Abstracts

To report an infrequently used treatment for refractory status epilepticus (RSE) and the successful treatment of a potentially life threatening condition.
This case study describes an uncommonly utilized treatment of RSE. The diagnostic studies which led to this clinical decision included an ictal single photon emission computed tomography (SPECT) study while the patient was in a pharmacologically induced burst supression state, a magnetic resonance imaging (MRI) scan , extracranial and intracranial ictal and interictal EEG monitoring and intraoperative somatosensory evoked potentials.
A 47 y/o male with a 45 year history of intractable epilepsy (seizure frequency: aproximately 1/week) presented with RSE. Clinical seizures abated with parenteral anticonvulsants but right frontal focal electrographic seizures continued in spite of a burst suppression pattern on EEG maintained first by Midazolam and then Pentobarbital. Whenever the Pentobarbital was lowered the patient continued to have focal clinical seizures with secondary generalization. An ictal SPECT scan of an electrographic seizure while the patient was still in burst suppression showed a right frontal region of ictal hyperperfusion. A MRI scan suggested a region of cortical dysplasia in the right frontal lobe, which appeared to correlate with the SPECT abnormality. Three weeks after the onset of RSE, the patient was taken to the operating room and a frontal craniotomy was performed and intracranial EEG electrodes were placed. Several electrographic seizures were recorded and a broad area of ictal involvement within the right frontal lobe was suggested. A right frontal lobectomy was performed after the motor cortex was identified with intraoperative somatosensory evoked potential motor/sensory mapping. Post-operatively, the patient was noted to have a mild contralateral motor deficit which has improved, but no clinical seizures have been noted during the three month followup period. Pathology of the right frontal lobe showed regions of cortical dysplasia within the resected tissue.
Focal surgical resection will typically not be needed to treat status epilepticus including RSE, but in certain cases where the RSE remains refractory to standard therapy and diagnostic studies suggest a focal epileptigenic source, this procedure should be considered. In this patient, the subsequent lack of seizures after the focal resection may suggest that this region was also the site of origin of the patient[apos]s typical seizures.