgery that leaves no remains of dysplasia can cure the disease it in many cases&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El t&#233;rmino displasia cortical focal &#40;DCF&#41; expresa una patolog&#237;a muy particular de trastorno de la migraci&#243;n que conlleva una sintomatolog&#237;a caracterizada principalmente por crisis epil&#233;pticas f&#225;rmaco-resistentes&#44; unas im&#225;genes neurorradiol&#243;gicas y unas caracter&#237;sticas histol&#243;gicas peculiares&#44; as&#237; como una respuesta al tratamiento quir&#250;rgico muy positiva en la mayor&#237;a de los casos&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudia a 7 pacientes&#44; 6 ni&#241;os con edad promedio de 34&#44;3 meses y un var&#243;n de 25 a&#241;os con crisis focales muy rebeldes e im&#225;genes de RM que mostraban DCF&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Tres de los pacientes &#40;todas ni&#241;as&#41; fueron operadas en edades muy tempranas&#44; con extirpaci&#243;n de la DCF y la zona circundante&#44; demostrando el estudio anat&#243;mico la concordancia de las im&#225;genes de RM con las macrosc&#243;picas de los cortes anat&#243;micos&#46; El estudio histol&#243;gico mostr&#243; los t&#237;picos hallazgos de la DCF tipo Taylor &#40;mala delimitaci&#243;n entre sustancia gris cortical y la sustancia blanca subcortical&#44; y &#171;c&#233;lulas balonadas&#187;&#41;&#46; Tres a&#241;os despu&#233;s de la resecci&#243;n de la DCF los 3 pacientes estaban curados de las crisis y sin medicaci&#243;n antiepil&#233;ptica&#46; Dos de los pacientes est&#225;n controlados de las crisis con medicaci&#243;n&#44; otro &#40;el adulto&#41; est&#225; en espera de decisi&#243;n quir&#250;rgica y el restante desech&#243; la operaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La DCF tipo Taylor es una patolog&#237;a asociada a una buena parte de las crisis focales f&#225;rmaco-resistentes&#44; que debe tratarse de identificar y de extirpar lo antes posible ya que la cirug&#237;a&#44; bien proyectada y realizada&#44; sin dejar residuos displ&#225;sicos&#44; puede curarla en un alto porcentaje de casos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Pascual-Castroviejo I&#44; et al&#46; Displasia cortical focal&#46; Correlaciones cl&#237;nico-radiol&#243;gicaspatol&#243;gicas&#46; Neurolog&#237;a&#46; 2012&#59;27&#58;472&#8211;80&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1385
            "Ancho" => 950
            "Tamanyo" => 144332
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case 1&#58; Coronal 3D MRI slice&#46; We observe a medium-sized FCD in the parasagittal region of the left posterior parietal lobe &#40;arrow&#41;&#46; Note the thickening of the FCD&#44; the loss of differentiation of cortical grey matter&#44; the indistinct junction between the cortex and subcortical white matter&#44; and signal changes inside the FCD&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1119
            "Ancho" => 980
            "Tamanyo" => 120408
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Case 2&#58; The coronal MRI slice in FLAIR sequence shows a small FCD as a hyperintense area of the cortex &#40;arrow&#41; in the left rolandic area&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 930
            "Ancho" => 1000
            "Tamanyo" => 130412
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Case 3&#58; Sagittal T1-weighted MRI slices showing an FCD in the parietal region with a moderate U-shaped hypointensity in the cortex and underlying white matter &#40;arrow&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1418
            "Ancho" => 950
            "Tamanyo" => 305752
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Anatomical and histological study of the surgical specimen from the same patient&#46; &#40;A&#41; Extracted neurosurgical specimen&#46; The cortex displays variations in width and the white matter shows areas of subcortical demyelination tracing a U-shape&#44; as was apparent on the MRI scan &#40;arrow&#41;&#46; &#40;B&#41; Histological study of the cerebral cortex showing structural changes&#44; dysmorphic and poorly distributed neurons&#44; and reactive gliosis&#46; H&#38;E stain 200&#215;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2485
            "Ancho" => 947
            "Tamanyo" => 232498
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Case 4&#58; Axial MRI slice showing a dysplastic area of the right occipital&#8211;parasagittal region before &#40;A&#41; and after &#40;B&#41; surgical resection&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1159
            "Ancho" => 1000
            "Tamanyo" => 266281
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anatomical and histological study of the surgical sample from the same patient shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46; &#40;A&#41; External appearance of the surgical sample shows severely deformed folds and sulci&#46; &#40;B&#41; Lateral slice of the surgical sample shows irregular cortical thickness with highly myelinated white matter&#46; &#40;C&#41; Histological preparation in which we observe isolated or grouped balloon cells in the cerebral cortex&#46; Masson&#39;s trichrome stain 200&#215;&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">R&#58; right&#59; FCD&#58; focal cortical dystrophy&#59; Fr&#58; frontal&#59; L&#58; left&#59; F&#58; female&#59; O&#58; occipital&#59; P&#58; parietal&#59; C&#8211;P&#58; central&#8211;parietal&#59; NN&#58; neonate&#59; PMR&#58; psychomotor retardation&#59; T&#58; temporal&#59; GT&#8211;C&#58; generalised tonic&#8211;clonic&#59; ADHD&#58; attention deficit hyperactivity disorder&#59; M&#58; male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age at 1st seizure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age at visit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Seizure type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EEG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Image &#40;FCD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Other pathologies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Progress&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right partial myoclonic seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LT focus affecting entire