Drug-resistant surgical failure

A 45-year-old right-handed Caucasian male was referred for evaluation of drug-resistant localization-related epilepsy. His seizures were characterized by an abrupt onset of staring with behavioral arrest, lip smacking, and transient impairment of consciousness. Occasionally, his focal seizures evolved into generalized seizures. His epilepsy had been refractory to multiple antiepileptic medications, so he underwent a comprehensive evaluation including an MRI of the brain which was normal. Prolonged video-EEG monitoring recorded seizures of left frontotemporal onset. He subsequently underwent surgical placement of intracranial electrodes for intracranial EEG (iEEG) monitoring. He was implanted with an electrode array providing left frontotemporal coverage for definitive lobar localization and to provide language mapping using electrical cortical stimulation, if necessary. Re-monitoring with iEEG demonstrated left temporal lobe onset for his typical seizures. He underwent en bloc left temporal lobectomy. He was seizure free for 2 months after his resective surgery, though unfortunately his seizures returned and again he manifested drug-resistance. Subsequently, he returned for reevaluation. Brain MRI (Fig. 33.1) showed only anticipated postoperative changes. Postoperative scalp video-EEG monitoring again recorded seizures of left temporal onset (Fig. 33.2).