Surgery Candidate (Scalp EEG)

Abstract

A 47-year-old right-handed Indian-American female was self-referred for uncontrolled seizures. She was healthy only taking antiepileptic drugs (AEDs) for “petit mal.” She experienced a prolonged febrile convulsion at 2 years of age lasting 15 min with a fever of 103°. At that time she was told “nothing was wrong.” She developed normally throughout childhood with above-average scholastic achievement. At 11 years of age she developed her first afebrile seizure. Seizures were diagnosed as “petit mal” seizures due to a prominent stare. As if in warning, she would develop an indescribable feeling just prior to a wide-eyed stare, subtle lip smacking, and impaired responsiveness for 45 s. Following this she would be sleepy with transient difficulty “getting the words out.” Five AEDs failed to control her and she was maintained on lamotrigine and levetiracetam. Several seizures/month occurred with rare injury. She never experienced a “grand mal” seizure. Her neurological examination was normal. A brain MRI demonstrated left mesial temporal sclerosis (MTS) and EEG revealed left anterior temporal epileptiform discharges (Fig. 31.1). A surgical evaluation was recommended to her. Subsequently, a FDG-PET scan of the brain revealed hypometabolism of the left temporal lobe. Video-EEG monitoring revealed three focal seizures (Fig. 31.2). Neuropsychological testing revealed mild verbal memory deficit. A Wada test ultimately revealed 8/8 object recall and aphasia on left hemispheric injection, with 0/8 recall on right injection. A left amygdalohippocampectomy was recommended; however her son (an anesthesiologist) recommended against it. Ten years elapsed before surgery was performed. She has been seizure free for more than 2 years.