SURGICAL TREATMENT FOR ACUTE SYMPTOMATIC REFRACTORY STATUS EPILEPTICUS USING MAGNETOENCEPHALOGRAPHY

Objectives: Refractory status epilepticus (RSE) is a life-threatening emergency that requires high-dose suppressive therapy (HDST) and is associated with significant mortality and morbidity. We describe the first report of resective surgery to treat acute symptomatic RSE in children.

Methods: A previously healthy 10 year old, right –handed boy presented with generalized convulsive status epilepticus. Seven days prior to presentation, he developed a mild febrile illness for two days. Lumbar puncture showed normal glucose and protein, 2 WBCs and 1 RBC. Metabolic and infectious screens were negative. We studied pronged video–scalp EEG (VEEG) monitoring, repeated MRI including diffusion- weighted images, and magnetoencephalography (MEG).

Results: MRI on day 1 was normal. VEEG revealed frequent right hemispheric seizures preceded by right temporal sharp waves. Midazolam drip, high dose topiramate and repeated phenobarbital boluses inducing a suppression -burst pattern did not control seizures. Repeat MR images on day 6 revealed restricted diffusion in the right hippocampus. MEG showed clustered anterior vertical or horizontal temporal dipoles indicative of the right mesial temporal discharges at the ictal onset of EEG seizures in addition to interictally. The patient underwent right anterior temporal lobectomy on day 9. Postoperatively, he gradually regained consciousness over 2 weeks. At 6 months follow up, neuropsychologic assessment revealed cognitive functions one grade level below his age. He attends regular school and has infrequent nocturnal seizures controlled by antiepileptic drugs.

Conclusion: Ictal and interictal MEG study can reveal the epileptogenic zone in selected patients during status epilepticus. In such case, epilepsy surgery should be considered after failure of HDST.