L hem&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MRI&#58; Left parietal FCDSPECT&#58; low uptake in FCD area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacological &#40;all&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">At 6 years&#58; PMR&#59; ADHDNo seizure control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L F-C Focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MRI&#58; smallFCD L C&#8211;P&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Still suffers focal seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left partial seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focus in right rolandic area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MRI&#58; FCD in R rolandic area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacological &#40;all&#41;FCD surgery at 2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative seizure controlDiscontinuation of all drugs 2 years after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L T-O focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PharmacologicalSurgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurologically normal at 14 yearsADHD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LT focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PharmacologicalSurgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seizure controlNeurologically normal at 10 yearsLost to follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right partial infantile spasms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HypsarrhythmiaLF focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seizure controlNeurologically normal at 8 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right partialGT&#8211;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LF &#40;superjacent arachnoid cyst&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seizures controlled during 3 yearsNeurologically normalSubsequently lost to follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab264989.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Focal cortical dysplasia &#40;FCD&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:52 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Focal dysplasia of the cerebral cortex in epilepsy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;F&#46;M&#46; Taylor"
                            1 => "C&#46; Bruton"
                            2 => "J&#46; Corsellis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                        "fecha" => "2000"
                        "volumen" => "13"
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                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46; Meencke"
                            1 => "D&#46; Janz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Epilepsia"
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                        "volumen" => "26"
                        "paginaInicial" => "368"
                        "paginaFinal" => "371"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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              ]
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            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46; Kuzniecky"
                            1 => "J&#46; Garc&#237;a"
                            2 => "E&#46; Faught"
                            3 => "R&#46; Morawetz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ana.410290311"
                      "Revista" => array:6 [
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                        "fecha" => "1991"
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                        "paginaFinal" => "298"
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                            "web" => "Medline"
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46;R&#46;O&#46; Adasbaum"
                            1 => "P&#46;A&#46; Cohen"
                            2 => "O&#46; Delalande"
                            3 => "M&#46; Fohlen"
                            4 => "G&#46; Kalifa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s002470050421"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Radiol"
                        "fecha" => "1998"
                        "volumen" => "28"
                        "paginaInicial" => "583"
                        "paginaFinal" => "590"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9716627"
                            "web" => "Medline"
                          ]
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            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perisylvian dysgenesis&#46; Clinical&#44; EEG&#44; MRI and glucose metabolism features in 10 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Van Bogaert"
                            1 => "P&#46; David"
                            2 => "C&#46;A&#46; Gillain"
                            3 => "D&#46; Wikler"
                            4 => "P&#46; Damhaut"
                            5 => "E&#46; Scalais"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Brain"
                        "fecha" => "1998"
                        "volumen" => "121"
                        "paginaInicial" => "2229"
                        "paginaFinal" => "2238"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9874476"
                            "web" => "Medline"
                          ]
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                        "itemHostRev" => array:3 [
                          "pii" => "S0168827809005856"
                          "estado" => "S300"
                          "issn" => "01688278"
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stages and patterns of centrifugal arrest of diffuse neuronal migration disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Palmini"
                            1 => "F&#46; Andermann"
                            2 => "H&#46; De Grissac"
                            3 => "D&#46; Tampieri"
                            4 => "Y&#46; Robitaille"
                            5 => "P&#46; Langevin"
                          ]
                        ]
                      ]
                    ]
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