Intracranial electroencephalography is frequently used to study patients with drug-resistant epilepsy and offers a unique opportunity to study human cognition. Its utility can be extended to better understand functional neuroanatomical profiles of patients and guide a tailored, minimally invasive surgical approach. We present prospective data on a 20-year-old patient with drug-resistant left temporal lobe epilepsy who underwent stereoelectroencephalography (SEEG) as a part of epilepsy surgical workup. Given obscurity regarding hemispheric dominance of language and memory, the patient’s workup included functional MRI, Wada procedure, and electrocortical stimulation and mapping of high frequency activity and phase amplitude coupling using SEEG to characterize his anatomofunctional profile. We describe the complementary use of these methods to inform surgical decision-making and functional prognostication. Data from mapping of high frequency activity and phase amplitude coupling, as a relatively new technique, is correlated with results from other procedures to advocate for increasing their utility in surgical planning.

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The piriform cortex is part of the olfactory system, principally receiving input from the lateral olfactory tract and projecting to downstream components of the olfactory network, including the amygdala. Based on preclinical studies, the piriform cortex is vulnerable to injury and can be easily kindled as an onset site for seizures. While the role of the piriform cortex in human epilepsy has been studied indirectly and the subject of speculation, cases of demonstrated piriform cortex seizure onset from direct intracranial recording are rare. We present a pediatric patient with drug-resistant focal re ex epilepsy and right mesial temporal sclerosis with habitual seizures triggered by coconut aroma. The patient underwent stereoelectroencephalography with implantation of olfactory cortices including the piriform cortex. We examined the eld potential effects of odorant presentation, the location of seizure onset and ability to recapitulate habitual seizures from olfactory cortices. Surgical workup resulted in resection of the patient's right amygdala, piriform cortex, and mesial temporal pole, following which she has been seizure free for 20 months without functional decline in cognition or smell.

The piriform cortex is part of the olfactory system, principally receiving input from the lateral olfactory tract and projecting to downstream components of the olfactory network, including the amygdala. Based on preclinical studies, the piriform cortex is vulnerable to injury and can be easily kindled as an onset site for seizures. While the role of the piriform cortex in human epilepsy has been studied indirectly and the subject of speculation, cases of demonstrated piriform cortex seizure onset from direct intracranial recording are rare. We present a pediatric patient with drug-resistant focal reflex epilepsy and right mesial temporal sclerosis with habitual seizures triggered by coconut aroma. The patient underwent stereoelectroencephalography with implantation of olfactory cortices including the piriform cortex. We examined the field potential effects of odorant presentation, the location of seizure onset and ability to recapitulate habitual seizures from olfactory cortices. Surgical workup resulted in resection of the patient’s right amygdala, piriform cortex, and mesial temporal pole, following which she has been seizure free for 20 months without functional decline in cognition or smell.