A 22-year-old male underwent a left anterior temporal lobectomy for drug-resistant epilepsy. He presented with complaints of memory and word-finding difficulties. He was first diagnosed with epilepsy at age 21 when he experienced a generalized tonic-clonic seizure. Risk factors for epilepsy included a motor vehicle accident with closed head injury at age 16 and repeated self-asphyxiation "play" during early adolescence. Prior to diagnosis, he reported a 9-month history of brief, recurrent, stereotyped spells characterized by sudden-onset "head rush" followed by a sense of "excitement" in his chest and extreme diaphoresis initially misdiagnosed as anxiety. He was unresponsive during his spells and afterwards felt "drained", with incomplete memory of the event. He became resistant to AEDs and underwent epilepsy surgery. A preoperative MRI, PET, and neuropsychological testing prior to surgery were normal. Video-EEG monitoring had interictal epileptiform discharges and three typical seizures with ictal onset in the left temporal region corroborated and localized by invasive monitoring with depth electrodes. Wada testing revealed left hemisphere dominance for language and bilateral representation of memory functioning. The patient underwent left anterior temporal neocorticectomy and partial left amygdalohippocampectomy guided by language mapping. Surgery resulted in seizure-free outcome and he returned to college 6 months later to complete an Associate's degree that he had started prior to the onset of his generalized seizures. At that time he noticed new-onset cognitive difficulties. He reported that it was taking him longer to learn new information in class and, even after understanding the material, he was less able to process and fully explain it to others or demonstrate his knowledge on tests. He was referred for repeat neuropsychological studies (Fig. 35.1) to evaluate his cognitive change and to offer recommendations to improve functional status.
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