Epilepsy, a recurrent seizure disorder affecting 1% of the population, can be genetic in origin and thereby affect multiple members in a family, or it can be sporadic. Many sporadic seizures come from a specific “focus” in the cortex. Focal-onset seizures account for 60% of all cases of epilepsy. Among patients with partial seizures, 35% respond poorly to available medication and may benefit from neurosurgical excisional surgery. In cases in which epilepsy is localized through different modes (electroencephalogram, magnetic resonance imaging, etc) to a specific area of the brain where there is an associated lesion, more than half of patients can expect a successful surgical outcome. In patients with consistent seizure-associated behavior but without a lesion, surgical treatment is less successful. Ms H, a young woman with a history of medically intractable partial epilepsy, does not have an anatomical lesion but wants to know if a surgical approach is a good option for her.
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A, Slow-wave activity (theta and delta) in the left temporal and central and right central areas is suggestive of localized cortical injury. The rare left temporal interictal epileptiform discharges are suggestive of an area of cortical irritability. B, Herald spike is the first physiological sign that a seizure is coming (appeared before every seizure); seizure onset is noted by reviewing the video recording linked to the EEG; pushbutton is an electrical artifact put on the EEG recording that marks the moment noted either by the patient or a family member that a clinical seizure has started.
A, Slightly enlarged right temporal horn (arrowhead), normal hippocampal volumes bilaterally. B, Mild cerebellar atrophy (arrowheads). No evidence of congenital or developmental anomalies.
Decreased fluorodeoxyglucose (FDG) use (circled areas) in the right temporal lobe is suggestive of decreased metabolic activity in that region.
Three-dimensional cortical reconstruction from high resolution T1-weighted magnetic resonance imaging scans of Ms H identifying regions of interest (boldface) involved in frontal lobe seizures (note: insula is not shown).
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