Pediatric Neuroscience Pathways Fall 2012 - Cleveland Clinic

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Case Study: Successful Epilepsy Surgery Despite Complicated EEG the following case is illustrative. a girl presented to cleveland clinic at 4 years old. her development was on track and her neurological examination was normal, but at 3 years old she had developed severe epilepsy with daily clusters of facial tonic seizures often evolving to lip smacking, confused speaking and unprotected falls. She was on four antiepileptic medications and had failed a total of five. Her MRI showed a round, circumscribed lesion in the right parietal lobe, posterior to the sensorimotor cortex (Figure 1). The lesion had no significant mass effect and did not enhance with gadolinium, so it wasn’t clear whether it was a low-grade tumor or a malformation of cortical development. Whereas her MRI showed a focal lesion, her EEG showed only generalized epileptiform discharges (Figure 2). These were abundant, nearly continuous during sleep, and lacked any focal features. EEG seizures also were generalized at the onset and maximal on the left (Figure 3). As seizures evolved, the left-sided predominance became even more apparent (Figure 4). In summary, this girl had medically intractable epilepsy, a right parietal lesion on MRI and generalized findings on EEG, sometimes maximum on the left. Would epilepsy surgery stop her seizures, or was her MRI figure 1. right parietal lesion Pediatric ePilePsy Right Parietal Lesion R abnormality just the “tip of the iceberg” of a more diffuse process? At Cleveland Clinic, each surgical candidate is discussed in detail at an epilepsy management conference, with input from all of the specialists. once a consensus has been reached, the recommendations are presented to the family for informed consent. In this case, the family was told that based on previous experience in similar cases, epilepsy surgery could be expected to resolve the epilepsy. However, this plan was clearly at the boundaries of epilepsy surgery because of the generalized eeg. after detailed informed consent with a full discussion of the possible risks and benefits, the parents elected to proceed. The lesion was resected at Cleveland Clinic in 2009, and histopathologic analysis showed that it was an oligoastrocytoma, World Health Organization grade II. the girl recovered from the surgery uneventfully and was discharged from the hospital after five days. Since surgery, she has had no seizures and has taken no antiepileptic medications, and her postoperative EEG shows no epileptiform discharges. this favorable result proves that the focal lesion was causing the epilepsy, even though the preoperative eeg features were generalized. Figure 1. Sagittal and axial MRI views of our patient’s right parietal lesion. 8 Pediatric NeuroscieNce Pathways | 2012 – 2013
figure 2. interictal eeg FP1–F7 F7-T7 T7-P7 P7-01 FP2-F8 F8-T8 T8-P8 P8-02 FP1-F3 F3-C3 C3-P3 P3-O1 FP2-F4 F4-C4 C4-P4 P4-02 figure 3. eeg at seizure onset FP1–F7 F7-T7 T7-P7 P7-01 FP2-F8 F8-T8 T8-P8 P8-02 FP1-F3 F3-C3 C3-P3 P3-O1 FP2-F4 F4-C4 C4-P4 P4-02 FP1–F7 F7-T7 T7-P7 P7-01 FP2-F8 F8-T8 T8-P8 P8-02 FP1-F3 F3-C3 C3-P3 P3-O1 FP2-F4 F4-C4 C4-P4 P4-02 Interictal EEG EEG Seizure, Onset EEG Seizure, +10 Seconds figure 4. eeg 10 seconds after seizure onset Pediatric ePilePsy Figure 2. Interictal EEG showing our patient’s abundant generalized slow spike-wave complexes. Figure 3. EEG at onset of one of our patient’s seizures, showing a generalized pattern with fast activity higher on the left (highlighted in blue). Figure 4. EEG seizure 10 seconds after onset, with more pronounced left-side predominance (highlighted in blue). Despite the generalized and contralateral ictal and interictal EEG features, this child was free of seizures after resection of her right parietal oligoastrocytoma. VISIT CLEVELANDCLINICCHILDRENS.ORG | 866.588.2264 9
Page 1 and 2: Pediatric Neuroscience Pathways 201
Page 3 and 4: Welcome from the Editors cleveland
Page 5 and 6: anticipated applications of dti and
Page 7 and 8: cover story | diagNostic radiology
Page 9: suggested readiNg Wyllie E, Lachhwa
Page 13 and 14: Health Survey. CSHCN have greater d
Page 15 and 16: Pediatric ePilePsy The first issue
Page 17 and 18: Pediatric ePilePsy reference-free,
Page 19 and 20: Pediatric ePilePsy aNd Neurosurgery
Page 21 and 22: establishment of Pediatric deep Bra
Page 23 and 24: Pediatric Neurosurgery figure 1. Bv
Page 25 and 26: table 1: arteriopathies in pediatri
Page 27 and 28: foremost among them are its diagnos
Page 29 and 30: Pediatric sleeP disorders Obstructi
Page 31 and 32: Pediatric Psychiatry of chronic sym
Page 33 and 34: develoPmeNtal aNd rehaBilitatioN Pe
Page 35 and 36: table 2 school days missed (week pr
Page 37 and 38: figure 1. sKamP ratings by extended
Page 39 and 40: Pediatric Neurosurgery Epilepsy Sur
Page 41 and 42: Pediatric Neuropsychology Pediatric
Page 43 and 44: sandra sommers, Phd Consulting Staf
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Pediatric Neuroscience Pathways Fall 2012 - Cleveland Clinic

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