A 57 year old right-handed Indian-American female was referred for pre-surgical evaluation. A febrile convulsion was noted in early childhood with seizure recurrence at 13 years. Seizures were manifest as an indescribable feeling prior to a stare, lip smacking, impaired responsiveness for 45 seconds following which she had transient difficulty "getting the words out". Five antiepileptic drugs had failed and she was maintained on LTG and LEV with several seizures/month. The neurological examination was normal. MRI revealed left MTS. FDG-PET demonstrated hypometabolism in the left medial temporal lobe. In-patient video-EEG monitoring revealed the following;
Figures: (A) Scalp EEG demonstrating repetitive T1 spike-and-waves with a temporal field noted during drowsiness and (B) an ictal recording depicting a left temporal seizure manifest as rhythmic temporal theta.
Neuropsychological testing revealed mild verbal memory deficit. A Wada test revealed 8/8 recall with aphasia on left hemispheric injection, 0/8 recall on right injection. A left amygdale-hippocampectomy was recommended, however her son (an anesthesiologist) recommended against it. 10 years elapsed before surgery was able to be performed at 57 years of age. She has been seizure free for more than 2 years.
This patient illustrates well the most common surgically-remediable syndrome of drug-resistant temporal lobe epilepsy (TLE). The pre-surgical evaluation above is classic for concordance in TLE localization. Unfortunately only a small percentage of potential surgical candidates are being referred to surgical epilepsy centers1. Lengthy delays of 18-23 years are unfortunately common and in this case included a medical practitioner in the family that still saw epilepsy surgery "as a last resort" despite a practice parameter that was developed nearly 1 decade ago to help limit the adverse consequences of epilepsy.
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