Abstracts

Rationale: Temporal lobe resection surgery is an effective treatment for refractory temporal lobe epilepsy.  Laser ablation surgery is a safe and effective adjunct when seizures are not well controlled post temporal lobe resection surgery. Methods: Thirty-seven-year-old right handed male, with history of febrile seizure and self-reported head injury as a child presented with medically refractory epilepsy.  Patient started to have episodes of confusion with right upper and lower extremities shaking at the age of 31.  Patient was diagnosed with focal seizures with impairment of consciousness which were described as olfactory aura of sulfur smell, headache, abdominal pain, followed by behavior arrest, and with or without generalized tonic-clonic seizures.  Phenytoin, oxcarbazepine, Levetiracetam, and lamotrigine were ineffective despite maximum dosing.  MRI of the brain and tilt table test were negative and 48-hour continuous video EEG monitoring did not capture epileptiform activities.Patient was admitted in EMU and had multiple seizures captured. EEG revealed runs of spike, runs of spike and wave complexes and paroxysmal fast EEG seizures in left mesial temporal lobe with semiology of behavior arrest, right head version and right arm tonic seizure to bilateral arm tonic seizure.  PET scan revealed left temporal hypometabolism in both neocortex and allocortex, neuropsychological testing revealed language and memory deficits to the dominant hemisphere. The patient underwent subdural in-bed grid monitoring which confirmed ictal onset zone in the left mesial temporal region, and cortical mapping showed some language function adjacent to the epileptogenic region.  Left anterior temporal lobectomy with amydylo hippocampectomy was performed. However, due to the unusually anterior located language area, the resection is less than standard left anterior temporal lobectomy.Despite the left anterior temporal lobectomy, patient continued to have seizure while on both lamotrigine and oxcarbazepine.  Repeated continuous video EEG monitoring revealed ictal discharges in left anterior temporal and left centro-temporal region.  Repeat MRI of the brain suggested incomplete removal of the left hippocampus.  Laser ablation surgery was offered to patient to remove the residual left hippocampus. Patient underwent laser ablation of left temporal lobe and seizure foci without complications. Results: Patient continued to take lamotrigine 400 mg twice a day and oxcarbazepine 900 mg twice a day after the procedure.  Except post operation day 1 with clusters of focal sensory seizure, patient has been seizure-free for over one year since the laser ablation surgery. Conclusions: Anterior temporal lobectomy remains the treatment of choice for patients with medically refractory epilepsy with mesial temporal involvement.  Partial removal of the anterior temporal lobe can occur, especially in left temporal lobe where language region can be found closer to the anterior temporal lobe.  Laser ablation surgery can be a safe and effective treatment to eliminate the remaining ictal foci in the setting of partial anterior temporal lobectomy. Funding: None