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June 2006

Efficacy of Surgical Treatment of De Novo, Adult-Onset, Cryptogenic, Refractory Focal Status Epilepticus

Author Affiliations

Author Affiliations: Epilepsy Service, Departments of Neurology (Drs Costello, Simon, Chiappa, and Cole) and Neurosurgery (Dr Eskandar), and C. S. Kubik Laboratory for Neuropathology (Dr Frosch), Massachusetts General Hospital, Boston; Department of Neurology, Maine Medical Center, Portland (Dr Henninger).

Arch Neurol. 2006;63(6):895-901. doi:10.1001/archneur.63.6.895

Background  There have been few published reports of successful surgical treatment of focal status epilepticus. Surgical intervention is considered a last resort after medical strategies have been exhausted.

Objective  To report a case of an adult who was initially seen with de novo, medically refractory, cryptogenic focal status epilepticus and underwent resection of an electrographically defined portion of the left middle frontal gyrus with multiple subpial transections of the adjacent cortex resulting in termination of the electroclinical seizure activity.

Design  Report of a case of successful surgical treatment of cryptogenic focal status epilepticus.

Intervention  After an initial 35 days of oral antiepileptic drug therapy and subsequent 16 days of continuous electroencephalography-guided intravenous antiepileptic drug therapy in an intensive care unit setting, and after extensive preoperative and intraoperative characterization of the epileptogenic zone, a tailored resection of the left middle frontal gyrus with multiple subpial transections of the surrounding cortex was performed.

Results  The restricted surgical resection and multiple subpial transections terminated the seizure activity. Neuropathological examination of the resected tissue revealed moderate inflammatory changes and a few abnormally located neurons without any definitive evidence of dysplasia, which was suspected preoperatively.

Conclusions  We suggest that focal cortical resection may be an appropriate intervention in medically refractory focal status epilepticus even when an overt structural etiology is not evident preoperatively and should be considered as an option at the onset of intractability.