Using Intraoperative ECoG for Limited Focal Resection in the Treatment of Super Refractory Status Epilepticus
Abstract number :
1.415
Submission category :
18. Case Studies
Year :
2023
Submission ID :
52
Source :
www.aesnet.org
Presentation date :
12/2/2023 12:00:00 AM
Published date :
Authors :
Presenting Author: Vincent Trung Ngo, MD, MPH – Trinity Health Grand Rapids
Mohammad Poostizadeh, MD – Epileptologist, Hauenstein Neurosciences, Trinity Health Grand Rapids; Jurgen Luders, MD – Chief of Neurosurgery, Hauenstein Neurosciences, Trinity Health Grand Rapids; Rebecca Tang, MD – Epileptologist, Hauen, Trinity Health Grand Rapids; Adriana Tanner, MD – Epileptologist, Hauenstein Neurosciences, Trinity Health Grand Rapids; Kristina Karanec, DO – Epileptologist, Hauenstein Neurosciences, Trinity Health Grand Rapids; Hussam Shaker, MD – Hauenstein Neurosciences – Trinity Health Grand Rapids
Rationale: Super refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues 24 hours or more after the onset of anesthetics, including cases that recur on withdrawal of anesthesia. The condition is associated with a particularly high rate of morbidity and mortality, and there is consensus for aggressive treatment in SE and SRSE. Surgical resection of epileptogenic foci using Intraoperative electrocorticography (ECoG) is widely used in the treatment of focal epilepsies, though not much is known about its utility in the treatment of SRSE. We detail our experiences with the use of surgical resection using intraoperative ECoG in a patient with focal SRSE.
Methods: The patient is a 52-year-old female with a history of long-standing focal epilepsy who initially presented with breakthrough seizures, eventually progressing towards SE and eventually SRSE for five weeks. Multiple IV anesthetics and anti-seizure medications (ASM) were needed to control her seizures which unfortunately recurred upon withdrawal of her IV anesthetics. The patient was also experiencing serious complications related to her prolonged inpatient stay including pneumonia, elevated liver enzymes, and encephalopathy. Thus, the need for urgent intervention was deemed warranted.
Results: The patient's seizure semiology was right leg numbness and tingling, which was the initial clue in localizing an epileptogenic network. The EEG data during the patient's hospital course showed ictal rhythm in the left parasagittal C3/CZ chains. Single-photon emission computed tomography (SPECT) and positron emission tomography (PET) scans were obtained though were not helpful in localization as the patient was having frequent seizures, and an interictal baseline could not be obtained. After a discussion between an interdisciplinary group that included the epilepsy faculty as well as the neurosurgery faculty, the decision was made to attempt a focal resection using intraoperative ECoG to help localize the epileptogenic foci. Intraoperatively, a 1x6 strip was placed medially in the left interhemispheric fissure which the teams knew as the epileptogenic zone. The strip showed ictal rhythms in all contacts, more pronounced in the medial ventral one through four contacts. Based on these data, a limited medial and ventral resection was performed.
The patient had an uncomplicated post-procedural course and eventually was able to be weaned off of IV anesthetics completely, as well as two additional ASMs. The patient was discharged to acute rehab after her hospital stay for mild weakness of her right leg. On the patient's last clinic follow-up, she had been seizure free for the last seven to eight months. She underwent physical therapy in the interim with noticeable improvement in her right leg strength.
Conclusions: Focal resection using intraoperative ECoG can be a practical option for SRSE, though there is still a need for more data on its efficacy. Interdisciplinary collaboration as well as communication with the patient and family are crucial aspects of this intervention. This modality of treatment shows promise for the treatment of SRSE after other treatments have been exhausted.
Funding: No funding was obtained for this case study.
Case Studies