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Neurosurgical treatment of refractory status epilepticus
D G Gorman1, W D Shields, D A Shewmon
1Department of Neurology, UCLA Pediatric Epilepsy Research Program.
Insights
Refractory status epilepticus (RSE) can be effectively treated with surgery. Surgical removal of the identified seizure focus led to long-term seizure freedom in a pediatric patient.
Area of Science:
- Neurology
- Neurosurgery
- Epileptology
Background:
- Refractory status epilepticus (RSE) is a life-threatening condition requiring aggressive management.
- Standard antiepileptic drugs (AEDs) and anesthetic coma are often insufficient for RSE control.
Observation:
- A pediatric patient with RSE refractory to maximal medical and anesthetic treatment was managed with pentobarbital coma.
- Despite burst suppression on EEG, seizures recurred upon pentobarbital reduction.
- Ictal PET revealed a hypermetabolic right frontal epileptic focus correlating with EEG and MRI findings.
Findings:
- Surgical resection of the right frontal epileptic focus achieved immediate and sustained seizure control.
- The patient remained seizure-free for over a year post-operation.
- This case highlights the efficacy of targeted surgical intervention for RSE.
Implications:
- Surgical intervention should be strongly considered for RSE patients with a demonstrable seizure onset focus.
- Early surgical evaluation may improve outcomes for select RSE cases.
- This approach offers a potential curative option for intractable epilepsy.
Abstract:
Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite aggressive treatment. A 9.8-year-old boy with a past history of daily left focal motor seizures was transferred to University of California at Los Angeles (UCLA) Hospital in pentobarbital coma after 4 days in RSE. The RSE was treated with very high doses of all appropriate antiepileptic drugs (AEDs), alone and in combination. The pentobarbital was titrated to burst suppression on EEG, but whenever pentobarbital was decreased, the seizures recurred. An ictal positron tomography scan of glucose metabolism demonstrated a right frontal area of hypermetabolism corresponding to an epileptic focus on EEG and magnetic resonance lesion. Eight days after the boy was admitted to UCLA, the right frontal focus was surgically removed, with immediate control of the status epilepticus. Whereas before onset of RSE, he had daily focal seizures, the boy has been seizure-free postoperatively for greater than 1 year. Operative treatment should be considered in patients with RSE in whom a focus of seizure onset can be demonstrated and who are reasonably considered surgical candidates.