Abstracts

Convulsive status epilepticus (SE) represents a major neurologic emergency, associated with high mortality and morbidity. There are patients who continue to seize despite prompt diagnosis and medical treatment, including barbiturate or general anesthesia coma. This refractory SE may resurface during weaning from this intensive treatment. In this case the physician is left with few options, including resubmit the patient to pharmacological deeper coma. An alternative is neurosurgical intervention with resection of the epileptic focus, although very few cases have been reported so far in the adult population. We reviewed our adult epilepsy surgery database to detect all cases with refractory SE within the last 3 years. Inclusion criteria were a) partial or secondary generalized SE, b) inability of successful weaning from barbiturate coma in the intensive care unit (ICU), c) craniotomy for epileptic focus resection Out of 85 patients, who underwent epilepsy surgery, we identified 3 patients with partial SE or epilepsia partialis continua. All patients were continuously monitored with Video-EEG in the Neuro-ICU and were given appropriate doses of anti-epileptic medications for a period of 7 to 51 days, including barbiturate burst suppression of 30 to 190 seconds. All patients had history of refractory epilepsy. One patient had a history of left temporal resection for Rasmussen[apos]s encephalitis, another resection of a multicystic astrocytoma and another encephalitis of unspecified etiology. Repeat MRI studies in the first and second patient showed focal lesions and in the third generalized atrophy. Invasive monitoring with grid placement for better localization was done in the first and intraoperative mapping and corticography in the other two patients. Neurosurgical procedures included left frontal topectomies, left frontal lobectomy and right anterior temporal lobectomy. Pathology revealed findings consistent with Rasmussen[apos] s encephalitis, recurrent glioma and gliosis, respectively. Postoperatively, all patients were successfully weaned from the barbiturate coma and extubated. The first two patients developed contralateral hemiparesis and underwent inpatient and outpatient rehabilitation. On last follow-up, the first patient continued having focal motor seizures with considerably less frequency than prior to surgery, the second patient has been seizure-free for the last 6 months with reduced anticonvulsant medications, and the third patient experienced infrequent complex partial seizures postoperatively, but became seizure-free 2 months after surgery with medication adjustment. Our results suggest that resective surgery may be an effective treatment for intractable SE and should be considered in any patient with electrographic and/or neuroimaging demonstration of focal seizure onset.