In our series of 33 children who underwent temporal and extended temporal lobe resections because of seizures, the average age at surgery was 7 years, 11 months. Sixteen cases (48%) were diagnosed as having tumors: low-grade astrocytoma (6), hamartoma (5), and ganglioglioma/neuroma (5). Other pathologic diagnoses included one or more cytoarchitectural abnormalities and/or reactive changes. Due to a more aggressive and early radiologic and electrophysiologic investigation of children with seizures, a resectable focus, e.g. neoplasm or structural abnormality, was found in a much younger age group of patients than previously reported. In children who had intractable seizures but normal radiologic studies, positron emission tomography was of great value in localizing the seizure focus. In a group of children with infantile spasms, seizures were controlled following the identification and resection of a focal lesion. Prompt detection and precise localization of lesions in the temporal lobe in the pediatric population may lead to surgical management and seizure control.

Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite aggressive treatment. A 9.8-year-old boy with a past history of daily left focal motor seizures was transferred to University of California at Los Angeles (UCLA) Hospital in pentobarbital coma after 4 days in RSE. The RSE was treated with very high doses of all appropriate antiepileptic drugs (AEDs), alone and in combination. The pentobarbital was titrated to burst suppression on EEG, but whenever pentobarbital was decreased, the seizures recurred. An ictal positron tomography scan of glucose metabolism demonstrated a right frontal area of hypermetabolism corresponding to an epileptic focus on EEG and magnetic resonance lesion. Eight days after the boy was admitted to UCLA, the right frontal focus was surgically removed, with immediate control of the status epilepticus. Whereas before onset of RSE, he had daily focal seizures, the boy has been seizure-free postoperatively for greater than 1 year. Operative treatment should be considered in patients with RSE in whom a focus of seizure onset can be demonstrated and who are reasonably considered surgical candidates.

Summary:Purpose: Increased risk of death has been reported in patients with intractable epilepsy (IE) taking nitrazepam (NZP).Methods: Between January 1983 and March 1994, 302 patients with IE were entered into a NZP compassionate-plea protocol. NZP was discontinued if there was 4 0 % seizure reduction or significant side effects. In some patients with >SO% reduction, it also was discontinued for lack of sufficient effect. At the end of follow-up for this study, 62 patients remained taking NZP. Patients took NZP from 3 days to 10 years.Results: Twenty-one of 302 patients died after institution of NZP. Fourteen of 2 1 of these were taking NZP at death, and in five of 2 1, the NZP had been discontinued. Two patients were excluded from analysis, because it is unclear whether NZP had been discontinued before death. Six other patients were lost from follow-up. Of the 14 deaths with NZP, seven were sudden, six were of pneumonia, and one was of cystinosis. Nine had at least one contributing factor, such as dysphagia, gastroesophageal reflux, or recurrent aspirations. The 294 patients took NZP for a total of 704 patient years (ptyrs), and were discontinued for a total of 856 ptyrs. There were I .98 deaths/ 100 ptyrs on NZP compared with 0.58 deaths/[ 00 ptyrs without NZP, most of the former being associated with side effects of NZP. Mortality in patients younger than 3.4 years was 3.98 with NZP compared with 0.26 deathdl00 ptyrs without NZP (p = 0.0002). Corresponding figures in patients 3.4 years or older were 0.50 and 0.86 deathdl00 ptyrs, respectively.Conclusions: NZP therapy for epilepsy apparently increases the risk of death, especially in young patients with IE. This should be considered in antiepileptic drug (AED) management decisions.

A great need persists for diagnostic criteria for both brain death in young children and irreversible loss of consciousness at all ages. This article examines the inferences derived from a hypothetical confirmatory study in which all of the N patients who fulfilled the criterion did in fact experience brain death (irreversibility). A Bayesian methodology proves that, for N in the range of a large clinical study, estimations of prior probabilities are, for all practical purposes, irrelevant to the calculation of the posterior probabilities. The risk of a false positive diagnosis for the next patient who meets the criterion is approximately 1/(N + 2). The chance of at least one false positive diagnosis among the next (N + 1) patients who meet the criterion is around 50 per cent. Thus, achievement of the requisite moral certainty of a declaration of death (irreversibility) necessitates an impossibly large N for the study. This does not mean that one cannot diagnose death, but rather that the validity of the diagnostic criteria must be self-evident on a priori grounds, and that confirmatory studies are necessarily either inadequate or superfluous.

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