Abstracts

Rationale: To report on a patient who had an asymptomatic superficially located left parietal meningioma that was treated with gamma knife radiosurgery. She subsequently developed focal Left parietal status epilepticus.Methods: Case report and review of the literature. A 63 year old right handed lady had an asymptomatic small left high convexity meningioma that was being followed by periodic imaging. However, while the patient was at another city (for which she makes frequent visits), another opinion was sought. It was felt, at the outside facility that the meningioma may have increased in size from a prior scan. Treatment was recommended and Gamma knife radiosurgery was suggested. The treatment was well tolerated but the patient needed to remain on steroids for several months due to significant edema. However, 7 weeks post radiation; she developed seizures manifested with language difficulty and right upper extremity paresis. Initial anticonvulsants were not effective. The patient presented to our epilepsy clinic for further care. An MRI of the brain only showed mild edema from the radiated site. EEG / video monitoring revealed near continuous seizure activity from the left parietal lobe. A diagnosis of epilepsia partialis continua was made. Trials of a number of anticonvulsants had limited efficacy. MRI and EEG montoring data will be presented.Results: Epilepsy surgery was planned. The necrotic area with surrounding gliosis was resected. Electrocorticography of the region revealed a small adjacent area of seizure activity. This was then excised. Post-operatively, the patient was seizure free and discharge to rehabilitation on anticonvulsants and on a tapering steroid protocol. Two weeks later, she had recurrent difficulty speaking and using her right upper extremity. EEG showed near continuous seizure activity in the left parietal cortex. Adjustment of medications failed to provide any relief. A second surgery was undertaken and subdural electrodes were implanted for prolonged monitoring. Extraoperative language and motor mapping was performed. The area of seizure onset was small and did not involve eloquent cortex. Oddly the area appeared grossly normal and located a few centimeters distant to the area that initially showed radiation necrosis. The patient subsequently was seizure free but had some residual hand weakness. She again was discharged to rehabilitation. Conclusions: Most superficially located meningiomas are still initially treated with resection rather than radiosurgery. Although seizures can be a complication of focused radiation for lesions, this is not common. Moreover, the incidence of seizures as a complication of superficially located tumors is not clear given that most of them are treated with surgery. The option of using gamma knife in this case may have originally been appealing because of avoiding surgery and its risks. However, in this case, surgical resection might have resulted in a better outcome. Not only might the development of epilepsy been avoided, but also the patient would not have been subjected to weeks or months of steroids and its risks.