Abstracts

Rationale: Aneurysm swelling and perianeurysmal edema have been documented post embolization procedures. The edema occurs in patients aged >40 years, following endovascular treatment of large unruptured aneurysms of the carotid artery. Edema may occur from a few hours to several months after treatment but is usually self-limiting. A significant proportion of patients are mostly asymptomatic, however some present with focal symptoms and visual deterioration as in cases of supraclinoid carotid aneurysms. Seizures are an exceptional presentation of perianeurysmal edema. Two previous case reports have demonstrated excellent management with steroids. We present the first case refractory to steroids requiring antiepileptic medication. Methods: A 55 year old female, post complete embolization of a large right middle cerebral artery aneurysm presented after 8 days with complaints of repetitive stereotypical episodes. Each paroxysm was described as an aura of 'bad smell', immediately followed by burning paresthesias starting in the head and rapidly spreading down to her abdomen. This was followed by an excruciating thunderclap headache of 10/10 severity along with photophobia, phonophobia and nausea accompanied by a loud scream but no loss of consciousness. Post ictally, she returned to baseline immediately. Paroxysms lasted for 60-90 seconds and occurred about 8-12 times a day. Results: MRI brain revealed inflammatory changes in the region of right temporal lobe, insular cortex, external and internal capsule i.e. around areas of coil insertion. Vascular imaging did not reveal changes in existing aneurysm size or character; nor showed evidence of any hemorrhage. She was diagnosed with uncinate seizures and started on steroid therapy. Video EEG monitoring captured multiple events but did not reveal any epileptic discharges. There was no improvement on steroids, hence lacosamide was initiated. Addition of anti-epileptic medication significantly lowered the seizure frequency to about 1-2 times a week. MRI brain at one month showed interval resolution of edema and inflammatory changes. Prednisone was tapered off. However, at subsequent follow up, seizure frequency increased to about 4-6 per day. The dose of Lacosamide was optimized which then helped control the seizures. Conclusions: Post embolization edema is an under-reported complication of embolization procedures. Most patients are relatively asymptomatic or have mild headaches responsive to OTC analgesics. Development of seizures is an extremely rare complication. We report the first case of refractory temporal lobe epilepsy associated with inflammatory changes post embolization. In previous case reports, steroid therapy resolved the symptoms. Our patient had uncontrolled epilepsy in spite of anti-inflammatory agents and required multiple anti-epileptic drugs for significant relief albeit inadequate control. Neurologists should recognize complications arising from such procedures and be aware of available therapeutic options. Funding: None