Monthly Case

A 49-year-old female patient suffers since puberty from partial epilepsy with eight to nine automotor (= complex partial) seizures per month. Cranial MRI reveals relevant atrophy in mesio-temporal und temporo-lateral structures on the right. The patient suffers from impaired mental development, she is living with her parents. Though her epilepsy is highly intractable against a number of antiepileptic drugs, for many years the patient and her family were opposed towards advanced presurgical assessment.

In autumn 2012, following a couple of further informative discussions, a first video-EEG-monitoring was performed and five of her habitual seizures were recorded. Surprisingly, the EEG seizure pattern was captured first over the left temporal regions, and then with a latency of appr. 10 sec ictal EEG was seen right temporally as well. Thus we were not able to demonstrate congruency between neuroimaging and initial ictal EEG results. We hypothesised that in the current case EEG lateralisation was misleading. Seizure onset was supposed to be confined to right mesio-temporal structures, but ictal activity then at first propagates to the left temporal lobe including temporo-lateral cortex. With some delay, the seizure pattern is then seen in the hemisphere of seizure onset (right), i.e. in termporo-lateral structures.

To confirm this hypothesis, in a next step, we recorded epileptic seizures with help of semiinvasive electrodes placed bilaterally into the foramen ovale that is in close spatial relation to mesio-temporal structures. Thus, we were able to prove that the seizures – as assumed – indeed start on the right side, then propagate to the contralateral hemisphere before they advance to further parts of the right temporal lobe. Now we were able to demonstrate congruency between MRI findings and ictal EEG patterns. On the basis of these findings, we recommended right temporal lobe resection to the patient and her family which was agreed upon.

Since the operation beginning of 2013, the patient is seizure free. In retrospect, the patient said that she should have agreed on presurgical assessment and a potential resection earlier in the course of her epilepsy.

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