Abstracts

Rationale: We report a 24 year old man with a progressive epilepsy characterized by increasing myoclonic, generalized tonic-clonic, and focal seizures, progressing into medication-refractory focal status epilepticus (recurrent seizures without full recovery of consciousness), ultimately resolving with repetitive transcranial magnetic stimulation (rTMS). He was an academically accomplished young man with normal cognitive and physical development. First clinical seizure was at age 22, with increasing seizure frequency thereafter leading to multiple ICU admissions and treatment to burst suppression with IV anesthetics, high dose corticosteroids, and numerous antiepileptic medications (AEDs). He continued to have up to 30 nonconvulsive seizures per day (almost exclusively from the left occipital region), nearly continuous interictal discharges from the same region, frequent myoclonus, secondary generalized convulsions once per week, and worsening mental status (likely due to the combination of frequent nonconvulsive seizures and high doses of multiple AEDs). Methods: To better localize his seizure focus, he underwent a 256 electrode dense array EEG with source estimation, which suggested that the interictal discharges had a source medial to the O1 EEG electrode. Based on this information, we initiated rTMS therapy directed at the left occipital focus, with the center of the coil immediately medial to O1. He received 11 inpatient sessions of rTMS, with each session consisting of three 10-minute trains of 1 Hz pulses at 95-100% resting motor threshold (1800 pulses total, with 1 minute between trains). Results: The number of electrographic seizures markedly declined in the first few days of treatment, eventually reaching and maintaining zero seizures per day. The left occipital interictal discharges also markedly decreased. This improvement occurred while minimal antiepileptic medication changes were made. His cognitive and motor status began to improve and myoclonic jerks significantly decreased, likely as a result of decreased seizure burden and subsequent gradual reduction in AEDs. Conclusions: Small randomized trials have suggested that rTMS may have beneficial effects in the treatment of medication-refractory focal epilepsy. Case reports have suggested that rTMS may also be beneficial in epilepsia partialis continua, and more recently, in status epilepticus. In this patient with medically refractory focal seizures, rTMS applied over the epileptogenic focus was associated with complete seizure control within a short period of time, stabilization of his progressively worsening epilepsy syndrome, and substantial improvement in cognitive and clinical status. This treatment has not only provided seizure freedom for the patient, but also has allowed him to return to normal activities and plan for return to academic pursuits.Our report, in addition to other recent reported cases, suggests that rTMS may be clinically effective and cost-effective in the treatment of select patients with refractory focal status epilepticus.