Seizure Relapse 13 Years After Successful Surgery
John R. Gates, MD, came from the inner city of Trenton, NJ and was raised by grandparents who died when he was 15 years of age. A teacher recognized his brilliance and helped him earn a scholarship for disadvantaged youth. After attending schools in Massachusetts and England, he attended Harvard University and graduated Magna Cum Laude. He attended the University of Minnesota Medical School and there he completed his internship, residency, and fellowship. He was awarded the Benjamin Shapiro Award for Most Outstanding Neurology Resident.
A Clinical Professor of Neurology at the University of Minnesota, Dr. Gates lectured, taught, authored, and edited hundreds of publications on psychogenic nonepileptic seizures, efficacious use of AEDs, and surgical management of epilepsy. He was the Co-Founder of the Minnesota Epilepsy Group in St. Paul, Minnesota, a world-renowned comprehensive epilepsy treatment center.
Recipient of the J. Kiffin Penry Award for Excellence in Epilepsy Care by the American Epilepsy Society, Dr. Gates held many leadership posts and was president of numerous organizations including: the Minnesota Epilepsy Group, the American Academy of Neurology Congress of Neurosocieties, the Association of Neurologists of Minnesota, and the Ramsey County Medical Society. He served on the ILAE Commission for Neurosurgery and participated in projects of the Subcommission for Pediatric Epilepsy Surgery. He chaired the Practice Committee of the American Epilepsy Society, served on a number of other AES committees and task forces and served on the AES Board of Directors. He was a member of the Editorial Board for Epilepsy & Behavior.
In September 2005, Dr. Gates died following a battle with cancer. In a special tribute published in Epilepsy & Behavior 9 (2006) 545-548 called: “In Remembrance, John Gates: An appreciation” Steven C. Schachter, MD, conveyed the following sentiments of John's closest colleagues and friends: “John was one of those special people, and there are very few, who made a critical difference in all levels in the epilepsy movement – patient care, research, public policy, and volunteerism.” He was “a powerful and effective voice in the world of epilepsy, one who spoke for the needs of clinicians who are truly devoted to the care of their patients.” “…His enthusiasm for teaching continued even after his constitutional energy was nearly depleted. “John couldn’t ‘turn it off’ even when critically ill. To the end, John was lecturing and educating even when he needed help walking up to the podium.”
We present here a case study by John R.Gates, MD as originally published in 2002.
Seizure Relapse 13 Years After Successful Surgery
By John R Gates
The patient was a 15-year-old, right-handed, white male with no previous head injury or CNS infection who began having seizures in September 1978. They were characterized by a ‘dizzy feeling’ and an inability to respond or speak during an event, although afterwards he could remember and reply to what had been said. He also felt a tingling in his left foot spreading up into the thigh and often had left arm stiffening. These episodes were occurring every 2–3 days. He also had a history of medication-controlled tonic–clonic seizures.
Examination and investigations
At the time of the evaluation, he was on valproate and mesantoin. He had failed phenytoin, phenobarbital, and primidone. The neurological examination was remarkable for mild upper motor neuron weakness of the left upper extremity with decreased rapid alternating movements of the left hand and decreased tapping of the left foot. Somatosensory testing was within normal limits. Deep tendon reflexes were symmetrical. Gait was normal. His CT scan revealed an avascular cystic mass in the right parietal area. Surface video-EEG recording confirmed partial seizure onset in the right parietal area. A subdural electrode array was placed.
Parietal lobe epilepsy.
Treatment and outcome
Functional cortical mapping and epileptogenic localization were performed resulting in a resection. Pathology revealed a grade I–II astrocytoma. He had no deficit from the intervention. Subsequently he completed a course of radiation therapy. After this intervention and while being maintained on both phenytoin 500 mg and carbamazepine 1200 mg per day, he obtained complete seizure control with yearly imaging showing no change in the tumor.
Thirteen years later he began to have simple partial somatosensory seizures behind his left knee. An imaging study showed increased size of the tumor in the right posterior frontal lobe with enlargement of both the cystic component and the adjacent T2 signal. He subsequently returned to surgery for a more localized resection performed stereotactically. No deficits were noted post operatively. This time, the pathology revealed a grade II oligodendroglioma. The old surgical slides were pulled and re-read as consistent with a grade II oligodendroglioma. After the stereotactic resection, he was maintained on gabapentin monotherapy 600 mg bid. He has continued to be seizure-free.
Why did I choose this case?
This patient had a tumor in a location that two other institutions had been uncomfortable pursuing because of the belief that it was in the anatomical primary motor strip.
Since he did not have a significant sensory or motor deficit in the left upper extremity, though he had some mild tone changes, we elected to perform the subdural electrode array placement. The absence of a deficit indicated to us that the tumor was not in the motor strip. The variability and the location of the primary motor strip and its incredible plasticity has been repeatedly observed (1,2). Consequently, in the absence of a deficit the function must be subserved elsewhere than the classical anatomical zones.
What did I learn from this case?
The remarkable course of this neoplastic process now spans 20 years from the patient’s first seizure. The 15-year-old boy is now a man in his early 30s who had recurrence of the tumor, yet we were able to resect it without further deficit because of the remarkable consistency of the functional cortical map over time. This is one of the longest maps to second resection that we have made and underscores the durability of cortical functional mapping with subdural electrode array.
Another aspect of this case is the remarkable variability of primary CNS neoplasia. When I first received the pathology report on this young man, I dreaded that in five or at most 10 years he would be dead. Instead, I followed him every year for a period of 15 years until the tumor recurrence and subsequent resection.
We have an arrangement. Every year he ‘visits’ the tumor and confidently ‘leaves’ it in my office until his return the next year. Of all the parameters followed, including neuropsychological testing, MRI scanning, neurological exam, and seizure frequency and type, it was the seizure frequency and type that was the most sensitive indicator of recurrence that prompted us to re-image at an earlier date than our regularly scheduled annual appointment.
This selection for "Challenging Cases" is from 110 Puzzling Cases of Epilepsy, edited by Dieter Schmidt, MD, and Steven C. Schachter, MD (Martin Dunitz, Publisher, London, 2002).
Topic Editor: Steven C. Schachter, MD
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