Lesional epilepsy Dr. M.Manoranjitha kumari Prof V.G.Ramesh‘s unitMadras Institute Of Neurology Chennai
Case14 yr old male, 8 th std, namakkalc/o seizures- 5 yrs durationHOPI: apparently normal till 5 yrs ago, one day he developed staring look, not responding to his mother call, lasting for 1 -2mnts without any clonic tonic movement, regained his activities after few minutes without any post ictal confusion , head ache, or weakness not preceeded aura. 1 episode in a month- 3 yrs. Started on CBZ and Levitiracetam, frequency of seizures increased to once in 10 days- 2 yrs.
• For the past one month 2-3 times a day, starts as a starring look followed by turning of head towards left side with deviation of eye towards left side,with tonic posturing of left hand followed by right hand, some times with clonic movements, with loss of consciousness lasting for 1-2 mnts, without any post ictal confusion or weakness, with or without preceeding aura• no head ache /vomiting/behavioural disturbances/limb weakness/cranial nerve disturbances/trauma
• Past history: evaluated for epilepsy in 2004 ct plain was reported as calcified glioma, started on AED, 2008 AED dose increased and ct was repeated and was reported as calcified granulomaAntenatal natal post natal history, family history nil relevant
• O/E : pt conscious, oriented thin bult, no neurocutaneous markerHMF: normalLobar functions: normalCranial nerves: normalSms : normalCerebellar function: normalSpine and cranium: normal
MRI3.5*2.5*2.5*cm sized T1 &T2hetero intense lesion noted inthe right superior middletemporal gyrus with corticalexpansion. Calvarialremodelling noted in theadjacent right temporal lobe.No evidence of diffusionrestriction in the corticallesion, minimal heterogenousenhancement noted in thelesion. Evidence of bloomingin GRED/D DNET Oligidendroglioma Ganglioglioma
• EEG- normal study• Other investigations- normal
Post op EEG• Background shows well formed alpha waves in posterior head regions, responding normally to eye opening. Bilateral sharp waves and spikes seen more during hyperventilation and after hyperventilation. No slow waves seen.• Imp : abnormal record suggestive of bilateral epileptiform avtivity
What is lesional epilepsy?• In some patients with longstanding epilepsy the cause of the seizure may be a slow growing tumors , vascular malformations, infections or congenital anomalies. These lesions are picked up in the MRI.• Removal of the lesion may cure a patients with epilepsy
Long term seizure control after lesionectomy9 years follow up of 53 patients operated forsupra tentorial cavernomas: 45 (84.9%)pts- free from disabling seizure-Engels class1 37(69.8%)pts –completely free of post opseizure Engels class 1A International league against epilesy JNS nov 2008- volume 63
• 22 out of 26 cases -84.6% of seizure control after surgery for temporal lobe ganglioglima (Morris et al)• Complete seizure relief in12 of16 patients(75%) operated for DNET Raymond et al
Predictors of seizure control after surgery• Lower pre op frequency of partial seizure associated with better outcome• Presence of CPS – supportive predictive parameters for satisfactory seizure relief• Secondary seizure generalization- negative predictor for seizure control• Because of very low rate of patients with discordant EEG patterns , information derived from EEG recordings is not suitable to discriminate patients with a lower expectation of seizure control.• Other studies found a significant contribution of EEG data in predicting outcome after surgery especially in patients with mesial temporal sclerosis.