Monthly Case

A 38-year-old male patient has suffered from epilepsy for more than 20 years, complex partial seizures lasting 30-40 sec. manifest 4-5 times per month; in the past, he also had generalized tonic clonic seizures. Epilepsy likely is caused by cMRI-proven hippocampal sclerosis on the right. So far, the patient had been treated with six different anticonvulsants, currently he is on 500 mg lamotrigine and 200 mg brivaracetam. In summary, this patient suffers from pharmacoresistant focal epilepsy.

During video-EEG-recording for 7 days, three typical complex partial seizures occurred. In each fit, a stereotyped EEG seizure pattern with onset in anterior temporal leads on the right was seen. This ictal EEG finding corresponds well to a seizure focus in right mesio-temporal structures.

In this constellation, we recommended to the patient resection of right-sided temporal lobe structures, the chance for sustained seizure freedom is 60-70%. However, the patient rejected the operation as he was too afraid of open brain surgery. In his view, ongoing seizures were less incriminatory than the brain operation. In the last 5 years, approximately 20% of patients in our center have rejected epilepsy surgery, after all examinations have been completed and resection of the seizure focus was recommended. Similar rejection rates have been found in studies from the epilepsy centers in Bonn, Bielefeld-Bethel and London.

For some years, in the U.S. a treatment approach is available which uses an intracerebral electrode to apply heat by laser and thus to ablate the epileptogenic focus. The principle is the same as in „open“ surgery – elimination of the seizure focus. The advantage of laser treatment is that the skull does not need to be opened; instead, via a smal borehole a small electrode is placed within the brain. First data have shown that 40-50% of patients with temporal lobe epilepsy become seizure-free with this minimally invasive approach.

Within the next weeks, laser ablation treatment will also be approved and available in Germany. In a collaboration project with the Department of Neurology at the University Magdeburg, we are going to establish this technique as one oft he first centers in Germany. In particular, we will offer this procedure to those patients with epilepsy, who are deeply concerned of „open“ brain surgery and thus reject this treatment option. Thus, we hope that the above mentioned 38-year-old patient agrees on laser ablation in order to get rid of his intractable epilepsy.

Cases of the months before