Abstracts

RATIONALE: The mortality of SE requiring anesthesia to stop it is up to 50%. We have recently managed 4 cases of SE in which surgery was considered. A fifth case was operated after status.
METHODS: We prospectively and retrospectively gathered data from cases of SE at our institution for which surgical treatement was suggested.
RESULTS: Case 1: 5 y/o with history of prenatal complications, developmental delay, uncontrolled tonic or atonic seizures since age 3. EEG showed left frontal SW, MRI normal, FDG-PET: L frontal hypometabolism. She developed SE, uncontrolled with 3 AEDs and pentobarbital coma. Viral, metabolic and genetic tests were normal; brain biopsy was non-diagnostic. After 6 weeks, she underwent implantation of subdural electrodes over the left frontal and temporal regions. This confirmed an inferior frontal focus, and resection was performed with motor mapping. Recovery from high barbituate levels was prolonged, but she regained milestones, and has had no seizures since, although frontal SW persists in sleep. Case 2: 6 mo/o with onset of encephalitis, (viral tests negative), and L occipital-temporal seizures which failed to respond to oral AEDs, and propofol/midazolam. He was taken for implantation of subdural strips, with plans to resect if possible. Poor hemostasis prevented this. The seizures finally responded to 15 mg/Kg Topiramate (TOP). He awoke with a visual tracking defect and depressed milestones. Case 3: 18 y/o male with onset of encephalitis (viral tests negative), SE and pentobarbital coma for 2 months. He finally awoke on 3 AEDs but continued to have 12 GTC/mo. After rehabilitation, motor functions were normal; IQ loss was 60 points with language at 1-3%. MRI showed diffuse volume loss; PET-L temporal hypometabolism. LTL resection decreased the seizures to 1 per month. Case 4: 22 y/o male with new onset R focal leg seizures failed to respond to 4 AEDs, then midazolam/propofol coma. Video-EEG showed a L dorsal frontal focus. MRI changed from normal to increased T2, L mesial frontal. Surgery with ECoG, motor mapping, and resection was recommended, but the family refused. The patient died of numerous medical complications. Autopsy revealed no pathology. Case 5: A 25 y/o male presented with new onset L facial seizures. These progressed and failed control with 5 AEDs and midazolam/propofol. MRI was normal, video-EEG showed a R frontal focus, viral tests were negative. After 5 days of coma, seizures persisted so he underwent implantation of R fronto-parietal and temporal subdural electrodes. Ictal onsets were recorded in the post-central gyrus and operculum. This area was resected and he was weaned off anesthesia on 3 AEDs. Pathology was negative. At one month post-resection he has had 1-2 SPS per week, and shows some frontal disinhibition.
CONCLUSIONS: In this series, 2/2 cases of SE undergoing surgery had good outcomes whereas of those not operated on, 1/3 died, 1/3 suffered severe cognitive damage, and 1/3 is too young to tell. When status appears to originate from a focal or regional area, surgery should be considered before irreversible brain damage ensues, and prospective studies in different age groups should be considered.
(Disclosure: Honoraria - Dr. Swartz is on speakers bureau for Pfizer, Ortho-McNeil, Abbott, UCB Pharma, Elan, and Glaxo.)