Successful Neurosurgical Treatment of Childhood Complex Partial Status Epilepticus with Focal Resection

Abstract

Summary:The treatment of complex partial status epilepticus continues to be controversial, especially with regard to the intensity of the treatment. Medical therapy and drug-induced coma are sometimes required. Rarely this may not be effective. A healthy 4-year old girl was first seen in complex partial status epilepticus. She had a 1-year history of cryptogenic partialonset seizures. Detailed magnetic resonance imaging (MRI) studies were normal. Her course was refractory to multiple medical therapies and multiple subpial transection (MST). An urgent epilepsy surgery evaluation resulted in a focal cortical resection being performed over the right mesial parietal region with resultant seizure freedom and no significant neurologic deficit 2 years later. This patient illustrates the need to consider occult focal cortical dysplasia as a cause of nonconvulsive status epilepticus (NCSE) in children, and if it is not responsive to medical management, the utility of performing an urgent epilepsy surgery evaluation.

The role of neurosurgery in status epilepticus

“…Marked seizure reduction is of course still very different to complete seizure freedom in terms of final outcome. We have previously reported the case of a non-lesional, 4-yearold girl in life-threatening complex partial status epilepticus who failed MSTs and subsequently had successful focal resection who has now been seizure-free without any deficit for over 4 years [11]. Hence although MSTs can be highly effective, it should probably remain a second choice option to focal resection unless eloquent cortex is involved.…”

“…The theory behind this therapeutic technique is based upon maintaining the columnar organization of the cerebral cortex while disrupting the lateral communication of epileptogenic discharges [8]. We have previously advocated the use of neurosurgical focal resection in the treatment of various forms of status epilepticus, including status gelasticus, although our original series of patients did not include the (successful) use of MSTs [9][10][11][12]. There has only been a single case report of the use of isolated MSTs in epilepsia partialis continua secondary to focal cortical dysplasia [13].…”

Status Epilepticus in the PICU: Quieting the Storm

“…Finally, when medical therapy fails, epilepsy surgery may be considered for carefully chosen candidates. Candidates can include those with focal cortical dysplasia or patients with lateralized lesions, such as Rasmussen's encephalitis [63][64][65]. In addition, implantation of a vagal nerve stimulator has been reported in the preceding days prior to EEG normalization and being able to wean from suppressive medications in a 6-year-old with RSE [66].…”

Refractory status epilepticus

“…Es folgte eine Reihe von Einzelfallberichten und kleinen Fallserien mit insgesamt 13 Patienten im Alter von einem Monat bis 31 Jahren [2,33,38,42,56,92,106,116]. Die Dauer der SE lag in den Studien zwischen 6 und 42 Tagen.…”

“…Bei allen Patienten konnte der SE operativ durchbrochen werden. Sieben Patienten erreichten eine Anfallsfreiheit im Nachbeobachtungszeitraum von 1 Monat bis 10 Jahren) [2,38,42,56,92,106,116]. Drei Patienten trugen operationsbedingte, chronische neurologische Defizite davon [38,42,106], 3 weitere Patienten zeigten reversible Paresen [38].…”